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{ "1": { "exist": true, "char_ranges": [ [ 30, 357 ] ], "word_ranges": [ [ 6, 70 ] ], "text": "the patient is in a situation of psychotic depression and is not able to decide for his life and it does not seem that the patient has filled in the last will and testament, the most convenient thing to do is to present the case to the ethics committee of the center to make a decision on the matter in accordance with the law." }, "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": "Ask the hospital ethics committee to help determine the decision that is in the best interest of the patient.", "2": "Assess whether the residence will take the patient if PEG is not performed.", "3": "Seek a court order to perform PEG.", "4": "Enrolling the patient in terminal palliative care.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0872_18464", "title": "The Case.", "score": 0.015476190476190477, "content": "Mr. Hope is a 40-year-old man who has resided at a long-term care facility for the past 10 years. The resident was originally admitted to the nursing home for his inability to care for himself secondary to advanced AIDS and complications from progressive multifocal leukoencephalopathy (PML). When he initially arrived at the nursing home, Mr. Hope was able to smile and appeared to respond to some of the staff's requests. Now, he responds by wincing when told that procedures are being performed and especially when he is told that he has to go back to the hospital. He is extremely contracted, with his arms wedded to his chest in a crossed fashion, as though he is protecting himself from blows. Mr. Hope's family consists of a partner, his parents, and one sibling. Numerous conversations have been had with the family, and according to the facility staff, \"they persist in continuing aggressive measures with the hope that the patient will wake up and walk out of the facility.\" What had been frequent visits to the local hospital ER have increased substantially in the last few months, for what appear to be new infections and pneumonia. During most visits he ultimately spends a few days in the hospital to resolve his acute issues. On his most recent return to the long-term care facility, the medical staff approached the family about Mr. Hope's code status. The family continues to insist on a full code status and that he be provided every opportunity to \"live.\" The staff is very concerned about Mr. Hope and his welfare. Many of the nursing staff have grown attached to him over the years, and watching him deteriorate has been distressing. They see part of their role as being his advocate and supporting him in ways that his own family has not. They express very strong reservations about performing CPR on Mr. Hope because they think it will be ineffective and they will have to break his upper extremities in order to gain access to his chest for resuscitation. The staff has contacted the ethics consultation service with the request that Mr. Hope needs protection and that his own family is not making the best decisions for him. " }, { "id": "pubmed23n0313_6771", "title": "[For terminal cancer patient inserted with four tubes to live at home--from discussion with family].", "score": 0.014296289442028313, "content": "The patient was an 86-year-old man with mild dementia, and a urinary bladder catheter already inserted for benign prostata hypertrophy. At this time he had jaundice due to duodenal papillary cancer and was inserted with a percutaneous transhepatic bile drainage tube (PTBD). Additionally, due to an obstruction of his duodenum, he received a percutaneous endoscopic gastrostomy tube (PEG) for suction of gastric juice and intravenous hyperalimentation catheter (IVH) for nutrition. He always wished to return home. The medical staff and his family discussed this many times to realize his hope. We his daughter-in-law how to handle the 4 tubes. When she learned how, he went home and was on the visiting care system. But only one week after, despite his stability, his son, who was living apart got drunk and sent him back to the hospital. We tried to persuade them, including all family members living apart. At last he could return home again, and one week after died quietly at home. We learn from this case that it is important and very difficult for a family to accept a terminal cancer patient at home. It is necessary to advice them from two stand-points, the medical techniques and the mental aspects." }, { "id": "pubmed23n1073_24590", "title": "Navigating Medical Care for a Young Adult with Developmental Disability.", "score": 0.009900990099009901, "content": "Sam is a 20-year-old young man with intermittent gastritis, autism spectrum disorder, and intellectual disability who was admitted to the hospital because of nutritional concerns. His parents have legal guardianship and report that he has had increasing frequency of refusal to eat, resulting in a 15-pound weight loss over the past 3 months. On admission, a multidisciplinary team including specialists in gastroenterology, nutrition, feeding (behavioral and mechanical), psychiatry, palliative care, and social work was engaged to develop an evaluation and care plan. Sam's nutritional assessment was significant for severe malnutrition. An upper endoscopy was performed and was without abnormalities, including signs of significant gastritis.An upper endoscopy was performed and was without abnormalities, including signs of significant gastritis.A carefully obtained history found that Sam does not have a primary care physician. He was recently hospitalized at another facility because of his weight loss and nutritional concerns but was discharged against medical advice because of parental dissatisfaction with his care. His mother shared that she has tried many strategies to encourage Sam to eat including pushing spoons of food into his mouth, syringe feeding, and verbally pleading with Sam to take a bite, but all of these have been without success.Because of concerns that persistent attempts to verbally and physically coerce Sam to eat may be contributing to his aversion to food/eating, the feeding team provided Sam's parents with education and coaching for utilization of behavioral cues to determine when Sam wanted to eat. Despite parents expressing their understanding of the importance of avoiding physical attempts to \"make\" Sam eat and the team palliative care physician meeting with Sam's parents to elicit their goals for Sam's care, his nurses reported observing several instances of Sam's mother tapping a loaded spoon on his lips. Because of minimal oral intake, a nasogastric tube was placed for provision of hydration and nutrition. Sam's parents consented to the use of soft restraints and the presence of a bedside patient care assistant because of Sam becoming agitated and pulling at the tube.After 10 days of hospitalization, Sam was taking about 50% of his goal intake by mouth. Unfortunately, Sam removed his NG tube, and his parents refused to allow the tube to be replaced. Sam's parents then discharged him against medical advice, stating that they believed he would recover better at home. What are important considerations in caring for patients like Sam in the hospital setting and beyond?" }, { "id": "pubmed23n0935_313", "title": "No Judge Required: M (By Her Litigation Friend, MRS B) v A Hospital; M (Withdrawal of Treatment: Need For Proceedings) (2017) EWCOP 19.", "score": 0.009900990099009901, "content": "The two titles of the judgment on which this commentary is based reflect the fact that its scope was wider than resolving the legal matter at issue between two parties. It records the reasons for Jackson J's decision on a set of facts, it clarifies whether legal proceedings were necessary and the form that they should take, and it explains why the Court of Protection appointed a patient's mother as her litigation friend. The case arose from a request for a declaration that it would be lawful to withdraw clinically assisted nutrition and hydration from a woman with Huntingdon's disease who had been in a minimally conscious state for about one year. The application for withdrawal was supported by everyone whose evidence was heard. Jackson J stated that, in such cases, clinicians would be protected by the Mental Capacity Act 2005, and that court proceedings were therefore unnecessary. He explained that, provided that certain criteria are met, and the circumstances are appropriate, a court may appoint a family member or friend-rather than the Official Solicitor-to act as a litigation friend. This commentary explores the implications of this judgment in the context of very recent clinical developments." }, { "id": "pubmed23n0956_4804", "title": "Autism Spectrum Disorder and Mental Health Comorbidity Leading to Prolonged Inpatient Admission.", "score": 0.00980392156862745, "content": "Sam is a 6-year-old boy with a diagnosis of autism spectrum disorder (ASD) who recently relocated and has an appointment with you, his new pediatric clinician, to establish care. He was previously followed by a psychiatrist for 2 years for additional diagnoses of insomnia, bipolar disorder, anxiety, attention deficit hyperactivity disorder, and intellectual disability. He has tried and (apparently) failed multiple psychotropic trials including stimulants, nonstimulants, mood stabilizers, atypical antipsychotics, and nonbenzodiazepine hypnotics. He has a delayed sleep onset and frequent night awakenings each night for the past 3 months, during which he \"screams, cries, and thrashes and can stay up for over an hour.\" His behaviors are described as irritable, self-injurious, and aggressive with no clear pattern of triggers according to his mother. He is nonverbal and communicates by leading and rarely pointing. The patient's current medication regimen includes clonidine 0.2 mg at night, lorazepam 1.5 mg as needed at night, olanzapine 5 mg twice daily, and diphenhydramine as needed for sleep/agitation. His mother is concerned that he is developing \"tolerance\" to the regimen and wants to wean him off some of the medications. His mother is struggling to take care of the patient given his worsening behavior and body habitus (body mass index &gt;99%; z = 3.41).There is a family history of depression, anxiety, bipolar disorder, and autism. He has a 3-year-old sister, who is also diagnosed with ASD, though she is not as severely impacted. His mother's partner recently moved in along with 2 children of his own, aged 3 and 4 years. Sam attends a specialized school, where he receives behavior therapy and occupational therapy. He has undergone inpatient pediatric hospitalization twice, 1 time for 3 weeks and the other for 6 days, for aggressive behavior, and in both instances, he was discharged before inpatient psychiatric placement because of a lack of available beds.After urgent consultation with your local developmental and behavioral pediatrician, a slight reduction was made in the lorazepam because of concerns about tolerance and side effects. However, within a week of this, he was brought to the emergency department for continued self-injurious behavior and increased trouble with sleeping. His mother voiced concerns about his safety in the home, which were particularly related to aggression toward his younger sister. He was admitted to the pediatric inpatient floor for observation, and medication adjustment (increasing olanzapine), which was initially helpful in improving behavior, but mostly behavioral/environmental strategies were used to soothe him, including frequent wagon rides through the hospital corridors.Despite the patient being stable from the medical standpoint, Sam's mother did not feel comfortable taking him home. Social work contacted local community mental health services to pursue outpatient resources and respite care options and sought inpatient pediatric psychiatry. After several failed attempts to find placement, he remained in pediatric inpatient care for 1 and a half months with no acute medical interventions other than his oral medications.He was finally accepted to the in-state pediatric psychiatric facility when a bed was available. During his week-long stay, he had further medication adjustments with a decrease in olanzapine and optimization of his clonidine dose. During his psychiatric hospital stay, care coordination succeeded in arranging center-based applied behavior analysis interventions and respite care and parent training for his family. Sam began to show improvement in his overall agitation and aggression, requiring less clonazepam, and his mother then maintained outpatient follow-up.The day before discharge, you visit him in the hospital, and a medical student asks you why he was in the hospital for so long. How would you answer the question?" }, { "id": "InternalMed_Harrison_5927", "title": "InternalMed_Harrison", "score": 0.00980392156862745, "content": "End-of-Life Decisions Unfortunately, a smooth transition in treatment goals from curative to palliative may not be possible in all cases because of the occurrence of serious treatment-related complications or rapid disease progression. Vigorous and invasive medical support for a reversible disease or treatment complication is assumed to be justified. However, if the reversibility of the condition is in doubt, 475 the patient’s wishes determine the level of medical care. These wishes should be elicited before the terminal phase of illness and reviewed periodically. Information about advance directives can be obtained from the American Association of Retired Persons, 601 E Street, NW, Washington, DC 20049, 202-434-2277, or Choice in Dying, 250 West 57th Street, New York, NY 10107, 212-366-5540. Some states allow physicians to assist patients who choose to end their lives. This subject is challenging from an ethical and a medical point of view. Discussions of end-of-life decisions should" }, { "id": "pubmed23n0480_17150", "title": "[A case of serious aspiration pneumonia associated with multiple cerebral infarctions and Alzheimer's disease followed by hospital and home care service team].", "score": 0.009708737864077669, "content": "A 81-year-old man, who had been diagnosed in multiple cerebral infarction and Alzheimer's disease, was followed up in his local clinic since 1997. He had been bedridden before admission, but could eat. He was admitted with severe aspiration pneumonia in December 1999. Since severe dementia and dysphagia were noted after admission, he was examined to find out whether or not he could swallow while the treatment of his pneumonia was conducted at the same time. The water swallowing test indicated a risk of aspiration, thus, percutaneous endoscopic gastrostomy was performed on January 26, 2000 after the completion of the treatment for pneumonia. Although the patient's condition was complicated by aspiration pneumonia, enteral feeding through the gastric fistula gradually became successful, and he was discharged in June 2000. His family physician followed him up by visiting at home to examine and observe his general physical condition including consciousness, vital signs, skin and respiration, while taking measures in cooperation with the local health care visiting nurse. The patient, thereafter, was repeatedly admitted and discharged because of exacerbation and remission of symptoms, including coughing, sputum and fever, probably caused by aspiration pneumonia. When he was admitted in December 2001, which was his sixth admission, since there were troubles with the infusion tube and frequent gastroesophageal reflux, the gastric fistula management was judged to be a great burden on the patient. In January 2002, the gastrostomy tube was removed and the patients, whose alimentation was managed using intra-venous hyperalimentation (IVH), was discharged. Besides periodic visits by his family physician, a 24-hour house visit system was introduced to control his IVH and deal with his family members' anxiety. His general condition, thereafter, has not markedly changed. The patient has continuously received medical treatment for 14 months after being discharged and his condition is stable." }, { "id": "pubmed23n1016_4277", "title": "Dying too soon or living too long? Withdrawing treatment from patients with prolonged disorders of consciousness after Re Y.", "score": 0.009708737864077669, "content": "In the ruling in Y [2018], the UK Supreme Court has confirmed that there is no general requirement for the courts in England and Wales to authorise the withdrawal of clinically assisted nutrition and hydration from patients with prolonged disorders of consciousness. The perceived requirement, which originated in a court ruling in 1993, encompassed those in the vegetative state and those in the minimally conscious state. The ruling in Y confirms that the court may still be approached to decide difficult or contested cases, but there is otherwise no routine requirement that the judges be approached. There is much to welcome in this ruling, particularly as it means that these decisions for these patients are no longer (unusually) singled out for a judicial decision, with all the financial and emotional costs that court proceedings can entail. However, there is also a risk that the ruling might have unwelcome consequences. First, there is the possibility that patients might die too soon, particularly if doctors should now adopt the courts' previous reasoning, which has suggested that patients in the vegetative state lack interests, so treatment may - perhaps must - be withdrawn. Secondly, there is the converse possibility that patients might live too long, since empirical research suggests that - whether intentionally or not - patients' families, clinicians, and the health system appear to promote treatment-by-default. Rather than adopt general positions, which may be contestable and potentially risky, this article argues, on a pluralistic basis, that the individual patient should be the focus of any decision made in his or her 'best interests'. The existing legal framework in England and Wales, which is provided by the Mental Capacity Act 2005, already points in this direction, although more efforts may be needed to ensure that those involved in making these decisions are suitably educated and supported. Fortunately, new guidance from the British Medical Association could help clinicians and families to make decisions in the future, which are appropriate for the incapacitated individual patient in question." }, { "id": "pubmed23n1151_20626", "title": "Interoception in Practice: The Gut-Brain Connection.", "score": 0.009615384615384616, "content": "Tony is a five and a half-year-old boy who has been a patient in your primary care practice since he was adopted at birth. He has been treated by a child and adolescent psychiatrist for behavioral concerns starting at age 3 years and has been diagnosed with autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD) combined type, anxiety disorder, and insomnia. He presents today with complaints of repeated emesis and refusal to eat or drink over the past 2 weeks and is now dehydrated. Tony was born at 30 weeks' gestational age by vaginal delivery with a birth weight of 4lbs 15oz and was described as minimally responsive at birth. There was known prenatal exposure to tobacco and methamphetamine and inadequate prenatal care. The maternal history is notable for a reported diagnosis of bipolar affective disorder, prostitution, and being unhoused at the time of delivery. Tony received antibiotics after delivery for presumed newborn infections. As an infant, he had kidney reflux, low serum ferritin, insomnia, and failure to thrive. Regarding developmental milestones, Tony was sitting up at 7 months, walking at 14 months, talking at 18 months, and speaking in full sentences by 24 months. When he presented to the psychiatric service at age 3 years, behavioral problems included irritability with destructive rages, excessive fears, separation anxiety, hyperactivity, and impulsivity with a lack of awareness of danger to the extent that he required a safety harness when in public and security locks in the home because of repeated elopements. Tony also had at the time of his initial presentation significant defiance, extreme tantrums, violent aggressive outbursts, cognitive rigidity, repetitive behaviors, resistance to change, frequent nondirected vocalizations, and self-injurious behaviors including slapping himself on the head and biting of his hands and feet. Review of systems includes complaints of frequent abdominal and neck pain, persistent insomnia, night terrors, restrictive eating habits with poor weight gain, and reduced sensitivity to pain. Treatment history included gabapentin and subsequently divalproex for seizure-like episodes (despite negative EEG) described as frequent staring spells with repetitive biting of his lips. Psychotropic medications were risperidone for irritability associated with autism and clonidine extended release for ADHD. He also took melatonin for sleep. During his well-child check at the age of 5 years, Tony is making good progress from a developmental standpoint, has age-appropriate expressive and receptive language skills, is fluent in both English and Spanish, is able to recite the alphabet, counts to 20, has learned to swim, and is demonstrating interest in planets and astrology. He is reported to have a secure attachment to his adoptive parents and is described as emotionally sensitive, caring, kind, considerate, and empathetic. He has good eye contact and can read facial expressions. He is affectionate and protective of his infant sibling, his biological sister, who is also adopted by his parents and now living in the home. Tony made an excellent adjustment to the start of kindergarten and up until this point was responding positively to his psychotropic medication regimen. But then at age five and a half, Tony experienced sudden and unexplained behavioral worsening, which was followed by the onset of recurrent vomiting and refusal to eat or drink. Comprehensive medical workup including upper endoscopy and biopsy resulted in a diagnosis of eosinophilic esophagitis (EoE). What would be your next step?" }, { "id": "pubmed23n0882_5637", "title": "Causes and consequences of delays in treatment-withdrawal from PVS patients: a case study of <i>Cumbria NHS Clinical Commissioning Group v Miss S and Ors</i> [2016] EWCOP 32.", "score": 0.009615384615384616, "content": "Life-extending treatment, in the form of artificial nutrition and hydration, is often provided to people in permanent vegetative states (PVS) in England and Wales for many years, even when their family believes the patient would not want it and despite the fact that no court in the UK has ever found in favour of continuing such treatment for a patient with a confirmed PVS diagnosis. The first half of this article presents a close analysis of the recent case of <iCumbria NHS Clinical Commissioning Group v Miss S and Ors</i [2016] EWCOP 32. It examines the causes of delay in bringing this case to court and reaching a final judgment. It draws not only on the published judgment, but also on the two authors' involvement in supporting the family (before, during and subsequent to the court hearings) as a result of their academic and policy-related work in this area. This includes conversations with the family and with members of the clinical and legal teams, and observations in court. The second part of the article draws out the ethical and practical implications of the findings for theory and policy and suggests ways forward in relation to (a) the provision and inspection of care for these patients; (b) legal practice in relation to 'best interests' and (c) the perceived requirement under English law for a court application before life-prolonging treatment can be withdrawn from PVS patients-even in the absence of any 'in principle' opposition." }, { "id": "pubmed23n0673_21473", "title": "[Reviewing the so-called ″Living Will″].", "score": 0.009523809523809525, "content": "Cases like those of Terry Schiavo or Eluana Englaro have given rise to a lot of discussions at all levels. What both of them have in common is that, beyond the reasons given for terminating their lives and the methods used to achieve it, their destiny was not decided by them. This has resulted in a lot of heated debates in the public sphere as well as in the juridical, political, medical and speculative-ethical fields. Many people have been led to ask themselves: ″Wouldn't a better solution have been found if the desire of both persons had been known without any shadow of doubt, in the case that they had foreseen the situation in which they eventually found themselves in?″. The concept of the so-called Living Will appears to be a good solution for such cases. However, in the years in which attempts have been made to introduce this into practice, important ethical questions regarding end-of-life situations have come up: Can everything in my life, including when and how I die, be part of a legacy? Is a person who enjoys good health in a position to autonomously determine how he would like to be treated if, in an uncertain future, he ends up in a situation where he is incapable of communicating his wishes? Is the ordinary citizen capable of domineering the multiplicity of treatments, diagnosis and prognosis which medical science has to offer? Is it the same thing to forego a complicated treatment as to renounce artificial feeding and hydration? This article examines all these arguments, offering at the same time the case for and the case against the so-called Living Will." }, { "id": "pubmed23n0984_8677", "title": "Features of Catatonia in a 12-Year-Old Boy with Autism Spectrum Disorder.", "score": 0.009433962264150943, "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": "pubmed23n0744_21507", "title": "The weight attributed to patient values in determining best interests.", "score": 0.009433962264150943, "content": "In W v M and Others (Re M) the Court of Protection considered whether withdrawal of artificial nutrition and hydration was in the best interests of a person in minimally conscious state. The Mental Capacity Act 2005 states that in determining best interests the decision-maker must consider, so far as is reasonably ascertainable, the patient's wishes, feelings, beliefs and values. Baker J. indicated that a high level of specificity is required in order to attribute significant weight to these factors. It is preservation of life which carries substantial weight in the best interests' balance sheet. Could the (prior) values of a patient ever meet the probative standard necessary to offset the weight accorded to preservation of life? Rather than referencing the patient's values to specific circumstances and treatments they could be more effectively considered as part of the patient narrative, how the patient would want her life story to continue/cease. " }, { "id": "pubmed23n1034_9702", "title": "The <i>Briggs</i>ian Heresy? Should Previously Expressed Wishes Determine Best Interests in Decisions Relating to Withdrawal of Clinically-Assisted Nutrition and Hydration?", "score": 0.009345794392523364, "content": "This paper examines the Court of Protection decision in <iBriggs v Briggs</i. It considers whether the approach of the Court, which gave effective decisive weight to a patient's previously expressed wishes about whether he should be kept alive in a minimally conscious state, is a proper application of the 'best interests' test under the Mental Capacity Act 2005. It assesses whether the <iBriggs</i approach is effectively applying a 'substituted judgement' test and considers the difficulties in ascertaining what a person's actual wishes are." }, { "id": "pubmed23n0402_11174", "title": "[The life of Dr. John William Heron, the second superintendent of Chejungwon].", "score": 0.009259259259259259, "content": "The purpose of this paper is to overview the life of John W. Heron, M. D. who was the first appointed medical missionary to Korea by the Presbyterian Church USA. Although he was a competent doctor as well as a devoted missionary, he is not well-known yet, because he died early after 5 years' service in Korea. Dr. Heron was born in Derbyshire, England on June 15, 1856. His father, Rev. E. S. Heron, was a Scotch Minister of Congregational Church. His family emigrated to America in 1870 when he was fourteen years old and settled in Knoxville, Tennessee. In 1881, he was admitted to the University of Tennessee Medical School and graduated with highest honors in 1883. After training in New York University Hospital, he refused the offer of professorship from the University of Tennessee to become a medical missionary to Korea. He arrived in Seoul on June 21, 1885 and began to work in Royal Government Hospital, Chejungwon, the predecessor of Severance Hospital. In 1887, he became the superintendent of the Hospital following Dr. Horace N. Allen. He also worked for the Royal family and sometimes traveled to the rural areas to care for the patients. He started Chejungwon Church which later became Namdaemoon Presbyterian Church. In 1887, Dr. Heron worked as a member of the Bible translation committee and in 1889, he was elected as the chairman of the Public Committee of the Presbyterian Churches. In 1890, he established 'The Korean Religious Tract Society (Chosunsyungkyoseohoi) with Underwood and Ohlinger. The society published and replenished Christian books, periodical magazines and booklets. In the Summer of 1890, Dr. Heron did his best to take care of the sick suffering from an epidemic dysentery and himself got infected because of the terrible overwork. He passed away on July 26th, 1890. On his deathbed, he told his soldier and native friends around him as follow: \"Jesus loves you. He gave His life for you. Stand by Him!\" The martyrdom of Dr. Heron should be remembered in the Korean history of mission, because he was the first victim among the foreign missionaries who had lived and worked in Seoul for Korean mission. Dr. Heron's mind of love, service and devotion should be remembered by the medical doctors working today in caring for the patients suffering from physical and spiritual illnesses." }, { "id": "pubmed23n0252_15904", "title": "Rehydration in palliative and terminal care: if not--why not?", "score": 0.009259259259259259, "content": "Patients who are in the last few days of life are often too frail to take oral fluids and nutrition. This may be due entirely to the natural history of their disease, although the use of sedative drugs for symptom relief may contribute to a reduced level of consciousness and thus a reduced oral intake. Rehydration with intravenous (i.v.) fluids is the usual response in acute care settings, whereas the hospice movement has often argued against this approach. The issues are complex and involve not only physical, psychological and social concerns, but also ethical dilemmas. A review of the literature gives conflicting reports of the physical discomfort that may be attributed to dehydration in dying patients. There are many confounding variables, including the concomitant use of antisecretory drugs, mouth breathing and oral infection. It remains unproven whether i.v. fluids offer symptomatic relief in this situation. Hospice doctors are concerned that the use of i.v. fluids gives confusing messages to relatives about the role of medical intervention at this stage in a patient's illness. A drip may cause a physical barrier between a patient and their loved one at this important time. The use of other methods of fluid replacement are discussed. In the absence of definitive research in this area, the balance of the burdens and benefits of such treatment remains subjective. The prime goal of any treatment in terminal care should be the comfort of the patient. Decisions should be made on an individual basis, involving both patients and their carers wherever possible. Prolonging life in such circumstances is of secondary concern and i.v. fluids given in this context may be futile. The ethical dilemmas of withholding and withdrawing medical treatment in addition to those of conducting research in this area are discussed." }, { "id": "pubmed23n0802_9071", "title": "Delayed Presentation of DPD Deficiency in Colorectal Cancer.", "score": 0.009174311926605505, "content": "Case Study  Mr. D., a 55-year-old male, presented to the medical oncology service with a diagnosis of stage III adenocarcinoma of the sigmoid colon. He presented 7 weeks post sigmoid colectomy with lymph node resection and was initiated on adjuvant chemotherapy with CAPOX (capecitabine [Xeloda] and oxaliplatin [Eloxatin]). Standard dosing was used: oxaliplatin at 130 mg/m(2) on day 1 and capecitabine at approximately 2,000 mg/m(2)/day (rounded to the nearest 500-mg tablet size) for 14 days on and 7 days off (1 cycle = 21 days). A capped body surface area of 2.4 m2 was used, due to the patient's body habitus. Adverse Effects  Mr. D. did not report any complications of therapy during cycle 1, days 1-7, other than grade 1 diarrhea, which was amenable to diphenoxylate/atropine when taken. The next week, he reported significant malaise and fatigue associated with persistent diarrhea occurring every 30 minutes for 5 days. Mr. D. was instructed to go to the emergency room for an immediate evaluation, but he refused. Mr. D. presented to the clinic in poor condition on day 14 of cycle 1. His diarrhea had increased to grade 3 and was not controlled with either loperamide or diphenoxylate/atropine, though he was not taking his medications as directed. He had been instructed to take two 2-mg loperamide tablets after the first loose stool, followed by 1 tablet of diphenoxylate/atropine 2 hours later. He could then alternate this with loperamide every 2 hours as needed, not to exceed 8 tablets of loperamide per day. Instead, he had taken 2 tablets of loperamide after the first loose stool, but either waited 6 hours to take 1 tablet of diphenoxylate/atropine or otherwise chose not to alternate the medications at all despite continued diarrhea, depending on the day. Mr. D.'s timing in taking his supportive medications was inconsistent, and his explanations of this timing were not exact. He also reported persistent grade 3 nausea with vomiting for 5 days, which did not improve with ondansetron and prochlorperazine, though he again did not take these consistently. He was advised to alternate ondansetron and prochlorperazine every 4 hours as needed, but only took one or the other medication approximately 3 times per day. According to Mr. D., his adverse effects initially began on day 9 of cycle 1. He had lost approximately 14 kg (31 lb) during cycle 1. Clinically, he was found to have grade 2 mucositis and grade 1 hand-foot syndrome. At the time of this visit, his absolute neutrophil count was 3,000/ìL, his hemoglobin was 14.4 g/dL, his hematocrit 42.2%, and his platelet count was 139,000/ìL. His kidney function was within the normal range. Mr. D. refused hospitalization despite the primary team's recommendation. He also refused to undergo stool sampling for Clostridium difficile. He was given IV fluids along with adjustments in supportive medications, including a prescription for 10% tincture of opium. He was instructed to use 0.6 mL every 6 hours in addition to alternating loperamide with diphenoxylate/atropine as noted previously. He was advised to rinse his mouth with a baking soda solution for relief of his grade 1 mucositis, and alternation of antiemetics every 4 hours was reiterated. He was to return prior to initiation of cycle 2 for further evaluation. Worsening Symptoms  The next day, Mr. D.'s wife called the clinic to report that her husband's diarrhea continued despite the use of tincture of opium and that it was associated with hematochezia. He was also experiencing a worsening of his mucositis, with an associated swelling of the tongue. He was instructed to present to the emergency center, which he did on day 16 of cycle 1. By then, he was found to be febrile at 39.5°C. He was tachycardic, with a heart rate of 126, and he was experiencing significant abdominal pain associated with the diarrhea. The mucositis was worsening, with new odynophagia. At this time, Mr. D.'s absolute neutrophil count had dropped dramatically to 160/ìL, his hemoglobin was 13.1 g/dL, his hematocrit was 39.2%, and his platelet count was 68,000/ìL. He was admitted to the inpatient service and started on empiric antibiotics. His blood cultures remained negative during hospitalization, but stool cultures were positive for C. difficile. His antimicrobial regimen was deescalated to oral vancomycin once his stool volume decreased. He was treated with an institutional compounded mouthwash of diphenhydramine, aluminum/magnesium hydroxide, and viscous lidocaine for the mucositis, which also slowly improved. He was given a dose of growth factor. Neutropenia eventually resolved, with an absolute neutrophil count of 4,820/ìL on the day of discharge. He was discharged 26 days after initiating cycle 1, at which time his myelosuppression and mucositis were also resolved. Throughout his course, he did not report any neurotoxicity. DPD Testing  Due to his severe symptoms of neutropenia, mucositis, and diarrhea, Mr. D. was tested for dihydropyrimidine dehydrogenase (DPD) deficiency. Testing confirmed a heterozygous IVS14+IG&gt;A mutation. For this reason, all further adjuvant therapy was withheld, and he was followed on clinical surveillance only. " }, { "id": "pubmed23n0251_3896", "title": "Ethical dilemmas in hospice and palliative care.", "score": 0.009174311926605505, "content": "In order to understand some of the ethical dilemmas that face hospice programs in the United States, one must understand the Medicare Hospice Benefit, which is the model by which hospice programs provide palliative care to terminally ill patients in the United States. Unlike palliative care programs outside the United States, patients must have a prognosis of 6 months or less to receive hospice care under the Medicare Hospice Benefit. Care is reimbursed on a per diem basis, and inpatient care is restricted to pain and symptom management that cannot be managed in another setting. Ethical dilemmas that face physicians referring patients to hospice programs include the ability of clinicians to predict accurately a patient prognosis of 6 months or less, and to what extent hospice programs and clinicians are obligated to provide patients with full information about their illness, as the Medicare Hospice Benefit requires that patients sign an informed consent in order to elect the hospice benefit. There are ethical dilemmas that affect day-to-day patient management in palliative care programs including physician concern over the use of morphine because of possible respiratory depression in the advanced cancer patient, the question of providing enteral or parenteral nutritional support to patients who refuse to eat near the end of life, and the question of providing parenteral fluids to patients who are unable to take fluids during the terminal phases of illness. A final ethical dilemma concerns the methodology for quality of life research in palliative care. By following current research dogma, and only considering patient-generated data as valid, the patient population that most needs to be studied is excluded. A new methodology specifically for palliative care research is needed to provide information on the patients who are cognitively or physically impaired and unable to provide input regarding their needs near the end of life." }, { "id": "pubmed23n0519_12634", "title": "Community powers under the Mental Health Act: care or control?", "score": 0.00909090909090909, "content": "District Nursing Sister Janet Jones had been visiting a young patient, Peter James, 20, at his bedsit on a weekly basis to assist him with the management of his diabetes. However some 6 months ago Peter stopped eating and began refusing to take his insulin because he believed that they had been contaminated by alien dust. Sister Jones and the GP also noticed that Peter was drinking considerable quantities of alcohol and there were reports of him engaging in bizarre sexual rituals. Concern about Peter's mental health and refusal of treatment resulted in him being detained under the Mental Health Act 1983. Sister Jones has now received a request from the mental health unit to visit Peter at his home during a period of leave he has been granted by his responsible medical officer (RMO) and to continue visiting as part of his aftercare arrangements when he is discharged. Sister Jones wonders if the mental health team will be able to manage Peter in the community given his previous reluctance to accept treatment and how Peter will afford the aftercare package of home care support and meals on wheels provided by the local authority." }, { "id": "pubmed23n0975_23836", "title": "An NHS Trust and others v Y and another [2018] UKSC 46: Reducing the Role of the Courts in Treatment Withdrawal.", "score": 0.00909090909090909, "content": "In An NHS Trust and others v Y and another, the Supreme Court was asked to address the question of whether a court order must always be obtained before clinically assisted nutrition and hydration (CANH), which is keeping alive a person with a prolonged disorder of consciousness (PDOC). This case note explores the Court's decision to dispense with the need for such a court order and analyses that important change in approach from the perspective of the right to life protected in Article 2 European Convention on Human Rights (ECHR) as well as in the broader context of end of life decision-making." }, { "id": "pubmed23n0648_15276", "title": "Who rules the roost?", "score": 0.009009009009009009, "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": "pubmed23n0514_18415", "title": "Dealing with conflict in caring for the seriously ill: \"it was just out of the question\".", "score": 0.009009009009009009, "content": "Physicians often assume that conflict is undesirable and destructive, yet conflict handled well can be productive, and the clarity that results can lead to clearer decision making and greater family, patient, and clinician satisfaction. We review the course of Mrs B, an 84-year-old woman with advanced dementia and an advance directive stating no artificial hydration or nutrition. Over the course of her illness, her family and physicians had conflicting opinions about the use of short-term tube feeding and intravenous hydration in her care. We describe the conflicts that arose between her physicians and family and a typology of conflicts common in care of patients who are seriously ill (family vs team, team member vs team member). Drawing from the business, psychology, and mediation literature, we describe useful communication tools and common pitfalls. We outline a step-wise approach that physicians can use to deal with conflicts and the use of treatment trials as a strategy to address conflicts about the use of life-sustaining medical interventions." }, { "id": "pubmed23n0659_1460", "title": "A toddler with hair fascination.", "score": 0.008928571428571428, "content": "Joseph is a 24-months old boy referred by his pediatrician because of an \"obsession\" with pulling and eating hair. When Joseph was 14 months old, he enjoyed touching and twirling his mother's long hair. She observed that it seemed to provide comfort to him. At 18 months, he initiated pulling out and eating his own hair, twirling his mother's hair around his thumb and then sucking on it. Currently, he searches the carpet or a hard floor and looks for hair to eat. The identical behavior is observed at daycare. Joseph's teacher commented, \"He pulled hair from a girl who has the longest hair of all the children. We try to distract him from this habit, but he is not distracted for long.\" Less frequently, Joseph has also eaten sand, chalk, and crayons at daycare. Joseph's mother describes him as a \"happy and outgoing\" child who interacts with his peers and has a best friend at the daycare. There have not been recent changes or stressful events in his life. Joseph separates from his mother with ease and he sleeps comfortably through the night in his own bed. There have been no episodes of nausea, vomiting, abdominal pain, or constipation. Strands of hair are occasionally seen in the stool. Prenatal and perinatal history was unremarkable. Joseph was breast-fed for 11 months, described as an \"easy\" baby, achieved motor, social, and language developmental milestones at the usual time, and has been in excellent health. He lives with his mother and maternal grandparents; the biological father has never been involved in his care. At 20 months, Joseph's pediatrician suggested cutting his hair. After several haircuts, Joseph stopped pulling his own hair. However, he continued to search the floor for hair. Hemoglobin and a blood lead level were normal. Joseph appeared pleasant and friendly with normal growth parameters and facial features. He was sitting comfortably on his mother's lap, sucking on his thumb. Social interactions with his mother were appropriate and reciprocal. He warmed up quickly to the examiner and engaged in play. He spoke in two to three word sentences and responded to questions with a speech pattern that was 50% intelligible. Physical and developmental examinations were normal. At the end of the examination, Joseph searched his mother's purse and located a piece of hair. He twirled the hair around his thumb and sucked on it. Initially, he refused to remove his thumb from his mouth. With gentle persuasion, he eventually removed his thumb and agreed to throw the hair in the trash. He did not appear distressed." }, { "id": "pubmed23n0758_18691", "title": "[The PEG-dilemma - pleading for an ethically responsible medical treatment].", "score": 0.008928571428571428, "content": "Within the 32 years of its existence our attitude towards artificial enteral nutrition via PEG-tubes has changed in a fundamental way: in our modern understanding nutrition via PEG is supportive, early, preventive, and in many cases temporary. PEG-feeding is not an alternative but a possible supplement to normal oral food intake and requires an individual medical indication as well as an ethical justification. This does not follow standardised algorithmic thinking but is decided on an individual base taking personal wishes, resources, and needs of the individual patient into account. Nutrition via PEG-tube is not a terminal basic or even symbolic treatment at the end of life. The present dilemma of the PEG is that the public discussion primarily focus one-sided on the problems of PEG-placement in multimorbid, elderly, and/or demented patients or patients in end-stage tumour diseases where indeed PEG-placement is neither medically nor ethically justified - we still place PEG-tubes to often in the wrong patients! On the other hand we still consider supportive and in many cases temporary nutrition via PEG too rare and even too late in those patients which clearly could benefit from an early, supportive, and preventive PEG-treatment on the base of our present evidence-based scientific knowledge - we still consider PEG-treatment not adequately and in most cases too late in the right patients! Placing a PEG-tube is not the second last step before death and physicians have to accept the ethically given limits of medical treatment by realizing our modern understanding of the benefits and limits of supportive artificial nutrition via PEG." }, { "id": "pubmed23n0590_22190", "title": "Case report: a case of intractable Meniere's disease treated with autogenic training.", "score": 0.008849557522123894, "content": "Psychological stress plays an important role in the onset and course of Meniere's disease. Surgical therapy and intratympanic gentamicin treatment are options for cases that are intractable to conventional medical therapy. Psychotherapy, however, including autogenic training (AT), which can be used for general relaxation, is not widely accepted. This paper describes the successful administration of AT in a subject suffering from intractable Meniere's disease. A 51-year-old male patient has suffered from fluctuating right sensorineural hearing loss with vertigo since 1994. In May 2002, he was first admitted to our hospital due to a severe vertigo attack accompanied by right sensorineural hearing loss. Spontaneous nystagmus toward the right side was observed. Since April 2004, he has experienced vertigo spells with right-sided tinnitus a few times per month that are intractable to conventional medical therapy. After four months, tympanic tube insertion was preformed in the right tympanic membrane. Intratympanic injection of dexamethasone was ineffective. He refused Meniett therapy and intratympanic gentamicin injection. In addition to his vertigo spells, he suffered from insomnia, tinnitus, and anxiety. Tranquilizers such as benzodiazepines and antidepressants such as serotonin selective re-uptake inhibitors (SSRIs) failed to stop the vertigo and only slightly improved his insomnia. In December 2006, the patient began psychological counseling with a psychotherapist. After brief psychological counseling along with cognitive behavior therapy (CBT), he began AT. He diligently and regularly continued his AT training in his home according to a written timetable. His insomnia, tinnitus, and vertigo spells disappeared within a few weeks after only four psychotherapy sessions. In order to master the six standard formulas of AT, he underwent two more sessions. Thereafter, he underwent follow-up for 9 months with no additional treatment. He is now free from drugs, including tranquilizers, and has continued AT. No additional treatment was performed. When we examined him six and nine months later for follow-up, he was free of vertigo and insomnia. AT together with CBT can be a viable and palatable treatment option for Meniere's disease patients who are not responsive to other therapies." }, { "id": "pubmed23n0508_20391", "title": "Living wills, duty of care and the right to treatment.", "score": 0.008849557522123894, "content": "Agnes Simon, a district nurse with 20 years' experience, has been caring for a man with motor neurone disease for the last 5 years. During this time the patient has shown remarkable tenacity but the disease has now progressed to the stage where artificial nutrition and hydration (ANH) is required. A percutaneous endoscopic gastrostomy tube has been inserted through which the patient receives food, water and medication. On her most recent visit the patient gave Agnes a signed and witnessed living will. Unusually, the living will did not indicate the patient's wishes regarding the limitation of treatment. Instead it made clear that the patient wished to continue to receive ANH up to the time of his death. He did not want the care team to withdraw this treatment without his permission, as he feared he would suffer from the indignity of slowly dying from thirst and starvation. Agnes has never seen a living will where a patient demands a right to treatment and wonders whether such a document is lawful and binding on her." }, { "id": "pubmed23n0128_5446", "title": "Decision making in the critically ill patient.", "score": 0.008771929824561403, "content": "In the preceding discussion we have attempted to set forth some realistic guidelines for the primary care physician in the critical care area. We feel that he is of utmost importance in setting the tone for his patient's care. He is the first physician to be called when his patient becomes critically ill. He decides whether or not consultation is needed immediately. He should choose appropriate consultants, trying to provide required expertise and compatible personalities to relate with his patient and the patient's family. His work does not end with establishing roles and delivering care. He is the single most important physician when difficult ethical and medicolegal decisions must be made. He is the physician who knows the patient and the patient's family best. They look to him for guidance and decision making about their health care. He is best able to discuss the wishes and desires of the patient if the patient becomes unable to decide for himself. The primary care physician can be extremely helpful when the appropriate medical decision is to withhold therapy. He can comfort and console the family and help them realize that the proper decisions have been made. His previous close relationship with the patient and family makes difficult decisions much easier to accept. He is also of primary importance when trying to provide care to a patient who ostensibly refuses such care. The trust he has earned in the past because of the care he was provided allows him to be much more forceful than the subspecialist who may have been on the case for 1 or 2 days. He can be the difference between survival and death merely by his presence and advice. Other difficult decisions are always made easier by a primary physician who can relate to the consultants as well as the patient and his family. In conclusion, we feel that the technologic advances of the past 30 years have tended to drive the primary care physician away from the critical care unit. This is mostly because of a need for particular expertise to run the machines of medicine. One cannot be expected to become or remain an expert in primary care and critical care medicine. The primary care physician should not feel or be excluded from the critical care area. His knowledge of general medicine and his expertise in interpersonal and family relationships allow him to provide the much needed \"high touch\" component of \"high tech\" critical care medicine." }, { "id": "pubmed23n0119_12604", "title": "Brophy v New England Sinai Hospital, Inc. Brief amicus curiae, Society for the Right to Die, Inc. on behalf of appellant.", "score": 0.008771929824561403, "content": "On September 11, 1986, the Supreme Judicial Court of Massachusetts, in a 4-3 decision, authorized removal of the artificial feeding tube. It held that the \"substituted judgment\" of an incompetent person in a persistent vegetative state to refuse artificially administered sustenance must be honored. The Court also refused to compel the hospital in this case to terminate the treatment, but permitted other hospitals to comply with the patient's wishes. We are publishing the amicus curiae brief filed by the Society for the Right to Die, Inc. in the Brophy case. Our purpose in doing this is to stimulate further discussion of the issue of the role of the patients who become incompetent, a matter of major concern to geriatric specialists. This brief has been well-prepared. It contains a legal and ethical history of considerable merit. It has not, however, been endorsed by the American Geriatrics Society (AGS). Some of the principles the AGS has endorsed can be found on its own brief filed in the Conroy case (published in the December 1984 issue of the Journal). Physicians and medical ethicists in particular may wish to consider the caveats noted by David Thomasma, PhD. in his editorial in this issue of the Journal. We invite further discussion." }, { "id": "pubmed23n1162_26423", "title": "Ethics Roundtable: Advance Directives, Autonomy, and Gastrostomy Placement.", "score": 0.008695652173913044, "content": "CL is a 94-year-old male who is brought to the Emergency Department from an assisted living facility due to a new onset of weakness and altered mental status. He was in his usual state of moderately compensated health, requiring assistance for most activities of daily living due to medical frailty and a previous right brain CVA with residual mild left sided weakness. On the day of admission, the staff found him lethargic and disoriented. The family requested a surgical consult for percutaneous, endoscopic, gastrostomy (PEG) tube placement. A review of the patient's records showed that the patient had refused a PEG tube during his last two hospitalizations. During the last admission, the hospitalist documented that the patient repeatedly refused nutritional support stating \"if it's my time, I've lived a full life. I'm ready to die and join my wife.\" There was no advance care plan (\"living will\"), but CL did sign a \"Selection of Surrogate Decision-maker\" form previously, assigning his nephew as primary surrogate. Under pressure from multiple family members, including the designated surrogate, the attending requested a surgical consultation. The surgical team determined that the patient did not have capacity and scheduled CL for PEG tube placement. The care team had concerns regarding the conflict between the patient's previously (and consistently) stated desires and the family's wishes; an ethics consult was requested." }, { "id": "wiki20220301en547_29861", "title": "End of Life Choice Act 2019", "score": 0.008695652173913044, "content": "The person must confirm their request by signing and dating a prescribed form in the presence of this practitioner. The second part of the form may be signed by someone else if the person cannot write for any reason." }, { "id": "pubmed23n1163_13281", "title": "Multidisciplinary team approach on tracheoesophageal fistula in a patient with home ventilator.", "score": 0.008620689655172414, "content": "A 68-year-old man was transferred to our tertiary hospital. Ten years ago, he received radiation therapy for tonsil cancer, and while there was no evidence of recurrence, he suffered from recurrent aspiration. We treated his aspiration pneumonia in the intensive care unit. Prior to his discharge, he received percutaneous dilatational tracheostomy (PDT) before he was transferred to a nursing hospital. Nine months later, he was readmitted owing to tracheoesophageal fistula (TEF). However, he was considered unsuitable for conservative intervention after a multidisciplinary team discussion. Esophageal stent insertion was impossible due to the high level of TEF in the esophagus. Additionally, the size of the TEF could not be covered by an endosponge and endoluminal vacuum therapy, and there was no tracheal stent that could cover his large trachea. The preceding percutaneous enteral gastrostomy (PEG) procedure was required for the primary closure operation of the esophagus; however, family's consent could not be obtained. After 1month, the patient and his family changed their minds and agreed to the procedure and we attempted to perform PEG procedure. However, we could not proceed with PEG owing to stenosis in the inlet of the esophagus. Then, the patient deteriorated clinically and died due to pneumonia with septic shock." }, { "id": "pubmed23n0744_17488", "title": "Are clarifications on feeding and hydration in PVS needed by Catholic authorities?", "score": 0.008620689655172414, "content": "Ever since the possibility of keeping a person on advanced life support the Catholic Church has been concerned with the rights of the individual to a dignified death and the right to refuse treatment. This right has traditionally and in documents of the Church been extended to the family in the absence of specified wishes of the patient. Again, since the controversies on patients in a persistent vegetative state (PVS) have come to public knowledge, especially with the case of Terry Schiavo, and more recently, in Italy, the case of Eluana Englaro, people have been confused about the issue of what constitutes extraordinary treatment. This article focuses on the history of advanced life support and extraordinary treatment, with special reference to PVS and attempts to conclude that given the information already available decision to withdraw such care, even if in principle it may be considered ordinary, can be pursued within the same teachings and should therefore not pose problems to medical personnel once a proper legal and ethical procedure is followed. Failure to acknowledge such history and facts is indeed admitting a failure of bioethics as a futile subject." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 604, 794 ] ], "word_ranges": [ [ 111, 143 ] ], "text": "Therefore the correct one is 1 since it is true that it has a favorable cytogenetics (5q-) and has a specific treatment lenalidomide, also used in other pathologies such as multiple myeloma." }, "2": { "exist": true, "char_ranges": [ [ 312, 603 ] ], "word_ranges": [ [ 56, 111 ] ], "text": "Option 2 is also incorrect since the indication for a bone marrow transplant in MDS is those patients with high or intermediate-2 IPSS, and in this case we do not know the risk, the only thing we know about the risk is the cytogenetics which is of good prognosis that would give us 0 points." }, "3": { "exist": true, "char_ranges": [ [ 137, 311 ] ], "word_ranges": [ [ 24, 56 ] ], "text": "Option 3 is also incorrect since we cannot know the patient's IPSS since we do not know the number of blasts and the number of leukocytes and platelets to calculate the risk." }, "4": { "exist": true, "char_ranges": [ [ 0, 136 ] ], "word_ranges": [ [ 0, 24 ] ], "text": "This is a young patient with no comorbidities and is therefore a candidate for treatment with curative intent, so option 4 is ruled out." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "This deletion (5q-) is an alteration of good prognosis and has a specific treatment (lenalidomide).", "2": "It would be advisable in this patient to perform HLA typing in order to organize an allogeneic transplant.", "3": "This is a patient with a high International Prognostic Index (IPSS).", "4": "Treatment in this case would be transfusion only.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0797_7579", "title": "Long-Term Response in a Patient with del(5q) Myelodysplastic Syndrome Who Discontinued Lenalidomide and Obtained a Good Response and Tolerance to Rechallenge.", "score": 0.01787984742530197, "content": "The introduction of the immunomodulatory drug lenalidomide has revolutionized the treatment of patients with myelodysplastic syndromes (MDS) and deletion of the long arm of chromosome 5. Treatment with lenalidomide results in transfusion independence in the majority of patients, but some questions remain unresolved, among them the duration of treatment. Moreover, a number of unexpected long-term remissions in patients who stopped lenalidomide for various reasons have been observed. We report the case of a 60-year-old Caucasian male with deletion of the long arm of chromosome 5 and International Prognostic Scoring System (IPSS)-defined low-risk MDS who was treated with lenalidomide, achieving complete cytogenetic remission and erythroid response. After tapering off and interrupting the treatment, the patient relapsed and showed a new response by lenalidomide retreatment. Six years after the initial treatment, we registered a durable erythroid long-term response and good tolerance, but there was no evidence of a very profound cytogenetic response compared to using lenalidomide as a first-line treatment. Cytogenetic and fluorescence in situ hybridization together with hemoglobin level, mean corpuscular volume (MCV) and vitamin B12 level helped us to monitor the patient response; during the various phases of lenalidomide treatment, MCV and vitamin B12 normalization correlated with good response. Lenalidomide interruption and rechallenge in some 5q- MDS patients, with low risk according to the IPSS, is safe and feasible but does not result in a profound cytogenetic response." }, { "id": "wiki20220301en010_35436", "title": "Myelodysplastic syndrome", "score": 0.01783749803551784, "content": "5q- syndrome Since at least 1974, the deletion in the long arm of chromosome 5 has been known to be associated with dysplastic abnormalities of hematopoietic stem cells. By 2005, lenalidomide, a chemotherapy drug, was recognized to be effective in MDS patients with the 5q- syndrome, and in December 2005, the US FDA approved the drug for this indication. Patients with isolated 5q-, low IPSS risk, and transfusion dependence respond best to lenalidomide. Typically, prognosis for these patients is favorable, with a 63-month median survival. Lenalidomide has dual action, by lowering the malignant clone number in patients with 5q-, and by inducing better differentiation of healthy erythroid cells, as seen in patients without 5q deletion. Splicing factor mutations Mutations in splicing factors have been found in 40–80% of cases with myelodysplastic syndrome, particularly in those with ringed sideroblasts." }, { "id": "pubmed23n1005_22302", "title": "How we manage adults with myelodysplastic syndrome.", "score": 0.017778128950695322, "content": "The prognosis in Myelodysplastic syndromes (MDS), although recently refined by molecular studies, remains largely based on conventional prognostic scores [International Prognostic Scoring System (IPSS), revised IPSS], classifying patients into \"lower risk\" MDS (LR-MDS) and \"higher risk\" MDS (HR-MDS). In LR-MDS, treatment mainly aims at improving cytopenias, principally anaemia, while in HR-MDS it aims at delaying disease progression and prolonging survival. In LR-MDS without deletion 5q, anaemia is generally treated first by erythropoietic stimulating factors, while second line treatments are currently not approved [lenalidomide, hypomethylating agents (HMA), luspatercept] or rarely indicated (antithymocyte globulin). Lenalidomide has major efficacy in LR-MDS with deletion 5q. Allogeneic stem cell transplantation (allo-SCT) is sometimes considered in LR-MDS, and iron chelation can be considered when multiple red blood cell transfusions are required. Allo-SCT is the only potentially curative treatment for HR-MDS; however, it is rarely applicable. It is generally preceded by intensive chemotherapy (IC) or HMA in patients with excess of marrow blasts (especially if &gt;10%). In other patients, HMA can improve survival. The role of new drugs, including venetoclax or, in case of specific mutations, IDH1 or IDH2 inhibitors, is investigated. IC is mainly indicated as a bridge to allo-SCT, in the absence of unfavourable karyotype." }, { "id": "pubmed23n0821_11929", "title": "[Myelodysplastic syndromes].", "score": 0.01727574750830565, "content": "Myelodysplastic syndrome (MDS) encompasses a heterogeneous group of diseases originating in hematopoietic stem cells and is characterized by inefficient hematopoiesis and dysplastic changes in the bone marrow. In peripheral blood patients show anemia (mostly macrocytic), frequently accompanied by neutropenia and thrombocytopenia. Thus, clinically the patients suffer from fatigue (anemia), increased bleeding (thrombocytopenia) and infectious complications (neutropenia). Approximately one quarter of MDS patients develop acute myeloid leukemia (AML) in the course of the disease, which is characterized by a 20 % or more increase of blasts in the bone marrow. The estimated overall survival as well as the risk for AML transformation can be calculated with the international prognostic scoring system (IPSS) as well as the revised IPSS score (IPSS-R). Novel sequencing methods (e.g. next generation sequencing) allow the detection of recurrent gene mutations in MDS patients. Genes of the splicing machinery as well as genes involved in epigenetic regulation (e.g. ASXL1 and TET2) are most frequently mutated in MDS. Therapy is selected based on the patient risk profile (IPSS). Allogeneic stem cell transplantation is a curative approach for high risk patients (i.e. IPSS int-2 and higher) with a good performance status and a biological age below 70 years. Otherwise, high risk patients are treated with demethylating agents (e.g. decitabine and azacitidine). Low risk patients (IPSS low and int-1) mainly receive supportive therapy including iron chelation. An exceptional position is presented by MDS with an isolated 5q deletion as it can be treated with lenalidomide with good success. Enrolling patients in clinical trials is strongly recommended to improve the prospects of this disease. " }, { "id": "pubmed23n0856_1490", "title": "[Lenalidomide treatment in myelodysplastic syndrome with 5q deletion--Czech MDS group experience].", "score": 0.016523867809057527, "content": "Myelodysplastic syndrome (MDS) is a common hematological disease in patients over sixty. Despite intensive research, the therapy of this heterogeneous blood disease is complicated. In recent years, two new therapeutic approaches have been proposed: immunomodulation and demethylation therapy. Immunomodulation therapy with lenalidomide represents a meaningful advance in the treatment of anemic patients, specifically those with 5q- aberrations. As much as 60-70% of patients respond and achieve transfusion independence. We present the initial lenalidomide experience of the Czech MDS group. We analyze Czech MDS register data of 34 (31 female; 3 male; median age 69 years) chronically transfused low risk MDS patients with 5q- aberration treated by lenalidomide. Twenty-seven (79.4%) patients were diagnosed with 5q- syndrome, 5 patients with refractory anemia with multilineage dysplasia, 1 patient with refractory anemia with excess of blasts 1, and 1 patient with myelodysplastic/myeloproliferative unclassified. Response, as represented by achieving complete transfusion independence, was achieved in 91% of patients. A true 5q- syndrome diagnosis in most our patients may be responsible for such a high response rate. Complete cytogenetic response was reached in 15% of patients and partial cytogenetic response in 67%, within a median time of 12 months. TP53 mutation was detected in 15% (3 from 18 tested) and 2 of these patients progressed to higher grade MDS. The majority of patients tolerated lenalidomide very well. Based on this albeit small study, we present our findings of high lenalidomide efficacy as well as the basic principles and problems of lenalidomide therapy." }, { "id": "pubmed23n0777_21113", "title": "Myelodysplastic syndromes: diagnosis, prognosis, and treatment.", "score": 0.015518967627099789, "content": "Myelodysplastic syndromes (MDS) are malignant stem-cell diseases that are usually diagnosed in elderly patients who present with anemia or, less commonly, bi- or pancytopenia. Their incidence in persons over age 80 is above 50 new cases per 100,000 persons per year. Their clinical course is highly variable. About one-quarter of all patients with MDS develop acute leukemia. The median survival time from the moment of diagnosis is about 30 months. We selectively searched the PubMed database for pertinent articles and guidelines from the years 2000-2013. We used the search term \"myelodysplastic syndromes.\" MDS are diagnosed by cytology, with consideration of the degree of dysplasia and the percentage of blast cells in the blood and bone marrow, and on a cytogenetic basis, as recommended in the WHO classification. In particular, chromosomal analysis is necessary for prognostication. The Revised International Prognosis Scoring System (IPSS-R) enables more accurate prediction of the course of disease by dividing patients into a number of low- and high-risk groups. The median survival time ranges from a few months to many years. The approved treatments, aside from transfusion therapy, include iron depletion therapy for low-risk patients, lenalidomide for low-risk patients with a deletion on the long arm of chromosome 5, and 5-azacytidine for high-risk patients. High-risk patients up to age 70 who have no major accompanying illnesses should be offered allogenic stem-cell transplantation with curative intent. The cure rates range from 30% to 50%. Mucositis, hemorrhages, infections, and graft-versus-host diseases are the most common complications of this form of treatment. Myelodysplastic syndromes are treated on an individualized, risk-adapted basis after precise diagnostic evaluation and after assessment of the prognosis. More studies are needed so that stage-adapted treatment can be improved still further." }, { "id": "pubmed23n0592_9749", "title": "Practical recommendations on the use of lenalidomide in the management of myelodysplastic syndromes.", "score": 0.015407319952774497, "content": "Lenalidomide, an oral immunomodulatory agent, has received approval in the USA from the Food and Drug Administration (FDA) for the management of myelodysplastic syndromes (MDS) classified by the International Prognostic Scoring System (IPSS) as low risk or intermediate-1 risk and with a deletion 5q (del(5q)) cytogenetic abnormality. Although some patients with del(5q) have a relatively good prognosis, all del(5q) patients will become transfusion-dependent at some point during the course of their disease. The results of two clinical trials in more than 160 patients with MDS have demonstrated clear therapeutic benefits of lenalidomide, with &gt;60% of patients achieving independence from transfusion during therapy, irrespective of age, prior therapy, sex, or disease-risk assessment. The recommendations presented in this review will aid the safe administration of lenalidomide for the treatment of patients with low-risk or intermediate-1-risk MDS and a del(5q) cytogenetic abnormality, and they will help physicians avoid unnecessary dose reduction or interruption, thus assuring the best efficacy for patients." }, { "id": "pubmed23n0835_16408", "title": "Polish experience of lenalidomide in the treatment of lower risk myelodysplastic syndrome with isolated del(5q).", "score": 0.015318168730204435, "content": "Lenalidomide has been approved for the treatment of lower-risk myelodysplastic syndrome (MDS) with 5q deletion (del(5q)). We present for the first time a retrospective analysis of low-risk MDS with isolated del5q treated with lenalidomide, outside the clinical trials. 36 red blood cell (RBC) transfusion-dependent patients have been included in the study. Patients received lenalidomide 10 mg/day on days 1-21 of 28-day cycles. 91.7 % of patients responded to lenalidomide treatment: 72.2 % achieved erythroid response, 19.4 % achieved minor erythroid response and 8.4 % of patients did not respond to treatment. Response depended on number of previous treatment lines (p = 0.0101), International Prognostic System Score (IPSS; p = 0.0067) and RBC transfusion frequency (p = 0.0139). Median duration of response was 16 months (range 6-60 months). Treatment was well tolerated. We observed hematological toxicity (grade 3 and 4): neutropenia in 16 (44.4 %) patients and thrombocytopenia in 9 (25 %) patients. Two patients (5.5 %) progressed to high-risk MDS and two subsequent progressed to acute myeloid leukemia. A Kaplan-Meier estimate for overall survival at 5 years in the study group was 79.0 ± 8.8 %. Lenalidomide in this group of patients was beneficial for the treatment of RBC transfusion-dependency with well-known safety profile." }, { "id": "pubmed23n0544_10854", "title": "Clinical management of myelodysplastic syndromes with interstitial deletion of chromosome 5q.", "score": 0.015213675213675216, "content": "Deletions of the long (q) arm of chromosome 5 [del(5q)]occur in patients with myelodysplastic syndromes (MDS) including, but not limited to, those who meet the WHO definition of the 5q- syndrome. Del(5q) MDS patients frequently have symptomatic anemia, and its treatment has traditionally consisted of RBC transfusions and, for some, iron chelation therapy. Erythropoietin, darbepoetin, hypomethylating agents, and lenalidomide can enhance erythropoiesis in MDS patients with anemia, increasing hemoglobin levels and abrogating RBC transfusion requirements. Lenalidomide is particularly active in treating the anemia of del(5q) MDS, which is especially relevant given the low response rate to erythropoietin in this group of patients. In a recent study of 43 MDS patients, 10 of 12 patients (83%) with del(5q) MDS achieved sustained RBC transfusion independence (or a &gt; 2 g/dL increase in hemoglobin), compared with 57% of those with a normal karyotype and 12% of those with other karyotypic abnormalities. Complete cytogenetic remissions were achieved in 75% (nine of 12) of the del(5q) MDS patients, suggesting that lenalidomide targets a fundamental pathogenetic feature of MDS that is more pronounced in the presence of chromosomal 5q deletions. This review highlights some issues about the classification and treatment of del(5q) MDS." }, { "id": "pubmed23n0739_24540", "title": "Lenalidomide for del(5q) and non-del(5q) myelodysplastic syndromes.", "score": 0.015209345362017117, "content": "Lenalidomide leads to high rates of erythroid transfusion independence in low and intermediate-1 risk International Prognostic Scoring System (IPSS) del(5q) myelodysplastic syndromes (MDS), with a considerable number of patients achieving complete and partial cytogenetic remissions. The median duration of transfusion independence is 2 years, mainly at the expense of neutropenia and thrombocytopenia in the first courses of therapy. At present, the optimal initial treatment dose has been determined to be 10 mg administered orally daily for 21 out of 28 days. In general, the effects in non-del(5q) disease can be divided by 50%: non-del(5q) patients show 50% of erythroid response, 50% of duration of response, and 50% incidence of grade 3 and 4 neutropenia and thrombocytopenia compared to del(5q) patients. Recent data suggest that the risk of acute myeloid leukemia (AML) progression of del(5q) patients is dependent on their individual risk factors before treatment initiation, including World Health Organization (WHO) prognostic scoring system parameters and TP53 mutations. These data also indicate that lenalidomide per se is not leukemogenic. Length of treatment can be tailored according to response, and patients who relapse during treatment might restart after a period of drug holiday. This article will also discuss combination strategies with lenalidomide in higher risk disease." }, { "id": "wiki20220301en039_31850", "title": "Chromosome 5q deletion syndrome", "score": 0.014681970349115257, "content": "Diagnosis Treatment Lenalidomide has activity in 5q- syndrome and is FDA approved for red blood cell (RBC) transfusion-dependent anemia due to low or intermediate-1 (int-1) risk myelodysplastic syndrome (MDS) associated with chromosome 5q deletion with or without additional cytogenetic abnormalities. There are several possible mechanisms that link the haploinsufficiency molecular lesions with lenalidomide sensitivity. Prognosis Most affected people have a stable clinical course but are often transfusion dependent. References External links Myeloid neoplasia Rare syndromes Autosomal monosomies and deletions Syndromes affecting blood" }, { "id": "pubmed23n0793_21063", "title": "Outcomes in RBC transfusion-dependent patients with Low-/Intermediate-1-risk myelodysplastic syndromes with isolated deletion 5q treated with lenalidomide: a subset analysis from the MDS-004 study.", "score": 0.014566148063067767, "content": "A subset analysis of the randomised, phase 3, MDS-004 study to evaluate outcomes in patients with International Prognostic Scoring System (IPSS)-defined Low-/Intermediate (Int)-1-risk myelodysplastic syndromes (MDS) with isolated del(5q). Patients received lenalidomide 10 mg/d (days 1-21; n = 47) or 5 mg/d (days 1-28; n = 43) on 28-d cycles or placebo (n = 45). From the placebo and lenalidomide 5 mg groups, 84% and 58% of patients, respectively, crossed over to lenalidomide 5 or 10 mg at 16 wk, respectively. Rates of red blood cell-transfusion independence (RBC-TI) ≥182 d were higher in the lenalidomide 10 mg (57.4%; P &lt; 0.0001) and 5 mg (37.2%; P = 0.0001) groups vs. placebo (2.2%). Cytogenetic response rates (major + minor responses) were 56.8% (P &lt; 0.0001), 23.1% (P = 0.0299) and 0%, respectively. Two-year cumulative risk of acute myeloid leukaemia progression was 12.6%, 17.4% and 16.7% in the lenalidomide 10 mg, 5 mg, and placebo groups, respectively. In a 6-month landmark analysis, overall survival was longer in lenalidomide-treated patients with RBC-TI ≥182 d vs. non-responders (P = 0.0072). The most common grade 3-4 adverse event was myelosuppression. These data support the clinical benefits and acceptable safety profile of lenalidomide in transfusion-dependent patients with IPSS-defined Low-/Int-1-risk MDS with isolated del(5q)." }, { "id": "pubmed23n0902_2707", "title": "Peripheral blood cytogenetics allows treatment monitoring and early identification of treatment failure to lenalidomide in MDS patients: results of the LE-MON-5 trial.", "score": 0.014476818764889134, "content": "Transfusion-dependent patients with low- or intermediate-1-risk myelodysplastic syndrome, &lt;5% bone marrow (BM) blasts and isolated 5q-deletion received lenalidomide within the German MDS study group phase-II clinical trial LE-MON-5 (EudraCT:2008-001866-10) of the University of Duesseldorf, Germany. Cytogenetic monitoring was performed by chromosome banding analyses (CBA) of BM cells and fluorescence in situ hybridization (FISH) analyses of peripheral blood (PB) mononuclear CD34+ cells using extended probe panels. Out of 144 patients screened for study enrollment, 24% failed to meet inclusion criteria due to cytogenetic findings. Eighty-seven patients were followed with a median observation time of 30 months. Cytogenetic response detected by FISH and CBA in 74 and 66% of patients, respectively, was predictive for hematologic response as well as of high prognostic relevance. After 2 years, AML rate was 8% for all patients. Karyotype evolution was detected in 21 (FISH)-34% (CBA) of patients associated with significantly shorter AML-free survival. Disease progression was first detectable on the cytogenetic level on average 5-6 months before recurrence of transfusion dependence. Our data show for the first time in a prospective setting that a cytogenetic monitoring from the PB helps to early identify treatment failure and progressive disease in lenalidomide-treated patients to improve clinical management. EudraCT:2008-001866-10." }, { "id": "pubmed23n0929_8903", "title": "Myelodysplastic syndromes: 2018 update on diagnosis, risk-stratification and management.", "score": 0.014317032794953246, "content": "The myelodysplastic syndromes (MDS) are a very heterogeneous group of myeloid disorders characterized by peripheral blood cytopenias and increased risk of transformation to acute myelogenous leukemia (AML). MDS occurs more frequently in older males and in individuals with prior exposure to cytotoxic therapy. Diagnosis of MDS is based on morphological evidence of dysplasia upon visual examination of a bone marrow aspirate and biopsy. Information obtained from additional studies such as karyotype, flow cytometry or molecular genetics is usually complementary and may help refine diagnosis. Prognosis of patients with MDS can be calculated using a number of scoring systems. In general, all these scoring systems include analysis of peripheral cytopenias, percentage of blasts in the bone marrow and cytogenetic characteristics. The most commonly used system is probably the International Prognostic Scoring System (IPSS). IPSS is now replaced by the revised IPSS-R score. Although not systematically incorporated into new validated prognostic systems, somatic mutations can help define prognosis and should be considered as new prognostic factors. Therapy is selected based on risk, transfusion needs, percent of bone marrow blasts and cytogenetic and mutational profiles. Goals of therapy are different in lower risk patients than in higher risk. In lower risk, the goal is to decrease transfusion needs and transformation to higher risk disease or AML, as well as to improve survival. In higher risk, the goal is to prolong survival. Current available therapies include growth factor support, lenalidomide, hypomethylating agents, intensive chemotherapy and allogeneic stem cell transplantation. The use of lenalidomide has significant clinical activity in patients with lower risk disease, anemia and a chromosome 5 alteration. 5-azacitidine and decitabine have activity in both lower and higher-risk MDS. 5-azacitidine has been shown to improve survival in higher risk MDS. A number of new molecular lesions have been described in MDS that may serve as new therapeutic targets or aid in the selection of currently available agents. Additional supportive care measures may include the use of prophylactic antibiotics and iron chelation. At the present time there are no approved interventions for patients with progressive or refractory disease particularly after hypomethylating based therapy. Options include participation in a clinical trial or cytarabine based therapy and stem cell transplantation." }, { "id": "wiki20220301en051_24502", "title": "Lenalidomide", "score": 0.014173023578363383, "content": "Myelodysplastic syndromes Lenalidomide was approved by the FDA on 27 December 2005 for patients with low- or intermediate-1-risk myelodysplastic syndromes who have chromosome 5q deletion syndrome (5q- syndrome) with or without additional cytogenetic abnormalities. It was approved on 17 June 2013 by the European Medicines Agency for use in patients with low- or intermediate-1-risk myelodysplastic syndromes who have 5q- deletion syndrome but no other cytogenetic abnormalities and are dependent on red blood cell transfusions, for whom other treatment options have been found to be insufficient or inadequate. Mantle cell lymphoma Lenalidomide is approved by FDA as a specialty drug requiring a specialty pharmacy distribution for mantle cell lymphoma in patients whose disease has relapsed or progressed after at least two prior therapies, one of which must have included the medicine bortezomib." }, { "id": "wiki20220301en010_35453", "title": "Myelodysplastic syndrome", "score": 0.014150943396226415, "content": "Agents have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of MDS: 5-azacytidine: 21-month median survival Decitabine: Complete response rate reported as high as 43%. A phase I study has shown efficacy in AML when decitabine is combined with valproic acid. Lenalidomide: Effective in reducing red blood cell transfusion requirement in patients with the chromosome 5q deletion subtype of MDS Decitabine/cedazuridine (Inqovi) is a fixed-dosed combination medication for the treatment of adults with myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML)." }, { "id": "pubmed23n0846_21903", "title": "Short- and long-term benefits of lenalidomide treatment in patients with lower-risk del(5q) myelodysplastic syndromes.", "score": 0.014085200689485348, "content": "The treatment of patients with myelodysplastic syndromes (MDS) begins with assessment of karyotype and risk. Lenalidomide is approved for the treatment of patients who have transfusion-dependent anemia due to lower-risk MDS with chromosome 5q deletion (del(5q)) with or without additional cytogenetic abnormalities, and isolated del(5q) only in the European Union. Mounting evidence suggests that lenalidomide is effective not only in reducing red blood cell (RBC) transfusion burden, but also in modifying the disease natural history by suppressing the malignant clone. Data discussed here from the pivotal phase 2 (MDS-003) and phase 3 (MDS-004) studies of lenalidomide demonstrate that lenalidomide treatment was associated with both short- and long-term benefits. These clinical benefits included high rates of RBC-transfusion independence (TI) with prolonged durations of response, high rates of cytogenetic response (CyR) associated with achievement of durable RBC-TI, no significant difference in rates of progression to acute myeloid leukemia (AML), and improvements in health-related quality of life (HRQOL). Achievement of RBC-TI and CyR with lenalidomide treatment was associated with extended survival and time to AML progression. Achievement of RBC-TI and hemoglobin response was additionally associated with HRQOL benefits. Recent data describing the impact of TP53 mutations and p53 expression on the prognosis of patients with del(5q) and the impact on response to lenalidomide are also discussed. The authors provide practical recommendations for the use of lenalidomide in patients with lower-risk del(5q) MDS. " }, { "id": "wiki20220301en010_35462", "title": "Myelodysplastic syndrome", "score": 0.014044674527849679, "content": "Indicators of a poor prognosis: Advanced age; severe neutropenia or thrombocytopenia; high blast count in the bone marrow (20–29%) or blasts in the blood; Auer rods; absence of ringed sideroblasts; abnormal localization or immature granulocyte precursors in bone marrow section; completely or mostly abnormal karyotypes, or complex marrow chromosome abnormalities and in vitro bone marrow culture with a leukemic growth pattern Karyotype prognostic factors: Good: normal, -Y, del(5q), del(20q) Intermediate or variable: +8, other single or double anomalies Poor: complex (>3 chromosomal aberrations); chromosome 7 anomalies The IPSS is the most commonly used tool in MDS to predict long-term outcome. Cytogenetic abnormalities can be detected by conventional cytogenetics, a FISH panel for MDS, or virtual karyotype." }, { "id": "wiki20220301en257_17739", "title": "Virtual karyotype", "score": 0.0139136484194965, "content": "Correlation of prognosis with bone marrow cytogenetic finding in acute lymphoblastic leukemia Unclassified ALL is considered to have an intermediate prognosis. Myelodysplastic syndrome Myelodysplastic syndrome (MDS) has remarkable clinical, morphological, and genetic heterogeneity. Cytogenetics play a decisive role in the World Health Organization's classification-based International Prognostic Scoring System (IPSS) for MDS. Good Prognosis: normal karyotype, isolated del(5q), isolated del(20q), -Y Poor Prognosis: complex abnormalities (i.e., >=3 abnormalities), −7 or del(7q) Intermediate Prognosis: all other abnormalities, including trisomy 8 and del(11q) In a comparison of metaphase cytogenetics, FISH panel, and SNP array karyotyping for MDS, it was found that each technique provided a similar diagnostic yield. No single method detected all defects, and detection rates improved by ~5% when all three methods were used." }, { "id": "pubmed23n0556_12908", "title": "Treatment of the 5q- syndrome.", "score": 0.013877207737594618, "content": "Defined by isolated del 5q and no excess of marrow blasts, the \"5q- syndrome\" is a specific type of myelodysplastic syndrome (MDS) with particular characteristics, including severe anemia, frequent thrombocytosis, typical dysmegakaryopoiesis and favorable outcome. Its pathogenesis remains uncertain, in particular the role of inactivation of gene(s) situated in 5q. It should be differentiated from other MDS with del 5q having an excess of marrow blasts and/or additional cytogenetic abnormalities, which carry a poor prognosis. Until the advent of lenalidomide, repeated RBC transfusions were generally the only treatment of the 5q- syndrome, which was resistant to other therapeutic approaches. Lenalidomide can lead to RBC transfusion independence in at least two thirds of cases of the 5q- syndrome, two thirds of those responses persisting after 2 years of treatment. Importantly, not only reversal of anemia but also frequent complete pathological and cytogenetic responses are obtained. Grade 3 or 4 neutropenia and thrombocytopenia, especially during the first 6 to 8 weeks of treatment, are the major side effect of lenalidomide, justifying close monitoring of blood counts and regular patient visits. Preliminary results suggest that lenalidomide is also very active in MDS with del 5q other than the 5q-syndrome. Although its mechanism of action remains uncertain, lenalidomide appears to target specifically the del 5q clone. By doing this, lenalidomide may have an effect on disease course and survival, which is currently being assessed in clinical trials." }, { "id": "pubmed23n0603_19959", "title": "Myelodysplastic syndromes associated with interstitial deletion of chromosome 5q: clinicopathologic correlations and new insights from the pre-lenalidomide era.", "score": 0.013874683150264598, "content": "To better estimate prognosis for patients with myelodysplastic syndromes (MDS) associated with clonal interstitial deletions of the long arm of chromosome 5 (del(5q)), we reviewed the medical records of 130 adults with del(5q) MDS seen at our institution over a 15-year period. Overall median survival of this cohort was 9.5 months, shorter than reported in earlier series. The least favorable outcomes are associated with complex cytogenetics, lack of any normal metaphases, normocytic rather than macrocytic erythrocyte indices, and low baseline lymphocyte counts. Lymphopenia but not neutropenia at the time of diagnosis appears to be a new adverse prognostic indicator. Cytogenetic breakpoints defined by G-banded karyotyping correlate poorly with particular disease features. Surprisingly, survival of patients with treatment-related MDS was equivalent to that of de novo MDS with del(5q) in this series. Morphologic features associated with del(5q) are diverse. Most patients with del(5q) MDS do not meet criteria for WHO-defined 5q-syndrome, and the presence of del(5q) does not appear to modify the clinical phenotype otherwise risk-stratified by the International Prognostic Scoring System (IPSS). Additional important prognostic factors not taken into account by the IPSS include the baseline erythrocyte indices, lymphocyte count, and clonal burden." }, { "id": "pubmed23n1000_24811", "title": "[Analysis of Cytogenetic Characteristics and Clinical Prognosis in 236 Patients with Myelodysplastic Syndrome].", "score": 0.013654362568840745, "content": "To investigate the relationship of cytogenetic features, clinical characteristics and prognosis in patients with myelodysplastic syndrome. The clinical characteristics and prognosis of 236 patients with MDS admitted to the Affiliated Hospital of Xuzhou Medical University from January 2013 to September 2017 were analyzed retrospectively, the follow-up observation and correlation analysis were performed. There were 33 cases of refractory cytopenia with unilateral dysplasia (RCUD), 8 cases of refractory anemia with ring-shaped iron granulocytes (RARS), 70 cases of refractory cytopenia with multiple dysplasia (RCMD), 23 cases of refractory anemia (RA), 46 cases of refractory anemia with excessive blasts (RAEB-1), 48 cases of (RAEB-2), MDS-U 2 cases, simple del(5q) 6 cases. The detection analysis showed that the chromosome abnormality rate and complex chromosome abnormality rate in RAEB group (RAEB-1 + RAEB-2) and in non-RAEB group (RARS+RCMD+RCUD+RA) were 48.94% vs 43.94%, and 18.09% vs 12.69%, respectively, which were no statistically different. The grouping according to IPSS-R and IPSS showed that the chromosome abnormality rate gradually increased along with enhancement of risk stratifi-cation (P&lt;0.05). The cytogenetic characteristics analysis showed that a total of 108 cases had chromosomal abnormalities, the detection rate was 45.76%, Out of 108 cases, 36 cases had complicated karyotypes, accounted for 15.25% of all patients. The types of chromosomal abnormalities mainly include numbers, structural abnormalities and mixed abnormalities. The chromosome abnormality with the highest detection rate was +8, accounted for 30.56% (33/100) of patients with chromosome abnormalities; followed by -7/7q-, del(5q), del(20q), etc. -7/7q-chromosome abnormalities accounted for 29.63% of all karyotypic abnormalities (including -7/7q-chromosome abnormalities alone and other chromosome abnormalities). The median age of the patients with MDS was 61 (13-88) years old, and the male-female ratio was 1.36∶1. Analysis of blood cell characteristics showed that the three lines were reduced or increased to varying degrees. The median WBC count was 2.8 (0.3-267.1)×10<sup9</sup/L, the median Hb level was 69 (20-156) g/L, and the median Plt count was 55 (2-1733)×10<sup9</sup/L. The 1 year OS rate in 32 cases of chromosome 7 abnormality and 128 cases of normal chromosome was 25% and 44.53%, respectively, the difference was statistically significant (χ<sup2</sup=4.05, P&lt;0.05) . Chromosome karyotype is an independent factor affecting the prognosis of patients with MDS. It is important for the diagnosis, treatment and prognosis evalnation of patients with MDS. The overall prognosis of patients with abnormal chromosome 7 is poor. ." }, { "id": "pubmed23n0948_1004", "title": "Myelodysplastic syndromes current treatment algorithm 2018.", "score": 0.01340542472854015, "content": "Myelodysplastic syndromes (MDS) include a group of clonal myeloid neoplasms characterized by cytopenias due to ineffective hematopoiesis, abnormal blood and marrow cell morphology, and a risk of clonal evolution and progression to acute myeloid leukemia (AML). Because outcomes for patients with MDS are heterogeneous, individual risk stratification using tools such as the revised International Prognostic Scoring System (IPSS-R) is important in managing patients-including selecting candidates for allogeneic hematopoietic stem cell transplantation (ASCT), the only potentially curative therapy for MDS. The IPSS-R can be supplemented by molecular genetic testing, since certain gene mutations such as TP53 influence risk independent of established clinicopathological variables. For lower risk patients with symptomatic anemia, treatment with erythropoiesis-stimulating agents (ESAs) or lenalidomide (especially for those with deletion of chromosome 5q) can ameliorate symptoms. Some lower risk patients may be candidates for immunosuppressive therapy, thrombopoiesis-stimulating agents, or a DNA hypomethylating agent (HMA; azacitidine or decitabine). Among higher risk patients, transplant candidates should undergo ASCT as soon as possible, with HMAs useful as a bridge to transplant. Non-transplant candidates should initiate HMA therapy and continue if tolerated until disease progression. Supportive care with transfusions and antimicrobial drugs as needed remains important in all groups." }, { "id": "pubmed23n1059_21225", "title": "Spectrum of Myelodysplastic Syndrome in Patients Evaluated for Cytopenia(s). A Report from a Reference Centre in Saudi Arabia.", "score": 0.013236481033091203, "content": "Myelodysplastic syndrome (MDS) is a clonal disorder of hematopoietic stem cells, characterized by ineffective hematopoiesis, peripheral cytopenias along with hypercellularity of the bone marrow, and marked dysplastic features. Establishing MDS diagnosis is difficult due to nonspecific clinical presentation and imprecise morphological criteria. In anticipation to improve the diagnostic approach in this field, we aimed to characterize the clinical and morphological features of patients presented with cytopenias with a special focus on MDS. We comprehensively reviewed all medical record of patients who were referred to the hematology laboratory at KFSH-RC, Riyadh, Saudi Arabia, between January 2009 and March 2016 for evaluation of bone marrow aspirates and trephine biopsies due to severe and persistent cytopenia(s) to rule out MDS. A total of 183 patients, 155 adult and 28 pediatric, were identified. In the adult group, MDS was diagnosed in 82 (52.9%) patients, with a male-to-female (M:F) ratio of 1.6:1 and mean age at diagnosis of 50 years. According to the World Health Organization (WHO) 2017 criteria, MDS subtypes were as follows: MDS with single lineage dysplasia (SLD, 5%), MDS with ring sideroblasts and SLD (MDS-RS-SLD 7%), MDS with multilineage dysplasia (MDS-MLD 21%), MDS with deletion of chromosome 5q (MDS del(5q), 2%), MDS unclassifiable (MDS-U7%), hypoplastic MDS (h-MDS 4%), MDS with excess blasts-1 (MDS-EB1, 20%), MDS with excess blasts-2 (MDS-EB2, 28%), and therapy-related MDS (6%). Laboratory and morphological features were described. In both groups, cytogenetic abnormalities were classified according to the Revised International Prognostic Scoring System cytogenetic risk groups. In adults, the dominating cytogenetic abnormalities were monosomy 5 and monosomy 7 seen in 20.7% and 24.4% of patients, respectively. Peripheral cytopenia not due to MDS was diagnosed in 54 (34.8%) patients, with a mean age of 43 years and M:F ratio of 1:1. The cause of these cytopenias were as follows: bone marrow failure (BMF, 22%), peripheral destruction (20%), drug induced (20%), anemia of chronic disease (16%), B12 deficiency (7%), infection (7%), paroxysmal nocturnal hemoglobinuria (4%), idiopathic cytopenia of undetermined significance (2%), and idiopathic dysplasia of undetermined significance (2%). A definite diagnosis of MDS was not possible in 19 patients due to insufficient clinical data. In the pediatric group, MDS was diagnosed in 14/28 (50%) patients, with M:F ratio of 1.8:1 and mean age at diagnosis of 4 years. MDS subtypes (WHO 2017) in 14 patients were as follows: refractory cytopenia of childhood (RCC, 42.8%), MDS-EB1 (42.8%), and MDS-EB2 (14.2%). Laboratory and morphological features were described. The prevalent cytogenetic abnormality was monosomy 7 in six/14 (42.8%) patients. Cytopenias due to other causes were diagnosed in eight/28 patients (28.5%), with a mean age of 6.5 years and M:F ratio of 1.6:1. The causes of non-MDS related cytopenia were: congenital BMF (4 patients), peripheral destruction (2 patients), immune deficiency (1 patient), and viral infection (1 patient). A definite diagnosis of MDS could not be made in six/28 (21.4%) patients. MDS is the cause of cytopenia in a significant number of patients referred for evaluation of cytopenias, appears at younger age, and tends to be more aggressive than that reported in international studies. Anemia, dysplastic neutrophils in the peripheral blood, and dysplastic megakaryocytes in the bone marrow trephine biopsy are the most reliable features in distinguishing MDS from other alternative diagnoses." }, { "id": "article-25435_29", "title": "Myelodysplastic Syndrome -- Prognosis", "score": 0.013217169570760731, "content": "The prognosis of patients with MDS varies widely depending upon several characteristics, including cytogenetics and severity of cytopenias. Patients with 5q- generally have a much better prognosis compared to MDS with monosomy 7, for example. The International Prognostic Scoring System (IPSS) and revised IPSS (R-IPSS) are risk stratification systems clinicians use to guide treatment and the potential clinical course. These systems can be used in addition to a clinical patient assessment, including age and co-morbidities, to determine the best therapeutic options. The IPSS includes the percentage of blasts in the bone marrow, karyotype, and the number of cell lineages with cytopenias. Karyotypes with a good prognosis include normal karyotype -Y, deletion 5q, and deletion 20q. Poor risk karyotypes include complex cytogenetics (greater than 3 abnormalities) or chromosome 7 abnormalities. All other karyotypes are categorized as intermediate risk. Based on these findings, a score is calculated to determine a risk score of either low, intermediate-1, intermediate-2, or high risk. [8]" }, { "id": "pubmed23n0940_21643", "title": "Lenalidomide treatment of myelodysplastic syndromes with chromosome 5q deletion: Results from the National Registry of the Italian Drug Agency.", "score": 0.01309931506849315, "content": "The most typical cytogenetic aberration in myelodysplastic syndromes is del(5q), which, when isolated, is associated with refractory anaemia and good prognosis. Based on high rates of erythroid response and transfusion independence, Lenalidomide (LEN) became the standard treatment. This multi-centre study was designed to supplement Italian Registry data on LEN by addressing prescription, administration appropriateness, haematological and cytogenetic responses and disease evolution. MORE study was an observational, non-interventional, multi-centre, retrospective and prospective study. Cases were recruited from 45 Haematological Centres throughout Italy. Data were collected from the Italian National Registry for Lenalidomide administration and supplemented by a MORE data form. Data from 190/213 patients were analysed. In all, 149 had been diagnosed by conventional cytogenetics (GROUP A) and 41 only by FISH (GROUP B). Overall erythroid response was obtained in 92.8% of cases. Overall cytogenetic remission was achieved in 22.6% of cases. Disease progression occurred in 15.6% of cases. Clonal cytogenetic evolution characterised progression to AML but not to higher risk MDS. Erythroid response to Lenalidomide was similar in MDS with isolated del(5q) and with del(5q) plus one anomaly. Progression to AML or higher risk MDS showed different cytogenetic features." }, { "id": "pubmed23n0763_2181", "title": "Lenalidomide: a review of its use in patients with transfusion-dependent anaemia due to low- or intermediate-1-risk myelodysplastic syndrome associated with 5q chromosome deletion.", "score": 0.013066349906668929, "content": "Lenalidomide (Revlimid(®)), a thalidomide analogue, is an orally administered second generation immunomodulator with anti-angiogenic, antineoplastic, anti-inflammatory and pro-erythropoietic properties. It is approved for the treatment of patients with transfusion-dependent anaemia due to International Prognostic Scoring System low- or intermediate-1-risk myelodysplastic syndrome (MDS) associated with either chromosome 5q deletion [del(5q)] with or without additional cytogenetic abnormalities (US, Japan and Switzerland etc.), or with an isolated del(5q) cytogenetic abnormality when other therapeutic options are insufficient or inadequate (EU) [featured indication]. In a randomized, double-blind, multicentre, registrational trial (MDS-004; n = 205) in this patient population, a significantly higher proportion of lenalidomide recipients than placebo recipients achieved red blood cell transfusion independence for ≥26 consecutive weeks (primary endpoint for efficacy) and cytogenetic responses. The erythroid response to lenalidomide was accompanied by an increase in the haemoglobin levels. These efficacy outcomes are generally consistent with those seen in an earlier noncomparative registrational trial (MDS-003; n = 148). In MDS-004, lenalidomide also significantly improved health-related quality of life compared with placebo at 12 weeks. Retrospective analyses that compared outcomes between lenalidomide-treated patients with low- or intermediate-1-risk del(5q) MDS and multicentre registry cohorts showed that lenalidomide treatment did not appear to increase the risk of progression to acute myeloid leukaemia. Lenalidomide had a manageable safety profile in the registrational trials, with ≤20 % of patients discontinuing treatment because of adverse events. The most common adverse events (incidence ≥20 %) occurring in lenalidomide recipients were thrombocytopenia and neutropenia, which were generally managed by dosage reductions and/or interruptions, and/or pharmacotherapy. Thus, lenalidomide is a useful option for the treatment of patients with transfusion-dependent anaemia due to low- or intermediate-1-risk del(5q) MDS, with or without additional cytogenetic abnormalities." }, { "id": "pubmed23n0641_13697", "title": "Patients with del(5q) MDS who fail to achieve sustained erythroid or cytogenetic remission after treatment with lenalidomide have an increased risk for clonal evolution and AML progression.", "score": 0.012981162981162982, "content": "Lenalidomide consistently induces transfusion independence and complete cytogenetic response in patients with myelodysplastic syndromes with 5q deletion. Only limited information on long-term outcome is currently available. We performed a long-term follow-up analysis of 42 patients with low or intermediate risk myelodysplastic syndromes and 5q deletion treated with lenalidomide. At a median follow-up of 40 months, 58% of the patients achieved an erythroid response and 48% a cytogenetic response. Thirty-six percent of patients progressed into acute myeloid leukaemia. Most of them (87%) acquired chromosome aberrations in addition to the 5q deletion, i.e. underwent clonal evolution during leukaemogenesis. There were no clinical, cytological or cytogenetic markers at study entry that allowed prediction of increased risk of leukaemic transformation. However, erythroid and cytogenetic responders had a significantly decreased risk of progression to acute myeloid leukaemia (p = 0.001 and p = 0.009, respectively) compared to non-responders. Three and 5 years after study entry, the cumulative incidence of acute myeloid leukaemia for patients with a cytogenetic response was 10% and 21%, respectively, and for patients without cytogenetic response, it was 46% and 60%. Patients with del(5q) myelodysplastic syndromes without erythroid or cytogenetic remission after treatment with lenalidomide have a high risk for clonal evolution and acute myeloid leukaemia progression. In refractory, or relapsing, patients, genetic instability and clonal evolution seem to be the driving forces of leukaemic transformation. Regular follow-up investigations of del(5q) myelodysplastic syndrome patients treated with lenalidomide may help to identify patients requiring alternative treatment strategies." }, { "id": "wiki20220301en599_2933", "title": "Transfusion-dependent anemia", "score": 0.012897332846181952, "content": "Prognosis Prognosis of MDS patients An International Prognostic Scoring System (IPSS) is specially designed to access the prognosis of myelodysplastic syndrome patients. Scores help to classify patients into low, intermediate-1, intermediate-2 and high risks based on their severity levels. Patients in the lower-risk group generally have a longer survival range of 3-8.8 years, comparing to only 0.8-1.6 years for high-risk patients. In general, the survival rate of transfusion-dependent anemia patients is increasing. This is due to the improvements in transfusion procedures, mature use of iron chelation therapies to reduce iron overloading, and more experiences in dealing with associated morbidities. References Transfusion reactions Anemias" }, { "id": "pubmed23n0778_21969", "title": "Transfusion dependence development and disease evolution in patients with MDS and del(5q) and without transfusion needs at diagnosis.", "score": 0.01264775413711584, "content": "Patients with isolated del(5q) and MDS are considered to have good prognosis as compared to other MDS subtypes. Most patients suffered of anemia and 50% of them required transfusions at diagnosis. It is known that for patients with MDS and del(5q) in transfusion dependence(TD), Lenalidomide is the first choice treatment. However, there are no data regarding natural evolution of anemia in patients diagnosed in MDS and del(5q) without TD, factors that may impact on the development of TD or disease outcome. In the present study we have performed a retrospective multicenter analysis on 83 patients with low-int 1 MDS and del(5q) without TD. During the study 61 patients became TD at a median of 1.7 years and only the Hb level 9 g/dL was associated with poorer TFS (p = 0.007) in the multivariate analysis. Among these 61 TD patients, 49 received treatment (19 Lenalidomide). Median follow up was 48 months, estimated OS at 2 and 5 year was 92% and 50% respectively. In the multivariate analysis for OS, platelets &lt;100,000 mm(-3) and Lenalidomide treatment retained the statistical significant impact. LFS at 2 and 5 years was 86% and 73% respectively, and median time to sAML was 8.16 years (CI 95%: 6.05-10.27). In the multivariate analysis only thrombocytopenia retained statistical significance. In summary, this retrospective study show that level of Hb is an important parameter in order to determine the time until TD, it should be also stressed the importance of an early treatment in order to prevent TD development and shorter survival." }, { "id": "pubmed23n0656_10182", "title": "[Elderly patients with myelodysplastic syndrome with del 5q receiving lenalidomide: two case reports with poor prognosis].", "score": 0.01258670407606578, "content": "We report two cases of myelodysplastic syndrome (MDS) with del(5q) isolated cytogenetic abnormality in elderly patients: AREB-1 in Patient 1, \"5q syndrome\" in Patient 2. A first line of treatment including hematopoietic growth factors (darbepoetin alone or associated with G-CSF) failed after several months and a treatment with lenalidomide was initiated in both cases. The treatment was poorly tolerated (myelosuppression) in Patient 1 without an improvement of the quality of life; a progression of the disease was observed with an increase of the bone marrow blastosis and a new acquired karyotypic abnormality (t13;17), leading to the prescription of 5-azacytidine. Patient 2 had a good response to lenalidomide for several months with an increase in the haemoglobin level and a transfusion independence. The patient's prognosis suddenly worsened with the occurrence of a blood blastosis (10%): 5-azacytidine was thus initiated. These two case reports illustrate the recent advances in the management of patients with MDS with del(5q), including the use of lenalidomide." }, { "id": "pubmed23n0729_15951", "title": "Diagnosis and therapy of myelodysplastic syndromes in Germany: a retrospective multicenter analysis.", "score": 0.012562427967729543, "content": "Myelodysplastic syndromes (MDS) are a heterogenous group of clonal hematopoietic stem cell disorders. In order to assess current diagnosis and treatment patterns in Germany, the data of 269 patients with MDS from 57 representative centers were analyzed. The most common symptom leading to an initial diagnosis of MDS was anemia (79%). WHO classification, cytogenetic analysis, and IPSS scoring were performed in 92, 67, and 61% of patients, respectively. 5q deletions were identified in 34% of patients whose cytogenetic status was analyzed. Symptomatic anemia was the major trigger for initiating therapy. 49% of patients received supportive care only, and 49% received active therapy (i.e., chemo-, immunomodulatory, or epigenetic therapy), including 5% who received allogeneic transplantation. Of those patients treated with active therapy, approximately half of the higher-risk patients received azacitidine, and approximately half of the lower-risk patients received lenalidomide. Overall, 80% of patients received some form of supportive care, mainly red blood cell transfusions. While the WHO classification system is widely used in clinical practice, karyotyping and IPSS risk assessment do not seem to be common standard. Despite encouraging data on the use of effective and novel drugs, such as lenalidomide and azacitidine in MDS therapies, management of the disease could be further improved by more widespread use of risk stratification of patients using cytogenetics and IPSS assessment." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 222, 303 ] ], "word_ranges": [ [ 37, 48 ] ], "text": "The patient is not hyperventilating but hypoventilating because PCO2 is elevated." }, "2": { "exist": true, "char_ranges": [ [ 304, 421 ] ], "word_ranges": [ [ 48, 69 ] ], "text": "The alveolar arterial oxygen gradient is altered since the patient has a normal PaO2, but because he has a high FiO2." }, "3": { "exist": true, "char_ranges": [ [ 0, 221 ] ], "word_ranges": [ [ 0, 37 ] ], "text": "Blood gas analysis shows an acute respiratory acidosis, due to an increase in PCO2 of short evolution time because the kidney has not yet had time to retain bicarbonates (bicarbonate level at the high limit of normality)." }, "4": { "exist": true, "char_ranges": [ [ 115, 221 ] ], "word_ranges": [ [ 19, 37 ] ], "text": "the kidney has not yet had time to retain bicarbonates (bicarbonate level at the high limit of normality)." }, "5": { "exist": true, "char_ranges": [ [ 472, 630 ] ], "word_ranges": [ [ 78, 101 ] ], "text": "Respiratory acidosis below 7.20 is a reason to consider noninvasive mechanical ventilation acutely and in principle temporarily in a patient with severe COPD." } }

{ "1": "The patient is hyperventilating.", "2": "The alveolar arterial oxygen gradient is elevated.", "3": "The patient is in respiratory acidosis.", "4": "Bicarbonate level is normal.", "5": "Initiation of mechanical ventilation should be considered." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en040_1133", "title": "Respiratory acidosis", "score": 0.016821509009009007, "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": "wiki20220301en049_36553", "title": "Non-invasive ventilation", "score": 0.01622784150156413, "content": "COPD The most common indication for acute non-invasive ventilation is for acute exacerbation of chronic obstructive pulmonary disease. The decision to commence NIV, usually in the emergency department, depends on the initial response to medication (bronchodilators given by nebulizer) and the results of arterial blood gas tests. If after medical therapy the lungs remain unable to clear carbon dioxide from the bloodstream (respiratory acidosis), NIV may be indicated. Many people with COPD have chronically elevated CO2 levels with metabolic compensation, but NIV is only indicated if the CO2 is acutely increased to the point that the acidity levels of the blood are increased (pH<7.35). There is no level of acidity above which NIV cannot be started, but more severe acidosis carries a higher risk that NIV alone is not effective and that mechanical ventilation will be required instead." }, { "id": "pubmed23n1027_15054", "title": "Acetazolamide Causes Worsening Acidosis in Uncompensated COPD Exacerbations: Increased Awareness Needed for Patient Safety.", "score": 0.015522691352449762, "content": "Acetazolamide has been studied extensively in post-hypercapnic alkalosis as a tool to facilitate ventilator weaning in chronic obstructive pulmonary disease (COPD). It has also been utilized to facilitate respiratory drive in nonmechanically ventilated patients with COPD. Although this is generally a forgiving intervention, providers must carefully select patients for this medication, as it can cause severe acidosis and deterioration of clinical status in severe COPD cases. The present report describes two cases of patients who developed worsening acidosis and hypercapnia after receiving acetazolamide in acute respiratory failure. Case 1 was a 72-year-old obese male with COPD who was dependent on supplemental oxygen and presented to the emergency department (ED) with acute on chronic hypercapnic respiratory failure. He was given a one-time dose of acetazolamide in the ED for \"respiratory failure made worse by severe metabolic alkalosis.\" His arterial blood gas (ABG) worsened overnight, accompanied by decreased mental status: pH 7.32, paCO<sub2</sub 82 mm Hg, paO<sub2</sub 50 mm Hg, HCO<sub3</sub 41.7 mmol/L, FiO<sub2</sub 32% to pH 7.21, paCO<sub2</sub 91.7 mm Hg, paO<sub2</sub 59 mm Hg, HCO<sub3</sub 36.6 mmol/L, and FiO<sub2</sub 32%. Case 2 was a 62-year-old male with COPD who was dependent on supplemental oxygen and presented to the ED with acute on chronic hypercapnic respiratory failure. He was given acetazolamide in the ED with similar results: ABG on presentation pH 7.37, paCO<sub2</sub 79.3 mm Hg, paO<sub2</sub 77.6 mm Hg, HCO<sub3</sub 45.5 mmol/L, and FiO<sub2</sub 32%. The next morning, ABG was pH 7.29, paCO<sub2</sub 79 mm Hg, paO<sub2</sub 77 mm Hg, HCO<sub3</sub 45.5 mmol/L, and FiO<sub2</sub 32%. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acetazolamide given early in the uncompensated setting can worsen acidosis and potentiate clinical deterioration." }, { "id": "wiki20220301en040_1128", "title": "Respiratory acidosis", "score": 0.015151515151515152, "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": "wiki20220301en013_157315", "title": "Arterial blood gas test", "score": 0.012437483548302184, "content": "In general, it is much easier to correct acute pH derangement by adjusting respiration. Metabolic compensations take place at a much later stage. However, in a critical setting, a person with a normal pH, a high CO2, and a high bicarbonate means that, although there is a high carbon dioxide level, there is metabolic compensation. As a result, one must be careful as to not artificially adjust breaths to lower the carbon dioxide. In such case, lowering the carbon dioxide abruptly means that the bicarbonate will be in excess and will cause a metabolic alkalosis. In such a case, carbon dioxide levels should be slowly diminished. See also Anion gap Radial artery puncture Chemical equilibrium Hemoximetry Arteriovenous oxygen difference References External links Online arterial blood gas calculator Diagnostic intensive care medicine Respiratory physiology Blood tests Respiratory therapy" }, { "id": "wiki20220301en159_7352", "title": "Alveolar–arterial gradient", "score": 0.012215804913824716, "content": "Because A–a gradient is approximated as: (150 − 5/4(P)) – at sea level and on room air (0.21x(760-47) = 149.7 mmHg for the alveolar oxygen partial pressure, after accounting for the water vapor), the direct mathematical cause of a large value is that the blood has a low , a low Pa, or both. is very easily exchanged in the lungs and low Pa directly correlates with high minute ventilation; therefore a low arterial Pa indicates that extra respiratory effort is being used to oxygenate the blood. A low indicates that the patient's current minute ventilation (whether high or normal) is not enough to allow adequate oxygen diffusion into the blood. Therefore, the A–a gradient essentially demonstrates a high respiratory effort (low arterial Pa) relative to the achieved level of oxygenation (arterial ). A high A–a gradient could indicate a patient breathing hard to achieve normal oxygenation, a patient breathing normally and attaining low oxygenation, or a patient breathing hard and still" }, { "id": "pubmed23n0306_15367", "title": "Effect of acute bicarbonate administration on exercise responses of COPD patients.", "score": 0.012138092290764046, "content": "Patients with severe chronic obstructive pulmonary disease (COPD) are limited in their exercise tolerance by the level of ventilation (VE) they can sustain. We determined whether acutely increasing blood bicarbonate levels decreased acid stimulation to the respiratory chemoreceptors during exercise, thereby improving exercise tolerance. Responses were compared with those obtained during 100% O2 breathing (known to reduce VE in these patients) and to the responses of healthy young subjects. Participants were six patients with severe COPD (forced expired volume in 1 s = 31 +/- 11% predicted) but without chronic CO2 retention and 5 healthy young subjects. Each subject performed three incremental cycle ergometer exercise tests: 1) control, 2) after ingestion of 0.3 g.kg-1 of sodium bicarbonate and 3) while breathing 100% O2. During these tests VE was measured continuously and arterialized venous blood (patients) or arterial blood (healthy subjects) was sampled serially to assess acid base variables. Bicarbonate loading increased standard bicarbonate by 4-6 mmol.L-1 and this elevation persisted during exercise. In both groups, bicarbonate loading resulted in a substantially higher arterial pH; arterial PCO2 was either unchanged (healthy subjects) or mildly (averaging 5 torr) higher (COPD patients). However, in neither group did bicarbonate loading result in an altered VE response to exercise or an increase in exercise tolerance. In contrast, superimposing hyperoxia on bicarbonate ingestion yielded, on average, 24% reduction in VE and 50% increase in peak work rate in the patients (but not in the healthy young subjects). We conclude that acute bicarbonate loading is not an ergogenic aid in patients with severe COPD." }, { "id": "wiki20220301en142_15270", "title": "Pulmonary gas pressures", "score": 0.011785834549332136, "content": "The alveolar pO2 is not routinely measured but is calculated from blood gas measurements by the alveolar gas equation. Partial pressure of carbon dioxide Pathology The partial pressure of carbon dioxide, along with the pH, can be used to differentiate between metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. Hypoventilation exists when the ratio of carbon dioxide production to alveolar ventilation increases above normal values – greater than 45mmHg. If pH is also less than 7.35 this is respiratory acidosis. Hyperventilation exists when the same ratio decreases – less than 35mmHg. If the pH is also greater than 7.45 this is respiratory alkalosis. See also Alveolar-arterial gradient Diffusing capacity Pulmonary alveolus References Respiratory physiology" }, { "id": "article-17837_19", "title": "Arterial Blood Gas -- Results, Reporting, and Critical Findings", "score": 0.011724670422374104, "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": "pubmed23n0063_17765", "title": "Intermittent short-term negative pressure ventilation and increased oxygenation in COPD patients with severe hypercapnic respiratory failure.", "score": 0.011665904189268675, "content": "With the aim of testing a method that allows increasing concentrations of oxygen to be administered to patients with severe hypoxemia and hypercapnia while avoiding the risk of increasing respiratory acidosis, we studied 17 male patients with advanced chronic obstructive pulmonary disease (COPD) and severe hypercapnic respiratory failure. During 6 h and on one day only, all patients were given intermittent negative pressure ventilation (INPV) together with oxygenation starting at a concentration of 24 percent and increasing to 30 percent. Using this procedure, it was possible to raise arterial PaO2 to safe levels (from 47.2 +/- 3 mm Hg to 61.5 +/- 6 mm Hg, p less than 0.001) without increasing hypercapnia, and a significant drop in PaCO2 levels (from 74.4 +/- 9 mm Hg to 65.6 +/- 12 mm Hg, p less than 0.005) was even observed. One hour after INPV ended, the mean values of PaO2, PaCO2, oxygen saturation, and pH were also significantly better than prestudy values. We conclude that INPV and oxygen therapy with increasing oxygen flow could constitute an alternative option to intubation and mechanical ventilation in cases of severe hypercapnic respiratory failure due to advanced COPD." }, { "id": "wiki20220301en040_1131", "title": "Respiratory acidosis", "score": 0.011572965884728264, "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": "wiki20220301en013_157313", "title": "Arterial blood gas test", "score": 0.01128314106456183, "content": "Respiratory alkalosis (Pa CO2 < 35 mmHg) occurs when there is too little carbon dioxide in the blood. This may be due to hyperventilation or else excessive breaths given via a mechanical ventilator in a critical care setting. The action to be taken is to calm the person and try to reduce the number of breaths being taken to normalize the pH. The respiratory pathway tries to compensate for the change in pH in a matter of 2–4 hours. If this is not enough, the metabolic pathway takes place. Under normal conditions, the Henderson–Hasselbalch equation will give the blood pH where: 6.1 is the acid dissociation constant (pKa) of carbonic acid () at normal body temperature [] is the concentration of bicarbonate in the blood in mEq/L PaCO2 is the partial pressure of carbon dioxide in the arterial blood in mmHg" }, { "id": "pubmed23n0008_12161", "title": "Arterial blood gases and pH during sleep in chronic obstructive pulmonary disease.", "score": 0.011152761857554448, "content": "Arterial blood gases were measured during 7 hours of sleep in 15 patients with severe stable chronic obstructive pulmonary discrease (COPD); 6 awake patients with COPD studies in recumbency for an average of 5 hours served as controls. Mean maximal decrease in arterial oxygen partial pressure (PaO2) (plus or minus SD) was 13.5 plus or minus 3.9 mm Hg for sleeping patients (p less than 0.005) and 5.5 plus or minus 1.7 mm Hg for controls (p less than 0.1), respectively. Changes in pH during sleep were of the magnitude expected with acute changes in arterial carbon dioxide partial pressure (PaCO2) in patients with chronic hypercapnia. Consistent changes in heart rate, respiratory frequency or cardiac rhythm were not observed during sleep. Nocturnal worsening of hypoxemia could be explained by alveolar hypoventilation in six sleeping patients and in five controls; in nine sleeping patients, further impariment of ventilation-perfusion mismatch also contributed to worsening of hypoxemia. There was no relationship between the decrease in PaO2 during sleep and the degree of airways obstruction or the PaO2 level when awake. Because of low PaO2, when awake, a fall in PaO2 during sleep brings values into the steep part of the oxyhemoglobin dissociation curve where slight changes in PaO2 result in marked changes in oxygen content. All patients with COPD whose waking PaO2 was below 60 mm Hg had PaO2 below 50 mm Hg during sleep; nocturnal oxygen therapy should be considered in such patients, particularly in the presence of polycythemia or troublesome right-sided heart failure." }, { "id": "InternalMed_Harrison_20608", "title": "InternalMed_Harrison", "score": 0.0111055900621118, "content": "Respiratory symptoms associated with acute hyperventilation can be the initial manifestation of systemic illnesses such as diabetic ketoacidosis. Causes of acute hyperventilation need to be excluded before a diagnosis of chronic hyperventilation is considered. Arterial blood gas sampling that demonstrates a compensated respiratory alkalosis with a near normal pH, low PaCO2, and low calculated bicarbonate is necessary to confirm chronic hyperventilation. Other causes of respiratory alkalosis, such as mild asthma, need to be diagnosed and treated before chronic hyperventilation can be considered. A high index of suspicion is required because increased minute ventilation can be difficult to detect on physical examination. Once chronic hyperventilation is established, a sustained 10% increase in alveolar ventilation is enough to perpetuate hypocapnia. This increase can be accomplished with subtle changes in the respiratory pattern, such as occasional sigh breaths or yawning two to three" }, { "id": "article-31075_61", "title": "Ventilator Management -- Clinical Significance -- Special Circumstances", "score": 0.01093073593073593, "content": "COPD is a special case, as lungs in pure COPD have high compliance which causes a high tendency for dynamic airflow obstruction due to airway collapse and air trapping, making COPD patients very prone to developing auto-PEEP. Using a preventive ventilation strategy with high flow and low respiratory rate may help prevent auto-PEEP. Another important aspect to consider in chronic hypercapnic respiratory failure (due to COPD or another reason) is that there is no need to correct the CO2 back to normal, as these patients usually have a metabolic compensation for their respiratory problems. If a patient is ventilated to normal CO2 levels, his bicarbonate will decrease, and when a patient is extubated he will quickly go to respiratory acidosis as his kidneys cannot respond as fast as his lungs and his CO2 will go back to his baseline, causing respiratory failure and reintubation. To prevent this, CO2 goals should be determined based on pH and previously known or calculated baseline." }, { "id": "wiki20220301en019_114900", "title": "Acidosis", "score": 0.010651097654786092, "content": "However, in cases where chronic illnesses that compromise pulmonary function persist, such as late-stage emphysema and certain types of muscular dystrophy, compensatory mechanisms will be unable to reverse this acidotic condition. As metabolic bicarbonate production becomes exhausted, and extraneous bicarbonate infusion can no longer reverse the extreme buildup of carbon dioxide associated with uncompensated respiratory acidosis, mechanical ventilation will usually be applied. Fetal respiratory acidemia In the fetus, the normal range differs based on which umbilical vessel is sampled (umbilical vein pH is normally 7.25 to 7.45; umbilical artery pH is normally 7.20 to 7.38). In the fetus, the lungs are not used for ventilation. Instead, the placenta performs ventilatory functions (gas exchange). Fetal respiratory acidemia is defined as an umbilical vessel pH of less than 7.20 and an umbilical artery PCO2 of 66 or higher or umbilical vein PCO2 of 50 or higher. See also" }, { "id": "wiki20220301en054_12513", "title": "Respiratory alkalosis", "score": 0.01056976955180548, "content": "Diagnosis The diagnosis of respiratory alkalosis is done via test that measure the oxygen and carbon dioxide levels (in the blood), chest x-ray and a pulmonary function test of the individual. The Davenport diagram allows clinicians or investigators to outline blood bicarbonate concentrations (and blood pH) after a respiratory or metabolic acid-base disturbance Classification There are two types of respiratory alkalosis: chronic and acute as a result of the 3–5 day delay in kidney compensation of the abnormality. Acute respiratory alkalosis occurs rapidly, have a high pH because the response of the kidneys is slow. Chronic respiratory alkalosis is a more long-standing condition, here one finds the kidneys have time to decrease the bicarbonate level. pH Alkalosis refers to the process due to which there is elevation of blood pH. Alkalemia refers to an arterial blood pH of greater than 7.45." }, { "id": "article-26709_8", "title": "Partial Pressure of Carbon Dioxide -- Clinical Significance", "score": 0.010400641372884661, "content": "There are differences in the acute and chronic stages of respiratory acidosis or alkalosis. Acute respiratory acidosis from increased PCO2 will result in immediate changes to serum bicarbonate levels due to the bicarbonate buffer system; however, this is limited in its ability to achieve homeostasis. The kidney will gradually increase the serum bicarbonate levels in chronic cases. Chronic respiratory acidosis is when the acidemia exists for 3 to 5 days, which is approximately how long it will take the kidney to buffer the acidemia. In acute respiratory acidosis, normally, the serum bicarbonate will increase by 1 mEq/L for every 10 mmHg increase in PCO2. For chronic respiratory acidosis, the serum bicarbonate will increase by 4 to 5 mEq/L for every 10 mmHg rise in PCO2. [6] [5] The result typically causes a mild chronic acidosis or low-normal pH near 7.35. [6] In regards to respiratory alkalosis, the same timeframe applies to acute versus chronic. In acute respiratory alkalosis, for every decrease in PCO2 by 10 mmHg, the serum bicarbonate will also decrease by 2 mEq/L. In chronic respiratory alkalosis, or alkalosis lasting 3 to 5 days, for every 10mmHg drop in PCO2, it is expected that serum bicarbonate will decrease by 4 to 5 mEq/L. [5] [6]" }, { "id": "wiki20220301en040_1132", "title": "Respiratory acidosis", "score": 0.010319829424307037, "content": "Acute respiratory acidosis: HCO3− increases 1 mEq/L for each 10 mm Hg rise in PaCO2. Chronic respiratory acidosis: HCO3− rises 3.5 mEq/L for each 10 mm Hg rise in PaCO2. The expected change in pH with respiratory acidosis can be estimated with the following equations: Acute respiratory acidosis: Change in pH = 0.08 X ((40 − PaCO2)/10) Chronic respiratory acidosis: Change in pH = 0.03 X ((40 − PaCO2)/10) Respiratory acidosis does not have a great effect on electrolyte levels. Some small effects occur on calcium and potassium levels. Acidosis decreases binding of calcium to albumin and tends to increase serum ionized calcium levels. In addition, acidemia causes an extracellular shift of potassium, but respiratory acidosis rarely causes clinically significant hyperkalemia. Diagnosis" }, { "id": "wiki20220301en020_19466", "title": "Hypercapnia", "score": 0.010258880192655027, "content": "In many people a high causes a feeling of shortness of breath, but the lack of this symptom is no guarantee that the other effects are not occurring. A significant percentage of rebreather deaths have been associated with CO2 retention. The effects of high can take several minutes to hours to resolve once the cause has been removed. Diagnosis Blood gas tests may be performed, typically by radial artery puncture, in the setting of acute breathing problems or other acute medical illness. Hypercapnia is generally defined as an arterial blood carbon dioxide level over 45 mmHg (6 kPa). Since carbon dioxide is in equilibrium with carbonic acid in the blood, hypercapnia drives serum pH down, resulting in respiratory acidosis. Clinically, the effect of hypercapnia on pH is estimated using the ratio of the arterial pressure of carbon dioxide to the concentration of bicarbonate ion, . Tolerance" }, { "id": "wiki20220301en013_157316", "title": "Blood gas test", "score": 0.010040816326530613, "content": "A blood gas test or blood gas analysis tests blood to measure blood gas tension values, it also measures blood pH, and the level and base excess of bicarbonate. The source of the blood is reflected in the name of each test; arterial blood gases come from arteries, venous blood gases come from veins and capillary blood gases come from capillaries. The blood gas tension levels of partial pressures can be used as indicators of ventilation, respiration and oxygenation. Analysis of paired arterial and venous specimens can give insights into the aetiology of acidosis in the newborn. Values measured" }, { "id": "wiki20220301en074_45830", "title": "Base excess", "score": 0.009992117587054296, "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": "pubmed23n0781_8165", "title": "Respiratory CO2 response depends on plasma bicarbonate concentration in mechanically ventilated patients.", "score": 0.009900990099009901, "content": "There is controversy about the effects of high plasma bicarbonate concentration ([HCO3(-)]) and the CO2 response test. We analyzed the relationship between [HCO3(-)] and the variation in hydrogen ion concentration (pH) for a given change in PaCO2, and its effects upon CO2 response. A retrospective study was carried out. Two intensive care units. Subjects with and without chronic obstructive pulmonary disease (COPD), at the beginning of weaning from mechanical ventilation. The CO2 response was evaluated by the re-inhalation of expired air method, measuring the hypercapnic ventilatory response (ΔVE/ΔPaCO2) and hypercapnic drive response (ΔP01/ΔPaCO2), where VE is minute volume and P0.1 is airway occlusion pressure 0.1s after the initiation of inspiration. [HCO3(-)] and CO2 response. A total of 120 patients in the non-COPD group and 48 in the COPD group were studied. COPD patients had higher mean [HCO3(-)] than non-COPD patients (33.2 ± 5.4 vs. 25.7 ± 3.7 mmol/l, p&lt;0.001). In both non-COPD and COPD patients we observed a significant inverse linear relationship between [HCO3(-)] and pH change per mmHg of PaCO2 (p&lt;0.001), ΔVE/ΔPaCO2 (p&lt;0.001) and ΔP0.1/ΔPaCO2 (p&lt;0.001). There is an inverse linear relationship between [HCO3(-)] and the variation of pH for a given change in PaCO2 and the CO2 response." }, { "id": "pubmed23n0569_615", "title": "Comparison of arterial and venous blood gases analysis in patients with exacerbation of chronic obstructive pulmonary disease.", "score": 0.00980392156862745, "content": "To investigate whether venous blood gases (VBG) test can be replace by an arterial blood gases (ABG) in exacerbation of chronic obstructive pulmonary disease (COPD). From October 2005 to March 2006, at the Emergency Room of Kashan Beheshti Hospital, the data of 107 patients with exacerbation of COPD were assessed. Arterial blood gases and VBG samples were obtained simultaneously, and indexes of pH, carbon dioxide partial pressure (PCO2), bicarbonate (HCO3), oxygen partial pressure (PO2) and Oxygen (O2) saturation level were analyzed. The mean +/- SD of indexes in ABG and VBG samples were as follows: pH = 7.37 +/- 0.47 versus 7.34 +/- 0.047; PCO2 = 53.88 +/- 7.63 mm Hg versus 59.55 +/- 8.96 mm Hg, HCO3= 30.66 +/- 4.49 mEq/L versus 31.94 +/- 4.39 mEq/L; PO2 = 55.37 +/- 11.19 mm Hg versus 43.08 +/- 10.54 mm Hg. The average difference between indexes in ABG and VBG samples were as follows: pH = 0.0241 +/- 0.004, p&lt;0.001, r = 0.864; PCO2 = 5.673 +/- 1.126 mm Hg, p&lt;0.001, r = 0.761; HCO3 = 1.279 +/- 0.604 mEq/L, p&lt;0.001, r = 0.749; and PO2 = 12.294 +/- 2.115 mm Hg, p&lt;0.001, r = 0.702. Venous blood gases, especially pH and PCO2 levels have relatively good correlation with ABG values. In view of the fact that, this correlation is not close, VBG cannot be substitute for ABG in exacerbation of COPD." }, { "id": "pubmed23n0764_18346", "title": "[Fallacies in arterial blood gas interpretation].", "score": 0.009708737864077669, "content": "The arterial blood gas analysis (ABGA) is a valuable diagnostic tool in daily clinical practice. It yields information about oxygenation, ventilation and acid-base status. ABGAs should always be interpreted within a clinical context. If a result is absolutely not compatible with a clinical situation, the probe should be repeated or prompt further differential diagnoses. A probe should be free of air bubbles and be rapidly proceeded in the laboratory. Body temperature and fraction of inspired oxygen are mandatory prerequisites for adequate interpretation. With CO-oximetry, not only oxygenated hemoglobin but also carboxihemoglobin and met-hemoglobin content can be measured in the case of a suspected intoxication. For the assessment of ventilation, PaCO2 must be interpreted in the context of PaO2, as already a \"normal value\" of PaCO2 may indicate severe ventilator failure in a patient with hypoxemia. A normal pH does not exclude acid-base disorders, PaCO2 and bicarbonate must also be taken into account. When FIO2 is changed, steady state conditions must be awaited before a next control especially in the case of ventilation-perfusion mismatch, e. g. in COPD, pneumonia, pulmonary embolism. In a hypoxic state, immediate application of oxygen is warranted, in hypercapnia, ventilation should be increased. In acid-base disorders, treatment of the underlying disease is most often conducive. " }, { "id": "pubmed23n0226_6399", "title": "Studies on the physiopathology of chronic obstructive pulmonary disease in the horse. IV. Blood gas and acid-base values at rest.", "score": 0.009637661013807804, "content": "Radiometer Blood Micro-system 2 was used in studies designed to, (a) compare the mean blood gas and acid-base values of 38 normal horses and 20 horses with chronic obstructive pulmonary disease (COPD), (b) determine the means and standard deviations of blood gas and acid-base values of Thoroughbred horses in training, and (c) investigate the relationships between clinical data, blood gas values, intracardiac and pulmonary arterial pressures in subjects with COPD. There were significant differences between the mean values for partial pressure of arterial oxygen (PaO2), arterial carbon dioxide (PaCO2) and mixed venous carbon dioxide (PvCO2) in normal and COPD subjects. The mean values and standard deviations for determinations of blood gases and acid-base status in Thoroughbred horses in training were as follows: PaO2 = 77,4 +/- 4,3 mm Hg; PvO2 (mixed venous oxygen partial pressure) = 36,2 +/- 4,1 mm Hg; PaCO2 = 40,9 +/- 5,8 mm Hg; PvCO2 = 49,4 +/- 5,0 mm Hg; pHa (arterial) = 7,358 +/- 0,051; pHv (venous) = 7,343 +/- 0,027; standard bicarbonate = 22,7 mM/l. The PaO2, the PaCO2 and the arterial pH were significantly correlated to the respiratory frequency in COPD subjects. The correlations of pulmonary diastolic pressure to both PaO2 and pHa were of probable significance (P less than 0,05) in COPD subjects. PaCO2 was highly significantly correlated to PaO2 and pHa in COPD subjects." }, { "id": "pubmed23n0063_13679", "title": "Chronic respiratory alkalosis. The effect of sustained hyperventilation on renal regulation of acid-base equilibrium.", "score": 0.009615384615384616, "content": "In normal subjects, chronic hyperventilation lowers plasma bicarbonate concentration, primarily by inhibiting the urinary excretion of net acid. The quantitative relation between reduced arterial carbon dioxide tension (PaCO2) and the plasma bicarbonate concentration in the chronic steady state has not been studied in humans, however, and the laboratory criteria for the diagnosis of chronic respiratory alkalosis therefore remain undefined. We wished to provide such reference data for clinical use. Moreover, because chronic hyperventilation paradoxically lowers blood pH still further in dogs with metabolic acidosis, we desired to study the effect of chronic hypocapnia on the plasma bicarbonate concentration (and blood pH) in normal human subjects in whom acidosis had been induced with ammonium chloride. Under metabolic-balance conditions, we used altitude-induced hypobaric hypoxia to produce chronic hypocapnia in nine normal young men, five of whom received ammonium chloride daily to cause metabolic acidosis (the mean [+/- SE] steady-state plasma bicarbonate level in these five was 12.0 +/- 0.5 mmol per liter). For each decrease of 1 mm Hg (0.13 kPa) in the PaCO2, the plasma bicarbonate concentration decreased by 0.41 mmol per liter in the subjects who started with a normal plasma bicarbonate concentration and by 0.42 mmol per liter in the subjects with acidosis. In contrast to the findings in previous studies of dogs, hypocapnia increased blood pH similarly in both groups; the blood hydrogen ion concentration decreased by about 0.4 nmol per liter for every decrease of 1 mm Hg (0.13 kPa) in PaCO2. These results provide reference data for the diagnosis of chronic respiratory alkalosis in humans. Although chronic hypocapnia decreased plasma bicarbonate levels similarly in normal subjects with acidosis and without acidosis, the percent reduction in PaCO2 was always greater than the corresponding percent reduction in the plasma bicarbonate concentration. Therefore, as was not true of the response in dogs, the subjects' blood pH always increased with hyperventilation, regardless of the initial plasma bicarbonate concentration." }, { "id": "pubmed23n0821_7370", "title": "Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: In patients presenting with an exacerbation of COPD can a normal venous blood gas pCO2 rule out arterial hypercarbia?", "score": 0.009615384615384616, "content": "A shortcut review was carried out to establish whether a normal partial pressure of carbon dioxide (pCO2) on a venous blood sample could be used to rule out hypercarbia. Eleven studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that a normal venous pCO2 effectively rules out arterial hypercarbia. " }, { "id": "pubmed23n0246_6905", "title": "The metabolic and respiratory alterations of heat stroke.", "score": 0.009523809523809525, "content": "The metabolic and respiratory changes of 21 patients with heat stroke were studied. Admission arterial blood gas levels were measured, and serum bicarbonate, lactate, calcium, phosphorus, and anion gap determinations were performed. Seven patients had a metabolic acidosis (pH 7.20 +/- 0.04, PCO2 32 +/- 2 mm Hg, and bicarbonate 12 +/- 1 mEq/L), seven a combined metabolic acidosis and respiratory alkalosis (pH 7.39 +/- 0.01, PCO2 25 +/- 1 mm Hg, and bicarbonate 15 +/- 1 mEq/L), four a respiratory alkalosis (pH 7.45 +/- 0.01, PCO2 30 +/- 1 mm Hg, and bicarbonate 20 +/- 1 mEq/L), one a metabolic and respiratory acidosis (pH 7.13, PCO2 52 mm Hg, and bicarbonate 17 mEq/L), and one a respiratory acidosis (pH 7.30, PCO2 56 MM Hg, and bicarbonate 27 mEq/L). The 15 patients with a metabolic acidosis had a pH of 7.28 +/- 0.03, PCO2 of 30 +/- 2 mm Hg, bicarbonate level of 14 +/- 1 mEq/L, lactate concentration of 6.5 +/- 1.0 mEq/L, and an anion gap of 26 +/- 4 mEq/L. Nine patients were hypocalcemic (7.8 +/- 0.3 mg/dL), and five patients were hypophosphatemic (2.0 +/- 0.2 mg/dL). The predominant metabolic change in heat stroke is a metabolic acidosis secondary to increased lactate content and/or a respiratory alkalosis. Hypocalcemia is common and hypophosphatemia is not infrequent." }, { "id": "pubmed23n0740_8470", "title": "[Correlation between arterial and venous blood gas analysis parameters in patients with acute exacerbation of chronic obstructive pulmonary disease].", "score": 0.009523809523809525, "content": "Arterial blood gas (ABG) analyses have an important role in the assessment and monitoring of the metabolic and oxygen status of patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). Arterial puncture could have a lot of adverse effects, while sampling of venous blood is simpler and is not so invasive. The aim of this study was to evaluate whether venous blood gas (VBG) values of pH, partial pressure of carbon dioxide (PCO2), partial oxygen pressure (PO2), bicarbonate (HCO3), and venous and arterial blood oxygen saturation (SO2) can reliably predict ABG levels in patients with acute exacerbation of COPD. Forty-seven patients with a prior diagnosis of COPD were included in this prospective study. The patients with acute exacerbation of this disease were examined at the General Hospital EMS Department in Prijepolje. ABG samples were taken immediately after venous sampling, and both were analyzed. The Pearson correlation coefficients between arterial and venous parameters were 0.828, 0.877, 0.599, 0.896 and 0.312 for pH, PCO2, PO2, HCO3 and SO2, respectively. The statistically significant correlation between arterial and venous pH, PCO2 and HCO3, values was found in patients with acute exacerbation of COPD (p&lt;0.001). When we cannot provide arterial blood for analysis, venous values of the pH, Pv,CO2 and HCO3 parameters can be an alternative to their arterial equivalents in the interpretation of the metabolic status in patients with acute exacerbation of COPD, while the values of venous Pv,O, and Sv,O2 cannot be used as predictors in the assessment of oxygen status of such patients." }, { "id": "wiki20220301en008_58623", "title": "Tracheal intubation", "score": 0.009433962264150943, "content": "Intubation may be necessary for a patient with decreased oxygen content and oxygen saturation of the blood caused when their breathing is inadequate (hypoventilation), suspended (apnea), or when the lungs are unable to sufficiently transfer gasses to the blood. Such patients, who may be awake and alert, are typically critically ill with a multisystem disease or multiple severe injuries. Examples of such conditions include cervical spine injury, multiple rib fractures, severe pneumonia, acute respiratory distress syndrome (ARDS), or near-drowning. Specifically, intubation is considered if the arterial partial pressure of oxygen (PaO2) is less than 60 millimeters of mercury (mm Hg) while breathing an inspired O2 concentration (FIO2) of 50% or greater. In patients with elevated arterial carbon dioxide, an arterial partial pressure of CO2 (PaCO2) greater than 45 mm Hg in the setting of acidemia would prompt intubation, especially if a series of measurements demonstrate a worsening" }, { "id": "pubmed23n0692_4788", "title": "Below what FEV1 should arterial blood be routinely taken to detect chronic respiratory failure in COPD?", "score": 0.009433962264150943, "content": "To diagnose and assess chronic respiratory failure in stable chronic obstructive pulmonary disease (COPD) the measurement of arterial blood gases (ABG) is required. It has been suggested that ABG be determined for this purpose when FEV1 ranges between 50% and 30% predicted, but these thresholds are not evidence-based. To identify the post-bronchodilator (BD) FEV₁ and arterial oxygen saturation (SaO(2)) values that provide the best sensitivity, specificity, and likelihood ratio (LR) for the diagnosis of hypoxaemic and/or hypercapnic chronic respiratory failure in stable COPD. A total of 150 patients were included (39 with PaO₂ &lt; 60 mmHg [8 kPa], 14 of them with a PaCO₂ ≥ 50 mmHg [6.7 kPa]). The best post-BD FEV(1) and SaO(2) cut-off points to predict chronic respiratory failure were selected using the PC and the Receiver Operating Characteristics (ROC) curves. A post-BD FEV(1) equal to 36% and an SaO(2) of 90% were the best predictive values for hypoxaemic respiratory failure and a post-BD FEV(1) equal to 33% for the hypercapnic variant. An FEV(1) ≥ 45% ruled out hypoxaemic respiratory failure. A post-BD FEV(1) of 36% is the best cut-off point to adequately predict both hypoxaemic and hypercapnic respiratory failure in the patient with stable COPD. For its part, an SaO(2) of 90% is the best value for isolated hypoxaemic failure. These values could be considered for future clinical recommendations/guidelines for COPD." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 208, 302 ] ], "word_ranges": [ [ 34, 50 ] ], "text": "Coronary revascularization does not appear to be of much benefit in this patient at this time." }, "2": { "exist": true, "char_ranges": [ [ 303, 563 ] ], "word_ranges": [ [ 50, 88 ] ], "text": "Nor does mitral valve replacement, firstly because mitral regurgitation is most likely the result of mitral annular dilatation, and secondly because we would need an echocardiographic assessment of the mitral valve to determine whether there is any alteration." }, "3": { "exist": true, "char_ranges": [ [ 564, 770 ] ], "word_ranges": [ [ 88, 117 ] ], "text": "Intra-aortic balloon counterpulsation implantation would not be indicated in this patient (it is used in situations of cardiogenic shock, in post-AMI mechanical complications, as a bridge to cardiac Tx...)." }, "4": { "exist": true, "char_ranges": [ [ 771, 845 ] ], "word_ranges": [ [ 117, 129 ] ], "text": "The ventricular assist device would also not be indicated in this patient." }, "5": { "exist": true, "char_ranges": [ [ 938, 1060 ] ], "word_ranges": [ [ 144, 160 ] ], "text": "By achieving simultaneous stimulation of both ventricles, a mechanical synergy is achieved that improves cardiac function." } }

{ "1": "Surgical coronary revascularization.", "2": "Mitral valve replacement.", "3": "Implantation of an aortic balloon pump.", "4": "Implantation of a ventricular assist device.", "5": "Implantation of a cardiac resynchronization system." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en275_12999", "title": "Management of heart failure", "score": 0.013998595752150254, "content": "Devices CRT: People with NYHA class III or IV, left ventricular ejection fraction (LVEF) of 35% or less and a QRS interval of 120 ms or more may benefit from cardiac resynchronization therapy (CRT; pacing both the left and right ventricles), through implantation of a bi-ventricular pacemaker. This treatment modality may alleviate symptoms, improving quality of life, and in some trials has been proven to reduce mortality. The COMPANION trial demonstrated that CRT improved survival in individuals with NYHA class III or IV heart failure with a widened QRS complex on an electrocardiogram. The CARE-HF trial showed that patients receiving CRT and optimal medical therapy benefited from a 36% reduction in all-cause mortality and a reduction in cardiovascular-related hospitalization." }, { "id": "pubmed23n0693_9669", "title": "Successful bridge to recovery with VAD implantation for anthracycline-induced cardiomyopathy.", "score": 0.013642249352571217, "content": "Anthracyclines are effective antineoplastic drugs, but they are known to be cardiotoxic. Recovery of cardiac function is rare. A few studies on implantation of a ventricular assist device (VAD) have been performed for anthracycline-induced cardiomyopathy. Recovery of left ventricular (LV) function with an LVAD is also rare. Recently, several adjunctive therapies were attempted to restore ventricular function. We report a successful bridge to recovery of ventricular function using VAD implantation for anthracycline-induced cardiomyopathy. The patient was a 57-year-old man who had been diagnosed with diffuse large B-cell lymphoma (DLBCL) at age 52. Combination chemotherapy including hydroxydaunorubicin was started. Complete remission was achieved after chemotherapy. Heart failure symptoms such as fatigue, dyspnea on exertion, and weight gain appeared 5 months later. A cardiac resynchronization device was implanted. His heart function deteriorated. He underwent implantation of a Toyobo LVAD and mitral annuloplasty. After implantation, he was prescribed carvedilol with spironolactone. He was weaned from the LVAD on postoperative day (POD) 239 and discharged on POD 37 after weaning. He remained in New York Heart Association classes within the first- to second-degree range, the LV dimention diastolic/systolic ratio was 56/46 mm, ejection fraction 38%, and mitral regurgitation mild at 3 years after weaning from the LVAD. Our patient could be weaned from LVAD probably due to the combination management strategy employing mitral valvuloplasty, use of cardiac resynchronization therapy, and taking carvedilol with spironolactone. Further studies will be needed to clarify the efficacy of these adjunctive therapies." }, { "id": "pubmed23n0722_2158", "title": "[Commentary on the 2010 ESC guidelines on device therapy in heart failure ].", "score": 0.01261732574242191, "content": "As part of the 2010 focused update of ESC guidelines on device therapy in heart failure, the guidelines on pacemakers in the treatment of heart failure were renewed. A new feature is that cardiac resynchronization therapy (CRT) is indicated for New York Heart Association (NYHA) class III and IV irrespective of the presence of left ventricular dilatation and specified for NYHA class IV (patient ambulatory, stable, life expectancy &gt;6 months). Furthermore, NYHA class II (but not class I) has been added when there is left bundle branch block and QRS duration ≥150 ms. CRT is also indicated for patients in NYHA class III-IV with permanent atrial fibrillation and heart failure [left ventricular ejection fraction (LVEF) ≤ 35%] when QRS is ≥ 130 ms and ventricular rate has slowed either spontaneously or by AV node ablation. In patients with heart failure (NYHA class II-IV, LVEF ≤ 35%) who need a pacemaker for AV block, CRT is generally indicated to avoid progression of heart failure caused by right ventricular stimulation, also in cases of intrinsic QRS &lt;120 ms. For patients with terminal heart failure who are not eligible for heart transplantation, treatment with a left ventricular assist device can be performed as destination therapy. The new guidelines expand the indication for device therapy in heart failure based on the newest study findings, particularly for patients in NYHA class II, and specify the old guidelines. There are still uncertainties that must be investigated in randomized trials regarding patients with permanent atrial fibrillation, the indication for CRT in heart block, and the question of CRT with pacemaker or defibrillator." }, { "id": "pubmed23n0817_25116", "title": "Autologous transplantation of bone marrow adult stem cells for the treatment of idiopathic dilated cardiomyopathy.", "score": 0.009900990099009901, "content": "Morbimortality in patients with dilated idiopathic cardiomyopathy is high, even under optimal medical treatment. Autologous infusion of bone marrow adult stem cells has shown promising preliminary results in these patients. Determine the effectiveness of autologous transplantation of bone marrow adult stem cells on systolic and diastolic left ventricular function, and on the degree of mitral regurgitation in patients with dilated idiopathic cardiomyopathy in functional classes NYHA II and III. We administered 4,54 x 10(8) ± 0,89 x 10(8) bone marrow adult stem cells into the coronary arteries of 24 patients with dilated idiopathic cardiomyopathy in functional classes NYHA II and III. Changes in functional class, systolic and diastolic left ventricular function and degree of mitral regurgitation were assessed after 3 months, 6 months and 1 year. During follow-up, six patients (25%) improved functional class and eight (33.3%) kept stable. Left ventricular ejection fraction improved 8.9%, 9.7% e 13.6%, after 3, 6 and 12 months (p = 0.024; 0.017 and 0.018), respectively. There were no significant changes neither in diastolic left ventricular function nor in mitral regurgitation degree. A combined cardiac resynchronization and implantable cardioversion defibrillation was implanted in two patients (8.3%). Four patients (16.6%) had sudden death and four patients died due to terminal cardiac failure. Average survival of these eight patients was 2.6 years. Intracoronary infusion of bone marrow adult stem cells was associated with an improvement or stabilization of functional class and an improvement in left ventricular ejection fraction, suggesting the efficacy of this intervention. There were no significant changes neither in left ventricular diastolic function nor in the degree of mitral regurgitation." }, { "id": "pubmed23n0043_17274", "title": "[Treatment results of patients with mitral valve disease in IV functional class of NYHA. II: Conservative treatment].", "score": 0.009900990099009901, "content": "In the group of 60 patients with mitral valve disease (67% in IV and 33% in III functional class of NYHA) the efficacy of medical treatment was analysed. In all of them clinical, noninvasive and invasive investigations were obtained. The conclusion is that survival during ca 1643 days was 15% of the patients in IV class of NYHA. The death was mostly due to severe heart failure." }, { "id": "pubmed23n0689_1897", "title": "Cardiac support device, restrictive mitral valve annuloplasty, and optimized medical treatment: a multimodality approach to nonischemic cardiomyopathy.", "score": 0.00980392156862745, "content": "Nonischemic dilated cardiomyopathy with functional mitral regurgitation carries a poor prognosis. Mitral valve surgery with implantation of a cardiac support device can treat mitral regurgitation and promote left ventricular reverse remodeling. This observational study evaluates clinical and echocardiographic outcomes of an individualized medico-surgical approach, focusing on mitral regurgitation recurrence and left ventricular reverse remodeling. Sixty-nine consecutive patients with heart failure (New York Heart Association class III/IV) with functional mitral regurgitation (grade 3+/4+) and left ventricular remodeling (end-diastolic volume 227 ± 73 mL, ejection fraction 26% ± 8%) underwent restrictive mitral annuloplasty (median ring size 26), with (n = 41) or without (n = 28) a cardiac support device and optimal postoperative medical treatment. Patients were clinically and echocardiographically evaluated at up to 3.1 years' median follow-up. Early mortality was 5.8%. Actuarial survival at 1, 2, and 5 years was 86% ± 4%, 79% ± 5%, and 63% ± 7%. New York Heart Association class improved from 3.1 ± 0.4 to 2.0 ± 0.5 (P &lt; .01). Cardiac support device implantation in addition to mitral valve surgery, applied in patients with more advanced left ventricular remodeling, resulted in similar clinical outcome, greater left ventricular end-diastolic volume decrease (33% vs 18%; P = .007), and in a trend toward less recurrent mitral regurgitation of grade 2+ or more (actuarial freedom at 3 years 89% ± 8% vs 63% ± 11%; P = .067). An individualized medico-surgical approach to nonischemic cardiomyopathy combining restrictive mitral annuloplasty, cardiac support device implantation, and optimal medical management leads to favorable survival and improved functional status, low incidence of significant recurrent mitral regurgitation, and sustained left ventricular reverse remodeling." }, { "id": "pubmed23n0043_17273", "title": "[Treatment results in patients with mitral valve disease in IV functional class of NYHA. I. Surgical treatment].", "score": 0.00980392156862745, "content": "In the group of 142 patients with mitral valve disease (61% in IV and 39% in III functional class of NYHA) the efficacy of mitral valve replacement (MVR) was analysed. In all of the patients clinical, noninvasive and invasive investigations were obtained and compared before an after surgery. After MVR a statistically significant differences (p &lt; 0.05 or p &lt; 0.01) of RHV, noninvasive and hemodynamic data was observed. The survival during ca 1836 days after surgery of patients in IV class of NYHA was 72%. The improvement of activities correlated well with changes of functional class of NYHA." }, { "id": "pubmed23n0582_19506", "title": "Selected ventriculoplasty for idiopathic dilated cardiomyopathy with advanced congestive heart failure: midterm results and risk analysis.", "score": 0.009708737864077669, "content": "To treat advanced heart failure due to idiopathic dilated cardiomyopathy, surgical ventricular restoration with mitral reconstruction was conducted and evaluated. In 95 patients (81 men, mean age: 54 years), New York Heart Association class III/IV was 44/51, and 33 patients (36%) were inotropic dependent preoperatively. Mitral regurgitation (&gt;or=2+) was noted in all patients. All patients underwent left ventriculoplasty (septal anterior ventricular exclusion in 38, partial left ventriculectomy in 57) and mitral reconstruction (repair 53, replacement 42). Fifty-two patients (55%) had concomitant tricuspid repair. Intra-aortic balloon pumping and left ventricular assist device was used in 24 patients and two patients, respectively. Hospital mortality was 11.6% (11 of 95), with 6.6% (5 of 76) in elective and 31.6% (6 of 19) in emergency operations. The ejection fraction and cardiac index increased from 22.3+/-6.3% to 27.2+/-8.0% and from 2.3+/-0.5 ml/m2/min to 2.8+/-0.5 ml/m2/min, respectively (p&lt;0.001). The endodiastolic volume index, endosystolic volume index and diastolic dimension decreased from 232.9+/-56.1 ml/m2 to 160.0+/-49.8 ml/m2, from 178.9+/-46.7 ml/m2 to 113.8+/-44.7 ml/m2 and from 82.0+/-9.0 mm to 68.9+/-11.6 mm, respectively (p&lt;0.001). Late death occurred in 27 patients with 22 cardiac deaths. The mean NYHA class was 1.7 among the survivors. One-, 3- and 5-year survival rates were 72.8%, 61.4% and 50.5%, respectively. In the 62 patients who were non-inotropic dependent preoperatively, 1-, 3-, and 5-year survival rates (81.8%, 73.7% and 62.9%) were significantly better than the inotropic-dependent group (55.3%, 37.3% and 28.0%). Patients with mitral annuloplasty showed a significantly higher 5-year survival rate than patients with mitral valve replacement (59.6% vs 43.6%) in univariate analysis. By application of the exclusion site selection method, the two different ventriculoplasty procedures did not show significant difference in survival rates. Multivariate analysis showed that preoperative inotropes and old age were significant predictors for postoperative mortality. The selected ventriculoplasty in combination with mitral annuloplasty is a useful option for patients with an extremely dilated left ventricle in idiopathic dilated cardiomyopathy. Surgery should be considered before inotropic dependency occurs when prior medical treatment has failed." }, { "id": "pubmed23n0724_13203", "title": "Therapeutic challenges and management of heart failure during pregnancy (part I).", "score": 0.009708737864077669, "content": "Therapeutic management in pregnant patients with heart failure still remains a challenge, even though in most pregnant women with cardiac diseases an outcome is good. A 32-year-old woman, 17 weeks pregnant, was admitted to hospital with heart failure (HF) NYHA class III/IV. Echocardiography revealed enlarged LV, LVEF 13%, significant mitral insufficiency and pulmonary hypertension. The patient wished to continue the pregnancy. In a life-threatening condition, metoprolol, enalapril, spironolactone (for 5 days), furosemide, and digitalis were administered. Enalapril was continued for 42 days. Then the patient was switched to a dihydralazine and isosorbide mononitrate regimen. The fetus was controlled ultrasonographically. In the 19th week of pregnancy, the patient's condition improved (NYHA class II, LVEF 23%). The patient experienced 2 more episodes of HF exacerbation. In the 26th week of pregnancy, in a primary prevention of sudden cardiac death and because of 2nd-degree AV block, an ICD was implanted. In the 32nd week of pregnancy a cesarean section was performed. A male infant was delivered. The patient made a good recovery and was discharged on the 7th postoperative day. The newborn was discharged after 4 weeks, in good general condition. At 1-year follow-up the patient presented NYHA class II.&lt;br /&gt;" }, { "id": "pubmed23n0492_5840", "title": "Comparison of benefits from cardiac resynchronization therapy in patients with ischemic cardiomyopathy versus idiopathic dilated cardiomyopathy.", "score": 0.009615384615384616, "content": "Cardiac resynchronization therapy (CRT) is a recently introduced therapeutic option for patients with severe heart failure and intraventricular conduction disturbances. However, it is estimated that 20% to 30% of patients may not respond to CRT. Patients with ischemic cardiomyopathy (IC) may respond less favorably to CRT compared with patients with idiopathic dilated cardiomyopathy (IDC). Accordingly, the beneficial effects of CRT were evaluated in 2 subsets of patients (IC and IDC). Seventy-four patients with end-stage heart failure, New York Heart Association (NYHA) class III or IV, left ventricular (LV) ejection fraction &lt;35%, QRS &gt;120ms, and left bundle branch block received a biventricular pacemaker. At baseline and 6 months after implantation these parameters were evaluated: NYHA class, Minnesota quality-of-life score, QRS duration, and 6-minute walking distance. LV ejection fraction and severity of mitral regurgitation were assessed before and 6 months after CRT using 2-dimensional echocardiography. Long-term follow-up and hospitalization rates were obtained up to 2 years. Of the 74 patients, 46% (n = 34) had IC and 54% (n = 40) IDC. At 6 months follow-up all clinical parameters, QRS duration, LV ejection fraction, and mitral regurgitation improved significantly in both groups. Long-term (2-year) follow-up showed a survival rate of 87.5% for patients with IDC and 88.3% for patients with IC. The percentages of responders to CRT (defined as an improvement in NYHA class &gt;or=1 grade) were comparable in both groups (65% vs 71%). Therefore, the underlying etiology of heart failure (IC vs IDC) was not related to the response to CRT." }, { "id": "pubmed23n0571_14598", "title": "[Guideline satisfying therapy for chronic heart failure].", "score": 0.009615384615384616, "content": "Chronic heart failure may be caused by systolic pump failure and/or impairment of diastolic filling of the ventricles. The standard pharmacotherapy for systolic heart failure includes an ACE inhibitor, betablocker, diuretics and, in patients with severe symptoms, a low dose aldosterone antagonist. An AT1 receptor blocker is indicated for those patients who do not tolerate ACE inhibitors. If patients remain in the functional class NYHA III-IV despite optimal medication and have cardiac dyssynchrony, biventricular pacing may improve the symptoms and prognosis. While evidence-based treatment significantly reduces morbidity and mortality in systolic heart failure, hardly any results from clinical trials are available for diastolic heart failure. Therefore, therapy in patients with diastolic heart failure remains in most cases empirical." }, { "id": "pubmed23n1123_11648", "title": "A case report of balloon-assisted tracking to overcome coronary sinus competent valve: a novel technique in left ventricular lead implantation.", "score": 0.009523809523809525, "content": "Competent lateral and posterolateral valves showed proximal tortuosity that might hinder left ventricular (LV) lead implantation in cardiac resynchronization therapy (CRT). A 57-year-old woman was diagnosed as non-ischaemic cardiomyopathy, no other comorbidities, complaining of dyspnoea [New York Heart Association (NYHA) class III], and on optimal medical therapy. Electrocardiogram showed left bundle branch block with QRS duration 150 ms. The patient was candidate for CRT. However, during LV lead implantation, a competent posterolateral vein valve and proximal tortuosity hindered LV lead implantation that was overcome by balloon-assisted tracking technique. At 9 months of follow-up, the patient had NYHA class II, ejection fraction improved to 38%, and all implanted leads were still in place. Balloon-assisted tracking technique can be used to cross coronary sinus and smaller veins with competent valves and coronary veins tortuosity." }, { "id": "pubmed23n0364_14894", "title": "[The use of beta blockers in heart failure: clinical studies].", "score": 0.009523809523809525, "content": "Although inhibitors of angiotensin-converting enzyme (ACE) have improved the treatment of chronic heart failure (CHF), mortality related to this disorder remains unacceptably high. Results from studies started more than 25 years ago in Sweden suggested that long-term therapy with beta-blockers could improve hemodynamics and increase survival in patients with CHF; this hypothesis is confirmed by the results of six double-blind, randomized, placebo-controlled trials (MDC, CIBIS, ANZ, US Carvedilol Study, CIBIS II and MERIT-HF) who enrolled about 9000 patients with CHF. In these trials beta-blockers (metoprolol, bisoprolol or carvedilol) where added to the stable usual treatment of each patient (ACE-inhibitors, diuretics, digoxin). Baseline characteristics of patients enrolled into the beta-blocker or placebo arm were similar in all these studies. Specifically the mean patient's age was &lt; 60 years, with a mean left ventricular ejection fraction of 25-26%, 30% of enrolled patients were in NYHA functional class II and 60% in NYHA functional class III, CHF was due to ischemic heart disease in about 60% of patients. The average follow-up for all the trials was 14.5 +/- 5.6 months. On the whole in patients on beta-blocker treatment there is a 33.3% reduction in total mortality rate, a 34.2% reduction in cardiac death rate, a 37.7% reduction in sudden death rate, and a 41.7% reduction in worsening heart failure mortality rate. Moreover, in beta-blocker patients there is a 31.7% reduction in all-cause readmissions to hospital and a 26% reduction in the combined end point (total mortality and hospital readmission). Beta-blockers improved ventricular function but there was no significant improvement in functional capacity. In conclusion, the results of the six trials considered indicate that there is convincing evidence supporting a favorable effect of beta-blockade on the risk of death and readmission to hospital in patients with dilated cardiomyopathy with systolic dysfunction, aged &lt; 70 years, in NYHA functional class II-III. The effects of these drugs in CHF patients a) with normal left ventricular ejection fraction, b) aged &gt; 65-70 years, c) in NYHA functional class IV, and d) with comorbilities such as obstructive lung disease, diabetes, peripheral arterial diseases, require additional study." }, { "id": "pubmed23n0534_252", "title": "Determinants of mortality in patients undergoing cardiac resynchronization therapy: baseline clinical, echocardiographic, and angioscintigraphic evaluation prior to resynchronization.", "score": 0.009433962264150943, "content": "In dilated cardiomyopathy (DCM) patients (pts) with cardiac resynchronization therapy (CRT) for ventricular dyssynchrony, long-term predictors of mortality and morbidity remain poorly investigated. We reviewed data of 102 pts, 68 +/- 10 years, NYHA Class II-IV (14 Class II, 67 Class III, 21 Class IV), who benefited from CRT (69 CRT, 33 CRT-ICD). Fifty-two patients had an ischemic DCM, 36 a previously implanted conventional PM/ICD, 29 a permanent atrial fibrillation, and 19 needed dobutamine in the month preceding implant. QRS duration was 187 +/- 35 ms, left ventricular end-diastolic diameter 72 +/- 10 mm, mitral regurgitation severity 1.9 +/- 0.8, echographic aorto-pulmonary electromechanical delay 61.5 +/- 25 ms and septo-lateral left intraventricular delay 86 +/- 56 ms, pulmonary artery pressure (PAP) 43 +/- 11 mmHg, angioscintigraphic left ventricular ejection fraction (EF) 20 +/- 9%, and right ventricular EF 30.5 +/- 14%. Over a mean follow-up of 23 +/- 20 months, 26 pts died (18 heart failures (HFs), 1 arrhythmic storm, 7 noncardiac deaths). Positive univariate predictors of death from any cause were NYHA Class IV (P &lt; 0.001), and need for dobutamine the month preceding CRT (P &lt; 0.008), while use of beta-blocking agents (P &lt; 0.08) and left ventricular EF (P &lt; 0.09) were negative ones. NYHA Class IV was the only independent predictor at multivariate analysis (P &lt; 0.01). Survival at 24 months was 85% in Class II, 80% in Class III, and 37% in Class IV (II vs III, P = ns; III vs IV, P &lt; 0.001). When using a composite endpoint of death from any cause and unplanned rehospitalization for a major cardiovascular event, there were 48 events (14 HF deaths, 3 noncardiac deaths, 26 HF rehospitalizations, 2 paroxysmal atrial fibrillation, 2 sustained ventricular tachycardia, 1 nonfatal pulmonary embolism). Predictors of death from any cause/unplanned rehospitalization for a major cardiovascular event in the follow-up were NYHA Class IV (P &lt; 0.001), need for dobutamine during the month preceding CRT (P &lt; 0.002), and PAP (&lt;0.02). NYHA Class IV was the only independent predictor at multivariate analysis (P &lt; 0.05). Event-free proportion at 24 months was 70% in Class II, 64% in Class III, and 37% in Class IV (II vs III, P = ns; III vs IV, P &lt; 0.01). When considering determinants of mortality only in NYHA Class IV patients, no variable was significantly correlated to mortality. Need for dobutamine during the last month preceding CRT did not add an adjunctive mortality risk. Baseline NYHA Class IV at implantation appears as the most important determinant of a poor clinical outcome in terms of both mortality and morbidity. No predictive criteria seem available for NYHA Class IV patients, in order to discriminate who will die after CRT and who will not. NYHA Class IV strongly influences the clinical outcome, suggesting that, in future studies planned on mortality and rehospitalization as major endpoints, baseline NYHA Class IV should be separately taken into account." }, { "id": "pubmed23n0627_870", "title": "Cardiac resynchronization therapy in NYHA class IV heart failure.", "score": 0.009433962264150943, "content": "Clinical practice guidelines recommend cardiac resynchronization therapy (CRT) for ambulatory New York Heart Association (NYHA) class IV patients with a QRS duration &gt;or= 120 ms and a left ventricular ejection fraction &lt;or= 35%. Only two prospective, randomized trials have compared outcomes after CRT in NYHA class III and IV patients. CRT improved mortality, exercise capacity, and quality of life in class IV patients, but the 1-year mortality remained high. Patients in these trials were in sinus rhythm at randomization and most patients had a left bundle branch block. Less data are available for NYHA class IV patients with atrial fibrillation, right bundle branch block, and previous ventricular pacing. No prospective randomized data are available for the use of CRT as rescue therapy in inotrope-dependent patients, but several case series have reported promising results. It is likely that \"rescue therapy\" with CRT will be most beneficial when patients improve enough with CRT to allow reinstitution of angiotensin-converting enzyme inhibitors and beta blockers." }, { "id": "pubmed23n0334_10774", "title": "Early and intermediate results of left ventricular reduction surgery.", "score": 0.009345794392523364, "content": "Left ventricular reduction surgery is a new surgical option for treatment of end-stage cardiac dysfunction, and little is known about hemodynamics and outcome in the European heart failure population. We present our early results with this operation. From January 1995 to September 1997, 30 patients (25 men, 5 women; mean age 61.2 years) underwent partial left ventriculectomy. The underlying disease was ischemic in 18 patients and idiopathic dilated cardiomyopathy in 12 patients. Preoperatively 23 patients were in New York Heart Association functional class IV and 7 were in class III. Mean cardiac index, stroke index and ejection fraction were 1.8 +/- 0.3 l/m2 per min, 23.5 +/- 5.1 ml/m2 and 19.3% +/- 6.8%, respectively. Associated procedures were coronary bypass in 18 patients, mitral valvuloplasty in one, aortic or mitral valve replacement in three, dynamic cardiomyoplasty in two, and left ventricular assist device implantation in 1. There were two early deaths: one from bleeding and one from anticoagulant-related cerebral hemorrhage. Regarding late deaths, one patient died from pneumonia 3 months after the operation and two died from dysrhythmia 4 and 17 months postoperatively. The estimated 1-year survival rate calculated by the Kaplan-Meier log-rank method was 85%. Mean cardiac index, stroke index, and ejection fraction rose significantly (P = 0.0001) to 2.9 +/- 0.51/m2 per min, 36.9 +/- 6.2 ml/m2 and 37.8% +/- 9.2%, respectively. Currently 26 patients are in New York Heart Association functional class I or II. Left ventricular reduction surgery improves objective and subjective parameters of cardiac performance significantly in early and intermediate follow-up. Randomized studies and carefully documented long-term results seem to be necessary to define the role of left ventricular reduction surgery." }, { "id": "pubmed23n0371_468", "title": "The management of heart failure--an overview.", "score": 0.009345794392523364, "content": "National and international societies have issued guidelines on the management of heart failure: The European Society of Cardiology, WHO, ACC/AHA Task Force Report, US Department of Health and Human Services, German Society of Cardiology. The therapeutic approaches to heart failure have undergone considerable changes during the last few years. The guidelines have to be updated almost yearly due to new results from prospective randomized studies. Although an agreement could be reached with respect to general measures and drug treatment, no agreement on mechanical devices, pacemakers and surgical interventions has been reached. The basis for medical treatment of chronic heart failure depends on diuretics, digitalis, ACE inhibitors, and beta-blockers. Calcium antagonists and other positive inotropic drugs, other than digitalis, should be avoided as far as possible. Thiazides, loop diuretics and aldosterone antagonists are needed for acute and chronic treatment of heart failure, alone or in combination (diuretic resistant heart failure!). Digitalis glycosides are needed in patients with atrial fibrillation with a fast ventricular rate or atrial flutter and in patients with systolic dysfunction, large hearts and symptomatic failure class NYHA III and IV. However, digitalis does not convert atrial fibrillation to sinus rhythm. Today there is no question that ACE inhibitors improve the prognosis of all patients with heart failure in all stages, if ejection fraction is reduced. Therefore, most patients after myocardial infarction or after having experienced pump failure due to myocarditis or cardiomyopathy are treated with ACE inhibitors and diuretics. The beneficial effects of ACE inhibitors seem to be most pronounced the worse the situation is. Relative risk reductions (mortality!) between 10% and 40% have been published depending on the severity of symptomatic left ventricular dysfunction. Those patients with high absolute risk have more to gain than those with low risk for any given \"risk reduction\", of course. Recent studies also indicate that most high risk cardiac patients profit from ACE inhibitors even if pump function is normal (i.e., patients with coronary heart disease, diabetes mellitus, cerebral vascular disease, hypertension) (15). AT1 antagonists can substitute for ACE inhibitors, if the latter are not tolerated due to cough. Up to now, beta-blocking agents apart from diuretics seem to be the best investigated drugs in heart failure. Large controlled studies with bisoprolol, carvedilol and metoprolol in addition to diuretics, digitalis and ACE inhibitors convincingly yielded positive results in chronic left ventricular failure patients. Reduction of mortality by 35% and even of sudden cardiac deaths by 40% have been proven beyond doubt. Thus, heart failure patients today should also receive beta-blocking agents in all stages of the disease. In the era of controlled prospective studies (evidence-based medicine), physicians are well advised to use only drugs that have been proven beneficial in large controlled studies." }, { "id": "pubmed23n0570_2042", "title": "[Recent advances and limitations of medical treatment on heart failure].", "score": 0.009259259259259259, "content": "Main part of the management of chronic heart failure is pharmaceutical therapy. In patients with chronic heart failure due to left ventricular systolic dysfunction, enhanced activation of neurohormonal systems including sympathetic nerve and renin-angiotensin-aldosterone system plays the most important role in its progression and poor prognosis. Therefore, principle of treatment of chronic heart failure is inhibition of the elevated neurohormonal activity. Angiotensin converting enzyme inhibitors and beta blockers are class I drugs of choice. In patients who can not tolerate angiotensin converting enzyme inhibitors, angiotensin II receptor blockers are used as replacement. In patients with severe heart failure [New York Heart Association (NYHA) class &gt; III], aldosterone antagonists are added. Diuretics are also class I drug necessary for an improvement of symptoms of heart failure. Recently, implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) are implanted more frequently, because volume of evidence indicates benefits of these non-pharmacological treatments. In this paper, recent advance in medical therapy for patients with heart failure and its limitation is discussed." }, { "id": "wiki20220301en063_19538", "title": "Valvular heart disease", "score": 0.009255696635458083, "content": "Mitral regurgitation Surgery is recommended for chronic severe mitral regurgitation in symptomatic patients with left ventricular ejection fraction (LVEF) of greater than 30%, and asymptomatic patients with LVEF of 30-60% or left ventricular end diastolic volume (LVEDV) > 40%. Surgical repair of the leaflets is preferred to mitral valve replacement as long as the repair is feasible. Mitral regurgitation may be treated medically with vasodilators, diuretics, digoxin, antiarrhythmics, and chronic anticoagulation. Mild to moderate mitral regurgitation should be followed with echocardiography and cardiac stress test every 1–3 years. Severe mitral regurgitation should be followed with echocardiography every 3–6 months." }, { "id": "pubmed23n0326_14065", "title": "Two-year experience of the Batista operation for non-ischemic cardiomyopathy.", "score": 0.009174311926605505, "content": "The Batista operation was performed in 30 patients (25 men and 5 women, mean age 47 years) to treat cardiac failure due to non-ischemic cardiomyopathy, mostly idiopathic dilated cardiomyopathy, from December 1996 to June 1998. Preoperative New York Heart Association (NYHA) class was IV in 21 patients including 17 receiving inotropic support, and class III in 9 patients. Seven patients required emergency surgery because of on-going shock and 23 patients were operated electively. Combined cardiac procedures were; mitral valve reconstruction in 26 patients (19 replacements, 7 repairs), tricuspid annuloplasty in 15, aortic valve replacement in 3 and one each of maze and coronary artery bypass grafting. All patients successfully weaned from cardiopulmonary bypass. Intraaortic balloon pump was used in 6 patients but no left ventricular assist device was used. Two of 23 patients (8.7%) who underwent elective operation died during hospitalization and 3 patients (13.0%) died in the late period. Six of 7 patients (85.7%) with emergency operation died in the hospital and only one survived. Sixteen of 19 survivors returned to NYHA class I-II, and 3 were in class III. Mean ejection fraction increased from 18 +/- 6% to 31 +/- 5%. Diastolic dimension decreased from 79 +/- 8 to 60 +/- 8 mm. End-diastolic and systolic volume indices decreased from 203 +/- 43 to 103 +/- 25 ml/m2 and from 164 +/- 39 to 70 +/- 25 ml/m2, respectively, at the second postoperative week. Six patients had ventriculography at one year after the operation, and no redilation was noted. Increased thickness of left ventricular wall was observed postoperatively. The Batista operation can be performed with relatively low risk and clinical improvement was obvious in elective operation, wheras risk is very high in emergency cases. Therefore, proper guidelines for patient selection and choice of procedure are critically important to achieve a successful outcome in the Batista operation." }, { "id": "pubmed23n0419_17043", "title": "[Therapeutic perspectives in heart failure]].", "score": 0.009174311926605505, "content": "Many different diseases may lead to heart failure. Nevertheless, the symptoms and pathophysiological changes in heart failure are uniform as are the basic principles of treatment. Although significant progress has been achieved in understanding the biology of heart failure and the therapeutic options, the quality of life of heart failure patients and their survival are often poor. Since cardiac transplantation as a final therapeutic option is limited by the availability of donor organs, new strategies and technologies need to be explored to treat the failing heart effectively. Approaches to improve the medical therapy of heart failure mainly focus on strategies to escape the vicious circle of decreased contractility and neurohumoral activation. Substances with promising experimental and clinical results include neutral endopeptidase inhibitors, endothelin antagonists or cytokine inhibitors, e.g. TNF antagonists. Mechanical and electrical devices are under development such as left ventricular assist devices (LVADs), biventricular pacemakers and artificial hearts, which may become valuable alternative therapies. Gene therapy approaches aim to improve the vascularization of the heart, the Ca-homeostasis of the myocytes or the survival of cardiac cells in disease. Finally, cellular cardiomyoplasty is a relatively novel approach to replace or support the cardiomyocytes of the diseased heart by implanting new ones. Which cell type under which conditions will turn out to be the most suitable is still unknown and subject to debate. Ongoing clinical studies will only help to demonstrate the safety and feasibility of this technique but not determine its long-term efficacy. It is highly desirable that one of these new therapeutic strategies or a combination of them will have a significant impact on the future management of heart failure. Currently, our main clinical focus must be to treat as many patients as possible with drugs that are known to improve symptoms and survival, like ACE inhibitors, beta-blockers, cardiac glycosides, diuretics and spironolactone." }, { "id": "pubmed23n0497_14966", "title": "Left ventricular reconstruction: Early and late results.", "score": 0.00909090909090909, "content": "In patients with coronary disease and poor left ventricular function, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. This study reports results achieved with ventricular reconstruction in 285 patients who had akinesia or dyskinesia associated with relative wall thinning. Data were prospectively collected. Reconstruction on the beating heart was accomplished by a modified linear closure plus septoplasty, when indicated, (dyskinetic septum). Preoperatively, 237 (83%) were in symptom class III or IV with congestive heart failure (n =174; 61%), angina (n = 157; 55%), or ventricular tachycardia (n = 107; 38%). Average ejection fraction was 24% +/- 11%, and 144 (51%) had preoperative grade 2+ mitral regurgitation. Operative procedures included coronary artery bypass grafting in 262 (92%), septoplasty in 64 (22%), ablation of ventricular tachycardia in 118 (41%), and a mitral valve procedure in 6 (2%). Operating room mortality was 2.8%. Perioperative support included intra-aortic balloon pumping in 49 (17%) and inotropic drugs in 154 (54%). During a mean follow-up of 63 +/- 48 months, 8 patients required transplantation (interval of 49 +/- 41 months), 2 needed mitral valve replacement, and 9 required use of an implantable cardioverter-defibrillator for ventricular tachycardia. At 1, 5, and 10 years actuarial survivals were 92%, 82%, and 62%. Freedom from sudden death was 99%, 97%, and 94%. Among survivors, symptom class improved in 140 of 208 patients (67%), mean improvement 1.3 +/- 1.1 functional class per patient. Average increase in ejection fraction postoperatively was 10% +/- 9%. Using wall thinning as a criterion for patient selection, left ventricular reconstruction can be performed with low operative mortality, provides good control of symptoms, excellent long-term survival, and freedom from sudden death. This approach should be considered in all patients with coronary disease, poor left ventricular function, and relative wall thinning." }, { "id": "pubmed23n0387_15203", "title": "Debate: Do all patients with heart failure require automatic implantable defibrillators for the prevention of sudden death?", "score": 0.00909090909090909, "content": "Recent clinical trials indicate that approximately two-thirds of patients in New York Heart Association (NYHA) class II and III, who comprise almost 90% of patients with heart failure, die suddenly. Patients in NYHA class IV usually die of progressive heart failure. Implantation of implantable cardioverters defibrillators (ICDs) in this population would represent a huge logistic problem and economic expense. Clinical trials have recently demonstrated that beta-blocker therapy with carvedilol, bisoprolol, and toprol XL decrease the sudden death rate by almost 50%, in addition to impacting significantly on death due to worsening heart failure. This medical approach is beneficial to all patients, and should be our major therapy. However, it is reasonable to attempt to identify that subpopulations of heart failure patients who could benefit from an ICD." }, { "id": "pubmed23n0852_10888", "title": "The clinical benefit of cardiac resynchronization therapy optimization using a device-based hemodynamic sensor in a patient with dilated cardiomyopathy: a case report.", "score": 0.009009009009009009, "content": "Results on the evolution of the clinical status of patients undergoing cardiac resynchronization therapy with a defibrillator after automatic optimization of their cardiac resynchronization therapy are scarce. We observed a rapid and important change in the clinical status of our non-responding patient following activation of a sensor capable of weekly atrioventricular and interventricular delays' optimization. A 78-year-old Caucasian man presented with dilated cardiomyopathy, left bundle branch block, a left ventricular ejection fraction of 35 %, New York Heart Association class III/IV heart failure, and paroxysmal atrial fibrillation. Our patient was implanted with a cardiac resynchronization device with a defibrillator and the SonRtip atrial lead. Right ventricular and left ventricular leads were also implanted. Because of the recurrence of atrial fibrillation, the automatic optimization was set off at discharge. Consequently, the device did not optimize atrioventricular and interventricular delays (programming at discharge: 125 ms for the atrioventricular delay and 0 ms for the interventriculardelay). Our patient was treated with an anti-arrhythmic drug. Five months after implantation, his clinical status remained impaired (left ventricular ejection fraction = 30 %). The SonR signal amplitude had also decreased from 0.52 g to 0.29 g. Nevertheless, because our patient was no longer presenting with atrial fibrillation, the anti-arrhythmic treatment was stopped and the SonR optimization system was activated. After 2 months of automatic cardiac resynchronization therapy with defibrillator optimization, our patient's clinical status had significantly improved (left ventricular ejection fraction = 60 %, New York Heart Association class II) and the SonR signal amplitude had doubled shortly after the first weekly automatic optimization. In this non-responding patient, device-based automatic cardiac resynchronization therapy optimization was shown to significantly improve his clinical status." }, { "id": "pubmed23n1047_5378", "title": "The Treatment of Heart Failure with Reduced Ejection Fraction.", "score": 0.009009009009009009, "content": "Chronic congestive heart failure is a common condition that, if untreated, markedly impairs the quality of life and is associated with a high risk of recurrent hospitalization and death. This review is based on articles retrieved by a selective search in PubMed, as well as on relevant guidelines. Evidence-based treatment options are available only for congestive heart failure with a low ejection fraction. Pharma - cotherapy is based on neurohumoral inhibition of the renin-angiotensin-aldosterone system and the adrenergic system. The prognosis of patients with this condition has been further improved recently through the introduction of combined angiotensin receptor antagonists and neprilysin inhibitors. Modern implantable devices are a further component of treatment. Implantable defibrillators and special pacemakers for cardiac resynchronization are well established; the utility of alternative devices (baroreflex modulation or cardiac contractility modulation) needs to be investigated in further studies. It was recently shown that the catheter-based treatment of secondary mitral regurgitation with a MitraClip improves the outcome of selected patients. The treatment of chronic systolic heart failure as recommended in the relevant guidelines, with drugs and implanted devices if indicated, can significantly improve the clinical outcome." }, { "id": "pubmed23n0526_24562", "title": "Resynchronization of mitral valve annular segments reduces functional mitral regurgitation in cardiac resynchronization therapy.", "score": 0.008928571428571428, "content": "Cardiac resynchronization therapy (CRT) reduces the severity of functional mitral regurgitation (FMR) in patients with heart failure and left bundle branch block. Our hypothesis was that the induction of a more synchronous mitral valve anulus contraction can be a mechanism of FMR reduction in CRT patients. An echo tissue Doppler imaging (TDI) examination was performed at baseline and 6 months after biventricular pacing system implant in 30 patients (4 females and 26 males, 74.1+/-6.1 years) with dilatative or ischemic chronic heart failure, NYHA class = or &gt;III, ejection fraction (EF) = or &lt;35% and QRS = or &gt;140 ms. EF, Myocardial Performance Index (MPI), left end-diastolic and systolic volumes (LVEDV, LVESV), mitral regurgitation jet area/left atrial area (JA/LAA), effective regurgitant orifice area (EROA), mitral anulus contraction (MAC) were evaluated. Using TDI, at the 6 left ventricle (LV) basal segments the time to the peak myocardial sustained systolic velocity (Ts) and the standard deviation (SD) of TS were evaluated. At 6 months follow-up NYHA class, EF, MPI were significantly improved, LV volumes were reduced. FMR degree, evaluated both as JA/LAA and EROA, was significantly reduced. This effect was associated with the 6 basal segments resynchronization and with a more effective annular contraction. Our data show that CRT by resynchronizing left ventricular basal segments produces a more effective mitral valve annulus contraction and contributes to FMR improvement. Further studies need to evaluate if this could be taken into account as new therapeutic perspective of functional mitral valve regurgitation." }, { "id": "pubmed23n1166_7465", "title": "Meta-Analysis on Drug and Device Therapy of New York Heart Association Functional Class IV Heart Failure With Reduced Ejection Fraction.", "score": 0.008928571428571428, "content": "Heart failure with reduced ejection fraction (HFrEF) is associated with significant morbidity and mortality, particularly in patients with New York Heart Association (NYHA) functional class IV symptoms. Decades of discovery have heralded significant advancements in the pharmacologic management of HFrEF. However, patients with NYHA IV symptoms remain an under-represented population in almost every clinical trial to date, leaving clinicians with limited evidence with which to guide drug treatment decisions in this patient group with severe heart failure. Randomized controlled trials of adult patients with NYHA IV symptoms of HFrEF randomized to current guideline-recommended medical therapy were included in this systematic review and meta-analysis. The outcomes of interest included the rate of all-cause mortality, cardiovascular mortality, and heart failure hospitalization. A total of 39 randomized controlled trials were included. A total of 6 studies examined angiotensin converting enzyme inhibitors, with meta-analyses of 2 demonstrating a reduced risk of all-cause mortality (relative risk (RR) 0.76, 95% confidence interval 0.59 to 0.97, p = 0.03). A total of 11 studies examined β blockers, with meta-analysis of 6 demonstrating a reduced risk of all-cause mortality (risk ratio 0.74, 95% confidence interval 0.60 to 0.92, p = 0.008). A study examined the mineralocorticoid antagonist spironolactone, reporting a reduced risk of all-cause mortality in the NYHA IV subgroup. A total of 6 studies examined device therapy, demonstrating the benefit of cardiac resynchronization therapy with or without an implantable cardiac defibrillator in reducing hospitalization in the NYHA IV subgroup. Although trial evidence exists for angiotensin converting enzyme inhibitors, β-blockers, and mineralocorticoid antagonist therapy in the NYHA IV population, the role of angiotensin receptor blockers is unclear. Ivabradine, angiotensin receptor neprilysin inhibitors, and sodium-glucose transport protein 2 inhibitors remain underinvestigated and have not been proved to provide any benefit above standard heart failure therapy in patients with HFrEF and NYHA IV symptoms." }, { "id": "wiki20220301en275_13001", "title": "Management of heart failure", "score": 0.008870433189066947, "content": "AICD: Patients with NYHA class II, III or IV, and LVEF of 35% (without a QRS requirement) may also benefit from an implantable cardioverter-defibrillator (ICD), a device that is proven to reduce all-cause mortality by 23% compared to placebo in patients who were already optimally managed on drug therapy. Patients with severe cardiomyopathy are at high risk for sudden cardiac death due to ventricular dysrhythmias. Although ICDs deliver electrical shocks to resynchronize heart rhythm which are potentially distressing to the patient, they have not been shown to affect quality of life. The number of (appropriate and inappropriate) shocks seems to be associated with a worse outcome. Although they are expensive, ICDs are potentially cost-effective in this setting." }, { "id": "pubmed23n0320_18873", "title": "[Results of aortic valve replacement surgery in patients over 75 years of age].", "score": 0.008849557522123894, "content": "The increase in the mean populational age has increased the number of elderly people eligible for cardiac surgery. The aortic pathology represents the most common valvular pathology, mainly of degenerative etiology. The efficiency of the aortic valve replacement in people aged over 75 years was studied, with evaluation of hospital mortality, survival and functional class (NYHA). A total of 51 patients (25 males and 26 females, mean age 76.4 years [range: 75-83]) underwent aortic valve replacement from October 1989 to February 1997. The most common condition was aortic stenosis (62.7%), followed by aortic insufficiency (19%) and double aortic lesion (17%). Moreover, 31.3% of patients required also coronary surgery with a mean of 1.1 grafts per patient. In 13.7% of cases surgery on mitral valve was performed (1 commissurotomy, 1 mitral prosthesis, 5 valve prostheses). In 10% of patients the procedure had to be performed on an emergency basis. The functional class of patients prior to surgery was NYHA grade III for 37% and grade IV for 10% of cases. The clinical symptoms corresponded to angor in 15 cases (29.4%) and syncope in four cases (7.8%). In nine patients the left ventricular ejection fraction prior to surgery was below 50%. Aortic bioprostheses were implanted in 86.2% of cases. The hospital fatality rate was 13.7% (7 cases). In the univariate analysis the following mortality risk factors reached statistical significance: left ventricular ejection fraction prior to surgery below 50%, associated surgery and size of aortic prosthesis. In the multivariate analysis the following risk factors were significant: left ventricular ejection fraction prior to surgery below 50% and associated mitral surgery. The follow-up was performed in 100% of patients, with a mean time of 29.6 months. One patient died during follow-up. The functional class was NYHA grade I in 95.2% of cases. The actuarial survival, including hospital mortality, was 84.2% at 5 years. Despite a higher mortality in the aortic valve replacement surgery in patients aged over 75 years compared with general population, results, long-term survival and life quality of patients, renders surgery a non refusable first option as therapy for aortic valve pathology in this age group. Nevertheless, avoiding the deterioration of preoperative left ventricular function is imperative, mainly in those cases with concomitant mitral pathology, as both factors significantly contribute to an increase in mortality in this group." }, { "id": "pubmed23n0543_12562", "title": "[Contemporary approaches to the treatment of chronic heart failure in adults (after materials of recommendations of American College of Cardiology and American Heart Association, 2005)].", "score": 0.008849557522123894, "content": "Detailed and critical analysis of a novel version of the \"Updated Guideline for the Diagnosis and Management of Chronic Heart Failure (CHF) in the Adult\" prepared by experts of American College of Cardiology and American Heart Association is given. The novel version contains somewhat modified recommendations on the management of patients with CHF. In particular this relates to the place of various classes of drugs in the treatment of CHF due to systolic left ventricular dysfunction. For the first time recommendations on the treatment of patients with CHF and normal left ventricular ejection fraction are presented in detail. Among statements of the updated guideline the following are considered controversial or deserving special discussion. Perindopril is mentioned among recommended ACE inhibitors despite the fact that it has never been studied in long term trials. Results of SENIORS trial are ignored and nebivolol is not included in the number of beta-blockers with proven efficacy. Despite multiple proofs of beneficial effects of aldosterone receptor blockers on clinical course of CHF wide use of spironolactone and eplerenone is not recommended because of multiple communications about life threatening hyperkalemia. Inherent dangers of digoxin therapy are disregarded and the use of cardiac glycosides in patients with sinus rhythm is not prohibited." }, { "id": "pubmed23n0650_7133", "title": "[Clinical experience of surgical treatment on hypertrophic obstructive cardiomyopathy].", "score": 0.008771929824561403, "content": "To evaluate the surgical outcome of hypertrophic obstructive cardiomyopathy (HOCM). From October 1996 to December 2007, 54 HOCM patients underwent surgical treatment. There were 37 males and 17 females ranging from 6 to 68 years old (36 +/- 16) with body weight 27-83 (60 +/- 14) kg. Operation was performed under general anesthesia and cardiopulmonary bypass (CPB) with the moderate systemic temperature and low volume blood flow. The concomitant operations included coronary artery bypass grafting in 5 cases, mitral valve plasty in 5 cases, mitral valve replacement in 9 cases, tricuspid valve plasty in 2 cases, aortic valve replacement in 4 cases and closure of patent ductus arteriosus in 2 cases. Preoperative and postoperative left ventricular (LV), left ventricular outflow tract (LVOT), left atrium (LA), mitral valve function and value of LVEF were evaluated by transesophageal echocardiograph examination. The time of CPB and aortic occlusion were 40 to 290 minutes (107 +/- 52) and 27 to 195 min (70 +/- 36 min) respectively. The endotracheal intubation durations were 5 to 21 hours (14 +/- 15) and ICU duration 11 to 183 hours (45 +/- 34). Comparing with the pre-operative echocardiographic parameters, the size of left atrium (42 +/- 8 vs 35 +/- 7), pressure gradients through LVOT (106 +/- 44 mm Hg vs 24 +/- 19 mm Hg), the thickness of septum (27 +/- 6 mm vs 19 +/- 5 mm) and the value of EF (70 +/- 10 vs 61 +/- 9) obviously decreased postoperatively (P &lt; 0.05). The surviving patients had either no mitral valve regurgitation or only mild mitral valve regurgitation. Four (7.4%) patients died during the perioperative period. The cause of death included severe low cardiac output, heart failure, severe ventricular arrhythmias and severe acute renal failure. There were 4 patients with a complete AV block postoperatively and 3 were implanted permanent pacemakers. The left bundle branch block or left anterior hemiblock were found in 26 cases, intraventricular conduction defect in 6 cases and type I AV block in 4 cases. All surviving patients were in NYHA functional class I/II during the follow-up of 1 month to 10 years. Surgical outcome for HOCM patients is satisfactory. Most HOCM patients achieve such a satisfactory relief of LV outflow tract obstruction as to lead a better life." }, { "id": "pubmed23n0392_19644", "title": "[Effect of long-term treatment with enalapril, losartan and their combination on the quality of life of patients with congestive heart failure].", "score": 0.008771929824561403, "content": "To study the effect a combination of enalapril and losartan on life quality in patients with congestive heart failure (HF). One hundred and eighty six patients with NYHA functional classes II to IV HF were examined. The study inclusion criteria were as follows: a left ventricular (LV) end-diastolic volume of &gt; 160 ml, a LV ejection fraction of &lt; 35%, sinus rhythm, a cardiothoracic index of &gt; 0.55, no history data on prior treatment with an angiotensin-converting enzyme inhibitor (ACEI) and/or an AT1-antagonist, a patient's written free-will consent to participate in the study. The exclusion criteria were as follows: pacemaker migration, an artificial pacemaker, high-degree block, atrial fibrillation, cerebral circulatory disorders. All the patients were divided into 4 groups and received basic therapy with cardicet, 60-120 mg/day, aspirin, 250 mg/day, furosemide, 80-440 mg/week, and digoxin, 0.25-0.5 mg/day. Group 1 comprised 60 patients who refused therapy with ACEI and/or AT1-antagonist despite that they had indications for their use and they had been convinced many times. In Group 2 (n = 82) enalapril, an ACEI, was added to the basic therapy. Its initial dose of 2.5 mg/day was given once and slowly incremented to the therapeutical one (10-20 mg/day). Group 3 patients (n = 56) on the basic therapy were additionally treated with the AT1-antagonist losartan in a daily dose of 25-50 mg. They were started on 12.5 mg a day. In group 4 the basic therapy was added by a combination of enalapril and losartan in the same doses. The follow-up was 48 weeks. The efficiency of the treatments was controlled by the personal questionnaires SF-36, Life with Heart Failure, by evaluating the magnitude of clinical HF manifestations and by estimating the total life quality inxed. The data were analyzed by assuming that all the patients received the treatments. As compared with the conventional therapy and the use of each drug alone, a combination of the ACEI enalapril and the AT1-antagonist losartan promotes a more significant increase in the satisfaction of the patients with their vital activity, in the critical rate of their self-assessment of the \"internal picture\" of disease, and leads to a greater improvement of the quality of their life as a whole. The ICAE-AT1-antagonist combination exerts a positive impact on life quality in patients with heart failure." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 25, 170 ] ], "word_ranges": [ [ 5, 21 ] ], "text": "Wiskott-Aldrich syndrome associates immunodeficiency, thrombopenia and atopic dermatitis with the immunological study described in the statement." }, "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": "Wiskott-Aldrich syndrome.", "2": "Hyper IgE syndrome.", "3": "Transient hypogammaglobulinemia of infancy.", "4": "Severe X-associated combined immunodeficiency.", "5": "Common variable immunodeficiency." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0423_22855", "title": "A case of IgG subclass deficiency with the initial presentation of transient hypogammaimmuno-globulinemia of infancy and a review of IgG subclass deficiencies.", "score": 0.018812930577636458, "content": "Primary immunodeficiency diseases are not common in children. The possibility of an immunological defect should be considered in any individual with repeated infections. A definite diagnosis for immodeficiency is sometimes difficult to achieve because of overlapping clinical manifestations. Immunoglobulin subclass deficiency is an immunological deficiency disease with which, one or more IgG subclasses are deficient. T cell immunity is normal. Patients may develop recurrent bacterial and respiratory infections or could remain asymptomatic. The authors report a case of immunoglobulin G subclass deficiency presenting initially as transient hypogammaglobulinemia of infancy. A 2 month-old boy presented to Siriraj Hospital with a history of chronic protracted diarrhea, disseminated scabies and sepsis. On presentation, he had generalized scaly and maculopapular rash with no palpable lymph nodes. CBC revealed WBC 22,100 cells/cm3 with PMN 42 per cent, lymphocytes 38 per cent, Eosinophils 4 per cent, Basophil 2 per cent and platelets 254,000/cm3. The immunoglobulin levels were as follows: IgG 181 mg/dl, IgA &lt; 6.6 mg/dl, IgM 26.3 mg/dl. Lymphocyte enumerations revealed CD4 of 2,433 cells/cm3 (N 1,460-5,160); CD8 4,682 cells/cm3 (N 650-2,450); CD19 1,588 cell/cm3 (N 500-1,500); CD16 230 cell/cm3 (N 573 +/- 264). The initial diagnosis was X-linked agammaglobulinemia vs common variable immunodeficiency disease. His diarrhea and five courses of sepsis responded well to antibiotics administration and courses of intravenous immunoglobulin (IVIG) replacement. His through IgG became normal at 2 years of age (after 12 months of IVIG). IVIG was stopped and the diagnosis was changed to transient hypogammaglobulinemia of infancy (THI). Nevertheless, during his 4 month follow-up he developed recurrent sinopulmonary infections (i.e, otitis media and pneumonia). Repeated immunoglobulin profile showed IgG 1,200 mg/dl, IgA 135 mg/dl, IgM 26 mg/dl, IgG subclass were IgG, 1,030 mg/dl (N 280-830), IgG2 30 mg/dl (N 40-2,400), IgG3 22 mg/dl (N 6-130), IgG4 3 mg/dl (N 3-120). A diagnosis of IgG2 subclass deficiency presenting early as transient hypogammaglobulinemia of infancy was then made. Treatment with monthly IVIG was reinitiated and the patient is currently doing well. The authors present a case of IgG subclass deficiency presenting as transient hypogammaglbulinemia of infancy. Follow-up of the immune profile and clinical manifestation is necessary for a definite diagnosis." }, { "id": "pubmed23n0703_8952", "title": "[Wiskott-Aldrich syndrome].", "score": 0.018311036789297658, "content": "The Wiskott-Aldrich syndrome is a primary immunodeficiency characterized by congenital microthrombocytopenia, eczema and recurrent infections. This paper reports the case of a 3-year-6-month male patient, whose maternal uncle died at the age of 3 months due to fulminant sepsis from a pulmonary infection. The patient was a product of the first pregnancy, he was born at 27 weeks' gestation and weighed 1,400 g. As a neonate he was hospitalized during the first 2 months of life because of a low gastrointestinal bleeding, thrombocytopenia and severe infections. In the next 4 months and before coming to our hospital the infant was hospitalized 54 times. On admission he presented disseminated dermatosis, enlarged neck lymph nodes and psychomotor retardation. Laboratory studies revealed hemoglobin 8.1 g/dL, platelets 31,000/uL, mean platelet volume 5.6 fL, IgM 39.3 mg/dL, IgA 67 mg/dL, IgG 1,380 mg/dL. On several occasions he received globular packages and platelet concentrates. The infusion of immunoglobulin G was started every 21 days. Bone marrow transplantation was delayed due to the complications that merited 13 hospitalizations and severe thrombocytopenia, low gastrointestinal bleeding, septic arthritis, infectious gastroenteritis, chronic suppurative otitis media and severe folliculitis. At the age of 4 years BMT of cord was performed, and 26 days after transplantation he presented septic shock and died. The prognosis of bone marrow transplantation in Wiskott-Aldrich syndrome and in other primary immunodeficiencies depends on the promptness of its performance at early stages in life. It is important that the first contact physicians be aware of the primary immunodeficiency signs and symptoms." }, { "id": "pubmed23n0521_19925", "title": "De novo mutation causing X-linked hyper-IgM syndrome: a family study in Taiwan.", "score": 0.017564043564963952, "content": "X-linked hyper-IgM syndrome (XHIM) is a rare primary immunodeficiency disorder caused by mutations of the gene encoding the CD40 ligand (CD40L). It is characterized by recurrent infections with markedly decreased serum IgG, IgA and IgE levels but normal or elevated IgM levels. We report the clinical manifestations and complete immune studies in the first family with molecularly proven XHIM in Taiwan. A 5-month-old boy presented with rapidly progressive pneumonia which responded poorly to antibiotics. High levels of IgM and very low levels of IgG, IgA, and IgE were noted in his plasma specimen: IgM, 128 mg/dl; IgG, 18 mg/dl; IgA, 4 mg/dl); IgE, 1 IU/ml. Whole blood flow cytometry when he was 21 months old showed that only a small percentage (0.48%) of his in vitro-activated CD4+ T cells expressed CD40L. When he was 3 years old, repeated flow cytometry showed essentially the same result (0.4%), compared with his father's CD40L expression of over 85%. The patient's mother had moderately decreased CD40L expression (74.4%). Hyper-IgM syndrome was confirmed by CD40L mutation analysis in the boy, which revealed a Lys 96 stop (nucleotide A307T) in exon 2 of CD40L, with a truncated protein resulting in the loss of the entire TNF domain. His mother was a carrier and apparently the individual in whom the mutation originated. Eleven other family members, including the patient's father, sister, and grandmother, and the mother's sisters and their children, all had normal results on CD40L mutation analysis. The patient has remained without significant bacterial infection on a regimen of monthly IVIG infusion and oral trimethoprim-sulfamethoxazole for Pneumocystis carinii pneumonia (PCP) prophylaxis, although he has had recurrent oral ulcers and neutropenia. Bone marrow transplantation is planned." }, { "id": "pubmed23n0525_4354", "title": "Wiskott-Aldrich syndrome complicated by an atypical lymphoproliferative disorder: a case report.", "score": 0.01694915254237288, "content": "Wiskott-Aldrich syndrome (WAS) is an X-linked syndrome consisting of eczema, recurrent pyogenic infection, and thrombocytopenia with decreased platelet volume. Immunologic studies reveal normal immunoglobulin G (IgG), decreased IgM, elevated IgA and IgE levels, and decreased T-cell function. Patients with WAS often have increased susceptibility to lymphoproliferative disorders (LPDs). We report a 3-year-old boy who had persistent thrombocytopenia with bleeding, recurrent infections, and chronic eczema with frequent skin infections since birth. A blood smear revealed small platelets (50% of normal size). Immunologic studies showed normal IgG (1880 mg/dL), decreased IgM (76 mg/dL) and increased IgA (228 mg/dL) and IgE (14,282 IU/mL) levels. The relative proportions of immune cells were CD2 52.2%, CD3 41.1%, CD4 23.4%, CD8 16.8%, CD19 8.0%, CD57 7.7% and active T cells 14.6%. T-cell dysfunction was detected on the multitest for cell-mediated immunity. The WAS diagnosis was confirmed by mutation analysis which demonstrated a 4-base pair deletion in WAS protein gene exon 1. His thrombocytopenia was uncontrolled despite intravenous immunoglobulin infusions, so splenectomy was performed. The platelet count then rose to about 60,000 to 80,000/microL. However, about 2 weeks after splenectomy, he developed generalized lymphadenopathy and lymphoma was misdiagnosed based on lymph node biopsy at another hospital where he was admitted for urgent care. However, our analysis of his lymph node pathology led to the diagnosis of atypical LPD (ALPD). The lymphadenopathy regressed spontaneously 1 month later without chemotherapy. Early and correct diagnosis of WAS complicated with ALPD is important to avoid unnecessary chemotherapy." }, { "id": "pubmed23n0393_18251", "title": "Recurrent pneumonia as warning manifestation for suspecting primary immunodeficiencies in children.", "score": 0.016628206868467492, "content": "Two hundred and eight children with recurrent pneumonia were studied over a 5-year period. Among these patients we found 10 cases with primary immunodeficiency disease: 6 cases of IgA deficiency, 1 case of X-linked agammaglobulinemia, 1 case of common variable immunodeficiency, 1 case of hyper IgM syndrome, and 1 case of Wiskott-Aldrich syndrome. This study describes the clinical features of these cases and assesses the usefulness of our immunodeficiency screening protocol. In this group 6 were males; the mean age at first episode of pneumonia was 3 years (range 3 months to 18 years), and the age of diagnosis ranged between 10 months and 19 years. The average number of episodes of pneumonia in each patient was 5 (range 2 to 12), and the number of hospitalizations ranged up to 13. The etiologic agents isolated from this recurrent pneumonia were S. pneumoniae, Moraxella, adenovirus, respiratory syncytial virus, and influenza B virus. Intravenous immunoglobulin was used in four cases. Two patients had chronic pulmonary damage with bronchiectasis and interstitial pneumonia. Only one patient died (Wiskott-Aldrich syndrome) during the follow-up from an intracranial hemorrhage. We found that the screening protocol applied to patients with recurrent pneumonia is a useful tool for ruling out the primary immunodeficiency disorders." }, { "id": "pubmed23n0703_8951", "title": "[Satisfactory evolution of a patient diagnosed in childhood with Bruton's disease].", "score": 0.01568133691981915, "content": "Bruton's agammaglobulinemia is a primary immunodeficiency with a disease onset during the first months of age, when the maternal serum immunoglobulin levels decrease. It is characterized by recurrent infections and agammaglobulinemia. We report the case of a 6-year-old male patient with third-degree consanguinity, product of a third pregnancy and complete immunization scheme. He had a history of oral candidiasis at the age of 3 months, chicken pox at the age of 7 months, and two episodes of complicated bronchopneumonia at the age of 1 year and 6 years. He was admitted to the hospital because of fever and cough. Examination of the chest showed rales and right basilar hypoventilation, and a blood cell count revealed leukocytosis and neutrophilia. The diagnosis of pneumonia was made. He was treated with IV antibiotics. Serum immunoglobulins were reported to be low (IgM 55 mg/dL, IgA 0.9 mg/dL, and IgG 199 mg/dL). With these findings the clinical diagnosis of X-linked agammaglobulinemia (ALX) was concluded. A molecular test was performed fining a BTK gene confirming the diagnosis of Bruton's disease. Therapy with intravenous IgG was started every 21 days. During his evolution, he presented three episodes of rhinosinusitis, one of suppurative otitis media, and four events of pneumonia that required 37 days of hospitalization. After hospital discharge, the patient was free of infections and he returned to his daily activities. In cases of recurrent and severe respiratory infections in children, we must consider primary immunodeficiency disease in the differential diagnosis, mainly antibiotic deficiency. Early diagnosis and treatment improves the survival and quality of life in these patients." }, { "id": "pubmed23n0517_20443", "title": "Hyper-IgM syndrome: report of one case.", "score": 0.015640273704789834, "content": "The hyper-IgM syndrome (HIM) is a rare primary immunodeficiency disorder caused by defects in the CD40 ligand (CD40L)/CD40-signaling pathway. It is characterized by recurrent infections with markedly decreased IgG, IgA and IgE levels but normal or elevated serum IgM levels. A 5-month-old boy presented with rapidly progressive pneumonia which responded poorly to antibiotics. High levels of IgM and very low levels of IgG, IgE and IgA were noted in his plasma specimen (IgM, 128 mg/dl; IgG, 18 mg/dl; IgE, 1 IU/ml; IgA, 4 mg/dl). The relative proportions of immune cells were CD3 24.6%, CD4 10.3%, CD8 2.2%, CD19 30.2%, CD57 1.0% and active T cells 1.1%. After IVIG treatment, the pneumonia improved. Repeat assessment at the age of 15 months showed IgM decreased to the normal range (32 mg/dl). Whole blood flow cytometry assay for CD40L expression confirmed the diagnosis of hyper-lgM syndrome when he was 21 months old. Only a small percentage (0.48%) of the patient's in vitro activated CD4+ T cells expressed CD40L, compared with 33.54% from a healthy control. The patient's father, mother and sister all had a normal CD40L expression activation patterns (43.52%, 40.78%, 34.11%, respectively). On a regimen of monthly IVIG infusion and oral trimethoprim-sulfamethoxazole for Pneumocystis carinii pneumonia (PCP) prophylaxis, the patient has had no recurrent infections." }, { "id": "pubmed23n0027_424", "title": "Serum IgD and IgE concentrations in immunodeficiency diseases.", "score": 0.015288919893035694, "content": "Concentrations of IgD and IgE were measured in sera from 165 patients with well-defined immunodeficiency in an effort to find information possibly relevant to the roles of antibodies of these classes in host defense. Values for both immunoglobulins were generally quite low in patients who had marked deficiencies of all three major immunoglobulins, although occasional normal or high normal values for IgD were seen in hypogammaglobulinemic patients. Group mean IgD concentrations were also depressed in patients with Wiskott-Aldrich syndrome and in those with selective IgA deficiency; IgE concentrations were depressed in patients with X-linked immunodeficiency with hyper-IgM and in those with ataxia telangiectasia. IgD and IgE were both significantly elevated in patients with extreme hyperimmunoglobulinemia E and undue susceptibility to infection and in a patient with the Nezelof syndrome; none of these patients had histories suggestive of atopy. In addition, the mean IgE concentration was significantly elevated in patients with selective IgA deficiency, many of whom were atopic, and in those with the Wiskott-Aldrich syndrome. The highest IgD concentration (163 mg/100 ml) was found in serum from a boy with variable immunodeficiency who had a lifelong history of severe recurrent pharyngeal infections, primarily streptococcal in etiology. Recurrent staphylococcal infection was a feature common to many but not all patients with elevated serum IgE concentration. These data may prove useful in the future delineation of biologic roles for antibodies in these two immunoglobulin classes." }, { "id": "pubmed23n0079_3796", "title": "[Hypogammaglobulinemia G and A with hypergammaglobulinemia M. Apropos of 12 cases].", "score": 0.015021929824561403, "content": "Hyper IgM with low IgG and IgA is a rare humoral immunodeficiency. We presently report 12 new observations which have been clinically and immunologically studied. On one occasion the syndrome was found to be associated with congenital rubella. Since 10/12 children were male, X-linked inheritance is suggested which has been confirmed in 2 cases. In most cases (9/12), the first infections occurred within the first year of life. The syndrome is causing upper and lower respiratory tract infections due to bacteria, as well as gut infections. Lymphoid organ hyperplasia has been noted in 11/12 patients. Polyclonal hyper IgM serum contrasts with low or absent IgG, IgA and IgE. In some instances, some IgM antibody response was detected. A dysfunction of cellular immunity was not detected. Autoimmunity was detected in 3 patients. Finally, transient neutropenia occurred in 50% of the patients. Intravenous immunoglobulin G substitution treatment resulted in a significant reduction in the occurrence of infections as well as in normalization of growth rate. Immunoglobulin infusion also frequently induced correction of hyper IgM and neutropenia." }, { "id": "wiki20220301en559_4909", "title": "List of primary immunodeficiencies", "score": 0.013970588235294117, "content": "Normal numbers of B cells with decreased IgG and IgA and increased IgM: Hyper-IgM syndromes Normal numbers of B cells with isotype or light chain deficiencies: heavy chain deletions, kappa chain deficiency, isolated IgG subclass deficiency, IgA with IgG subclass deficiency, selective immunoglobulin A deficiency Specific antibody deficiency to specific antigens with normal B cell and normal Ig concentrations Transient hypogammaglobulinemia of infancy (THI)" }, { "id": "wiki20220301en037_31604", "title": "Wiskott–Aldrich syndrome", "score": 0.013203463203463203, "content": "Signs and symptoms WAS occurs most often in males due to its X-linked recessive pattern of inheritance, affecting between 1 to 10 males per million. The first signs are usually petechiae and bruising, resulting from a low platelet count (i.e. thrombocytopenia). Spontaneous nose bleeds and bloody diarrhea are also common and eczema typically develops within the first month of life. Recurrent bacterial infections typically develop by three months of age. The majority of children with WAS develop at least one autoimmune disorder, and cancers (mainly lymphoma and leukemia) develop in up to a third of patients. Immunoglobulin M (IgM) levels are reduced, IgA and IgE are elevated, and IgG levels can be normal, reduced, or elevated. In addition to thrombocytopenia, WAS patients have abnormally small platelets (i.e. microthrombocytes) and ~30% also have elevated eosinophil counts (i.e. eosinophilia)." }, { "id": "wiki20220301en037_31610", "title": "Wiskott–Aldrich syndrome", "score": 0.0131599023497101, "content": "Diagnosis The diagnosis can be made on the basis of clinical findings, the peripheral blood smear, and low immunoglobulin levels. Typically, IgM levels are low, IgA levels are elevated, and IgE levels may be elevated; paraproteins are occasionally observed. Skin immunologic testing (allergy testing) may reveal hyposensitivity. Individuals with Wiskott–Aldrich syndrome however are at higher risk for severe food allergies. Not all patients have a positive family history of the disorder; new mutations do occur. Often, leukemia may be suspected on the basis of low platelets and infections, and bone marrow biopsy may be performed. Decreased levels of WASp are typically observed. The current gold standard for diagnosis is DNA sequence analysis, which can detect WAS and the related disorders XLT and XLN in 95% of patients and carriers." }, { "id": "wiki20220301en067_45376", "title": "Hypogammaglobulinemia", "score": 0.013145163980916157, "content": "of primary immunodeficiency (PID). These different forms can affect different parts of the immune system, including immunoglobulin production. Primary immunodeficiencies usually have a delay of several years between initial clinical presentation and diagnosis. Some primary immune deficiencies include ataxia-telangiectasia (A-T), autosomal recessive agammaglobulinemia (ARA), common variable immunodeficiency (CVID), hyper-IgM syndromes, IgG subclass deficiency, isolated non-IgG immunoglobulin deficiencies, severe combined immunodeficiency (SCID), specific antibody deficiency (SAD), Wiskott-Aldrich syndrome, or X-linked agammaglobulinemia. CVID is the most common form of primary immunodeficiency. SCID is considered a medical emergency and suspected cases require immediate specialist center referral for diagnosis and treatment. It is more often that hypogammaglobulinemia develops as a result of another condition, which are called secondary or acquired immune deficiencies. These" }, { "id": "wiki20220301en062_59354", "title": "X-linked agammaglobulinemia", "score": 0.01297361049683031, "content": "Signs and symptoms Affects males 50% of the time if mother is a carrier for the gene. Children are generally asymptomatic until 6–9 months of age when maternal IgG decreases. Present with recurrent infections with Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, hepatitis virus, and enterovirus CNS infections. Examination shows lymphoid hypoplasia (tonsils and adenoids, no splenomegaly or lymphadenopathy). There is significant decrease in all immunoglobulins. Genetics Most antibodies are gamma globulins. Antibodies are made mainly by plasma cells, which are daughter cells of the B cell line. The Btk enzyme plays an essential role in the maturation of B cells in the bone marrow, and when mutated, immature pro-B lymphocytes are unable to develop into pre-B lymphocytes, which normally develop into mature (naive) B cells that leave the bone marrow into the blood stream." }, { "id": "article-17681_26", "title": "Antibody Deficiency Disorder -- Differential Diagnosis", "score": 0.012905655210187595, "content": "The most important differential diagnosis includes the following: X-linked agammaglobulinemia characterizes by recurrent bacterial infections in boys, and genetic studies may reveal the presence of Bruton tyrosine kinase (BTK) mutations. Transient hypogammaglobulinemia of newborns presents in newborns above the age of 4 months and characterizes by recurrent pneumonia, meningitis, otitis media, and other problems that resemble Bruton disease. It is a physiological defect in the immune system caused by maternal IgG disappearance and corrected soon but requires treatment. In super-IgM syndrome, recurrent bacterial infections occur, but the cause of this illness is a mutation in the gene encoding for CD40 on T lymphocytes that causes a failure in T and B lymphocyte cooperation. Common variable immunodeficiency presents with recurrent bacterial infections, including sinopulmonary problems but later in life (second-fourth decade), and the diagnosis is made once all causes of immunodeficiency have been ruled out. [6] [7] [21] [33]" }, { "id": "article-23400_15", "title": "Biochemistry, Immunoglobulin M -- Clinical Significance -- Selective IgM Deficiency", "score": 0.012712797759526731, "content": "Selective IgM deficiency (SIGMD) is a rare disorder with fewer than 300 cases reported. SIGMD is associated with an isolated deficiency in IgM in the presence of normal levels of other immunoglobulins such as IgG and IgA and normal levels of T cells and other leukocytes. [12] Individuals with SIGMD may be asymptomatic, or they may suffer from recurring infections from encapsulated bacteria (e.g., S. pneumoniae and H. influenzae ) in addition to viral infections. Additionally, SIGMD can be associated with malignancy, autoimmunity, or allergy. SIGMD may occur as a secondary effect of another disease, such as malignancy or bacteremia. Yet, primary causes of SIGMD have also been described, as some are associated with deletions on chromosome 22, for example. [12] The diagnosis of SIGMD is one of exclusion. Other diseases that result in low levels of multiple isotypes must be excluded, such as common variable immunodeficiency or X-linked agammaglobulinemia, which will likely result in reduced levels of several antibody isotypes. Conversely, Wiskott-Aldrich syndrome is often associated with low IgM yet elevated levels of IgG and IgA. Cold Agglutinin Disease" }, { "id": "wiki20220301en225_1951", "title": "Humoral immune deficiency", "score": 0.012265056292863329, "content": "Absent B cells with a resultant severe reduction of all types of antibody: X-linked agammaglobulinemia (btk deficiency, or Bruton's agammaglobulinemia), μ-Heavy chain deficiency, l 5 deficiency, Igα deficiency, BLNK deficiency, thymoma with immunodeficiency B cells low but present, but with reduction in 2 or more isotypes (usually IgG & IgA, sometimes IgM): common variable immunodeficiency (CVID), ICOS deficiency, CD19 deficiency, TACI (TNFRSF13B) deficiency, BAFF receptor deficiency. Normal numbers of B cells with decreased IgG and IgA and increased IgM: Hyper-IgM syndromes Normal numbers of B cells with isotype or light chain deficiencies: heavy chain deletions, kappa chain deficiency, isolated IgG subclass deficiency, IgA with IgG subsclass deficiency, selective immunoglobulin A deficiency Transient hypogammaglobulinemia of infancy (THI)" }, { "id": "wiki20220301en218_4190", "title": "List of skin conditions", "score": 0.012197606315253375, "content": "Bare lymphocyte syndrome Chronic granulomatous disease (Bridges–Good syndrome, chronic granulomatous disorder, Quie syndrome) Common variable immunodeficiency (acquired hypogammaglobulinemia) Complement deficiency DiGeorge syndrome (DiGeorge anomaly, thymic hypoplasia) Graft-versus-host disease Griscelli syndrome Hyper-IgE syndrome (Buckley syndrome, Job syndrome) Immunodeficiency with hyper-IgM Immunodeficiency–centromeric instability–facial anomalies syndrome (ICF syndrome) Isolated IgA deficiency Isolated primary IgM deficiency Janus kinase 3 deficiency Leukocyte adhesion molecule deficiency LIG4 syndrome Myeloperoxidase deficiency Neutrophil immunodeficiency syndrome Nezelof syndrome (thymic dysplasia with normal immunoglobulins) Omenn syndrome Purine nucleoside phosphorylase deficiency Severe combined immunodeficiency (alymphocytosis, Glanzmann–Riniker syndrome, severe mixed immunodeficiency syndrome, thymic alymphoplasia) Shwachman–Bodian–Diamond syndrome" }, { "id": "pubmed23n0626_19418", "title": "[Hyper-IgM syndrome in a boy with recurrent pneumonia and hepatosplenomegaly].", "score": 0.012178072111846946, "content": "We present a boy diagnosed at age 14 years with hyper-immunoglobulin (Ig) M syndrome, a congenital immunodeficiency characterized by reduced plasma concentrations of IgA, IgE and IgG, with normal or elevated concentrations of IgM. This syndrome is caused by a defect of CD40 ligand (CD40L) on T-helper lymphocytes, impeding the \"second signal\" during activation of B lymphocytes and interactions of T cells with dendritic cells and macrophages, resulting in the absence of secondary immune response (class switching, affinity maturation, immune memory), as well as responses to T-dependent antigens, with an impairment of cellular immunity. The history of the presented patient was dominated by frequent lower respiratory infections and failure to thrive. Physical examination demonstrated severe hepatosplenomegaly. The suspicion of hyper-IgM syndrome was raised by low plasma IgA (0.36 g/l) with high plasma IgM (35.5 g/l), while the concentration of IgG was within the normal range (12.1 g/l). The diagnosis was confirmed by flow cytometry, which demonstrated the absence of expression of CD40L on lymphocytes following stimulation by phorbolmyristylacetate and calcium ionophore. Since the time of diagnosis, intravenous immunoglobulin therapy has led to catch-up growth, recession of hepatosplenomegaly and reduction in the frequency of respiratory infections. Our report emphasizes the importance for the primary healthcare paediatrician to be well informed about the clinical presentation and pathogenesis of hyper-IgM syndrome, in order to provide early detection and increase the likelihood of success in treating this rare immunodeficiency. To the best of our knowledge, this is the first case of hyper-IgM syndrome reported in the Republic of Serbia." }, { "id": "wiki20220301en559_4908", "title": "List of primary immunodeficiencies", "score": 0.012153455681374464, "content": "Predominantly antibody deficiencies In primary antibody deficiencies, one or more isotypes of immunoglobulin are decreased or don't function properly. These proteins, generated by plasma cells, normally bind to pathogens, targeting them for destruction. Absent B cells with a resultant severe reduction of all types of antibody: X-linked agammaglobulinemia (btk deficiency, or Bruton's agammaglobulinemia), μ-Heavy chain deficiency, l 5 deficiency, Igα deficiency, BLNK deficiency, thymoma with immunodeficiency B cells low but present or normal, but with reduction in 2 or more isotypes (usually IgG & IgA, sometimes IgM): common variable immunodeficiency (CVID), CD19 deficiency, TACI (TNFRSF13B) deficiency, BAFF receptor deficiency. Normal numbers of B cells with decreased IgG and IgA and increased IgM: Hyper-IgM syndromes" }, { "id": "wiki20220301en071_14447", "title": "Common variable immunodeficiency", "score": 0.012084118016321406, "content": "Diagnosis According to a European registry study, the mean age at onset of symptoms was 26.3 years old. As per the criteria laid out by ESID (European Society for Immunodeficiencies) and PAGID (Pan-American Group for Immunodeficiency), CVID is diagnosed if: the person presents with a marked decrease of serum IgG levels (<4.5 g/L) and a marked decrease below the lower limit of normal for age in at least one of the isotypes IgM or IgA; the person is four years of age or older; the person lacks antibody immune response to protein antigens or immunization. Diagnosis is chiefly by exclusion, i.e. alternative causes of hypogammaglobulinemia, such as X-linked agammaglobulinemia, must be excluded before a diagnosis of CVID can be made." }, { "id": "pubmed23n0533_4200", "title": "Bone and joint disease associated with primary immune deficiencies.", "score": 0.011971126357918811, "content": "Primary immune deficiencies (PIDs) are characterized by functional and/or quantitative abnormalities of one or more immune system components. Several bone and joint abnormalities can occur in patients with PID, with arthritis being the most common. Joint manifestations, of which arthritis is the most common, occur chiefly in humoral PIDs (agammaglobulinemia, common variable immunodeficiency, hyper-IgM syndromes, and IgA deficiency) and occasionally in other PIDs (chronic granulomatous disease and Wiskott-Aldrich syndrome). Monoarthritis or oligoarthritis is the usual pattern, although polyarthritis may occur, occasionally with nodules suggesting rheumatoid arthritis. Arthritis in patients with PID is usually infectious in nature, the most common causative organism being Mycoplasma, followed by Staphylococcus, Streptococcus, and Haemophilus. These bacteria can induce not only synovial infections, but also aseptic arthritogenic inflammatory responses. Arthritis having no demonstrable relation to chronic infection has been reported also and ascribed to dysimmunity-driven mechanisms that exhibit a number of specific features. Bone lesions are far less common and usually due to infections complicating humoral PID. Distinctive bone manifestations occur in a number of rare PIDs (e.g., hyper-IgE syndrome and Di George syndrome) and in syndromes characterized by spondyloepiphyseal dysplasia. Familiarity with PID syndromes both enhances the diagnostic capabilities of physicians and provides insight into the pathophysiology of bone and joint abnormalities associated with immune dysfunction. In children and occasionally in adults, a combination of bone and/or joint manifestations and hypogammaglobulinemia may indicate PID. When there is no evidence of lymphoproliferative disease, infection, or iatrogenic complications, investigations for PID should be obtained. PID-related arthritis is a unique model for studying the pathogenesis of presumably postinfectious arthritis and of inflammatory joint diseases including rheumatoid arthritis." }, { "id": "wiki20220301en218_4191", "title": "List of skin conditions", "score": 0.011906552363763975, "content": "Severe combined immunodeficiency (alymphocytosis, Glanzmann–Riniker syndrome, severe mixed immunodeficiency syndrome, thymic alymphoplasia) Shwachman–Bodian–Diamond syndrome Thymoma with immunodeficiency (Good syndrome) Transient hypogammaglobulinemia of infancy Warts–hypogammaglobulinemia–infections–myelokathexis syndrome (WHIM syndrome) Wiskott–Aldrich syndrome X-linked agammaglobulinemia (Bruton syndrome, sex-linked agammaglobulinemia) X-linked hyper-IgM syndrome X-linked hypogammaglobulinemia X-linked lymphoproliferative disease (Duncan's disease) X-linked neutropenia" }, { "id": "pubmed23n0059_21268", "title": "Early bone marrow transplantation in an infant with Wiskott-Aldrich syndrome.", "score": 0.0118989118989119, "content": "The Wiskott-Aldrich Syndrome (WAS) is a rare X-linked immunohematological disorder characterized by eczema, profound thrombocytopenia, and progressive immunodeficiency. Severe hemorrhage, overwhelming sepsis, or lymphoreticular malignancy usually cause death in childhood. Recently, bone marrow transplantation (BMT) has been curative in some well-established cases, but there is no general agreement about the place of BMT in infants with WAS before the development of significant immunological abnormalities. We describe the successful use of early histocompatible BMT in a 10-month-old infant in whom WAS was diagnosed on the basis of eczema, thrombocytopenia, small platelets, and raised serum immunoglobulin A (Ig) and IgE, but before the development of immunodeficiency as evidenced clinically by recurrent infections, or immunologically by low serum IgM or consistently abnormal lymphocyte responses to mitogens. After an unstable period for several weeks posttransplantation when he developed marked hepatomegaly and severe interstitial pneumonitis, he made a good recovery. His eczema and thrombocytopenia resolved and he has shown no clinical or laboratory evidence of immunodeficiency. It is now over 2 years since his BMT. Because of the poor prognosis of WAS, where a histocompatible donor is available, BMT at the earliest opportunity, despite the inherent risks of such a procedure, may be the best option for an infant with WAS." }, { "id": "pubmed23n0329_9114", "title": "Severe combined immunodeficiency with B-lymphocytes (T-B+SCID): report of two cases.", "score": 0.011664152840623429, "content": "Severe combined immunodeficiency (SCID) is a rare pediatric medical emergency in Taiwan. The early diagnosis of infants with SCID is very important because it can save the life of these critical infants. The essential clues important for early diagnosis of SCID patients include positive family history of early infant death, paucity of tonsil and lymphoid tissue, cutaneous fungal infection and lymphopenia. Severe combined immunodeficiency is a heterogeneous group of inherited disorders characterized by the failure of both cellular and humoral immunity. It can be categorized into SCID with B-lymphocytes predominant (T-B+SCID) and SCID with paucity of B-lymphocytes (T-B-SCID), according to the number of B-lymphocytes in the patient's peripheral circulation. We report two male infants with T-B+SCID who had been suffering from severe pulmonary distress with persistent O2 desaturation when they were transferred to our pediatric intensive care unit. Tracing back these infant's family histories, it was discovered that both of them had an elder brother who had died to overwhelming infection within the first year of life, and Pneumocystis carinii pneumonitis (PCP) was confirmed in the elder brother of case 2. After hospitalization, the immune condition of these two infants were evaluated which showed a decrease in T-cell and NK cell number, an increase in B-cell number, and decreased serum levels of all the Igs except IgM, which was elevated in case 1. These were the diagnostic immunological findings for T-B+SCID, which included X-linked SCID and Jak-3-deficient SCID. During hospitalization, severe mucocutaneous candidiasis and PCP were noted and confirmed in case 1 and PCP was highly suspected in case 2. Bone marrow transplantation, the only curable treatment for T-B+SCID at present, could not be performed in these two patients because of their grave clinical condition. Both of them expired due to their progressively downhill pulmonary conditions." }, { "id": "pubmed23n0113_5663", "title": "Update of the Wiskott-Aldrich syndrome. From a new case report.", "score": 0.011662726556343577, "content": "After presenting the case of a male patient who was diagnosed as suffering from the Wiskott-Aldrich syndrome at the age of 4 months, we review the main clinical (infections, bleeding and eczema), immunological (deficiency of IgM, normal IgG, elevated IgA and IgE, deficiency of total T lymphocytes, normal T4 levels, decreased levels of T8, diminished response to phytohemagglutinin and partial depletion of the lymphocyte population in biopsies of lymph nodes and spleen) and haematological (thrombocytopenia, dysmegakaryocytosis, decreased half-life and decreased granulation in the protoplasm of megakaryocytes) manifestations of this syndrome. In general, our aim is to carry out an up-to-date review of the syndrome, and to include comments on the diagnostic and therapeutic aspects." }, { "id": "wiki20220301en186_26784", "title": "Immune disorder", "score": 0.011429127725856697, "content": "Primary immune deficiencies Severe combined immunodeficiency (SCID) DiGeorge syndrome Hyperimmunoglobulin E syndrome (also known as Job's Syndrome) Common variable immunodeficiency (CVID): B-cell levels are normal in circulation but with decreased production of IgG throughout the years, so it is the only primary immune disorder that presents onset in the late teens years. Chronic granulomatous disease (CGD): a deficiency in NADPH oxidase enzyme, which causes failure to generate oxygen radicals. Classical recurrent infection from catalase positive bacteria and fungi. Wiskott–Aldrich syndrome (WAS) Autoimmune lymphoproliferative syndrome (ALPS) Hyper IgM syndrome: X-linked disorder that causes a deficiency in the production of CD40 ligand on activated T-cells. This increases the production and release of IgM into circulation. The B-cell and T-cell numbers are within normal limits. Increased susceptibility to extracellular bacteria and opportunistic infections." }, { "id": "pubmed23n0858_16600", "title": "[Clinical features and genotype analysis of 132 patients with Wiskott-Aldrich syndrome].", "score": 0.011365103964871497, "content": "To investigate the clinical and immunological laboratory features, gene mutations, treatment and prognosis in children with Wiskott-Aldrich syndrome (WAS). The clinical, laboratory characteristics, treatment and prognosis of 132 children with WAS, who visited Children's Hospital of Chongqing Medical University from April 2000 to June 2015, were analyzed retrospectively. All patients were male. The median age of disease onset was 15 days and the median age at diagnosis was 10 months. Of the 132 cases, 112 had classic WAS, 20 had X-linked thrombocytopenia (XLT). The median platelet count was 23×10(9)/L. All cases had the clinical characteristics of WAS including bleeding, eczema, and being susceptible to infection. The initial symptoms include hemorrhage (75.0%) and eczema (16.7%). Twenty-one cases had autoimmune diseases and one patient had leukemia. WAS protein (WASP) expression in 115 cases were measured by flow cytometry, 88 cases were negative, in 12 cases WASP decreased, in 5 cases it was normal, 10 cases had bimodal distribution. Eighty-one kinds of mutations were found in 122 families, including eight kinds of hot-spot mutations, which were 290 C&gt; N / 291G&gt; N (R86C / H / L), 665 C&gt; T (R211X), 155 C&gt; T (R41X), 168 C&gt; T (T45 M), IVS1+ 1 g&gt; t/ a, IVS6 + 5 g&gt; a, IVS8 + 1 g&gt; a and IVS8 + 1to + 6del gtga. Meantime, 29 kinds of novel mutations were found, which were 321T&gt;C, 415C&gt;A, 471C&gt;T, 102-105delC, 521 del C, 1330 del A, IVS2-2 a&gt;c, 168 C&gt;A/1412 C&gt; T, exon1-2 del/1412 C&gt;T, and so on. The proportion of CD3(+) T cells (31.3%), helper T cells (37.3%) and cytotoxic T cells (38.6%) in the peripheral blood declined. The serum levels of IgG (51.1%), IgA (43.3%) and IgE (40.0%) increased, IgM (25.6%) decreased. Of the 132 cases, 72 remain survived, of whom 36 cases received hematopoietic stem cell transplantation (HSCT), 14 patients with classic WAS received intravenous immunoglobulin (IVIG) therapy. With regular IVIG therapy, the frequency of infections was reduced and the patients' symptoms were improved. The clinical characteristics of Wiskott-Aldrich syndrome were early age of onset, microthrombocytopenia, eczema and recurrent infections. The proportion of T lymphocyte declined, the serum levels of IgG, IgA, and IgE increased, and level of IgM decreased in a part of patients. The detection of WAS gene mutation and WAS protein detection was the key diagnostic methods. Regular IVIG can gain more time for children who will receive HSCT and improve their quality of life." }, { "id": "wiki20220301en121_8056", "title": "Hyper-IgM syndrome type 2", "score": 0.011316107444929826, "content": "Hyper IgM Syndrome Type 2 is a rare disease. Unlike other hyper-IgM syndromes, Type 2 patients identified thus far did not present with a history of opportunistic infections. One would expect opportunistic infections in any immunodeficiency syndrome. The responsible genetic lesion is in the AICDA gene found at 12p13. Hyper IgM syndromes Hyper IgM syndromes is a group of primary immune deficiency disorders characterized by defective CD40 signaling; via B cells affecting class switch recombination (CSR) and somatic hypermutation. Immunoglobulin (Ig) class switch recombination deficiencies are characterized by elevated serum IgM levels and a considerable deficiency in Immunoglobulins G (IgG), A (IgA) and E (IgE). As a consequence, people with HIGM have an increased susceptibility to infections." }, { "id": "Pediatrics_Nelson_1643", "title": "Pediatrics_Nelson", "score": 0.011191014867485456, "content": "Common variable immunodeficiency (CVID) is a heterogeneous disorder characterized by hypogammaglobulinemia developing after an initial period of normal immune function, most commonly in the second and third decades of life (see Table 73-1). Serum IgG levels are less than 500 mg/dL (usually <300 mg/dL) with IgA levels less than 10 mg/dL and/or low IgM levels. Antibody titers to protein antigens, suchas tetanus and diphtheria, and to polysaccharide antigens,such as pneumococcus, are low or absent. T-cell numbersand function are highly variable, and B-cell numbers can be normal or low. Patients exhibit normal-sized or enlargedtonsils and lymph nodes and may have splenomegaly. Theyare susceptible to frequent respiratory tract infections due to Streptococcus pneumoniae, Haemophilus influenzae type b, and Mycoplasma. Gastrointestinal infections with Giardia, Campylobacter, Salmonella, Helicobacter, and enteroviruses are common. Autoimmune hemolytic anemia and thrombocytopenia occur" }, { "id": "pubmed23n0378_18676", "title": "[Common variable immunodeficiency. Review].", "score": 0.01085551822176273, "content": "Common variable immunodeficiency (CVI) is a primary immunodeficiency characterized by deficient antibody production. The cause of this immunodeficiency is unknown; several in vitro studies have revealed a significant number of alterations that could explain the hypogammaglobulinemia present in this syndrome. Among those described are primary B cell alterations, numerical and functional T cell abnormalities, and defects in the interaction between accessory cells. The alteration typical of CVI is the failure of B lymphocytes to differentiate from antibody-producing cells, resulting in deficient immunoglobulin secretion. Among the T cell abnormalities described are a diminished proliferative response to mitogens and antigens, alterations in the level of production of several cytokines, especially reduction in the production of IL-2, diminished antigen-specific T cells and increase basal apoptosis after stimulation. Antigen presenting cells, monocytes and dendritic cells can also present alterations and contribute to deficient antigen response. The clinical manifestations of these patients is variable; most present recurrent bacterial infections due to encapsulated bacteria, especially sinusitis, otitis, bronchitis, and pneumonias. A few patients can present mycobacterial or fungal infection and occasionally Pneumocystis carinii. Viral infection is uncommon in these patients although some suffer recurrent herpes zoster infection. Clinical features of septicemia and central nervous system infections are less frequent. The incidence of digestive tract infections in these patients is high. The most common cause of diarrhea is Giardia lamblia; Salmonella, Shigella and Campylobacter are also common pathogens. Autoimmune disease is also more prevalent in these patients than in the general population. The most frequently associated diseases are hemolytic anemia, idiopathic thrombocytopenic purpura and autoimmune neutropenia. Cancer is also frequently associated with CVI, the most common forms being lymphoproliferative syndromes, especially non-Hodgkin's lymphoma. Granulomas are a unusual manifestation in some patients with CVI; their localization varies but the most commonly affected organs are the spleen and lungs. Some authors have compared these granulomas with those characterizing sarcoidosis, especially when appearing in the lung. Diagnosis of CVI is usually by exclusion of other diseases, such as cystic fibrosis, immotile cilia syndrome or allergic processes. CVI should be suspected in all patients with recurrent bacterial infections especially those localized in the respiratory tract. Other primary immunodeficiencies which present clinical findings similar to CVI and which should be ruled out are selective IgG subclass deficiency, IgA deficiency and selective deficiency in the response to polysaccharide antigens with normal immunoglobulin levels. The serum hypogammaglobulinemia present in all patients with CVI provides the diagnostic key. The age at which clinical manifestations appear, the absence of familial antecedents and the presence of circulating B lymphocytes form the basis of the differential diagnosis between X-linked agammaglobulinemia and autosomal recessive forms. The treatment of choice of patients with CVI is treatment with human gamma-globulin. Currently, the most common route of administration is intravenous; these molecules have a half-life of approximately 21 days and a high degree of safety concerning the possible transmission of viral infections. Adverse reactions are generally few and clinically unimportant. The most frequently used doses oscillate between 200 and 400 mg/kg body weight every 2-4 weeks. Both the dose and its frequency should be personalized for each patient. Early diagnosis of patients with CVI, application of treatment with appropriate antibiotics for infections and treatment with gamma-globulins prevent long-term complications of this disease and dramatically improve the quality of life and life expectancy of these patients." }, { "id": "First_Aid_Step2_928", "title": "First_Aid_Step2", "score": 0.010637289741767354, "content": "Combined (continued) Wiskott-Aldrich syndrome An X-linked disorder with less severe Band T-cell dysfunction. Patients have eczema, ↑ IgE/IgA, ↓ IgM, and thrombocytopenia. The classic presentation involves bleeding, eczema, and recurrent otitis media. ↑↑ risk of atopic disorders, lymphoma/leukemia, and infection from S. pneumoniae, S. aureus, and H. infl uenzae type b. Phagocytic Chronic granulomatous disease (CGD) Leukocyte adhesion def ciency Chédiak-Higashi syndrome An X-linked (2/3) or autosomal-recessive (1/3) disease with def cient superoxide production by PMNs and macrophages. Anemia, lymphadenopathy, and hypergamma-globulinemia may be present. A defect in the chemotaxis of leukocytes. An autosomal-recessive disorder that leads to Chronic skin, pulmonary, GI, and urinary tract infections; osteomyelitis and hepatitis. Infecting organisms are catalase . ↑ risk of infection with Aspergillus. May have granulomas of the skin and GI/GU tracts. Recurrent skin, mucosal, and pulmonary" } ] } } }

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{ "1": "Lumbar puncture.", "2": "C Reactive Protein.", "3": "Magnetic resonance angiography.", "4": "Carotid ultrasound.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0334_10172", "title": "Lessons to be learned: a case study approach--a case of temporal arteritis.", "score": 0.014409963460449798, "content": "A 71-year-old male presented with a history of sudden partial visual loss in the right eye with an inferior visual field defect over the past 3-4 days. He had no history of headache or of facial pain. Clinical examination confirmed that vision on the right side was reduced to 6/18 and on the left to 6/12. The right eye showed a relative afferent pupillary defect. There was no other abnormality of the anterior segment of either eye. The right retina showed a pale swollen optic disc and a provisional diagnosis of anterior ischaemic optic neuropathy (AION) was made. An urgent erythrocyte sedimentation rate (ESR) was ordered and the patient was asked to return to the eye clinic in one month. However, 16 days later--when it was first recognised that his ESR was elevated to 75 mm in the first hour--the patient was recalled immediately in order to commence systemic steroid treatment; but regrettably, by this time, his right eye had become totally blind. In this case, although the attending doctor made a correct clinical diagnosis on presentation, he failed to act upon the result of the blood test." }, { "id": "InternalMed_Harrison_1431", "title": "InternalMed_Harrison", "score": 0.011852560525126897, "content": "A careful neurologic examination is an essential first step in the evaluation. In most cases, patients with an abnormal examination or a history of recent-onset headache should be evaluated by a computed tomography (CT) or magnetic resonance imaging (MRI) study. As an initial screening procedure for intracranial pathology in this setting, CT and MRI methods appear to be equally sensitive. In some circumstances, a lumbar puncture (LP) is also required, unless a benign etiology can be otherwise established. A general evaluation of acute headache might include cranial arteries by palpation; cervical spine by Pain induced by bending, lifting, cough Pain associated with local tenderness, e.g., region of temporal artery the effect of passive movement of the head and by imaging; the investigation of cardiovascular and renal status by blood pressure monitoring and urine examination; and eyes by funduscopy, intraocular pressure measurement, and refraction." }, { "id": "pubmed23n0810_19941", "title": "Atypical retinal vaso-occlusion with structural and functional resolution.", "score": 0.009900990099009901, "content": "The purpose is to report a patient with primary open-angle glaucoma that developed sudden painless unilateral vision loss, a sequential ophthalmoscopic appearance with features of both central retinal artery and later central retinal vein occlusion, and objective visual system dysfunction in the form of a relative afferent pupil defect, who spontaneously recovered vision along with complete resolution of the pupillary defect over several weeks. A 50-year-old woman with a long-standing history of glaucoma presented with acute, painless vision loss in one eye, a pallid retina with a cherry red macula, diffuse retinal hemorrhages, and a relative afferent pupil defect. Spectral domain optical coherence tomography and fluorescein angiography were essentially normal with neither retinal edema nor retinal ischemia to account for the visual dysfunction. Over the course of 2 months, the patient regained vision and the relative afferent pupil defect, typically a permanent manifestation of retinal destruction, resolved. Not all retinal vaso-occlusive phenomena can be completely attributed to a central retinal vein or artery occlusion. In the patient presented, there was no objective diagnostic testing that revealed a cause for the patient's vision loss or relative afferent pupillary defect. This combined with the complete recovery of vision and resolution of the relative afferent pupillary defect underscores a lack of comprehensive understanding of retinal vaso-occlusive disease." }, { "id": "First_Aid_Step2_614", "title": "First_Aid_Step2", "score": 0.009900990099009901, "content": "If a 20-year-old female develops headaches after drinking red wine, think migraine. Associated symptoms/signs: Significant findings include fever or rash (consider meningitis or other infectious causes), jaw claudication (specific for temporal arteritis), or constitutional symptoms such as weight loss (associated with neoplastic, inflammatory, or infectious conditions). Photophobia, nausea, and vomiting are associated with migraine, aneurysmal SAH, and meningitis, but neck stiffness is more likely to accompany the latter two. Neurologic sequelae: Look for diplopia, mental status changes or associated symptoms (numbness, weakness, dizziness, ataxia, visual disturbances), papilledema, or pupillary abnormalities (partial CN III palsy or Horner’s syndrome). Patient risk factors: High-risk patients are > 50 years of age, immunocompromised, or with preexisting malignancy. If SAH is suspected, obtain a head CT without contrast. If CT is , LP is mandatory. Obtain a CBC." }, { "id": "pubmed23n0995_14786", "title": "Ultrasound-Assisted Diagnosis of Optic Neuritis in the Emergency Department: A Case Report.", "score": 0.00980392156862745, "content": "Optic neuritis is a common cause of subacute unilateral vision loss, occurring in 1-5 per 100,000 persons per year. It is more common in Caucasians, women, and those from countries with northern latitudes. Those aged 20-49 years are at greatest risk. The condition arises due to inflammation of the optic nerve. Inflammation may occur due to systemic inflammatory disorders, most commonly multiple sclerosis. A 21-year-old African-American male presented to our emergency department with a complaint of painful unilateral vision loss. On examination he was found to have a relative afferent pupillary defect and red desaturation. A bedside ultrasound suggested pseudopapilledema suggestive of optic neuritis. He was admitted to Neurology for confirmation of and treatment for optic neuritis. Magnetic resonance imaging confirmed optic neuritis. The patient was treated with i.v. steroids and discharged after improvement in visual function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Optic neuritis is a clinical diagnosis. The subtle historical components and examination findings make it a diagnostic challenge for the busy emergency physician. Early diagnosis may improve visual outcomes. Discovery of pseudopapilledema on bedside ultrasound may be seen in optic neuritis, and is another finding that emergency physicians may assess for in patient presenting with unilateral vision loss." }, { "id": "pubmed23n0321_12634", "title": "Masticatory muscle pain: an important indicator of giant cell arteritis.", "score": 0.00980392156862745, "content": "Giant cell arteritis (GCA) is a polysymptomatic disease which constitutes an ophthalmic emergency because early recognition and management can prevent blindness. There is conflicting information in the literature on the validity, sensitivity, and specificity of various systemic symptoms and signs of GCA. This paper presents a review of our prospective studies on the subject, and our findings are particularly relevant to dentists. We investigated 363 patients in a prospective study. Positive temporal artery biopsy was seen in 106 patients and negative in 257 referred for diagnosis of GCA. Systemic symptoms and signs of GCA and erythrocyte sedimentation rate (Westergren-ESR) and C-reactive protein (CRP) levels were compared in these two groups of patients. The odds of having a positive temporal artery biopsy (i.e., GCA) were 9.1 times greater with jaw claudication (pain in masticatory muscles on eating), 3.4 times with neck pain, 3.2 times with CRP &gt; 2.45 mg/dL, 2.0 times with ESR 47.107 mm/hr, 2.7 times with ESR &gt; 107 mm/hr, and 2.0 times when the patients were aged &gt; or = 75 years. Other signs and symptoms did not show a significant association with a positive biopsy. Our study showed that \"normal\" ESR values do not rule out GCA but that CRP is a more useful test than ESR. Since jaw claudication is one of the most important symptoms of GCA, dentists should keep this possibility in mind when older patients come complaining of jaw pain while eating." }, { "id": "pubmed23n1076_12839", "title": "Childhood-Onset Leber Hereditary Optic Neuropathy: Particular Features.", "score": 0.009708737864077669, "content": "Leber hereditary optic neuropathy (LHON) is an optic neuropathy of mitochondrial inheritance. Childhood-onset disease is relatively rare and there are limited data on this important patient subgroup. We present 3 particular presentations of LHON. Patient 1 was an 8-year-old boy admitted to the emergency department reporting a progressive bilateral visual loss and intermittent headaches. Neuro-ophthalmological examination revealed a bilateral pseudopapilledema. Lumbar puncture identified intracranial hypertension and the brain and orbits magnetic resonance imaging showed T2 hyperintensity in the posterior region of the left optic nerve and the optic chiasm. Patient 2 was a 12-year-old boy admitted to the emergency department reporting painless, progressive central vision loss in the right eye. Fundus examination revealed a hyperemic disc and vascular network papillary and peripapillary vascular microdilations. Three months later, the left eye presented visual loss. Patient 3 was a 6-year-old female child referred to the neuro-ophthalmology specialist due to painless central visual loss in both eyes. Her BCVA was 1/10 and counting fingers in right and left eye, respectively, and fundus examination revealed a pallor optic disc in the temporal sector. The phenotype of childhood-onset disease may present itself distinct from classical adult-onset LHON. The absence of classical clinical features could lead to initial misdiagnosis. There should exist a high index of suspicion in children presenting unexplained subnormal vision in order to avoid potential diagnostic delays." }, { "id": "First_Aid_Step2_571", "title": "First_Aid_Step2", "score": 0.009708737864077669, "content": "Also called giant cell arteritis; due to subacute granulomatous infl ammation of the large vessels, including the aorta, external carotid (especially the temporal branch), and vertebral arteries. The most feared manifestation is blindness 2° to occlusion of the central retinal artery (a branch of the internal carotid artery). Risk factors include polymyalgia rheumatica (affects almost half of TA patients), age > 50, and female gender. Presents with new headache (unilateral or bilateral); scalp pain and temporal tenderness; and jaw claudication. Fever, permanent monocular blindness, weight loss, and myalgias/arthralgias (especially of the shoulders and hips) are also seen. ESR > 50 (usually > 100). Ophthalmologic evaluation. Temporal artery biopsy: Look for thrombosis; necrosis of the media; and lymphocytes, plasma cells, and giant cells." }, { "id": "pubmed23n1121_13718", "title": "Atypical Leber hereditary optic neuropathy with a 34-year interval between vision loss in both eyes.", "score": 0.009615384615384616, "content": "Leber hereditary optic neuropathy (LHON) is an inherited mitochondrial disease characterized by painless vision loss affecting both eyes. The disease usually develops in both eyes within weeks to months of onset. We report a case of LHON who presented with unilateral vision loss in childhood with an interval of more than 30 years between vision loss in the two eyes. A 43-year-old man presented with a 1-month history of vision loss in his right eye. At 9 years of age, his visual acuity in the left eye declined, and he had been treated with glaucoma eyedrops bilaterally at his eye clinic. At his first visit to our hospital, his BCVA was 0.15 in the right eye and 0.1 in the left eye, and critical flicker frequency was 16 Hz in the right eye and 15 Hz in the left eye, and he was negative for a relative afferent pupillary defect. The Goldman visual field showed central scotoma in both eyes. Fundus examination revealed slight redness of the right optic disc with meandering retinal small vessels, and the left optic disc had a slight pallor. Fluorescein angiography could not be performed because of liver dysfunction. OCT showed prominent bilateral thinning of the RNFL and retinal ganglion cell layer. Enhancement of the optic nerve was not apparent on orbital gadolinium-enhanced magnetic resonance imaging. Hematologic analysis revealed macrocytic anemia and low levels of vitamin B12 and folate. His mother had a presumptive diagnosis of LHON but did not receive genetic testing. A male cousin also had severe vision loss. Based on the likely family history of LHON, we performed genetic testing, which revealed the 11778 mitochondrial point mutation associated with this condition. We report a case of LHON with 34 years interval in vision loss in the fellow eye. LHON may develop in the second eye decades after its onset in the first. Detailed medical interviews and scrutiny, such as examination of family history, are warranted in consideration of LHON." }, { "id": "pubmed23n0574_18362", "title": "[Temporal arteritis presenting with headache and abducens nerve palsy. Report of a case].", "score": 0.009615384615384616, "content": "A 71-year-old man visited our clinic with a 3-day history of severe throbbing headache and 1-day history of horizontal diplopia. He had had jaw claudication and pain in the neck and shoulder several days previously. His right eye was slightly esotropic and did not move laterally. There was no blepharoptosis, proptosis, lid edema, or conjunctival injection. The pupils were unremarkable. The remainder of the cranial nerve functions was intact. There was no limb weakness or sensory impairment. Superficial temporal arteries were swollen and tender on both sides. Laboratory examination showed elevated CRP level and high erythrocyte sedimentation rate. Cranial MR images were unremarkable. The cerebrospinal fluid was acellular with 45 mg/dl of protein. A diagnosis of temporal arteritis was made. Treatment with 50 mg of prednisolone brought about prompt disappearance of the headache. Right ocular movement fully recovered in 10 days. Temporal artery biopsy findings and response to corticosteroid were consistent with temporal arteritis. The motility pattern of the right eye was consistent with complete abducens nerve palsy, which is a rare manifestation of temporal arteritis. Although temporal arteritis is a rare cause of ophthalmoplegia in the elderly patients, swift diagnosis and treatment is necessary to avoid blindness." }, { "id": "pubmed23n1037_7823", "title": "A tearfully painful darkness.", "score": 0.009523809523809525, "content": "A 70-year-old woman presented with new onset of left eye and facial pain. Ophthalmic and neurological examinations, magnetic resonance imaging brain, erythrocyte sedimentation rate, and C-reactive protein were unrevealing. A few days later, she developed vision loss in her left eye. Examination revealed decreased visual acuity with a relative afferent pupillary defect in the left eye and a diffuse mild swelling of the left optic nerve head. Repeat magnetic resonance imaging showed T2 hyperintensity and enhancement of the intraorbital optic nerve and surrounding tissues with no other intracranial abnormalities. Serum studies showed elevated myelin oligodendrocyte glycoprotein IgG titer. She was treated with IV methylprednisolone 1000 mg daily for 3 days and was discharged on prolonged prednisone taper with return of vision to baseline." }, { "id": "pubmed23n0596_4516", "title": "Anterior ischemic optic neuropathy due to giant cell arteritis with normal inflammatory markers.", "score": 0.009523809523809525, "content": "In anterior ischemic optic neuropathy (AION), it is important not to miss the diagnosis of giant cell arteritis (GCA) because this requires immediate steroid treatment to prevent involvement of the second eye and possible blindness. A missed diagnosis also might lead to fatal systemic complications. Observational case report. A 79-year-old woman noticed decreased visual and visual field loss in the right eye. At presentation, right visual acuity was 10/20 (ETDRS chart 2000). There was a right relative afferent pupillary defect of 0.6 log units. Asked for symptoms of GCA she complained about temporal and occipital headache, jaw claudication combined with malaise, and myalgia of the upper limbs. Laboratory tests showed normal inflammatory markers. Repeated tests confirmed ESR and CRP to be within the normal range. GCA being suspected, ultrasound of the superficial temporal arteries and temporal artery biopsy were performed unilaterally on the right side. Histology showed a chronic inflammatory cell infiltrate consistent with active GCA. The patient was treated with high-dose corticosteroids (250 mg methylprednisolone, three times/day, initially) and symptoms rapidly resolved, but visual loss remained unchanged. The case presented here proves that GCA with typical related visual loss (AION) is possible even when both ESR and CRP are in the normal range. Therefore, in the presence of typical symptoms, the clinician must not rely solely on laboratory testing, but start steroid therapy immediately and order a temporal artery biopsy." }, { "id": "pubmed23n1145_24843", "title": "Paracentral Acute Middle Maculopathy After COVID-19 Disease: Multimodal Evaluation.", "score": 0.009433962264150943, "content": "To report the case and multimodal imaging findings of a healthy young woman who developed paracentral acute middle maculopathy (PAMM) 9 weeks after COVID-19 disease. Case report. Ultra-widefield fundus photography, macular spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography (FA), and OCT-angiography (OCT-A) were performed. A 36-year-old woman who developed PAMM 9 weeks after SARS-CoV-2 infection. A 36-year-old woman went to the emergency department (ED) with sudden, painless, left eye (LE) vision loss. The only relevant past medical history was COVID-19 disease 9 weeks before. Best corrected visual acuity (BCVA) was 20/200, a LE relative afferent pupillary defect (RAPD) was present and superficial hemorrhages throughout the macular area and peripheral retina were found. Nearly four hours after admission, LE BCVA recovered to 20/20 without RAPD. Five days after presentation in the ED, the patient returned with recurrent LE vision loss, with spontaneous recovery within 12 hours. Macular SD-OCT revealed hyperreflectivity of the inner plexiform and inner nuclear layers and the diagnosis of PAMM was established. The patient started oral acetylsalicylic acid and oral prednisolone. The patient did not report any new episodes of vision loss and there was a progressive resolution of abnormal fundus findings. SARS-CoV-2 infection increases the risk of vascular thrombotic events with possible involvement of the retinal circulation, and PAMM may present as a possible complication. Ophthalmologists should be able to recognize it promptly through multimodal imaging findings." }, { "id": "pubmed23n0525_4392", "title": "[Blindness in both eyes due to late diagnosis of giant cell arteritis].", "score": 0.009433962264150943, "content": "Giant cell arteritis (GCA) is often diagnosed very late, variable \"facets\" of the disease exist render the diagnosis more difficult. Follow-up observations of five very old patients are reported in whom diagnosis was made too late, resulting in blindness of both eyes. Five patients (age 76-84 years, 4 women, one man) with GCA became blind in both eyes because diagnosis had been delayed (two patients) or onset of therapy was too late (three patients). In two patients who also had arterial hypertension, the symptom \"headache\" had been misleading. Symptoms of accompanying general diseases masked the real diagnosis, particularly in the second patient who had renal insufficiency, coronary artery disease, and unilateral obstruction of the internal carotid artery. Symptoms that failed to lead to the correct diagnosis were: muscle or chewing pain (three patients), circumscribed numbness around the mouth (second patient), and persistent headache despite normalization of blood pressure. Normal findings from cranial CTAs (two patients) led to the wrong reassurance of the patient. Swelling of the optic disk (two patients) was misdiagnosed by ophthalmologists, as was a retinal branch arterial occlusion (first patient). Three patients, afraid of possible side effects caused by glucocorticoids, took ineffective alternative medications. Poor vigilance led to blindness of the fifth patient with long-standing polymyalgia rheumatica. Targeted examinations at the onset of symptoms are necessary. GCA-symptoms were mis-constructed by additional diseases that disguised the correct diagnosis. The danger of bilateral blindness is particularly great in patients of great age." }, { "id": "wiki20220301en053_41040", "title": "Posterior ischemic optic neuropathy", "score": 0.009345794392523364, "content": "Defective light perception in one eye causes an asymmetrical pupillary constriction reflex called the afferent pupillary defect (APD). Arteritic PION A-PION most commonly affects Caucasian women, with an average age of 73. At onset vision loss is unilateral, but without treatment it rapidly progresses to involve both eyes. Vision loss is usually severe, ranging from counting fingers to no light perception. Associated symptoms are jaw pain exacerbated by chewing, scalp tenderness, shoulder and hip pain, headache and fatigue. Perioperative PION Vision loss is usually apparent upon waking from general anesthesia. Signs observable to a bystander include long surgery duration and facial swelling. Vision loss is usually bilateral and severe, ranging from counting fingers to no light perception. Cause" }, { "id": "pubmed23n0314_1466", "title": "[A 62-year-old man with an acute onset of consciousness disturbances].", "score": 0.009345794392523364, "content": "We report a 62-year-old man who developed coma and died in a fulminant course. The patient was well until May 1, 1996 when he noted chillness, tenderness in his shoulders, and he went to bed without having his lunch and dinner. In the early morning of May 2, his families found him unresponsive and snoring; he was brought into the ER of our hospital. He had histories of hypertension, gout, and hyperlipidemia since 42 years of the age. On admission, his blood pressure was 120/70, heart rate 102 and regular, and body temperature 36.3 degrees C. His respiration was regular and he was not cyanotic. Low pitch rhonchi was heard in his right lower lung field. Otherwise general physical examination was unremarkable. Neurologic examination revealed that he was somnolent and he was only able to respond to simple questions such as opening eyes and grasping the examiner's hand, but he was unable to respond verbally. The optic discs were flat; the right pupil was slightly larger than the left, but both reacted to light. He showed ptosis on the left side, conjugate deviation of eyes to the left, and right facial paresis. The oculocephalic response and the corneal reflex were present. His right extremities were paralyzed and did not respond to pain Deep tendon reflexes were exaggerated on the right side and the plantar response was extensor on the right. No meningeal signs were present. Laboratory examination revealed the following abnormalities; WBC 18,400/ml, GOT 131 IU/l GPT 50 IU/l, CK616 IU/l, BUN 30 mg/dl, Cr 2.1 mg/ dl, glucose 339 mg/dl, and CRP 27.4 mg/dl. ECG showed sinus tachycardia and ST elevation in II, III and a VF leads and abnormal q waves in I, V5, and V6 leads. Chest X-ray revealed cardiac enlargement but the lung fields were clear. Cranial CT scan revealed low density areas in the left middle cerebral and left posterior cerebral artery territories. The patient was treated with intravenous glycerol infusion and other supportive measures. At 2: 10 AM on May 3, he developed sudden hypotension and cardiopulmonary arrest. He was pronounced dead at 3:45 AM. The patient was discussed in a neurological CPC, and the chief discussant arrived at the conclusion that the patient had acute myocardial infarction involving the inferior and the true posterior walls and left internal carotid embolism from a mural thrombus. Post mortem examination revealed occlusion of the circumflex branch of the left coronary artery due to atherom plaque rupture and myocardial infarction involving the posterior and the lateral wall with a rupture in the postero-lateral wall. Marked atheromatous changes were seen in the left internal carotid, the middle cerebral and the basilar arteries; the left internal carotid and the middle cerebral arteries were almost occluded by thrombi and blood coagulate. The territories of the left middle cerebral and the occipital arteries were infarcted; but the left thalamic area was spared. The neuropathologist concluded that the infarction was thrombotic origin not an embolic one as the atherosclerotic changes were severe. Cardiac rupture appeared to be the cause of terminal sudden hypotension and cardiopulmonary arrest. It appears likely that a vegetation which had been attached to the aortic valve induced thromboembolic occlusion of the left internal carotid artery which had already been markedly sclerotic by atherosclerosis. It is also possible that the vegetations in the aortic valve came from mural thrombi at the site of acute myocardial infarction, as no bacteria were found in those vegetations." }, { "id": "wiki20220301en015_138436", "title": "Sciatica", "score": 0.009259259259259259, "content": "Cancer should be suspected if there is previous history of it, unexplained weight loss, or unremitting pain. Spinal epidural abscess is more common among those with diabetes mellitus or immunocompromised or who had spinal surgery, injection or catheter; it typically causes fever, leukocytosis and increased erythrocyte sedimentation rate. If cancer or spinal epidural abscess are suspected, urgent magnetic resonance imaging is recommended for confirmation. Proximal diabetic neuropathy typically affects middle aged and older people with well-controlled type-2 diabetes mellitus; onset is sudden causing pain usually in multiple dermatomes quickly followed by weakness. Diagnosis typically involves electromyography and lumbar puncture. Shingles is more common among the elderly and immunocompromised; usually (but not always) pain is followed by appearance of a rash with small blisters along a single dermatome. Acute Lyme radiculopathy may follow a history of outdoor activities during warmer" }, { "id": "pubmed23n0019_2125", "title": "[Arteriitis temporalis--a major disease developing in advance age (author's transl)].", "score": 0.009259259259259259, "content": "Arteriitis temporalis, a disease that was largely unknown in the early fifties, has gained importance in recent years. In the past ten years 32 patients suffering from arteriitis temporalis were diagnosed and treated both in the eye hospital and in the rheumatic-cardiological hospital of the Berlin-Buch Municipal Hospital. The following clinical findings were essential for the diagnosis: advanced or old age of the patient, massive headache in the temporal and/or occipital regions, myalgia primarily in the shoulders and the neck that responded relatively poorly to treatment, reduced eyesight, loss of weight and decrease in vitality. Extremely high BSR, an increased amount of alpha-2 and an increased level of alkaline phosphatase were most important among the laboratory findings. Corticosteroids have proved to be the medicine of choice for treating this condition." }, { "id": "wiki20220301en019_114604", "title": "Ankylosing spondylitis", "score": 0.009174311926605505, "content": "These diagnostic criteria include: Inflammatory back pain:Chronic, inflammatory back pain is defined when at least four out of five of the following parameters are present: (1) Age of onset below 40 years old, (2) insidious onset, (3) improvement with exercise, (4) no improvement with rest, and (5) pain at night (with improvement upon getting up) Past history of inflammation in the joints, heels, or tendon-bone attachments Family history for axial spondyloarthritis or other associated rheumatic/autoimmune conditions Positive for the biomarker HLA-B27 Good response to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) Signs of elevated inflammation (C-reactive protein and erythrocyte sedimentation rate) Manifestation of psoriasis, inflammatory bowel disease, or inflammation of the eye (uveitis) If these criteria still do not give a compelling diagnosis magnetic resonance imaging (MRI) may be useful. MRI can show inflammation of the sacroiliac joint. Imaging" }, { "id": "pubmed23n0259_159", "title": "[C-reactive protein or blood sedimentation reaction os preventive studies in the physician's laboratory?].", "score": 0.009174311926605505, "content": "The laboratory examinations are more and more significant in the practical internal medicine. The results are basic for decision-making in medicine. The patients are asking for check-up examinations, including screening examinations in the laboratory. We try to compare the significance of two important laboratory tests. The C-reactive protein (CRP) is very sensitive and allows a graduation of the inflammatory reaction. It is useful to take the CRP in a valuable screening examination. Compared with the erythrocyte sedimentation rate (ESR), an elevated CRP always signifies an organic illness. A normal ESR has a poor predictive value. An elevated ESR supports only the history and the clinical findings of a suspected diagnoses. There is no possibility to screen patients without symptoms by ESR. We use ESR to follow-up diseases like arteritis temporalis and polymyalgia rheumatica and to measure the therapeutic effect." }, { "id": "pubmed23n0945_12479", "title": "Man with a Swollen Eye: Nonspecific Orbital Inflammation in an Adult in the Emergency Department.", "score": 0.00909090909090909, "content": "Nonspecific orbital inflammation (NSOI) is a rare idiopathic ocular pathology characterized by unilateral, painful orbital swelling without identifiable infectious or systemic disorders, which can be complicated by optic nerve compromise. A 50-year-old man presented to the Emergency Department with recurring, progressive painless left eye swelling, decreased visual acuity, and binocular diplopia in the absence of trauma, infection, or known malignancy. His physical examination was notable for left-sided decreased visual acuity, an afferent pupillary defect, severe left eye proptosis and chemosis, and restricted extraocular movements; his dilatated funduscopic examination was notable for ipsilateral retinal folds within the macula, concerning for a disruption between the sclera and the retina. Ocular examination of the right eye was unremarkable. Laboratory data were unrevealing. Gadolinium-enhanced magnetic resonance imaging showed marked thickening of the left extraocular muscles associated with proptosis, dense inflammatory infiltration of the orbital fat, and characteristics consistent with perineuritis. The patient was diagnosed with NSOI with optic neuritis and admitted for systemic steroid therapy; he was discharged on hospital day 2 after receiving high-dose intravenous (i.v.) methylprednisolone with significant improvement. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: NSOI is a rare and idiopathic ocular emergency, with clinical mimicry resembling a broad spectrum of systemic diseases such as malignancy, autoimmune diseases, endocrine disorders, and infection. Initial work-up for new-onset ocular proptosis should include comprehensive laboratory testing and gadolinium-enhanced magnetic resonance imaging. Timely evaluation by an ophthalmologist is crucial to assess for optic nerve involvement. Signs of optic nerve compromise include decreased visual acuity, afferent pupillary defect, or decreased color saturation. Patients with optic nerve compromise require admission for aggressive anti-inflammatory therapy with i.v. steroids in an attempt to reduce risk of long-term visual sequelae. Our case demonstrates a severe presentation of this disorder and exhibits remarkable visual recovery after 48 h of systemic i.v. steroid treatment." }, { "id": "InternalMed_Harrison_1707", "title": "InternalMed_Harrison", "score": 0.00909090909090909, "content": "diagnostic pointers are numerous and diverse but may be missed drug is the cause. In patients without PDCs or with only misleading on initial examination, often being detected only by a very care-PDCs, funduscopy by an ophthalmologist may be useful in the early ful examination performed subsequently. In the absence of PDCs, stage of the diagnostic workup. When the first-stage diagnostic tests the history and physical examination should therefore be repeated do not lead to a diagnosis, scintigraphy should be performed, esperegularly. One of the first steps should be to rule out factitious or cially when the ESR or CRP level is elevated. fraudulent fever, particularly in patients without signs of inflammation in laboratory tests. All medications, including nonprescription Recurrent Fever In patients with recurrent fever, the diagnostic drugs and nutritional supplements, should be discontinued early in workup should consist of thorough history-taking, physical examithe evaluation to" }, { "id": "pubmed23n1033_13514", "title": "Leber's hereditary optic neuropathy following unilateral painful optic neuritis: a case report.", "score": 0.009009009009009009, "content": "Leber's hereditary optic neuropathy (LHON) is a maternally inherited mitochondrial disease, characterized by acute or subacute, painless, bilateral visual loss. LHON is often misdiagnosed as optic neuritis at an early stage because of the similarity of their clinical presentation. To date, there has been no reported case of actual optic neuritis and LHON in one patient. A 40-year-old, healthy man was referred to our clinic with acute painful visual loss in the right eye for 2 weeks. In the right eye, visual acuity decreased to 20/40, and the Ishihara colour test score was 8/14 with a relative afferent pupillary defect. Optic disc swelling was found only in the right eye, and magnetic resonance imaging revealed enhancement of the the right optic nerve, consistent with optic neuritis. After receiving 1 g of intravenous methylprednisolone daily for three days, his ocular pain resolved, and visual acuity improved to 20/20 within 2 weeks. Seven months later, the patient developed acute painless visual loss in the right eye. Visual acuity decreased to 20/200 in the right eye. There was no response to the intravenous methylprednisolone therapy at that time. Eight months later, he developed subacute painless visual loss in the left eye. Genetic testing for LHON was performed and revealed the pathologic mtDNA 11778 point mutation. We report a case with painful unilateral optic neuritis preceding the onset of LHON. Even if a typical optic neuritis patient has completely recovered from steroid treatment once in the past, it is advisable to keep in mind the possibility of LHON if acute or subacute loss of vision subsequently or simultaneously occurs in both eyes and does not respond to steroids." }, { "id": "pubmed23n0491_3108", "title": "Sometimes (what seems to be) a heart attack is (really) a pain in the neck.", "score": 0.009009009009009009, "content": "A 31-year-old patient complained of severe crushing chest pain that radiated to his left arm and jaw. After admission to the hospital, tests revealed a normal electrocardiogram, normal treadmill, normal coronary arteriogram, and normal cardiac enzymes. However, the patient continued to have pain, which was relieved by sublingual and intravenous nitroglycerine. He was discharged from the hospital with a diagnosis of \"musculoskeletal\" chest pain, taking nonsteroidal anti-inflammatory drugs, muscle relaxants, and narcotics. Two weeks later, the patient returned with worsening symptoms. Cardiac work-up was again negative. Thoracic and cervical spine radiographs were ordered for possible discogenic pain. After abnormalities were found on cervical radiographs, magnetic resonance imaging (MRI) was ordered, and the patient was referred to an orthopedic surgeon. Further work-up revealed a herniated disk at C6-C7, with radicular pain. Surgery on the suspect disk totally relieved the patient's pain." }, { "id": "wiki20220301en053_41039", "title": "Posterior ischemic optic neuropathy", "score": 0.008928571428571428, "content": "Signs and symptoms PION is characterized by moderate to severe painless vision loss of abrupt onset. One or both eyes may be affected and color vision is typically impaired. Ophthalmoscopic exam Looking inside the person's eyes at the time of onset, ophthalmoscope exam reveals no visible changes to the optic nerve head. Weeks after ischemic insult, nerve atrophy originating from the damaged posterior optic nerve progresses to involve the anterior optic nerve head. Four to eight weeks after onset, atrophy of the optic nerve head is observable upon ophthalmoscope exam. Pupils If both eyes are affected by PION, the pupils may look symmetrical. However, if the eyes are asymmetrically affected, i.e. one eye's optic nerve is more damaged than the other, it will produce an important sign called an afferent pupillary defect. Defective light perception in one eye causes an asymmetrical pupillary constriction reflex called the afferent pupillary defect (APD)." }, { "id": "pubmed23n0738_18367", "title": "Diagnostic work-up of an elderly patient with unilateral head and neck pain. A case report.", "score": 0.008928571428571428, "content": "Headache patients frequently contact physiotherapists and manual therapists. In case of elderly patients with unilateral headache, neck and facial pain clinical practice guidelines recommend further referral for medical investigation to exclude red flags. The present patient was seen in a multidisciplinary headache clinic. He was referred by the neurologist (headache specialist) for physiotherapeutic assessment after screening for red flags, including giant cell arteritis (GCA). After first assessment, GCA was considered unlikely, since the sedimentation rate, as a marker for inflammation, was only slightly elevated. The purpose of the referral was to exclude cervicogenic headache (CEH) and to explore physical treatment as a therapeutic option. Physiotherapeutic assessment consisted of a history taking on CEH signs (Sjaastad criteria, 1998), followed by cervical spine assessment including tests for neck mobility, joint pain, and endurance of the short neck flexors. The patient's history revealed no specific signs of CEH and cervical spine assessment was negative. In consultation with the neurologist, the diagnosis of CEH was abandoned. Since palpation of the temporal artery proved to be painful, laboratory examination and biopsy of the temporal artery were thereafter performed, this time revealing GCA. Appropriate treatment (high dose steroids) was initiated promptly, with a good clinical evolution. The presented case shows the potential of a multidisciplinary collaboration in the clinical diagnostic work-up of patients with head and neck pain. " }, { "id": "pubmed23n1041_6439", "title": "Central retinal artery occlusion as a post-transfusion complication of red blood cells.", "score": 0.008849557522123894, "content": "A 32-year-old woman presented with a history of uterine myomatosis and repeated bleeding for 6 months. This produced a haemoglobin concentration of 6.5 g/dL, with a requirement for a red blood cell transfusion. One hour after the transfusion, she presented with a sudden and painless loss of vision in the right eye (RE). As she had no other symptoms, she was referred to the Neuro-Ophthalmology Department. On admission, her corrected visual acuity was hand movement in RE, and 0.6 in the left eye (LE). The anterior segment was unremarkable, except for a relative afferent pupillary defect in RE. In the fundus examination, the RE showed a diffuse pale retina with a cherry spot, consistent with occlusion of the central artery of the retina. Management was attempted but with no improvement. The studies corroborated retinal ischaemia in RE. During the systemic evaluation, the neuroimaging, autoimmune and haematology studies were negative, thus this complication was attributed to the red blood cell transfusion." }, { "id": "wiki20220301en003_97415", "title": "Headache", "score": 0.008813730048039672, "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": "pubmed23n1030_6059", "title": "Central retinal artery occlusion as initial presentation of Moyamoya disease in a middle-aged woman.", "score": 0.008771929824561403, "content": "To present a case of central retinal artery occlusion as the first symptomatic manifestation of Moyamoya disease in a middle-aged patient. Case report of a 48-year-old female Chinese-American patient who presented with sudden onset painless unilateral vision loss. Fundus photos, optical coherence tomography, fluorescein angiography, magnetic resonance angiography, computed tomography angiography, and catheter cerebral angiogram were performed. The patient's dilated fundus examination showed classic findings of a central retinal artery occlusion. Diagnostic brain imaging demonstrated extensive stenosis of the cerebrovascular network, with almost complete unilateral occlusion of the internal carotid artery along with compensatory collateral vessels. This led to a new diagnosis of Moyamoya disease. The patient was treated with extracranial-intracranial bypass surgery. Arterial abnormalities in patients with Moyamoya disease are uncommon and have previously only been reported in younger patients in their teens and 20s. Young and middle-aged patients presenting with central retinal artery occlusions should undergo complete neurologic workup including stroke evaluation; in this case, revealing Moyamoya disease, a rare yet life-threatening condition, as the underlying etiology." }, { "id": "pubmed23n0640_14621", "title": "Diagnosis of a 65-year-old male patient with Takayasu's arteritis by 18F-FDG PET/CT.", "score": 0.008771929824561403, "content": "Takayasu's arteritis (TA) is characterized by a chronic inflammatory arteriopathy with unknown etiology affecting large vessels. As TA occurs mostly in young females, elderly males with this disease may be under-diagnosed. A 65-year-old Chinese male with a 6-week history of fever, fatigue, low appetite, night sweats, and a 5-kg weight loss did not experience symptoms of jaw claudication, localized headache, sudden visual change, upper or lower extremity claudication, arthralgia, and rashes. On physical examination and laboratory findings, there was no evidence of infectious disease or malignancy. (18)F-Fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) was performed which suggested TA. The patient was treated with methylprednisolone and clopidogrel. His symptoms subsided gradually and hematological examination showed decreases of erythrocyte sedimentation rate and high-sensitivity C-reactive protein. We reported here a patient who presented with fever of unknown origin and was diagnosed with TA using PET/CT. Although elderly males are beyond the predominant population of TA, TA should be considered when there is no evidence of infectious disease and malignancy." }, { "id": "wiki20220301en455_20429", "title": "Ultrasound-guided lumbar puncture", "score": 0.008695652173913044, "content": "Ultrasound-guided lumbar puncture is a medical procedure used in some emergency departments to obtain cerebrospinal fluid for diagnostic purposes. In contrast to standard lumbar puncture by palpation, the use of ultrasound imaging may reduce the number of failed punctures, needle insertions, and needle redirections. Ultrasound-guided lumbar puncture was first described in Russian medical literature in 1971. References CSF tests Medical ultrasonography Neurology procedures" }, { "id": "pubmed23n0479_17655", "title": "Progression of preexisting trigeminalgia to Tolose-Hunt-like syndrome. The importance of neuroimaging for early differential diagnosis.", "score": 0.008695652173913044, "content": "Recurrent unbearable, paroxysmal, unilateral facial pain in the distribution of one or more branches of the trigeminal nerve often provoked by sensory stimuli is typical for idiopathic trigeminal neuralgia. The less frequent localization in the area of ophthalmic branch (5%) is particularly controversial and should be distinguished from pathological lesions in the brainstem and middle and posterior cranial fossa and from diseases of the orbit and eye. This case study presents a 79-year-old woman with typical clinical features of 1st division trigeminalgia without any neurological loss and with normal results of laryngological, ophthalmological, and stomatological examinations as well as neuroimaging CT, and MR /MRA evaluation. Only the evoked potential blink and masseter reflexes demonstrated the pathological values in the early phase of illness. After 1 year of pharmacological treatment no improvement was achieved and the pain became neuropathic and paresis of 3rd, 4th and 6th nerves developed, as observed in Tolose-Hunt syndrome. MRI of the orbit revealed a pathological mass in its apex with a connection to the superior orbital fissure. However, treatment with steroids was completely ineffective. Surgical resection of the tumor (leiomyosarcoma) only partially reversed oculomotor palsy and diminished aching. In differential diagnosis of idiopathic and symptomatic trigeminalgia, early MR and MRA imaging is the most essential and sometimes may be the best single test to evaluate lesions even in distant areas of the nervous system branches." } ] } } }

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{ "1": "Statin therapy is indicated to stabilize the thrombus.", "2": "Urgent diagnostic aortography is necessary.", "3": "At surgery, the aneurysmal segment is replaced by a tubular prosthesis with reimplantation of the supra-aortic trunks.", "4": "Thoracic stent implantation is indicated.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1020_17591", "title": "Endovascular Approach to Severe Acute Type B Aortic Dissection.", "score": 0.017507645259938837, "content": "Acute aortic dissection (AAD) is an important emergency that should be identified promptly. The classification of AAD follows two different systems: Stanford (which defines lesions as types A, on the ascending aorta, or B, on the descending aorta) and DeBakey, which also accounts for the extension of the aortic dissection. We present a notable case of a 63-year-old male who presented with a history of abrupt abdominal pain radiating to the dorsal region for endovascular treatment. He was oliguric with symmetric pulses in the superior limbs and reduction of pulses in the left lower limbs, with signs of hypoperfusion. Angiotomography evidenced acute abdominal thoracic aortic dissection classified as DeBakey III and Stanford B, extending through the left iliac artery. He was submitted to endovascular correction of the abdominal thoracic aortic dissection, with implantation of two straight Valiant type endoprosthesis (26x200 mm and 38x200 mm), positioned after the emergence of the left subclavian artery and right above the celiac trunk, respectively. There was also implantation of the stent graft Viabahn (5x60 mm) and Assurant stent (7x30 mm) in the left renal artery. After the urgent surgical intervention, the patient has recovered well. He has been checked in outpatient follow-ups for the past three years with preserved renal function (1.5 mg/dl creatinine) and correct positioning of the endoprosthesis (confirmed by CT without contrast). Hypertension and a smoking history are the most important risk factors associated with aortic dissections, and should be considered when evaluating a patient with chest or back pain (typically described as sharp rather than tearing or ripping) in the emergency department. The endovascular approach to descending dissections was introduced in 1999 and has been established as the standard approach to descending dissections of the aorta, because of the excess mortality of the open approach (32% in open surgery and 7% for those managed with endovascular techniques) and low rate of complications. Ten-year survival rates for patients with AAD ranging from 30% to 60% justifies an aggressive follow-up strategy of discharge, with the goal of minimizing aortic wall stress through drugs (such as β blockers) and surveillance to detect progression. Our report shows that an early detection of symptoms coupled with an aggressive and precise endovascular intervention has produced satisfactory clinical, laboratorial and quality-of-life outcomes in an older patient with an extensive type B arterial dissection." }, { "id": "pubmed23n0944_25224", "title": "Endovascular Solutions for Thoracic Aortic Aneurysms with Challenging Anatomies.", "score": 0.01595677050222505, "content": "The suitability of the proximal and distal landing zones remains one of the main limitations to thoracic endovascular aortic repair. The advent of custom-made scalloped stent grafts widened the endovascular options in some challenging anatomies. The authors present three cases of thoracic aortic aneurysm (TAA), with three different hostile anatomies, successfully treated with custom-made scalloped stent grafts. Case1: Male patient, 47 years old, no relevant medical history. Angio-CT revealed a 54mm post- traumatic TAA, extending distally from the origin of the left subclavian artery. Inadequate sealing in Ishimaru zone 2 was evident. The patient was sequentially treated by means of a carotid-subclavian bypass followed by TEVAR with proximal scallop to the left common carotid artery. Proper proximal sealing was obtained. Case2: Male patient, 76 years old, diagnosed with a 65mm diameter TAA, involving the origin of the left subclavian artery. Presence of a bovine trunk, and inadequate landing zone distally to it, were noted. The patient was sequentially treated by means of a carotid-subclavian bypass followed by TEVAR with proximal scallop to the bovine trunk. Proper sealing in Ishimaru zone 2 was granted. Case3: Male patient, 77 years old, multiple comorbidities. Angio-CT revealed a 59,3mm saccular aneurysm of the distal thoracic descending aorta, extending proximally from the origin of the celiac trunk. Good collateralization was observed after celiac trunk occlusion test. Proper distal seal was obtained by means of selective embolization of the celiac trunk followed by TEVAR with distal scallop to the superior mesenteric artery. All procedures were uneventful, with no reported endoleaks, birdbeaks, migrations or re- interventions. There are no reported complications at 1-year follow-up. Custom-made scalloped thoracic stentgrafts are an accessible, reproducible and safe therapeutic option when dealing with hostile descending thoracic anatomies, and should be considered as a minimally-invasive effective solution in selected cases." }, { "id": "pubmed23n0706_8355", "title": "Successful treatment of a ruptured aortic arch aneurysm using a hybrid procedure.", "score": 0.01582751744765703, "content": "Aortic rupture has a high mortality rate and can be considered a medical emergency. The standard treatment for aortic rupture is surgical repair. An aortic stent graft for a ruptured descending aorta is considered an effective alternative treatment. However, an aortic stent graft is difficult when the aortic aneurysm is in the aortic arch due to supra-aortic vessels. We report on a patient with a ruptured aortic arch aneurysm treated with a hybrid procedure, which involved a carotid to carotid bypass operation and an aortic stent graft. A 71-year-old male patient visited our cardiovascular center suffering from hemoptysis. The chest CT and aortography showed a 9 cm sized aortic arch aneurysm 0.5 cm distal to the left subclavian artery and a hemothorax in the left lung. The patient refused to undergo a full open operation. We performed a carotid to carotid bypass in advance, and two pieces of aortic stent grafts were placed across the left carotid artery and left subclavian artery. The follow up CT showed the aortic stent grafts, no endoleaks and no thrombus in the aortic arch aneurysm. The patient was discharged from the hospital without complication." }, { "id": "wiki20220301en359_24618", "title": "Hybrid cardiac surgery", "score": 0.013536953242835596, "content": "For aneurysms of the thoracic aorta, thoracic endovascular aortic repair (TEVAR) has become a valid alternative to open repair. This method may even be applied to pathologies of the aortic arch and the distal descending aorta. A common complication of EVAR are endoleaks. These may be missed by 2D angiographic evaluation. Rotational angiography, providing CT-like 3D imaging with the angiographic C-arm enables the surgeon to diagnose this complication intraoperatively and correct it right away. An indication that a hybrid technique would be most beneficial and successful is that the patient has had a previous aortic repair. Patients with chronic dissecting aneurysms are not good candidates for the hybrid approach. In the hybrid one-stage procedure the graft can be check immediately after the placement of the stent. In the hybrid two-stage procedure the total operation time is much shorter and decreases postoperative complications, however there is a risk that the aneurysm could" }, { "id": "wiki20220301en158_2279", "title": "Endovascular aneurysm repair", "score": 0.01330085450257124, "content": "The endograft acts as an artificial lumen for blood to flow through, protecting the surrounding aneurysm sac. This reduces the pressure in the aneurysm, which itself will usually thrombose and shrink in size over time. Staging such procedures is common, particularly to address aortic branch points near the diseased aortic segment. One example in the treatment of thoracic aortic disease is revascularization of the left common carotid artery and/or the left subclavian artery from the innominate artery or the right common carotid artery to allow treatment of a thoracic aortic aneurysm that encroaches proximally into the aortic arch. These \"extra-anatomic bypasses\" can be performed without an invasive thoracotomy. Another example in the abdominal aorta is the embolization of the internal iliac artery on one side prior to coverage by an iliac limb device. Continued improvement in stent-graft design, including branched endografts, will reduce but not eliminate multi-stage procedures." }, { "id": "Surgery_Schwartz_5783", "title": "Surgery_Schwartz", "score": 0.013071895424836602, "content": "a sternotomy approach. Aneu-rysms involving the descending thoracic aorta are evaluated in terms of criteria (described in the following section) for poten-tial endovascular repair; those unsuitable for an endovascular approach are repaired with open techniques through a left thora-cotomy. A CT scan can reveal detailed information about aortic calcification and luminal thrombus. These details are important in preventing embolization during surgical manipulation.Indications for Operation Thoracic aortic aneurysms are repaired to prevent fatal rupture. Therefore, on the basis of clini-cal history studies and other data, practice guidelines for tho-racic aortic disease43,44,62 recommend elective operation in asymptomatic patients when the diameter of an ascending aortic aneurysm is >5.5 cm, when the diameter of a descending thoracic aortic aneurysm is >6.0 cm, or when the rate of dilata-tion is >0.5 cm per year. In patients with heritable disorders such as Marfan and Loeys-Dietz" }, { "id": "pubmed23n0421_13212", "title": "Endovascular exclusion of thoracic aortic aneurysms: mid-term results of elective treatment and in contained rupture.", "score": 0.012740882306099698, "content": "The purpose is to present results of endovascular exclusion (stent-graft treatment) of aneurysms of the descending thoracic aorta both in elective cases and in emergencies. Indications for stent-graft treatment were dependent on multislice angio-CT evaluation revealing a proximal neck of at least 10 mm between the left common carotid artery and the onset of aneurysm. All stent grafts were inserted in the operating room; 43 transfemoral, 2 transiliac. The stent grafts used were Corvita, Stenford, Vanguard, AneuRx, Talent, and Excluder. Deployment was achieved under fluoroscopic control, endoleaks were checked for with D S A on the operating table and postoperatively by angio-CT. Long-term follow-up consisted of evaluation with angio-CT after 6 and 12 months, and from there on once a year and with plain chest X-rays. Follow-up was achieved in all patients. Mean follow-up is 21 months (1-66); 30-day mortality is 3/45, no permanent neurologic deficit. Thirty patients were treated electively, 15 with contained rupture. Left subclavian artery overstenting proved to be necessary in 12 patients for proper proximal sealing of the aneurysm, type I endoleaks were observed in 10 patients, one early conversion, 7 proximal extension cuffs, one sealed spontaneously, one still at risk. Among patients where LSA had been overstented only one wanted a transposition, all others did well without left-hand ischemia or subclavian steal syndrome. Endovascular treatment is less invasive and has reasonable mortality and morbidity but is limited to well-defined morphologies. Mid-term results are promising but it has to be observed whether these will translate into long-term durability." }, { "id": "wiki20220301en437_24793", "title": "Open aortic surgery", "score": 0.012151353568498769, "content": "Medical uses OAS is used to treat patients with aortic aneurysms greater than 5.5 cm in diameter, to treat aortic rupture of an aneurysm any size, to treat aortic dissections, and to treat acute aortic syndrome. It is used to treat infrarenal aneurysms, as well as juxta- and pararenal aneurysm, thoracic and thoracoabdominal aneurysms, and also non-aneurysmal aortic pathology. Disease of the aorta proximal to the left subclavian artery in the chest lies within the specialty of cardiac surgery, and is treated via procedures such as the valve-sparing aortic root replacement. Prior to the advent of EVAR, OAS was the only surgical treatment available for aortic aneurysms. It is still preferred at some institutions and by some patients as it may be more durable than EVAR and does not require post-operative surveillance CT scans." }, { "id": "pubmed23n1003_14128", "title": "Total Arch and Descending Aorta Replacement for Retrograde Type A Aortic Dissection After Endovascular Stent Graft Replacement for Complicated Type B Aortic Dissection.", "score": 0.012125791594703512, "content": "Retrograde type A aortic dissection (RTAD) is a severe complication of thoracic endovascular aortic repair (TEVAR). In this regard, we present our unique surgical methods for total arch and descending aorta replacement for RTAD after TEVAR for complicated type B aortic dissection (TBAD). A 52-year-old man with a history of distal arch large aneurysm was diagnosed with TBAD. Because he had sustained chest pain and his aneurysm diameter was 67 mm, TEVAR was urgently performed. After a right axillary-left axillary artery bypass, a stent graft was deployed in the descending aorta via the right femoral artery. Coil embolization was performed in the left subclavian artery. After the condition of the stent graft was checked by angiography, no Type 1 endoleak and backflow from the re-entry was observed. However, seven days after the operation, he experienced chest pain suddenly. Computed tomography (CT) revealed forward blood flow in the descending aorta (type IA endoleak) and thrombosed aortic dissection in the ascending aorta. The distal arch diameter exceeded 70 mm. A decision was taken to immediately perform an operation. Total aortic arch and descending aorta replacement were performed through a median sternotomy with left 5th interspace thoracotomy. The operation was performed under deep hypothermic circulatory arrest, and selective antegrade cerebral perfusion was accomplished. As a result of the exploration of the aortic arch, it was found that the intimal injury by the bare stent caused RTAD. The patient was successfully extubated after the operation and was discharged without any complications. RTAD can present as an early complication after descending stent grafting because of aortic instability or due to the strength of bare stents. Aortic arch and descending aorta replacement after TEVAR via a clamshell incision can be safely performed if RTAD is diagnosed early." }, { "id": "pubmed23n1009_3210", "title": "Forced Complete Femoral Approach for Urgent Thoracoabdominal Aneurysm Repair Using an Inner Branched Endograft.", "score": 0.012121212121212121, "content": "A successful case of urgent type II thoracoabdominal aneurysm repair with an inner branched endograft conducted entirely through femoral accesses without the bailout possibility to achieve an upper extremity approach for bridging stents delivery is described. A 70-year-old male patient underwent hybrid treatment for a thoracic aortic aneurysm on complicated type B dissection in 2 steps. First, arch debranching with carotid-carotid-subclavian bypass and then ascending aortic replacement with reimplantation of the anonymous trunk plus TEVAR were performed. The scheduled 1-month control computed tomography angiography (CTA) showed a rapid increase of the false lumen thoracoabdominal aneurysm, with axial diameter measuring more than 10 cm. The repair procedure was based on the use, as off-the-shelf graft, of a prosthesis customized for another patient with inner branches for visceral vessels that well suited the characteristics of the case. A steerable guiding sheath was essential to stabilize the system in the selective and sequential cannulation of 2 of the 4 inner branches (for celiac trunk and superior mesenteric artery) and to complete the bridging stents deployment. Procedure was carried out without complications. In an urgent setting, total endovascular correction of a thoracoabdominal aortic aneurysm exclusively through femoral accesses appears to be feasible when the appropriate tools are available." }, { "id": "pubmed23n0253_14174", "title": "[Simultaneous operations for both the repair of the aortic arch aneurysm and repeated CABG].", "score": 0.010857477319285923, "content": "A 73-year-old female complaining of left thoracic pain was referred to our hospital. In 1988, she had the first CABG of the left circumflex coronary artery (CX) and right coronary artery. On admission in April 1994, chest X-ray and CT scan revealed a saccular aortic aneurysm, 5 x 5 cm in size, extending to the distal to the left subclavian artery. Coronary arteriography showed a patency of the CX graft, but 99% stenosis of the proximal left anterior descending branch (LAD) with delayed opacification. After the repeated median sternotomy, cardiac arrest was achieved with the aortic cross clamping and St. Thomas Hospital solution infusion. CABG to the LAD branch using a saphenous vein was accomplished. Following this, the replacement of the aortic aneurysmal lesion with a prosthetic graft was performed under the selective cerebral perfusion with deep hypothermia. Proximal anastomosis of the vein graft was completed during a rewarming period. The operation was performed without complications. Postoperative course was satisfactory except a few minor transient complications such as athelectasis of the left upper lobe and the intra-thoracic hematoma. After one month's hospitalization, she was discharged, and currently (six months postoperative) remains asymptomatic." }, { "id": "wiki20220301en027_45804", "title": "Aortic aneurysm", "score": 0.009900990099009901, "content": "Screening with ultrasound is indicated in those at high risk. Prevention is by decreasing risk factors, such as smoking, and treatment is either by open or endovascular surgery. Aortic aneurysms resulted in about 152,000 deaths worldwide in 2013, up from 100,000 in 1990. Classification Aortic aneurysms are classified by their location on the aorta. An aortic root aneurysm, or aneurysm of the sinus of Valsalva. Thoracic aortic aneurysms are found within the chest; these are further classified as ascending, aortic arch, or descending aneurysms. Abdominal aortic aneurysms, \"AAA\" or \"Triple A\", the most common form of aortic aneurysm, involve that segment of the aorta within the abdominal cavity. Thoracoabdominal aortic aneurysms involve both the thoracic and abdominal aorta. Thoracoabdominal aortic aneurysms comprise some or all of the aorta in both the chest and abdomen, and have components of both thoracic and abdominal aortic aneurysms." }, { "id": "pubmed23n0667_16098", "title": "Treatment of symptomatic mobile aortic thrombus.", "score": 0.009900990099009901, "content": "Mobile thoracic or abdominal aortic thrombi are a potential source of embolism to visceral organs or lower limbs. Detection levels of this type of aortic pathology after any embolic event have increased considerably. Nevertheless, therapeutic management of an intraluminal mobile thrombus of the aorta remains controversial. The aim of this study is to describe the treatment modalities for symptomatic mural aortic thrombi based on three cases diagnosed at our institution and to review the literature. During the last decade, several patients with peripheral embolisation were diagnosed with an intraluminal mobile aortic thrombus. Three patients who were treated differently were selected and reviewed. In addition a literature search was performed on PubMed and Medline from their inception to the present for all English language articles using the following keywords: blue toe syndrome, peripheral arterial embolisation, mobile thrombus and aorta. The advantages and drawbacks of medical management, open and endovascular treatment are described. Three particular patients with embolisation due to a floating aortic thrombus were reviewed. The first patient underwent a thoracotomy with replacement of the descending thoracic aorta. Another case was treated successfully by implanting an endovascular stent graft in the descending thoracic aorta. The last patient was treated medically because of the involvement of the visceral vessels. When reviewing the literature, no randomised controlled trials were found but several case reports have described both open and endovascular techniques. No long-term follow up of this rare pathology is available. In the literature there is no consensus how to treat a symptomatic floating aortic thrombus. This report shows that therapeutic strategies are influenced by the localisation of the thrombus, the co-morbidities of the patient and the physician' s preferences. Endovascular treatment in combination with high dose statins has become the preferred treatment method although long-term data are lacking." }, { "id": "pubmed23n0332_2621", "title": "[Completion pneumonectomy combined with graft replacement of thoracic aortic aneurysm by simple clamping].", "score": 0.00980392156862745, "content": "A 59-years-old male patient who had left upper lobe partial resection 30 years ago. He was seen at the family physician because of cough. A chest X-ray was showing an abnormal mass shadow measuring 3 x 4 cm in left lower lobe like honey comb. And squamous cell carcinoma (SCC) was detected in his sputum. He was diagnosed as primary lung cancer and introduced to our department to have operation. Chest CT-scan was showing lung tumor suspected SCC measuring 4.3 x 2.6 cm in segment 8 faced chest wall. At the same time, we detected thoracic aortic aneurysm and subcarinal lymph node, but could not see where the boundary is, so it was hard to distinguish between parietal thrombus with thoracic aortic aneurysm and swelling subcarinal lymph node. We decided it swelling subcarinal lymph node by three-dimensional treated CT-scan. Aortic angiography was showing proximal descending aortic aneurysm measuring diameter was 4.5 cm. Abdominal CT-scan was showing infrarenal abdominal aortic aneurysm measuring diameter was 5.5 cm. He was diagnosed as primary lung cancer (It. S8, SCC) (cT2N2M0, Stage IIIB), thoracic aortic aneurysm, abdominal aortic aneurysm, and idiopathic pulmonary fibrosis, and had completion pneumonectomy (R 2 b) for primary lung cancer and graft replacement with aneurysm dissection for thoracic aortic aneurysm without extracorporeal circulation. In this operation, we could find swelling subcarinal lymph node measuring 5 x 3 cm instead of parietal thrombus with thoracic aortic aneurysm. Pathological examination diagnosed middle differential SCC and no metastasis from dissected lymph node (PT2N0M0, Stage I A)." }, { "id": "pubmed23n0533_12702", "title": "Aneurysm hybrid treatment by simultaneous replacement of ascending aorta and aortic arch and endoluminal stenting of the descending aorta.", "score": 0.009708737864077669, "content": "Resection of the descending thoracic aorta and replacement with a vascular prosthesis is associated with an increased risk of paraplegia, as opposed to endoluminal stenting. We report on the first case in which a thoracic aortic aneurysm was treated in a hybrid approach, combining surgery with the implantation of a new intraluminal stent during 1 procedure. A 76-year-old man with long-standing hypertension suffered from acute chest pain. Magnetic resonance imaging (MRI) revealed a complex aortic aneurysm with increased diameters of the ascending aorta (55 mm), the aortic arch (75 mm), and the descending aorta (50 mm). Supracoronary replacement of the ascending aorta with a 30-mm prosthesis was carried out during cardiopulmonary bypass, cardioplegic arrest, and hypothermia (25 degrees C). Surgery and stenting were carried out during circulatory arrest and antegrade cerebral perfusion. Two stents (length: 23 cm and 17 cm) were placed in the descending aorta via the opened aortic arch under X-ray control, covering the left subclavian artery. Then aortic arch replacement was finished by anastomosing the distal end of the aortic prosthesis to the proximal stent's customized proximal end (Polyester cuff, length 25 mm/diameter 36 mm) together with the aortic wall. The brachiocephalic trunk and left carotid artery along with a vein graft to the left subclavian artery were implanted in the prosthesis. Postoperative course was uneventful except for a pericardial effusion. MRI revealed normal dimensions of the thoracic aorta with complete exclusion of the aneurysm and no leakage. Simultaneous replacement of ascending aorta and aortic arch with antegrade endoluminal stenting of the descending aorta using a new type of stent were safely and effectively performed in a patient with an aortic aneurysm." }, { "id": "pubmed23n1131_15944", "title": "False lumen thrombus following aortic dissection diagnosed as the source of repeat lower extremity emboli with angioscopy: a case report.", "score": 0.009708737864077669, "content": "Acute arterial embolization caused by a free-floating thrombus of the false lumen after surgery for acute aortic dissection is a rare complication; hence, determining its cause may be difficult. We report a case in which angioscopy was valuable in diagnosing and treating the unstable thrombus within the false lumen. The patient was a 71-year-old woman who underwent hemiarch replacement for Stanford type A acute aortic dissection. Two months after the operation, left renal infarction occurred. Eighteen months after the operation, the patient visited the hospital for treatment of intermittent claudication of her left leg. Computed tomography (CT) showed occlusion below the left common femoral artery. Surgical thrombectomy was performed for acute lower extremity arterial occlusion. One month later, thrombectomy was performed again for the same phenomenon and again after 2 months. She had no history of cardiac arrhythmia. No obvious source for the repeat embolization could be found on echocardiography or enhanced CT. Angiography was performed to further identify the cause, revealing a new entry site at the distal anastomosis, which exhibited antegrade flow into the false lumen. Furthermore, selective false lumen angiography via the re-entry revealed a thrombus in the false lumen corresponding to the descending aorta. A non-obstructive angioscopy system in the false lumen revealed a free-floating thrombus. As the patient had undergone multiple surgeries over a short period and desired minimally invasive treatment, coil embolization of the new entry site as well as false lumen was performed. As a result, blood flow from the true to the false lumen resolved. More than 1 year has passed following coil embolization with no signs of embolism. We experienced a case of repeat embolism caused by unstable thrombus formation in the false lumen resulting from antegrade blood flow in the false lumen secondary to development of a new entry site. Angioscopy revealed that this antegrade flow caused formation of an unstable thrombus which caused recurrent acute lower extremity arterial occlusion. Therefore, angioscopy may be a useful option for the diagnosis of false lumen thrombosis." }, { "id": "pubmed23n0018_601", "title": "[Surgical therapy of arterial occlusions. Indication and results of revascularization in 5370 peripheral arteriosclerotic occlusions].", "score": 0.009615384615384616, "content": "The results of 5370 revascularizations in peripheral arteriosclerotic occlusive diseases are reported. The operative mortality in 532 carotis interna desobliterations with ischaemia stage II was 2.3%. In stage I of 98 prophylactic operations we lost no patient. Instead of the transthoracic reconstruction we now prefer the extrathoracic bypass because of the lower risk involved. The abdominal aortic aneurysm always is an indication for resection because of the danger of rupture. In cases of 100 operated patients with aneurysm we had a mortality rate in the elective stage of 5.3%, in stage of covered rupture of 47.1% and in ruptured aneurysm 85.7%. The complications in vascular reconstruction of the lower extremity are low. The mortality rate after implantation of aortic bifemoral prosthesis is 3.7%, after an unilateral aortic-femoral prosthesis 2.8% and after all operations below the inguinal ligament 1.0%. Also the femoro-tibial occlusions could be revascularized in bypass-technique with a risk of 1.5% and good early results of 90.3%." }, { "id": "pubmed23n0889_7371", "title": "[Early type I Endoleak after Endovascular Management of an Aorto-esophageal Fistula].", "score": 0.009523809523809525, "content": "Presentation of a clinical case of an aorto-esophageal fistula secondary to thoracic aorta pseudoaneurysm, complicated by early type Ia endoleak after endovascular repair. A 64 years old male patient, with a history of arterial hypertension, smoking, alcohol abuse and ischemic heart disease with previous coronary revascularization was observed because of chest pain and abundant hematemesis, with Angio-CT revealing a 77mm pseudoaneurysm of the descending thoracic aorta, close to the left subclavian artery, with mass effect on the esophagus and trachea and signs of fistulization. He was proposed to endovascular repair with sealing in zone 2 of the aortic arch after building a left carotid-subclavian bypass. In the first 24 hours there were two episodes of massive hematemesis, with new Angio-CT revealing a early distal migration of the prosthesis, conditioning a type Ia endoleak. A carotid-carotid right-left bypass with left carotid ligation was performed and a new endoprosthesis was implanted in the origin of the brachycephalic trunk (zone 1). The final angiography showed aneurysm exclusion with permeability of the supra-aortic trunks. Later contrasted esophageal examination and endoscopy revealed an ulcer of the posterior left lateral wall with clot suggestive of fistula, and an esophageal prosthesis was successfully implanted. It held seven days of antibiotic therapy with ceftriaxone and metronidazole with no evidence of mediastinal infection and with aneurysm exclusion in the CT follow-up. The recognized biomechanical and anatomical complexity of the aneurysmatic thoracic aorta represents a considerable challenge to the endovascular treatment of aorto-esophageal fistulas, especially in aneurysmatic sealing of the aortic arch, with significant rates of type Ia and III endoleaks." }, { "id": "Surgery_Schwartz_6314", "title": "Surgery_Schwartz", "score": 0.009523809523809525, "content": "the continuing evolution of endovascular technology and the skills of individual interventionalists when stating that the patient’s comorbidities, fully informed patient preference, and the local operator’s long-term success rates Brunicardi_Ch23_p0897-p0980.indd 94227/02/19 4:14 PM 943ARTERIAL DISEASECHAPTER 23Figure 23-52. A. Multidetector computed tomography angiography of the aortoiliac artery circulation in a 63-year-old male with buttock claudication. B. Three-dimensional image reconstruction shows intra-arterial calcification of the aorta (large arrow) and right common iliac artery (small arrow). This is consistent with type I aortoiliac occlusive disease.Figure 23-53. Atherosclerotic disease involving the aortoiliac segment can result in microembolization of the lower leg circulation, resulting in trash foot or digital gangrene of toes.must be considered when making treatment decisions for type B and type C lesions.1,115General Treatment ConsiderationsThere is no effective" }, { "id": "pubmed23n1088_19871", "title": "Free-floating thrombus of the aorta: 3 case reports.", "score": 0.009433962264150943, "content": "Idiopathic free-floating thrombus (FFT) of the aorta is a rare occurrence, but it can lead to catastrophic consequences. The initial symptoms are typically cerebral or peripheral embolisms. Surgical thrombectomy and thrombolysis are two primary treatments for FFT. Here, we report three cases of patients with idiopathic FFT in the absence of coagulopathy who were treated successfully by surgery with no recurrent thrombi or relapse of symptoms. Case 1 involved a 72-year-old male patient with a pedunculated thrombus in the distal aortic arch. Case 2 involved a 62-year-old female patient with a cylinder thrombus in the aortic arch and left common carotid artery. Case 3 involved a 65-year-old male patient with three pedunculated thrombi in the ascending aorta, aortic arch, and left subclavian artery. None of the patients had clinical signs of coagulopathy. Pedunculated or cylinder thrombi have a greater risk of breaking off, which can produce severe peripheral embolism in contrast with intramural thrombi (73% vs. 12%). Due to the high embolism risk for each patient, conservative medical treatment by heparinization was deemed inappropriate, so each patient underwent emergency surgical thrombus removal. After surgery, each of the three patients was treated with warfarin for secondary prevention of thromboembolism. At 7-month follow-up in outpatient practice, a computed tomography (CT) scan indicated that Patient 1 had no recurrent thrombus, and the patient has been symptom-free for 11 months. At 1-month follow-up in outpatient practice, a CT scan indicated that Patient 2 had no recurrent thrombus, and the patient has been symptom-free for 8 years. At 3-week follow-up in hospital, a CT scan indicated that Patient 3 had no recurrent thrombus, but he failed to follow-up after discharge, so his follow-up status is unknown. For a large pedunculated or cylinder thrombus located in the thoracic aorta, surgical thrombectomy should be performed. And, in surgical thrombectomy, the location of the cannulas and cross-clamp should be selected carefully according to the location of the thrombus. After surgery, anticoagulant is important to prevent recurrent idiopathic thrombi." }, { "id": "Surgery_Schwartz_5782", "title": "Surgery_Schwartz", "score": 0.009404574132492113, "content": "and planning necessary procedures. Note that patients with a thoracic aortic aneurysm may also have a second, remote aneurysm.2 In such cases, the more threatening lesion usually is addressed first. In many patients, staged operative procedures are necessary for complete repair of extensive aneurysms involving the ascending aorta, transverse arch, and descending thoracic or thoracoabdominal aorta.61 When the descending segment is not disproportionately large (compared with the proximal aorta) and is not causing symptoms, the proximal aortic repair is carried out first. An important benefit of this approach is that it allows treatment of valvular and coronary artery occlusive disease at the first operation.Proximal aneurysms (proximal to the left subclavian artery) usually are addressed via a sternotomy approach. Aneu-rysms involving the descending thoracic aorta are evaluated in terms of criteria (described in the following section) for poten-tial endovascular repair; those unsuitable" }, { "id": "pubmed23n0882_12127", "title": "Repair of Chronic Aneurysmal Aortic Dissection Using a Stent Graft and an Amplatzer^® Vascular Plug: A Case Study.", "score": 0.009345794392523364, "content": "We report a case in which a stent graft and an Amplatzer<sup®</sup vascular plug (AVP) were effective for the treatment of chronic aneurysmal aortic dissection. The patient was a 52-year-old man. At 45 years of age, he developed acute aortic dissection, for which he underwent surgery 4 times with prosthetic graft replacement in the abdominal aorta, descending thoracic, ascending aorta (without neck branch reconstruction), and thoracoabdominal aorta with the reconstruction of the celiac, superior mesenteric, and bilateral renal arteries. At the time of thoracoabdominal aortic surgery, strong adhesion was evident, particularly in the thoracoabdominal area. The adhesion was dissected in a part of the chest, and prosthetic graft replacement was performed the following day. Subsequently, the dissection of the residual distal aortic arch enlarged, and the patient was examined at our hospital. Computed tomography (CT) revealed a small intimal tear at the site of anastomosis distal to the graft in the ascending aorta and a large intimal tear in the descending thoracic aorta with a maximum diameter of 67 mm. Furthermore, open repair by prosthetic graft replacement seemed difficult; therefore, treatment with stent grafting was considered. Because the prosthetic graft in the abdomen was extremely tortuous, stent-graft insertion via the femoral artery seemed to be impossible. The planned treatment involved the placement of a thoracic stent graft using the chimney technique which included reconstruction of the brachiocephalic artery and left common carotid arteries using chimney stent graft and coverage of the left subclavian artery. The thoracic stent graft was planned to be inserted via the abdominal prosthetic graft site because the abdominal prosthetic graft was crooked and was located close to the body surface. However, a small intimal tear distal to the graft in the ascending aorta which had not been revealed by intraoperative aortography was detected by the selective angiography, and closure with an AVP was attempted for this. The site was successfully closed using an AVP with a wire passing through the tear and into the false lumen. Thereafter, the large tear in the descending thoracic aorta was closed using a stent graft. The patient made good postoperative progress without evidence of paraplegia, and complete thrombosis of the false lumen was confirmed by postoperative CT. CT at 1 year after thoracic endovascular aneurysm repair (TEVAR) showed complete thrombosis of false lumen and aneurysm shrinkage." }, { "id": "pubmed23n0076_10971", "title": "[Surgical therapy of ruptured aortic aneurysm involving a Shuford type-3 right-sided aortic arch].", "score": 0.009345794392523364, "content": "A 64-year-old man was admitted to our hospital with a complaint of severe back pain of sudden onset on Nov. 2, 1988. Aortogram and chest-CT demonstrated a ruptured dissecting aortic aneurysm involving a Shuford type-3 right-sided aortic arch. Emergency operation was done under temporary brachio-femoral arterial bypass. The thoracic aorta was transected distal to an aberrant left subclavian artery. The entry which located proximal to the aberrant subclavian artery was closed by two u-stay sutures with pledgets. The transected aorta was closed and reinforced with Sandwich method using Teflon-felt. The false lumen completely disappeared on chest-CT on 36th day postoperatively, and the patient is now doing well, although re-thoracotomy was necessary because of post-operative bleeding. To our knowledge, this is the first case of repair of a ruptured dissecting aortic aneurysm involving a right-sided aortic arch which is reported to be very rare." }, { "id": "wiki20220301en229_26848", "title": "Randall B. Griepp", "score": 0.009259259259259259, "content": "Spielvogel D, Etz CD, Silovitz D, Lansman SL, Griepp RB. Aortic arch replacement with a trifurcated graft. Annals of Thoracic Surgery. 2007 Feb; 83(2): 3791-3795. Etz CD, Halstead JC, Spielvogel D, Shahani R, Lazala R, Homann TM, Weisz DJ, Plestis K, Griepp RB. Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time? Annals of Thoracic Surgery. 2006 November; 82(5): 1670-1677. Carroccio A, Spielvogel D, Ellozy SH, Lookstein RA, Chin IY, Minor ME, Sheahan CM, Teodorescu VJ, Griepp RB, Marin ML. Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage. Vascular. 2005 January–February; 13(1): 5-10. Hagl C, Strauch JT, Spielvogel D, Galla JD, Lansman SL, Squitieri R, Bodian CA, Griepp RB. Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival? Annals of Thoracic Surgery. 2003 September; 76(3): 698-702." }, { "id": "pubmed23n0207_4285", "title": "[Angioplasty of the arteries of the extremities. Early and mid-term results (up to 3 years) in 492 cases].", "score": 0.009259259259259259, "content": "Results of iliac, femoral and/or iliac artery percutaneous transluminal angioplasty (P.T.A.) in 492 cases are presented, and the latest technical improvements in the procedure reviewed. Short and medium-term results in iliac artery stenoses were excellent (98 and 96% respectively), obstructions in this region not being treated. The advantage of P.T.A. over surgery is the lack of exposure of patients to the risk of circulatory insufficiency. Very good results were obtained in stenosis of the distal femoral artery, the method being much less effective in cases of long thrombosis. The essential indications are all types of stenosis of limb arteries, while contraindications can be summarized as iliac artery obstructions (because of possible severe retroperitoneal hematomas) and massive atheromatous calcifications. Aortic and graft stenoses are particular indications. Complications are mainly hematomas and thromboses, but these can be reduced in incidence by increasing experience of radiologists in the use of P.T.A. and by improved selection of patients. Progress will also depend on improved control of anticoagulant and thrombolytic treatments. The question is raised as to the need to treat early claudication due to femoral artery stenosis following detection by the Doppler effect test. The essential argument in favor of P.T.A. is the simplicity and safety of the method to the compared reconstructive surgery, a method involving too high a risk." }, { "id": "wiki20220301en028_36929", "title": "Abdominal aortic aneurysm", "score": 0.009174311926605505, "content": "Hemodynamics affect the development of AAA, which has a predilection for the infrarenal aorta. The histological structure and mechanical characteristics of the infrarenal aorta differ from those of the thoracic aorta. The diameter decreases from the root to the aortic bifurcation, and the wall of the infrarenal aorta also contains a lesser proportion of elastin. The mechanical tension in the abdominal aortic wall is therefore higher than in the thoracic aortic wall. The elasticity and distensibility also decline with age, which can result in gradual dilatation of the segment. Higher intraluminal pressure in patients with arterial hypertension markedly contributes to the progression of the pathological process. Suitable hemodynamic conditions may be linked to specific intraluminal thrombus (ILT) patterns along the aortic lumen, which in turn may affect AAA's development." }, { "id": "wiki20220301en028_36958", "title": "Thoracic aortic aneurysm", "score": 0.00909090909090909, "content": "Age The diagnosis of thoracic aortic aneurysm usually involves patients in their 60s and 70s. Risk factors Hypertension and cigarette smoking are the most important risk factors, though the importance of genetic factors has been increasingly recognized. Approximately 10 percent of patients may have other family members who have aortic aneurysms. It is also important to note that individuals with a history of aneurysms in other parts of the body have a higher chance of developing a thoracic aortic aneurysm. Diagnosis Thoracic aortic aneurysm is defined as a cross-sectional diameter exceeding the following cutoff: 4.5 cm in the United States 4.0 cm in South Korea A diameter of 3.5 cm is generally considered dilated. However, average values vary with age and size of the reference population, as well as different segments of the aorta. Screening" }, { "id": "pubmed23n0094_2386", "title": "[Surgical treatment of aneurysms of the abdominal aorta. Consecutive experience for 12 years].", "score": 0.00909090909090909, "content": "The authors present their experience with abdominal aortic aneurysm during the last 12 years. From 1976 up to now they treated 70 patients with abdominal aortic aneurysms. Sixty-seven patients (96%) were male, while 3 (4%) female. Mean age was 65 years (S.D. +/- 7.97). 82% of the patients were heavy smokers. Sixty-five patients were treated by means of resection and vascular reconstruction. Their associated pathologies were: M.I. or severe heart ischemia 34 (52.3%), diabetes 13 (20%), hypertension 25 (38.4%), T.I.A. 6 (9.2%), renal insufficiency 13 (20%), and respiratory insufficiency 18 (27.6%). Results demonstrated a 12-year patency rate of 91.8%. Five high-risk patients were treated by means of \"palliative\" treatment. Associated pathologies and risk factors were: smoking 5 (100%), M.I. or severe heart ischemia 5 (100%), diabetes 2 (40%), hypertension 4 (80%), T.I.A. 2 (40%), renal insufficiency 2 (40%), respiratory insufficiency 3 (60%). Treatment consisted in the sac thrombosis by means of Gianturco-Wallace coils into the aneurysm (2 cases) and iliac artery ligation (3 cases). Both techniques allowed acute thrombosis of the aneurysm. Vascular supply to the lower limbs was performed by means of an axillo-bifemoral reconstruction in all cases. Long-term prognosis of these five patients was poor due to their general condition." }, { "id": "pubmed23n0377_18283", "title": "[Immediate results of surgical treatment of proximal aortic dissection].", "score": 0.009009009009009009, "content": "From 1984 to 1997, 112 patients have been operated at the Department of Cardiac Surgery of the Azienda Ospedaliera of Parma for acute dissection of ascending aorta. They were 73 males and 39 females of mean age 59.2 years (range 19-79); in the majority they presented a history of essential hypertension and atherosclerotic disease: the first diagnostic suspicion has been confirmed either by angio-CT scan or by CT scan plus aorthography and, from 1994, with transesophageal color doppler echocardiography that is becoming a valuable and precise tool wich can be used in emergency room. Bentall type composite repair or modified Bentall technique has been possible in 37 patients, while in the remaning 75, surgical aortic repair has been achieved by interposition of a dacron vascular prosthesis. Cardiac procedures that were performed in addition were coronary bypass grafthing, resuspension of the aortic valve, AVR. Total arch replacement with reimplantation of brachiocephalic vessels were performed in 6 patients and partial in 10, when intimal tear extended into the arc. Thirthythree in hospital deaths (29.4%) occurred (15 in S.O. and 18 in UCI). Follow up of the hospital survivors was conducted at a mean postoperative interval of 55 months (range 2 to 149 months with 6 late death related to aortic dissection). Our experience shows an increased incidence hypertension and aortic atherosclerosis, compared with marfan's syndrome as a source of acute aortic dissection in the late years, transesophageal echocardiography is a excellent tool for aortic dissection but it may miss dissection localized in other aortic portion, the need of an individualized and conservative surgical approach tailored to the pathology encountered." }, { "id": "pubmed23n0248_6887", "title": "Lesions of the thoracic aorta and its arch branches simulating neoplasm.", "score": 0.008928571428571428, "content": "Abnormal radiographic densities in the midportion of the chest are most commonly caused by neoplasms, cysts, or inflammatory disease. However, vascular lesions may present an identical x-ray appearance, with no distinguishing clinical history or physical findings. The cardiothoracic surgeon must be aware of this similarity in order to ensure the most appropriate diagnostic and therapeutic approach. In our experience, the most frequent problem in differential diagnosis is a lesion of the thoracic aorta or its arch branches simulating neoplasm. Nine such cases are presented, with pertinent conventional radiographs angiograms, and computed tomographic (CT) scans. These are considered in anatomic sequence: (1) ruptured sinus of Valsalva aneurysm; (2) ascending aortic aneurysm; (3) tortuosity or aneurysm of the innominate and subclavian arteries; (4) transverse arch aneurysm; (5) pseudocoarctation; and (6) descending aortic aneurysm. Such vascular lesions must be considered early in the evaluation of any juxta-aortic chest density, particularly if the patient is hypertensive and has other manifestations of atherosclerosis. Angiography and computed tomography establish the diagnosis in most instances, although both are less reliable when thrombus fills all or part of an aneurysm. If these methods fail to establish a vascular origin, the possibility of neoplasm is pursued. When neither a vascular nor neoplastic origin can be proved, surgical exploration is indicated in the otherwise good-risk patient." }, { "id": "pubmed23n0863_22150", "title": "Hybrid treatment of a true thyreocervical trunk aneurysm in a patient with Type B aortic dissection.", "score": 0.008928571428571428, "content": "We would like to describe a case with a complex aortic disease treated in hybrid fashion. We present an interesting case of a 65-year-old man with a medical history of hypertension, hyperlipidemia, and coronary artery disease percutaneously treated. An acute Type B aortic dissection occurred and treated with the implantation of a stent-graft which occluded the left subclavian artery due to its extension to the aortic arch. This event required a carotid-subclavian artery bypass due to ischemia of the left arm. An aneurysm in the innominate artery also detected, was treated with another stent-graft implantation 3 months later. At 5-year follow-up, an aneurysm of the thyreocervical trunk was found while the stent-graft of the aorta was well-tolerated without endoleak and the carotid-subclavian graft was patent. The aneurysm was asymptomatic but considering the risk of spontaneous rupture of an aneurysm of this size, elective surgery was indicated. Because the aneurysm was very close to the brachiocephalic bifurcation, open surgical repair would require a sternotomy. The right common carotid artery and right subclavian artery were exposed. The thyrocervical trunk, right internal mammary artery and right vertebral artery were occluded by ligations to isolate the aneurysm. An 8-mm Dacron graft was anastomosed end-to-end to the distal part of subclavian artery. We would like through this case, discuss the role of the hybrid cardiovascular surgery to minimize the postoperative complications in complex cardiovascular pathology. We also discuss the international bibliography about the thyreocervical trunk aneurysm and the treatment options. " }, { "id": "wiki20220301en333_2588", "title": "Adventist HealthCare White Oak Medical Center", "score": 0.008849557522123894, "content": "CT imaging Angiography Emergent and routine abdominal aortic aneurysm (AAA) stent graft Carotid stenting Arterial embolization Full spectrum of cardiac surgery Bypass Surgery Beating Heart Surgery Aortic Valve Surgery Mitral Valve Surgery Tricuspid Valve Surgery Thoracic Aortic Procedures Atrial Fibrillation (Maze) Surgery Endoscopic Vein Harvesting Cardiac Tumor Registry Full spectrum of vascular surgery Comprehensive electrophysiology service Catheter ablation Pacemaker and defibrillator implants Monitored Cardiac Rehabilitation Cardiac and Vascular Research through the Center for Cardiac and Vascular Research (CCVR) Percutaneous coronary intervention (PCI) Primary PCI- an early life-saving medical procedure for heart attack patients" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": true, "char_ranges": [ [ 25, 214 ] ], "word_ranges": [ [ 5, 31 ] ], "text": "Vulvar carcinoma is characterized by chronic vulvar itching resistant to multiple treatments, appearance of lumpiness or ulceration, dysuria and urinary urgency, and late pain and bleeding." } }

{ "1": "Genital herpes.", "2": "Paget's disease of the vulva.", "3": "Urethral caruncle.", "4": "Chronic granuloma of the vulva.", "5": "Vulvar squamous cell carcinoma." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0765_14621", "title": "Unusual locations of primary subepithelial squamous cell carcinomas of the vulva.", "score": 0.014043844196515953, "content": "This study aimed to report 2 cases of squamous cell carcinoma (SCC) of the vulva, arising from unusual subepithelial locations. The first case was of an 85-year-old woman with a 65-year history of a mass in the left labium majus. The second case was of a 54-year-old woman who presented with a 1-week history of a painful left inguinal mass. She had previously sought medical attention for a 2-year history of a left-sided painless vestibular mass. In the first case, a simple excision showed a purely dermal SCC with no attachment to the epidermis. After the diagnosis of SCC, a wide, deep local excision of the left side of the vulva and left inguinofemoral lymph node dissection were performed. Pathological findings showed no residual tumor in the vulva, and the lymph nodes were clear. Based on the long history of a mass at the same site, the pathogenesis of the SCC was considered to be malignant degeneration of a previously benign epidermal cyst.In the second case, SCC was diagnosed on fine-needle aspirations of the vulvar and groin masses. The patient was treated with primary chemoradiation. Subsequently, wide, deep local excision of the left side of the vulva and left inguinofemoral lymph node dissection were performed. No residual tumor was found in the vulva, although atrophic Bartholin gland tissue was found at the site of the SCC. One 5-mm inguinofemoral lymph node metastasis was found in the groin node dissection. In the absence of any evidence of another pathogenesis, it was believed that the SCC had arisen from an unusually anterior located Bartholin gland. Subepithelial SCC should be considered in the differential diagnosis of unusually located vulvar masses." }, { "id": "pubmed23n0684_11696", "title": "A case of usual (basaloid)-type vulvar intraepithelial neoplasia that failed to respond to imiquimod cream: clinical implications.", "score": 0.01323440076369001, "content": "The authors report a case of usual-type (basaloid-type) vulvar intraepithelial neoplasia (VIN) 3 that failed to respond to imiquimod cream. A 51-year-old Japanese woman visited her local gynecologist complaining of vulvar itching. Atypical cells were noted in cytology smears, but nine vulvar biopsy specimens showed benign proliferation of epithelial tissue. The patient was placed under careful observation for 8 months, when the vulvar smears once again showed atypical cells and biopsy specimens revealed VIN3. The patient was then referred to our hospital where she was given a diagnosis of VIN 3, basaloid type of usual type. The biopsy specimens were positive for p16 and the lesions were confirmed to be human papilloma virus (HPV)-related. We recommended simple vulvectomy but the patient requested conservative treatment with imiquimod cream. With her written informed consent, we prescribed imiquimod cream to be self-administered 3 times a week. Colposcopy and pap smear test were performed every 2 weeks. Four weeks after the start of treatment, a fingertip-sized papule was detected at the patient's vaginal introitus. By 6 weeks, the lesion had enlarged, and biopsy specimens revealed invasive squamous cell carcinoma. At 7 weeks, we performed simple vulvectomy. The surgical specimen showed stage pT1b keratinizing-type squamous cell carcinoma. HPV-16 DNA was detected in the specimen." }, { "id": "pubmed23n1022_23213", "title": "Concurrence of Primary Cutaneous Extra Mammary Paget's Disease and Squamous Cell Carcinoma in situ of Vulva: A Case Report.", "score": 0.012923203963666391, "content": "Extramammary Paget's disease and vulvar intraepithelial neoplasia are common lesions of vulve, but synchronous occurrence is rare in a same location. Herein we describe a concurrence of primary cutaneous extra mammary Paget's disease and squamous cell carcinoma in situ of vulva in an Iranian women. A 59 year old woman, initially presented to Kosar teaching hospital gynecology clinic April 2017 with a single, well defined, scaly, white ulcerated mass, 2 cm in diameter on right minor labia, but other examinations were normal. She had no urinary or gastrointestinal symptoms. Incisional biopsies from the mass represented concurrence extramammary Paget's disease and VIN3. She underwent radical vulvectomy .No evidence of disease recurrence was noted after 16 months follow up. Participant consent was obtained before patient was enrolled in this study. There are lot of diseases that involve genitalia and lead to vulvar lesions. But in this rare case, we diagnosed concurrence of extramammary Paget's disease and vulvar intraepithelial neoplasia in a same location. Additionally, the clinical presentation as a vulvar mass was found unusual. Therefore, we report the case to sensitize gynecologists and pathologists for uncommon pathologies and their manifestations in vulva." }, { "id": "wiki20220301en001_202239", "title": "Vulvodynia", "score": 0.010025062656641603, "content": "It is estimated that among sufferers, only half will seek medical help, among whom many will see several doctors before a correct diagnosis is made. Only 2% of the people that seek help do obtain a diagnostic. Many gynecologists are not familiar with this family of conditions, but awareness has spread with time. Sufferers are also often hesitant to seek treatment for chronic vulvar pain, especially since many women begin experiencing symptoms around the same time they become sexually active. Moreover, the absence of any visible symptoms means that before being successfully diagnosed many patients have been told that the pain is \"in their head\" (a medical stance more associated with the 1970s than with modern medicine). Differential diagnosis Infections: candidiasis, herpes, HPV Inflammation: lichen planus Neoplasm: Paget's disease, vulvar carcinoma Neurologic disorder: neuralgia secondary to herpes virus, spinal nerve injury" }, { "id": "pubmed23n0594_7725", "title": "Ulcus vulvae acutum in a 13-year-old girl after influenza A infection.", "score": 0.009900990099009901, "content": "A 13-year-old otherwise healthy premenarchal girl presented with acute onset of painful vulvar ulcerations. One day before developing vulvar ulcerations, she experienced flu-like symptoms, including a low-grade fever, cough, sore throat, and myalgia. Results of a throat swab were positive for influenza A infection (polymerase chain reaction [PCR] assay), and the patient was treated with oseltamivir. The patient's constitutional symptoms improved slightly, but within 2 days after her initial presentation, she returned to her primary care provider and described 24 hours of dysuria and vulvar swelling. She had a history of herpes labialis (cold sores) and rare episodes of minor oral aphthae (canker sores) that occurred less than twice a year. The patient denied a history of sexual activity, sexual abuse, or physical trauma. Physical examination showed ulceration and swelling of the labia minora, and the patient received an empiric dose of acyclovir (200 mg 4 times daily) for presumed autoinoculated herpes simplex virus (HSV) infection. An ulcer swab was performed, and urinalysis revealed no evidence of infection. Two days later, the patient presented to the emergency department with increasing vulvar pain and vaginal discharge. The previous ulcer swab findings were negative for HSV (PCR assay), and consequently, acyclovir was discontinued after 1 day of therapy. She received topical viscous lidocaine and an empiric dose of oral fluconazole. The lidocaine provided temporary symptomatic relief. Results of DNA amplification studies were negative for Chlamydia trachomatis and Neisseria gonorrhoeae. A potassium hydroxide preparation was negative for fungi, and an ulcer swab for bacterial culture revealed usual flora. Of note, the PCR assay for Epstein-Barr virus was not performed on ulcer cells. The patient was referred to the department of dermatology, and results of a physical examination showed copious white mucoid discharge and a 2-cm ulceration of the left labia minora (Figure, panel A). Two smaller pinpoint ulcerations and swelling of the left labia minora were also noted. The lesions were clinically indistinguishable from the genital aphthous ulcers of patients with complex aphthosis (recurrent, severe aphthous ulcers on oral or genital mucosa). A diagnosis of ulcus vulvae acutum was made, and treatment was started with clobetasol 0.05% ointment (4 times daily) and lidocaine gel as needed. Four days later, the patient reported marked symptomatic improvement. Physical examination showed near resolution of the large vulvar ulceration (Figure, panel B). The patient tapered use of clobetasol ointment over the next several days until the ulcerations healed completely. Two months after her initial episode, the patient again had 3 small vulvar erosions after symptoms that included low-grade fever, malaise, and vomiting. She did not receive oseltamivir for this illness; clobetasol ointment was applied 4 times daily, and the vulvar erosions ameliorated within a few days. Her constitutional symptoms resolved without treatment. The patient has not experienced any further episodes of vulvar ulcerations in the 18 months after the most recent treatment." }, { "id": "pubmed23n0102_10238", "title": "Dermatological conditions of the vulva.", "score": 0.009900990099009901, "content": "Management of vulval conditions in the elderly will present no special problems if the following points are borne in mind: 1. The patient's condition will often be multifactorial; the components should be unravelled and the patient followed until the picture is clear. 2. Point 1 is particularly important because infections and neoplasia can easily go unrecognized. 3. Biopsy will often be needed. 4. Management of chronic dermatological conditions (especially where systemic treatment is indicated) is usually best carried out by the dermatologist. 5. It is vital to consider the area as one would any other as regards diagnosis of cutaneous and mucosal lesions. With this approach the vast majority of lesions can be accurately named and reasonable treatment given. To this end the naked-eye morphology, and the histopathological evidence which will sometimes be a necessary supplement, must be accurately described and understood. 6. The study of vulval conditions is interdisciplinary. 7. Much old and contentious terminology is now obsolete. The new classification is simple and should be universally applied by gynaecologists, dermatologists and pathologists so that other involved clinicians are helped rather than confused." }, { "id": "pubmed23n0476_7565", "title": "Vulvar Langerhans cell histiocytosis: a case report and review of the literature.", "score": 0.00980392156862745, "content": "Langerhans cell histiocytosis (LCH) of the female genital tract is rare. Only, seven cases of primary vulvar LCH have been previously reported in the medical literature. We describe an additional case of LCH in which the disease was confined to the vulva. A 33-year-old gravida 0, para 0 Ethiopian woman presented with a nodular lesion on her left vulva. The lesion was biopsied, and the results were consistent with LCH. A metastatic workup did not reveal any evidence of disease beyond the vulva. The patient was initially treated with radiotherapy to the vulva. She was diagnosed with recurrent disease in the vulva 21 months after the completion of radiotherapy. At that time, she underwent a wide local excision. Five months later, we found a lesion on her right labium majus that was consistent with a recurrence. The patient's vulva was treated with a higher dose of radiotherapy than it had been the first time. Six months later the patient again experienced a local recurrence. She underwent a wide radical vulvar excision of diffuse bilateral lesions and was free of disease for approximately 3 months, after which she experienced another recurrence and underwent treatment with thalidomide. Within 2 months of starting thalidomide therapy, the patient experienced resolution of her symptoms and of her vulvar lesions. Primary LCH of the vulva is very rare. Its etiology and pathophysiology, as well as the most effective modes of therapy, remain elusive. We propose that thalidomide is a useful alternative for patients with this disease." }, { "id": "pubmed23n0620_14180", "title": "Effectiveness of treating non-specific pruritus vulvae with topical steroids: a randomized controlled trial.", "score": 0.00980392156862745, "content": "To determine the effectiveness of triamcinolone cream in the treatment of non-specific pruritus vulvae. A total of 50 patients, aged between 8 and 55 years, with non-specific pruritus vulvae were consecutively included in a double-blind randomized controlled trial by their general practitioner in 25 general practices in the Netherlands. Analysis was by \"intention to treat\". An infectious cause was excluded by a vaginal and cervical swab. After randomization, 27 patients were treated with triamcinolone cream and 23 patients with a placebo cream. The effectiveness was assessed by: change in the severity of itch visual analogue scale (VAS) score; the percentage of patients with complete recovery; and changes in general health according to COOP/WONCA charts. The mean decrease in severity of itch was 2.08 points in the triamcinolone group compared to 3.26 points in the placebo group. Forty-two per cent of the women in the triamcinolone group completely recovered versus 35% in the placebo group. There was no difference in general health perception between the two groups. After 12 weeks, more than 80% in both groups reported recurrent vulval itch. No significant differences in effectiveness were found between the two groups, because both treatments were ineffective. We can conclude that triamcinolone cream is therefore not the treatment of first choice for non-specific pruritus vulvae." }, { "id": "pubmed23n1004_25988", "title": "Oral and Vulvar Lichen Sclerosus.", "score": 0.009708737864077669, "content": "Lichen sclerosus (LS) is a chronic, inflammatory, mucocutaneous disorder of genital and extragenital skin (1). Simultaneous involvement of the oral mucosa is extremely rare, but it may be the only affected area (2). A 55-year-old woman was referred to the Department of Oral Medicine, School of Dental Medicine University of Zagreb due to whitish lesions on the right ventrolateral part of the tongue and buccal mucosa with desquamative gingivitis (Figure 1, a-c). The lesions were asymptomatic but indurated on palpation. Histology was conclusive for oral lichen sclerosus (OLS). The lesions on gingiva were successfully treated with betamethasone ointment, three times a day for two weeks. One year earlier, she had been referred to the Department of Dermatology and Venereology with progressive pruritus and dyspareunia, white patches, obliteration of the labia minora, and stenosis of the introitus (Figure 2). Histology was conclusive for vulvar LS (Figure 3, a and b). She was successfully treated for 5 months with clobetasol propionate 0.05% ointment. The patient was taking levothyroxine to treat hypothyroidism associated with Hashimoto's thyroiditis and was otherwise healthy. Oral LS is clinically characterized by the appearance of white macules, papules, or plaques mostly appearing on labial mucosa but also on buccal, palate mucosa and on the lower lip (2,3). On the genitals, it typically manifests as atrophic white plaques, which may be accompanied by purpura or fissuring (1). While vulvar LS is often associated with pruritus, dyspareunia, and dysuria, OLS is often asymptomatic, although pain, soreness, pruritus, and tightness when opening the mouth can be present (1,2). Oral manifestations of LS, as well as association of anogenital and oral LS, are rarely reported in the literature (4-6). Tomo et al. searched the Medline database for papers reporting oral LS cases with histological diagnosis confirmation from 1957 to 2016 and found only 34 cases of oral LS with histopathologic confirmation of the diagnosis (4). Kakko et al. reported 39 histologically proven cases of OLS (2). Attilli et al. (5) reviewed the clinical and histologic features of 72 cases of LS with oral/genital involvement. They reported that LS was diagnosed with exclusive genital lesions in 45, exclusive lip involvement in 20, and orogenital involvement in only 7 cases (5). Some believe that many cases of clinically diagnosed lichen planus may actually be LS and that isolated oral mucosal LS may not be as rare as is generally thought (2). While vulvar LS can occur at any age with increasing incidence with age, the median age of patients with OLS was 34 years and most of the patients were female (1,2,5). Due to the small number of patients in the literature, treatment recommendations for OLS are not available. In case of symptomatic oral lesions, topical or intralesional corticosteroids are considered to be the first-line treatment (2). First-line treatment for anogenital LS is a potent to very potent topical corticosteroid ointment, and second-line therapies include topical calcineurin inhibitors 1% pimecrolimus and 0.1% and 0.03% tacrolimus (1). For treatment-resistant genital LS, oral retinoids, methotrexate, and possibly local steroid injections for single lesions are mainly applicable for women (1). There is limited evidence for systemic treatments for both conditions. If it is not treated, genital LS is associated with a greater degree of scarring and an elevated risk of progression to squamous cell cancer; however, malignant transformation of OLS has not been reported (1-6). Due to the very rare presentation in the oral cavity, it is important to notice these lesions during a dental exam." }, { "id": "pubmed23n0069_7453", "title": "[The vulvar clinic].", "score": 0.009708737864077669, "content": "Until recently, vulvar diseases have not been given sufficient attention by gynecologists. This might be attributable to the timidity of patients with chronic vulvar pruritus, tumor or dyspareunia, which delays diagnosis and treatment. In addition, the nomenclature of vulvar disease was complicated by having been adapted from various dermatological disorders. Only following the establishment of the International Society for the Study of Vulvar Disease (ISSVD) and of specialized clinics, has awareness increased and more attention is now being paid to vulvar disorders. The findings in 242 patients seen during the first year of operation of a vulvar clinic were analyzed. The most common presenting symptom was chronic vulvar pruritus. Non-neoplastic epithelial disorder (dystrophy) was the most common histological finding in the 79 women with pruritus, while 2 were diagnosed as having vulvar intraepithelial neoplasia, and 1 had basal cell carcinoma. In contrast, vulvar vestibulitis was the main diagnosis in 34 women referred for vulvar pain (vulvodynia). Vulvodynia was also associated with other inflammatory processes and with human papilloma virus (HPV) lesions (condylomata). The primary finding in 26 women referred for evaluation of a vulvar \"tumor\" was epidermal cyst. In only 55 (75.5%) of the 73 referred for suspected HPV lesions was the histologic diagnosis confirmatory. In addition, a few vulvar ulcers were associated with HPV. A single treatment with carbon dioxide laser eradicated the HPV lesions in 93% of the cases. The vulvar clinic contributes to the ambulatory gynecological service by concentrating diagnosis and treatment in a single specialized unit and increases understanding of, and interest in vulvar disease." }, { "id": "pubmed23n0671_5806", "title": "Treatment of recurrent vulvar Paget disease with imiquimod cream: a case report and review of the literature.", "score": 0.009615384615384616, "content": "Extra-mammary Paget disease is one of the rare neoplastic conditions of the skin. The most common site of involvement is the vulva and presents itself with erythematous plaques. Surgery is the most important treatment option. In the recent years, there are publications of the topical use of imiquimod cream in extra-mammary cutaneous Paget disease. We report the case of a woman with recurrent vulvar Paget disease, who underwent successful treatment with imiquimod cream. We also review the reports of other patients with vulvar Paget disease who were treated with topical imiquimod cream. A 65-year-old woman presented to the Oncology Outpatient Clinic with an itchy lesion in her vulva for 2 years. In the gynecologic examination, a hyperkeratotic erythematous lesion was found starting from the right labium to involve clitoris, with a size of 4 × 3 cm. Pathology result was reported as Paget disease. She was operated and wide vulvar excision was performed with a safety margin of 2 cm. Then recurrence two times occurred. Because she refused surgery, imiquimod cream 5% was applied for treatment. Imiquimod cream is an effective and safe therapeutic agent for both primary and recurring vulvar Paget disease." }, { "id": "Gynecology_Novak_7595", "title": "Gynecology_Novak", "score": 0.009615384615384616, "content": "When vulvar cancer arises in the presence of VIN, vulvar dystrophy, or some nonneoplastic epithelial disorder, treatment is influenced by the patient’s age. Elderly patients who often had many years of chronic itching may not be disturbed by the prospect of a vulvectomy. In younger women, it is desirable to conserve as much of the vulva as possible. Radical local excision should be performed for the invasive disease, and the associated intraepithelial disease should be treated in the manner most appropriate to the patient. For example, topical steroids may be required for lichen sclerosus or squamous hyperplasia, whereas VIN may require superficial local excision with primary closure or laser ablation." }, { "id": "pubmed23n0564_1641", "title": "Occlusive irritant dermatitis: when is \"allergic\" contact dermatitis not allergic?", "score": 0.009523809523809525, "content": "CASE 1: A 38-year-old teacher presented with a 3- to 4-week history of a linear, erythematous, vesicular, and pruritic eruption of her left wrist. She had been wearing a new elastic bracelet for 4 weeks before the onset of her eruption. Although there was no history of allergy to rubber products or jewelry, an allergic contact dermatitis to rubber was suspected. Patch testing to rubber chemicals and the elastic bracelet revealed no reactions at 48, 72, and 96 hours. She stopped wearing the bracelet and used a corticosteroid cream with rapid resolution of the problem. The patient resumed wearing the bracelet, and there has been no recurrence in the past 2 months. CASE 2: A 12-year-old boy presented with a 1-month history of an itchy, scaly, erythematous 1-cm patch over the midline of his lower lip. The patient complained of tiny blisters initially with persistent erythema, mild scaling, and associated pruritus. The patient plays the saxophone and he had been practicing more intensely (3 to 4 h/d) for a musical competition. Allergic reaction to his wood reed was suspected, but patch testing with a moistened portion of his reed and reed shavings in a drop of water revealed no reaction at 48 and 72 hours. Treatment with hydrocortisone 1% cream bid for 3 days led to complete resolution of the dermitis and pruritus. Playing the saxophone 1 h/d has not led to any recurrence. CASE 3: A 33-year-old woman presented with erythema, scaling, and pruritus of 1 month's duration beneath her engagement and wedding rings, which were worn together on her left fourth finger (Figure 3). Although she had no history of previous sensitivity to earrings, watch clasp, blue jean rivets, or other jewelry, allergic contact dermatitis to nickel was suspected. Patch testing was performed to the common metal allergens nickel, cobalt, chromium, and gold. Readings at 48 hours and 1 week revealed no positive reactions. The patient wore her rings on the right hand for 1 week and used fluocinonide 0.5% cream twice daily for 1 week with resolution of the dermatitis. She has subsequently begun wearing the rings again on her left hand with care to dry her hands and rings after washing, and there has been no recurrence of her dermatitis." }, { "id": "pubmed23n0374_19688", "title": "[Screening strategies for vulvar preneoplastic and neoplastic lesions].", "score": 0.009523809523809525, "content": "Although they cover superficial areas, preneoplastic and neoplastic lesions of the vulva are often diagnosed late. The reasons for this delay is the low incidence of this invasive neoplasm, the advanced age of patients, the non-specific symptoms mainly taking the form of itch, burning, dyspareunia and blood loss, which are also compatible with a non-neoplastic infective pathology. The late diagnosis of carcinoma of the vulva may also be linked to the inadequate examination of the external genitals by doctors as a result of insufficient specific knowledge. Epidemiological data and the natural history of VIN lesions and carcinoma of the vulva argue that mass screening is not feasible, but an adequate programme of early diagnosis must be introduced. Early diagnosis is linked to three key elements: targeted anamnesis, clinical examination and the appropriate use of the various diagnostic procedures. Vulvoscopy represents the most reliable method, above all because it allows a biopsy to be taken of any suspected lesion. From January 1992 to December 1998, a total of 1678 vulvoscopies were performed at the Institute of Clinical Obstetrics and Gynecology of the University of Catania in patients aged between 16 and 82 years old. Biopsies were taken of all suspected lesions. Sixty-nine cases of VIN (4.11%) were diagnosed: 28 VIN1, 24 VIN2 and 17 VIN3. Lesions were only symptomatic in 39.1% of cases. The association of vulvoscopy with biopsy of suspected lesions, even in the absence of vulvar symptoms, represents the most efficacious method for the diagnosis of intraepithelial lesions." }, { "id": "pubmed23n0876_17161", "title": "Trichotillomania: Bizzare Patern of Hair Loss at 11-Year-old Girl.", "score": 0.009433962264150943, "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": "pubmed23n0251_14494", "title": "The chronically symptomatic vulva: aetiology and management.", "score": 0.009433962264150943, "content": "To determine the causes and management of chronic vulval symptoms and to compare the findings in patients first presenting to a gynaecologist with those in patients first presenting to a dermatologist. A prospective study of 144 patients, approximately half each being referred to a gynaecologist and a dermatologist. Diagnosis was based on clinical history, vulvoscopy, vulval biopsy and bacteriology. Biopsies were examined by a histopathologist experienced in dermatopathology and gynaecological pathology. The two patient groups were similar in both range and frequency of conditions. The commonest cause of chronic vulval symptoms was dermatitis, which was found in 64% of our patients. Dermatitis occurred alone in 55% and was found in association with histological evidence of human papilloma virus (HPV) in a further 9%. These patients responded to simple dermatological methods, mainly topical corticosteroids. Histopathological evidence of HPV was encountered in only 23% of our patients, and of these 36% also demonstrated dermatitis on biopsy. Most responded to topical corticosteroids. Another 7% had lichen sclerosus, and all responded to potent topical corticosteroid. The remaining 15% demonstrated a range of diagnoses, including psoriasis, dysaesthetic vulvodynia, vulval intraepithelial neoplasia (VIN) and chronic candidiasis. The majority of patients had a corticosteroid responsive dermatosis rather than a gynaecological condition. The majority of patients with a chronically symptomatic vulva who present to either a gynaecologist or a dermatologist have a dermatological condition that responds to simple dermatological treatments. We believe that the presence or absence of the human papilloma virus is not relevant to most patients with a chronically symptomatic vulva and treatments should not be aimed at eradicating this virus. Histopathologists and gynaecologists who have focused on gynaecological disorders have often missed simple dermatological conditions that are easily treatable." }, { "id": "pubmed23n1073_702", "title": "Unwarranted hysterectomy in a case of oro-vaginal-vulvar lichen planus in a young woman: a case report.", "score": 0.009345794392523364, "content": "Lichen planus is a rare autoimmune disease primarily affecting the skin and mucous membranes of the oral mucosa, vulva, and vagina. Diagnosis is difficult and often delayed as the clinicians do not associate the oral symptoms with the genital symptoms. This has a negative impact on the out-of-pocket expenditure and quality of life of the patients. We report this case, as only anecdotal cases have been reported so far from a developing country such as India. We highlight the unindicated hysterectomy that the patient had undergone because of lack of awareness regarding this condition. Our case report also highlights the importance of the multidisciplinary team approach to optimize outcomes and avoid unnecessary morbidity to such patients. We report a North-Indian patient with oro-vaginal-vulvar lichen planus who presented to us with complaints of recurrent vulvovaginal symptoms for the last 5 years. She had been previously treated with multiple courses of antibiotics, antifungals, and topical steroids over the course of 3 years and finally offered laparoscopic-assisted vaginal hysterectomy (LAVH) by a private practitioner but got no relief. She also had complained of oral symptoms in the form of a burning sensation after eating spicy food, but did not seek any treatment for this. After multidisciplinary team discussion, a final diagnosis of oro-vaginal-vulvar lichen planus was made at our institute based on the clinical and histopathological findings. The patient was immediately started on oral prednisolone to which she responded with improvement in her symptoms. Lichen planus is a chronic painful condition with significant impact on the quality of life. Women often suffer for several years before an accurate diagnosis is made. Treatment is challenging and needs to be individualized with a multidisciplinary approach to prevent progressive anatomical distortion and associated morbidity." }, { "id": "pubmed23n0298_21202", "title": "The chronically symptomatic vulva: prevalence in primary health care.", "score": 0.009345794392523364, "content": "To examine within the primary health care setting, the frequency of chronic vulval disorders, their frequency, investigation, management and referral patterns. A questionnaire based survey at general practitioners surrounding a district general hospital. A total of 79 (72%) GPs replied to the questionnaire. Thirty-six (45%) GPs saw more than one patient per month with recurrent vulval symptoms and ten (13%) GPs saw more than three patients per month. The predominant symptom amongst patients with recurrent vulval symptoms was itching (55%) followed by soreness (26%), burning (14%) and dyspareunia (5%). Topical-antifungals and steroid medications were the commonest treatments prescribed for all women with vulval symptoms. Women who have vulval complaints commonly attend their GP for treatment. In many instances women with chronic vulval complaints are inadequately investigated and inappropriately managed." }, { "id": "pubmed23n1111_3680", "title": "Vulvar Leiomyosarcoma in Pregnancy.", "score": 0.009259259259259259, "content": "Vulvar leiomyosarcoma is a rare smooth muscle malignant neoplasm but it is the commonest type of vulvar sarcomas. It may mimic benign tumors and misdiagnosis could delay proper management. We report a case of a 38-year-old pregnant woman with leiomyosarcoma of the vulva. The patient presented to her primary general practitioner with a small vulvar mass that she had first noticed one year prior. The tumor was suspected to be benign Bartholin's cyst and treated with antibiotics. The patient declined improvement and had many consultations to different clinics where she had been diagnosed and treated the same. The tumor size started to grow rapidly after she got pregnant, and the patient was referred to our hospital where she underwent tumor resection. Histopathology revealed leiomyosarcoma. The patient had further assessment and close follow-up and has had no recurrence for 12 months. There is little literature available on vulvar leiomyosarcoma, most of which are case reports, and most gynecologic oncologists will go through their whole careers without seeing a single case." }, { "id": "pubmed23n1153_16682", "title": "Vulvar dermatoses: a cross-sectional 5-year study. Experience in a specialized vulvar unit.", "score": 0.009259259259259259, "content": "Vulvar diseases are common in the general population and have a negative impact on the quality of life. To describe our experience as dermatologists in the management of vulvar dermatosis consultations. A retrospective observational study was conducted with patients who attended monographic vulvar consultations over a 5-year period. Clinical information was obtained from the patient's charts. 148 women were studied. Their mean age was 43.24 years (standard deviation: 15.15 years), with ages ranging from 4 months to 80 years. 53.4% of patients took between 2 and 5 years to seek medical attention for the first time. The most frequent diagnosis was lichen sclerosus (41.9%), irritative eczema of the vulva (14.9%), and lichen simplex chronicus (10.1%). 83.8% reported anogenital itching, 66.2% pain, and 45.9% dyspareunia. The most frequently prescribed treatment was ultra-potent topical corticosteroids (clobetasol propionate; 41.2%). Patients with lichen sclerosus were significantly older than those who presented with any of the other diseases. No differences were found in terms of either the time of disease evolution or in symptom presentation. Retrospective study. Vulvar diseases with an infectious cause are usually managed in primary care, therefore, were not included. All patients were recruited from a single private hospital which limits the comparisons with the public health system. Vulvar diseases frequently occur and are associated with high morbidity. It is essential to promote the development of specific vulvar consultations in hospitals. Specialties such as dermatology, gynecology, urology, or physiotherapy must be part of these units." }, { "id": "pubmed23n0867_5820", "title": "Lung Metastasis in a Case of Recurrent Poorly Differentiated Leiomyosarcoma of the Bartholin Gland: A Case Report and Review of the Literature.", "score": 0.009174311926605505, "content": "Vulvar neoplasms represent four percent of all gynecological cancers. While most cases of vulvar neoplasms are benign, two percent of patients present with malignant disease. We present the case of a 37-year-old premenopausal female who presented to an outside institution with a lump in her left vulva, which had progressively enlarged to the size of an egg. A wide local excision of the left vulva was performed, and the pathology revealed a high-grade sarcoma, not otherwise specified (NOS), with negative margins. Imaging showed enlarged bilateral external iliac lymph nodes, likely metastatic. After discussion at a multidisciplinary gynecology oncology tumor board, she was treated with gemcitabine/docetaxel chemotherapy, followed by a left inguinal lymph node dissection and a left radical vulvectomy after being referred to our centre. The final pathology at that time showed a residual sarcoma of 3.5 mm in the left vulva with no lympho-vascular invasion (LVI) and negative margins, with the closest, laterally, at 2 mm. A total of three lymph nodes were negative. She received additional chemotherapy postoperatively. Approximately one year later, she returned to her gynecologist with a 1 cm mass on the left vulva. She underwent a left hemi-vulvectomy and lymph node dissection, and pathology confirmed the presence of a high-grade sarcoma with close margins. She received adjuvant radiotherapy. Three months later, she presented with persistent cough and pneumonia. Imaging revealed a 10 cm lung mass, which was believed to be metastasis from the vulva. This was confirmed with biopsy and was completely resected. Any mass in the Bartholin gland area should be investigated carefully. Poorly differentiated vulvar leiomyosarcoma in the Bartholin gland can recur locally but may also lead to distant metastasis. Despite surgical and systemic treatment, as well as adjuvant radiation, the tumor recurred. Due to the rarity of this condition, there are no clear recommendations for treatment of this disease. To our knowledge, this is the first report of vulvar leiomyosarcoma of the Bartholin gland with metastasis to the lung. " }, { "id": "pubmed23n0292_10485", "title": "Women's experiences of general practitioner management of their vaginal symptoms.", "score": 0.009174311926605505, "content": "Little is known about the management of vaginal symptoms despite their frequency. Most vaginal symptoms in non-menopausal women are managed as thrush, although bacterial vaginosis is commoner. The aim of this study was to measure the experiences of women attending their general practitioner with vaginal symptoms including self-reporting of symptoms, duration and severity, informal support, over-the-counter remedies, sources of information, gender of doctor, expected and actual vaginal examination, and explanations and knowledge of common vaginal infections. A postal questionnaire survey was conducted of 490 patients presenting with vaginal symptoms aged between 18 and 48 years who had attended 10 general practices within the previous 3 months in the East Midlands of England. A total of 85% of patients had suffered a previous episode, with 39% having had three or more infections in the previous year. Overall, 68% consult with each episode, and most consult within 7 days of onset of symptoms (median = 4 days). In all, 68% discussed their symptoms with partners, families or friends, but 32% relied solely on their doctor. Some 33% bought over-the-counter remedies. A total of 65% informed themselves further from encyclopaedias, leaflets and women's magazines, but there was a strong request for more information. Out of those questioned, 75% expected a vaginal examination, whereas 57% had such an examination performed. Most were told their symptoms were caused by thrush (78%), but patients' ideas on causation were varied. Most believed sexual transmission played a role in transmission of symptoms. Women were socially embarrassed by their symptoms, with 46% admitting to having the condition on their minds all or most of the time. Twenty-eight per cent of women wished to see a female doctor, with gender being unimportant to the remainder. Vaginal symptoms were commonly recurrent, socially embarrassing and managed as candidiasis. Just over half the patients had a vaginal examination. There is a shortage of suitable information on vaginal infections available to patients, many of whom used over-the-counter medications." }, { "id": "pubmed23n0743_7472", "title": "Synchronous of breast and vulvar Paget's disease: a case report.", "score": 0.00909090909090909, "content": "Synchronous Paget's disease of breast and vulva is extremely rare and has only been reported in the literature in one other case. A 58-year-old postmenopausal woman was found to have crusting, bleeding, and discharge from left nipple, as well as vulvar pruritis at the same time. Biopsy of breast lesion demonstrated Paget's disease with an underlying foci of ductal carcinoma in-situ that required total mastectomy of left breast with sentinel node biopsy and breast reconstruction. For vulvar symptoms, the patient was initially diagnosed with dermatitis and topical ointment was prescribed. However, her symptoms persisted for the next several months, and she underwent vulvar biopsy that demonstrated Paget's disease. She underwent partial vulvectomy. Multiple episodes of recurrent vulvar Paget's disease were noted in the postoperative course that medical therapy with Imiquimod and a second partial vulvectomy was performed. Synchronous of breast and vulvar Paget's disease is presented. There was a delay in diagnosing vulvar Paget's disease in this experienced case. While coincidence of breast and vulvar Paget's disease is likely, ectopic mammary tissue in vulvar as well as secondary metastasis from a focal lesion of breast Paget's disease needs to be carefully evaluated whenever the patient complains of vulvar symptoms in the setting of breast Paget's disease." }, { "id": "pubmed23n0020_1938", "title": "The vulvar clinic: an eight-year appraisal.", "score": 0.00909090909090909, "content": "One thousand forty-three patients made 2,750 visits to the Vulvar Clinic at the Milwaukee County Medical Complex from July, 1970, to July, 1978. This experience is analyzed and the various diseases are grouped in order of frequency. The results shed light on those vulvar problems most likely to be encountered in general office practice and point the way toward future areas of research." }, { "id": "pubmed23n0360_16339", "title": "Unusual presentation of lichen sclerosuis in an adolescent", "score": 0.009009009009009009, "content": "Background: The presentation of lichen sclerosus has been described in detail in the adult literature. Typically present with symptoms of itching and soreness in the vulvar area at which time a vulvar evaluation reveals a specific appearance. The presentation is believed to be similar in prepubertal children and adolescents. In this case report we encountered an unusual initial presentation of this disease.Methods: Case presentation.Results: An 18-year-old female presented for the first time to her gynecologist with complaint of difficulty with complete emptying of bladder and dribbling. She had noted the onset of these symptoms two months prior to presentation. She denied any long-term history of vulvar itching or irritation. Her menses were normal with no complaints of dysmenorrhea. Onset of menarche and pubertal development were also normal. She denied any pre-pubertal history of labial adhesions or lichen sclerosis. The patient was not sexually active. She was diagnosed with labial adhesions and her first course of treatment included topical estrogen therapy for 8 weeks. Her second course of therapy included topical testosterone for 6 weeks without any improvement or side effects. On evaluation at our institution the posterior aspect of the labia minora could not be seen and the area of the vaginal introitus was completely obstructed (see picture). The clitoral hood could not be retracted and the surrounding vulva appeared atrophic and white. The degree of obstruction was such that the urethra could not be seen. In the operating room the labia minora were manually separated. The patient applied clobetasol.05% ointment for the next two weeks to the vulva and then switched to a less potent steroid. Follow-up evaluation 2 and 4 weeks after the procedure did not show any adhesions. Punch biopsy was consistent with diagnosis of lichen sclerosis.Conclusion: The presentation of lichen sclerosis may be variable in adolescents; thus, a high index of suspicion must be maintained to make this diagnosis." }, { "id": "pubmed23n0784_11987", "title": "Vulvar skin disorders throughout lifetime: about some representative dermatoses.", "score": 0.009009009009009009, "content": "The objective of this paper is to present general considerations which should be kept in mind by clinicians in charge of women with vulvar diseases. Four representative vulvar dermatoses are described. Lichen simplex chronicus is a pathological condition related to chemical and mechanical irritant agents. Detrimental effects of these irritants, in the presence of other dermatoses, have to be considered when therapeutic responses are unsatisfactory. Lichen sclerosus is the most common vulvar dermatosis in elderly. However, it should be kept in mind that it may be diagnosed at any age. Lichen planus, in spite of sharing a similar range of etiological factors with lichen sclerosus, is a very distinct entity. Finally, Paget's disease, although rare, is also described especially because of the challenge it represents both clinically and therapeutically. " }, { "id": "pubmed23n0807_8843", "title": "Vulvar carcinoma in pregnant women aged less than 40 years: case report.", "score": 0.008928571428571428, "content": "Invasive squamous cell carcinoma of the vulva is primarily a disease of postmenopausal women and thus is rarely associated with pregnancy. We have reported on a young woman under 40 years old with vulvar carcinoma, which occurred during the pregnancy but optimal treatment was delayed to the postpartum period. This 37-year-old woman was diagnosed with 3x3 cm vulvar lesion, 2 weeks after cesarean section, subsequent biopsy revealed squamous cell carcinoma. She had a history of an ulcer on her left labia minor at the third month of the pregnancy. She was treated by a modified radical vulvectomy and bilateral groin lymphadenectomy. She did not receive any additional treatments. Now after two years, she has had no recurrence of the disease. This case emphasizes on the need to consider malignancy as a differential diagnosis in vulvar lesions of pregnant young women." }, { "id": "pubmed23n0395_2355", "title": "Vulval disease from the 1800s to the new millennium.", "score": 0.008928571428571428, "content": "The study of vulval disease has become important over the last few decades. Although several inflammatory dermatoses were described at the end of the 19th century, vulval involvement in these conditions was only realized some time later. Indeed, the vulva may be a site of predilection of some inflammatory dermatoses such as lichen sclerosus. There are now groups of interested dermatologists, gynecologists, and genitourinary physicians that have cooperated to study patients with vulval disease. Hopefully, this will increase our knowledge over the next century. This review article examines vulval disease from an historical viewpoint and highlights important developments that have increased our understanding of the disorders that specifically affect the vulva." }, { "id": "pubmed23n0830_18825", "title": "Amelanotic vulvar melanoma: a case report.", "score": 0.008849557522123894, "content": "A 14-year-old girl stated that she has vulvar pruritus, pain, and bleeding and underwent a complete gynecological evaluation during which a suspicious 2-cm achromic lesion on her vulva was observed. Initially, it was suspected to be a pyogenic granuloma, in relation to the patient's age. A biopsy was taken, and a histopathological diagnosis of amelanotic mucosal melanoma was made. Pyogenic granuloma is a reactive hyperproliferation vascular response to trauma or other stimuli. It predominantly occurs in the second decade of life in young females, in relation to the vascular effects of female hormones. Primary mucosal melanoma is a rare and aggressive neoplasm, characterized by a higher aggressiveness and a worse prognosis than her cutaneous counterpart. The female genital tract is the second most common site of onset of mucosal melanoma; it represents the 3% of melanomas diagnosed in women. " }, { "id": "pubmed23n0297_14145", "title": "The commonest causes of symptomatic vulvar disease: a dermatologist's perspective.", "score": 0.008849557522123894, "content": "A prospective study of 141 consecutive adult patients with chronic vulvar symptoms referred to a dermatologist was carried out to determine the commonest conditions seen. Eighty-nine per cent of patients underwent vulvar biopsy. The commonest cause of chronic vulvar symptoms in this group of patients was dermatitis, seen in 54% of patients. The other commonly seen conditions were lichen sclerosus (13%), chronic vulvovaginal candidiasis (10%), dysaesthetic vulvodynia (9%) and psoriasis (5%). Although 38% of patients had previously been diagnosed as suffering from human papillomavirus (HPV) vulvitis, histopathological evidence of HPV was seen in only 5%. All cases showing HPV also demonstrated spongiotic dermatitis on biopsy. In this study group, a majority (overall 72%) of patients with a chronic vulvar complaint had a corticosteroid responsive dermatosis rather than a gynaecological condition. The patients with HPV on biopsy also responded to topical corticosteroids, and it was concluded that their symptoms may have been due to dermatitis unrelated to the presence of HPV. In such patients, the assumption that 'subclinical HPV' is a cause of symptoms and the practice of focusing medical and particularly surgical treatment on eradication of the virus may be inappropriate. A review of the commonest vulvar conditions seen by the author is presented." }, { "id": "pubmed23n1100_5241", "title": "Vulvar Paget's Disease Presenting with Fever and Left Inguinal and Peritoneal Lymphadenopathies.", "score": 0.008771929824561403, "content": "BACKGROUND Asymptomatic vulvar Paget's disease is rare and commonly presents with vulvar eczema, erosions, or pruritus. The time from onset to diagnosis of vulvar Paget's disease tends to be rather long because of difficulty making a correct diagnosis owing to similar skin findings with eczema or patients' reluctance to undergo physical examination of their pubic area because of embarrassment. CASE REPORT A 55-year-old woman experienced recurrent episodes of fever for 10 months. Her primary care physician indicated inguinal lymphadenopathy 2 months prior to presentation at our hospital. Contrast-enhanced abdominal computed tomography revealed multiple intra-abdominal lymphadenopathies. With the failure of finding the primary lesion after biopsy, and with a diagnosis of metastatic carcinoma, she was referred to our hospital. On admission, she did not report having vulvar symptoms. As imaging studies revealed no primary lesions, we subsequently added immunostaining to the lymph node biopsy specimens, which suggested Paget's disease. We finally performed a vulvar physical examination and identified eczema. We performed a skin biopsy and histopathological examinations, which provided the final diagnosis of vulvar Paget's disease. CONCLUSIONS We experienced a case of vulvar Paget's disease presenting with inguinal and intraperitoneal lymphadenopathies, without a patient report of vulvar symptoms. When identifying lymphadenopathies, it is crucial to obtain a careful history and perform appropriate physical examinations, suspecting diseases of the vulva or perineum. In addition, immunostaining of lymph node biopsy specimens could be useful in making a correct diagnosis." }, { "id": "pubmed23n0853_1754", "title": "Verrucous Carcinoma of the Vulva: A 20 Year Retrospective Study and Literature Review.", "score": 0.008771929824561403, "content": "The aim of the study was to assess the clinicopathological characteristics of patients with verrucous carcinoma (VC) of the vulva. We reviewed data on the age, disease course, clinical manifestation, pathologic diagnosis, treatment, and follow-up of patients with vulvar VC who were treated at Tianjin Medical University General Hospital and cases that were reported in the Chinese and English literature during the past 20 years. Six cases were identified in Tianjin Medical University General Hospital, the mean age of patients was 55 years, and their mean disease course was 26 months. Primary symptoms were exophytic neoplasm with pruritus and/or pain. Surgical treatment included wide local excision, simple vulvectomy, and radical vulvectomy with or without lymph node dissection in the groin. Vulvar VC occurred simultaneously with vulvar intraepithelial neoplasia in 2 cases and well-differentiated squamous cell carcinoma in 2 cases. The mean follow-up was 16.8 months with no recurrence in those 6 cases. During the 20-year period, 20 and 41 cases were reported in Chinese and English literature, respectively. Three cases were misdiagnosed with giant condyloma acuminatum in China. One case (1/20) was reported with coexistent squamous carcinoma in Chinese literature and 8 cases (8/41) in the English literature. The recurrence rate was 12.5% (2/19) and 17.5% (7/40) in Chinese and English literature, respectively. Vulvar VC is a distinct type of slow-growing, nonmetastatic tumor with unclear etiology. These tumors should be distinguished from giant condyloma acuminatum and well-differentiated squamous cell carcinoma. Surgery is the most effective treatment." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 426, 708 ] ], "word_ranges": [ [ 59, 101 ] ], "text": "in small abscesses with Hinchey grade I divertciulitis, in patients without great deterioration of the general condition as in the proposed case, they can be managed by conservative treatment with intravenous antiobiotic therapy and absolute diet, therefore the correct option is 1." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 709, 807 ] ], "word_ranges": [ [ 101, 116 ] ], "text": "The urgent surgical approach should be reserved for cases that present peritonitis (grade III, IV)" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Admission to the ward with absolute diet and broad-spectrum antibiotic treatment.", "2": "Discharge colostomy.", "3": "Drainage by laparoscopic surgery.", "4": "Urgent surgery with sigmoidectomy and colorectal anastomosis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0724_25325", "title": "Danish national guidelines for treatment of diverticular disease.", "score": 0.018614718614718615, "content": "In order to elaborate evidence-based, national Danish guidelines for the treatment of diverticular disease the literature was reviewed concerning the epidemiology, staging, diagnosis and treatment of diverticular disease in all its aspects. The presence of colonic diverticula, which is considered to be a mucosal herniation through the intestinal muscle wall, is inversely correlated to the intake of dietary fibre. Other factors in the genesis of diverticular disease may be physical inactivity, obesity, and use of NSAIDs or acetaminophen. Diverticulosis is most common in Western countries with a prevalence of 5% in the population aged 30-39 years and 60% in the part of the population &gt; 80 years. The incidence of hospitalization for acute diverticulitis is 71/100,000 and the incidence of complicated diverticulitis is 3.5-4/100,000. Acute diverticulitis is conveniently divided into uncomplicated and complicated diverticulitis. Complicated diverticulitis is staged by the Hinchey classification 1-4 (1: mesocolic/pericolic abscess, 2: pelvic abscess, 3: purulent peritonitis, 4: faecal peritonitis). Diverticulitis is suspected in case of lower left quadrant abdominal pain and tenderness associated with fever and raised WBC and/or CRP; but the clinical diagnosis is not sufficiently precise. Abdominal CT confirms the diagnosis and enables the classification of the disease according to Hinchey. The distinction between Hinchey 3 and 4 is done by laparoscopy or, when not possible, by laparotomy. Uncomplicated diverticulitis is treated by conservative means. There is no evidence of any beneficial effect of antibiotics in uncomplicated diverticulitis, but antibiotics may be used in selected cases depending on the overall condition of the patients and the severity of the infection. Abscess formation is best treated by US- or CT-guided drainage in combination with antibiotics. When the abscess is &lt; 3 cm in diameter, drainage may be unnecessary, and only antibiotics should be instituted. The surgical treatment of acute perforated diverticulitis has interchanged between resection and non-resection strategies: The three-stage procedure dominating in the beginning of the 20th century was later replaced by the Hartmann procedure or, alternatively, resection of the sigmoid with primary anastomosis. Lately a non-resection strategy consisting of laparoscopy with peritoneal lavage and drainage has been introduced in the treatment of Hinchey stage 3 disease. Evidence so far for the lavage regime is promising, comparing favourably with resection strategies, but lacking in solid proof by randomized, controlled investigations. In recent years, morbidity has declined in complicated diverticulitis due to improved diagnostics and new treatment modalities. Recurrent diverticulitis is relatively rare and furthermore often uncomplicated than previously assumed. Elective surgery in diverticular disease should probably be limited to symptomatic cases not amenable to conservative measures, since prophylactic resection of the sigmoid, evaluated from present evidence, confers unnecessary risks in terms of morbidity and mortality to the individual as well as unnecessary costs to society. Any recommendation for routine resection following multiple cases of diverticulitis should await results of randomized studies. Laparoscopic resection is preferred in case of need for elective surgery. When malignancy is ruled out preoperatively, a sigmoid resection with preservation of the inferior mesenteric artery, oral division of colon in soft compliant tissue and anastomosis to upper rectum is recommended. Fistulae to bladder or vagina, or stenosis of the colon may be dealt with according to symptoms and comorbidity. Resection of the diseased segment of colon is preferred when possible and safe; alternatively, a diverting stoma can be the best solution." }, { "id": "wiki20220301en026_25410", "title": "Diverticulitis", "score": 0.014192835592572133, "content": "Antibiotics Mild uncomplicated diverticulitis without systemic inflammation should not be treated with antibiotics. For mild, uncomplicated, and non-purulent cases of acute diverticulitis, symptomatic treatment, IV fluids, and bowel rest have no worse outcome than surgical intervention in the short and medium term, and appear to have the same outcomes at 24 months. With abscess confirmed by CT scan, some evidence and clinical guidelines tentatively support the use of oral or IV antibiotics for smaller abscesses (<5 cm) without systemic inflammation, but percutaneous or laparoscopic drainage may be necessary for larger abscesses (>5 cm). Emergency surgery is required for perforated diverticulitis with peritonitis." }, { "id": "pubmed23n0326_10303", "title": "[Laparoscopic treatment of generalized peritonitis with diverticular perforation of the sigmoid colon. Report of 10 cases].", "score": 0.01400898507318487, "content": "The classical treatment of perforated sigmoid diverticulitis with generalised peritonitis is based on the principle of two-stage surgical procedures with a temporary initial defunctioning colostomy. This approach is associated with significant morbidity, concerning mainly the abdominal wall. Ten consecutive patients, eight female and two male, with a mean age of 54.6 years, underwent an emergency laparoscopy for generalised peritonitis secondary to perforated diverticula. Six had had previous infectious episodes; six were obese; four were diabetic and two had chronic lung disease. After exploration of the abdominal cavity and discovery of a purulent peritonitis (n = 8) or faecal peritonitis (n = 2), an extensive peritoneal lavage was performed (average 15 litres), the contaminating sigmoid lesion was covered with biological glue and a drain inserted at the site of the lesion. In some cases, drainage of dependent zones was also performed. No colostomies were performed. Antibiotic therapy instituted as soon as the diagnosis had been made was continued, on average, for 7 days. There was no mortality. There was a low morbidity: one case of lymphangitis on catheter and one of broncho-pulmonary infection. No cases of abdominal wall sepsis or residual deep collections were observed. The mean duration of hospitalisation was 8 days. Nine patients underwent a sigmoid resection (laparoscopic in eight cases) 3 to 4 months later, with a mean duration of hospitalisation of 6 days. One conversion to laparotomy was necessary. Laparoscopic treatment of generalised peritonitis secondary to perforated sigmoid diverticulitis constitutes an alternative to classical surgery. It is associated with a decreased morbidity and a marked reduction in duration of the hospitalisation. Colostomy can be avoided and the patient's quality of life is improved during the period previous to secondary colectomy, performed by laparoscopy eight times out of nine. In addition, the cost of this approach is significantly lower." }, { "id": "pubmed23n0349_1868", "title": "Same admission colon resection with primary anastomosis for acute diverticulitis.", "score": 0.013496376811594202, "content": "Current standard of care for complicated diverticulitis includes urgent resection with colostomy versus antibiotic treatment, followed by delayed resection with primary anastomosis at a second admission. In certain circumstances, it is possible to perform resection and anastomosis on the same admission for acute diverticulitis. A retrospective review was completed for patients undergoing surgery for diverticulitis from 1991 to 1998. Groups included: 1) sigmoid resection with primary anastomosis on same admission (n = 18); 2) resection with protective end colostomy (n = 16); and 3) in-patient antibiotic treatment alone, followed by a second admission for resection with primary anastomosis (n = 5). Four patients initially treated with antibiotics worsened symptomatically or developed radiographic evidence of perforation and required resection with colostomy. Five patients in Group 1 had abscesses or contained perforations based on radiographic studies. Findings on CT scans did not predict treatment. Group 1 patients had uneventful recoveries and few minor complications (wound infections and an incisional hernia). One anastomotic leak occurred in Group 2 after colostomy closure. Although there will continue to be a role for emergent operation for diverticulitis, same admission sigmoid resection with primary anastomosis after antibiotic treatment is safe, uses a shorter course of antibiotics, and has a low complication rate." }, { "id": "pubmed23n0716_10066", "title": "Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment.", "score": 0.012951630480342024, "content": "In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of \"perforated\" AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA. The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed. There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas \"distant\" location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100-450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4-23). Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected." }, { "id": "pubmed23n0780_122", "title": "Position paper: management of perforated sigmoid diverticulitis.", "score": 0.012298001574744104, "content": "Over the last three decades, emergency surgery for perforated sigmoid diverticulitis has evolved dramatically but remains controversial. Diverticulitis is categorized as uncomplicated (amenable to outpatient treatment) versus complicated (requiring hospitalization). Patients with complicated diverticulitis undergo computerized tomography (CT) scanning and the CT findings are used categorize the severity of disease. Treatment of stage I (phlegmon with or without small abscess) and stage II (phlegmon with large abscess) diverticulitis (which includes bowel rest, intravenous antibiotics and percutaneous drainage (PCD) of the larger abscesses) has not changed much over last two decades. On the other hand, treatment of stage III (purulent peritonitis) and stage IV (feculent peritonitis) diverticulitis has evolved dramatically and remains morbid. In the 1980s a two stage procedure (1st - segmental sigmoid resection with end colostomy and 2nd - colostomy closure after three to six months) was standard of care for most general surgeons. However, it was recognized that half of these patients never had their colostomy reversed and that colostomy closure was a morbid procedure. As a result starting in the 1990s colorectal surgical specialists increasing performed a one stage primary resection anastomosis (PRA) and demonstrated similar outcomes to the two stage procedure. In the mid 2000s, the colorectal surgeons promoted this as standard of care. But unfortunately despite advances in perioperative care and their excellent surgical skills, PRA for stage III/IV diverticulitis continued to have a high mortality (10-15%). The survivors require prolonged hospital stays and often do not fully recover. Recent case series indicate that a substantial portion of the patients who previously were subjected to emergency sigmoid colectomy can be successfully treated with less invasive nonoperative management with salvage PCD and/or laparoscopic lavage and drainage. These patients experience a surprisingly lower mortality and more rapid recovery. They are also spared the need for a colostomy and do not appear to benefit from a delayed elective sigmoid colectomy. While we await the final results ongoing prospective randomized clinical trials testing these less invasive alternatives, we have proposed (based primarily on case series and our expert opinions) what we believe safe and rationale management strategy. " }, { "id": "pubmed23n1108_21536", "title": "Septic Shock Secondary to a Pyogenic Liver Abscess Following Complicated Appendicitis.", "score": 0.011978831438174926, "content": "Pyogenic liver abscesses (PLAs) are a rare condition in North America and Europe and, rarer still, the cause of septic shock. This case report will describe the rare occurrence of a PLA producing septic shock in a 36-year-old male residing in the United Kingdom following a case of complicated appendicitis. The patient presented to the emergency department (ED) with a three-week history of intermittent loose stools, cramping abdominal pain, recurrent fevers, a heart rate of 111 beats per minute, a blood pressure of 94/58 mmHg, and a fever of 40.1 degrees Celsius. Despite prompt broad spectrum antibiotic administration and three liters of fluid resuscitation, the patient remained shocked which led to an ICU admission. A CT scan prior to transfer found a 7 cm x 6 cm x 6 cm lesion representing a liver abscess (LA) as well as gross inflammatory change affecting the distal small bowel. The LA was managed through insertion of a percutaneous drain under ultrasound guidance performed by the interventional radiology team, as well as ongoing IV antibiotics. Following growth of the gut commensal <iStreptococcus constellatus</i from the abscess fluid culture, a colonoscopy was performed which found a severely distorted and inflamed terminal ileum with an impassable stricture, raising not only the suspicion of appendicitis but also Crohn's disease. Following the colonoscopy, after a total of 10 days admission, the patient was allowed to go home with a four-week course of oral co-amoxiclav. After discharge, the patient's case was discussed in the gastroenterology inflammatory bowel disease (IBD) multi-disciplinary team meeting due to concerns raised about possible Crohn's disease from the admission CT and following colonoscopy findings. Given the absence of relevant IBD symptoms, a reassuring outpatient MRI small bowel scan (found considerable resolution of the right iliac fossa inflammatory process) and a fecal calprotectin of 29 four months post discharge (normal=0-51 μg/g), it was concluded the terminal ileum changes were most likely accounted for by a complicated course of appendicitis. When reviewed in a telephone clinic 10 weeks post discharge, he was found to have no persistent gastrointestinal (GI) symptoms and was subsequently discharged. This case highlights the importance of comprehensive imaging and colonoscopy in the work up of those patients with PLAs with no otherwise evident precipitating factor." }, { "id": "pubmed23n0116_16190", "title": "[Emergency interventions in complicated colonic diverticulosis].", "score": 0.009900990099009901, "content": "An account is given in this paper of 480 patients who had been hospitalised for colonic diverticulosis or diverticulitis in the surgical department of the Municipal Waid Hospital of Zurich, between 1970 and 1986. Laparotomy had to be performed on 219 of them (45.6 per cent), among them 84 emergency interventions. The average age of these patients was 70.7 years. Indications for emergency surgery included diffuse or locally delimited peritonitis with abscess development in 72 patients, ileus in ten cases, and massive colon haemorrhage in two. The latter two cases were handled with good success by subtotal colectomy with ileorectostomy and, one of them with the source of bleeding known, by colotomy and suturing of that source of bleeding. Sigmaincontinence resection according to Hartmann has been considered the optional approach since 1977 to diffuse peritonitis and to many cases of ileus (n = 39). In more recent time, anastomosis has been used as primary approach to some patients who survived fibrinous abdominal peritonitis (n = 4). The mortality rate associated with drainage operations according to expectation, has been clearly higher than that following resection, the comparable figures being 32.3 and 17.2 per cent. That has been attributable to non-removal of the septic focus. After all, nowadays combined antibiotic therapy is commonly used for seven to ten days for simultaneous control of both aerobic and anaerobic pathogens. This has become routine practice and involves aminoglycoside, metronidazole, and ampicillin. Overall mortality associated with emergency interventions is clearly higher than that after planned operations, the figures being 22.6 and 4.4 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0592_21971", "title": "[Management of complications of sigmoid diverticulosis].", "score": 0.00980392156862745, "content": "Computed tomography (CT) with contrast enhancement for vascular and bowel opacification is the reference examination for suspected sigmoid diverticulitis because it makes it possible to confirm the diagnosis and look for signs of severity (pericolic abscess, or presence of air or extraintestinal contrast product). Therapeutic management depends on the patient's general condition and on the severity of the intraperitoneal infection, assessed according to Hinchey's 4-stage classification. For Hinchey stages I and II (pericolic or pelvic abscess), radiologically guided puncture-drainage is an effective treatment, combined with antibiotic therapy. Emergency surgery is only indicated if this drainage fails. Two to three months later, elective prophylactic sigmoidectomy, by laparoscopy, is indicated. In stage III or IV diverticulitis (generalized purulent or fecal peritonitis), the surgical treatment of reference is a Hartmann procedure (sigmoidectomy and left iliac colostomy with closure of the rectal stump). But because of burden of the procedure and the risk of failing to re-establish gastrointestinal continuity, it is preferable, if local conditions allow, to propose resection-anastomosis with a temporary protective stoma. Prophylactic sigmoidectomy is controversial. It is indicated regardless of the number of episodes and regardless of age in patients at high risk of recurrence, that is, those with a complicated clinical form or radiologic signs of severity. There is no consensus for patients aged younger than 75 years with a first uncomplicated episode, for whom the risk of recurrence is also elevated. Finally, for patients older than 50 years with an uncomplicated episode on CT, the role of prophylactic surgery, even after 2 or 3 episodes, has not been demonstrated, because of the very low risk (&lt;5%) of subsequent complications. More than 80% of diverticular hemorrhages stop spontaneously but their rate of recurrence is high (25% of cases) and they sometimes require emergency colectomy." }, { "id": "pubmed23n0339_171", "title": "[Perforated diverticular disease of the left colon. Proposed single-stage left colectomy protected by a three-way lavage and active aspiration tube (di Gullino) positioned inside or below the anastomosis. Experience in 65 cases].", "score": 0.00980392156862745, "content": "The incidence of perforative diverticulitis of the left colon is steadily increasing. Today the decision is generally taken to perform two-stage surgery: segmentary resection without (Hartmann's operation) or with anastomosis, but protected by a colostomy (\"limited intervention\"). This study aimed to examine standard colectomy performed in a single operation (\"ideal intervention\"). Left colectomy with primary ligature of the lower mesenteric artery and vein at the source and outlet, en bloc removal of the colon-mesocolon and immediate transverse colorectal anastomosis. Anastomosis protected by the omentum which is also used to peritonise the retroperitoneum and to wrap around the anastomosis, and anastomosis also protected by the author's three-way lavage and active aspiration tube in either a trans- or subanastomosis and transanal position. Urgency is essential for this single-stage operation, together with massive dose antibiotic treatment limited to the pre- and postoperative stages, but above all peritoneal cleansing using accurate, methodical, repeated and abundant lavage with 8-10-20 or more litres, but only used 500 ml at a time. Of these 65 cases, 40 (62%) were purulent localised peritonitis and 25 (38%) were generalised (14 purulent, 4 fecaloid and 7 fecal). 8 cases (12.3%) underwent surgery in three stages and 16 (24.6%) underwent sigmoidectomy in one or two stages (\"limited intervention\"), 41 cases (63%) (1985-95, when Gullino's three-way tube became available) underwent standard colectomy in a single stage. Morbidity in 10 cases/65 (15%) and septic mortality in 5 cases/65 (7.7%) (limited to generalised peritonitis alone) only affected patients undergoing \"limited interventions\", but none of the 41 patients undergoing \"ideal intervention\". Mortality was significantly influenced by age: 50% of over 80 year-olds, none below 60. Postoperative hospitalisation was 17.1 days (in the first stage) of \"limited interventions\" and 9.7 days for \"ideal interventions\". The results argue clearly in favour of the \"courageous\" ideal colectomy with peritoneal lavage and protection of the colorectal anastomosis using Gullino's three-way tube." }, { "id": "pubmed23n1114_16355", "title": "Pyomyoma mimicking tubo-ovarian abscess: Two case reports.", "score": 0.009708737864077669, "content": "Pyomyoma is an extremely rare complication, defined as an infection of a uterine leiomyoma. We describe two cases of pyomyoma that were initially considered to be tubo-ovarian abscesses but were later diagnosed as pyomyomas and managed with laparoscopic surgery. Case 1 was a 26-year-old nulliparous woman who was previously diagnosed with bilateral endometriomas and presented to the hospital with lower abdominal pain. Magnetic resonance imaging revealed bilateral endometrial cysts and a 4-cm mass consistent with a tubo-ovarian abscess. The patient experienced continuous pain, and the cyst in the left adnexa enlarged; thus, laparoscopic surgery was performed. The cystic tumor in her uterus contained purulent fluid. Therefore, an abscess in the degenerative subserous myoma was diagnosed. Case 2 was a 47-year-old nulliparous woman who had undergone total mastectomy and postoperative radiotherapy for breast cancer. She was undergoing hormone therapy when she presented to the hospital with lower abdominal pain, fever, and increased inflammatory markers. Computed tomography revealed a 7-cm tumor with rim enhancement in her left adnexa; therefore, a tubo-ovarian abscess was suspected. After admission, drainage was performed under transvaginal ultrasound guidance, and antibiotics were administered. However, these treatments did not relieve her abdominal pain. Emergency laparoscopic surgery was performed, and intraoperative findings demonstrated an abscess in the degenerative subserous myoma of the uterus with normal adnexa. Laparoscopic hysterectomy and bilateral salpingectomy were performed. Laparoscopic surgery was effective for both patients. Delayed diagnosis of pyomyoma can result in serious complications. Timely surgery with concomitant antibiotic treatment may facilitate good outcomes." }, { "id": "pubmed23n0288_2961", "title": "The Hartmann procedure. First choice or last resort in diverticular disease?", "score": 0.009708737864077669, "content": "To critique changing trends in the surgical management of diverticular disease. Case series. Two hundred twenty-seven consecutive patients required surgery for diverticular disease from 1988 to 1993. Patient records were reviewed retrospectively. Operative procedures included primary resection in all patients with either anastomosis, anastomosis with proximal ileostomy, or the Hartmann procedure. Morbidity, mortality, and length of stay were then compared with each operative procedure and stage of disease. Patients were categorized according to the following pathologic stages: stage 0, no inflammation; stage I, chronic inflammation; stage II, acute inflammation with or without microabscesses; stage III, pericolonic or mesenteric abscess; stage IV, pelvic abscess; and stage V, purulent or feculent peritonitis. A university hospital and private affiliated hospitals in a large metropolitan area. Study outcome parameters included mortality, morbidity, length of hospital stay, and leak rates. These outcomes were then compared with different disease stages and treatments. Mean patient age was 66 years (range, 25-98 years). Male-female ratio was 84:143. Mean follow-up was 23 months (range, 1-132 months). There were 50 fistulas: 24 colovesical, 21 colovaginal, 3 colocolonic, 1 coloenteric, and 1 colouterine. Surgery was categorized as elective for 196 patients (86%), urgent for 12 (5%), and emergent for 19 (8%). Primary resection was performed in all cases. Primary anastomosis was performed in 200 patients (88%), 183 without and 17 with proximal diversion. Twenty-seven patients (12%) underwent a Hartmann procedure with colostomy; 19 patients (70%) have since undergone colostomy closure. Morbidity occurred in 52 patients (23%), including 4 anastomotic leaks (2%). There were 3 perioperative deaths (1%). Mean length of initial hospital stay was 11 days (range, 4-59 days). Length of stay was 5 days (range, 4-7 days) for ileostomy closure (7% morbidity) and 13 days (range, 7-35 days) for the colostomy closure after the Hartmann procedure (33% morbidity). Primary resection is virtually always possible in complicated diverticular disease. Primary anastomosis, with or without proximal diversion, is safe for patients with no abscesses or localized abscesses and should be considered on an individual basis for patients with pelvic abscesses and peritonitis. Colostomy closure after the Hartmann procedure is associated with significant length of hospitalization and morbidity and leaves one third of patients with permanent stomas." }, { "id": "pubmed23n1003_17066", "title": "Hybrid transvaginal natural orifice transluminal endoscopic surgery of radical sigmoidectomy for sigmoid colon cancer.", "score": 0.009615384615384616, "content": "Transvaginal natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique - \"scarless\" abdominal operations performed with a multi-channel endoscope passed through a natural orifice (mouth, urethra, anus, vagina etc.) and offers less invasive and more excellent cosmetic results [1]. It is regarded as safe and feasible in patients with benign disease [2,3]. The first case of pure NOTES for sigmoid colon cancer was reported in 2012 [4]. We describe here a case of curatively intended resection for early-stage sigmoid colon cancer using the hybrid transvaginal NOTES approach. This video demonstrates the case of a 52-year-old woman with sigmoid colon cancer treated by hybrid transvaginal NOTES. Her body mass index was 20.4 kg/m<sup2</sup. A laparoscope was inserted above the umbilicus and tumor's position was located. Two 5 mm trocars inserted in the right lower abdominal quadrant were mainly used for the assistant's instruments to provide traction and exposure. A single-port was inserted into the abdominal cavity transvaginally through the colpotomy. Then all the procedures were performed transvaginally with conventional rigid laparoscopic instruments. The sigmoid colon was mobilized using a lateral to medial approach. Then the root of the inferior mesenteric artery and the inferior mesenteric vein were divided with absorbable clips. After complete isolation of the proximal rectum, the rectum was transected 5 cm distal to the lesion with a linear stapler inserted through the single port. The proximal resection margin of descending colon was identified and the transection of the colon was performed. The specimen was removed transvaginally. The colon was then exteriorized and the anvil was fixed in the colon. An end-to-end anastomosis was performed using a circular stapler, and a leak test was done. The operative time and estimated blood loss were 182 min and 50 mL. A 20 cm long segment of sigmoid colon was resected with negative tumor margins, and 16 lymph nodes were harvested. There was no intraoperative or postoperative morbidity. The patient was with out-of-bed activity on day 1, fluid diet on day 2, bowel movement on day3, and the drainage tube and catheter removing on day 4. On day 5, she was discharged. Pathological examination revealed a moderately-differentiated adenocarcinoma: 50 × 45 × 10 mm, with growing into subserosa, without vascular or nervous invasion, pT3N0M0 and pStage IIA. There were two scars less than 5 mm and one scar less than 10 mm visible on the abdominal wall at one month. The patient was alive without recurrence after one year's follow-up. Hybrid transvaginal NOTES of radical sigmoidectomy may be safe and feasible for selected patients with sigmoid colon cancer and give less pain, potentially low rates of complication, faster recovery, and better cosmesis. A future large study is warranted to better evaluate this procedure. Although there are many reasons for skepticism, there is undoubted interest in this field from both surgeon and patient." }, { "id": "pubmed23n0324_13398", "title": "[The value of peroperative colonic lavage in urgent colonic surgery. Apropos of 54 patients].", "score": 0.009615384615384616, "content": "The effects of on-table colonic irrigation followed by primary large bowel resection and anastomosis for emergency left colonic disease were prospectively studied in 54 patients. Eighteen patients had a diverticular sigmoiditis complicated by localized (8) or generalized (4) peritonitis, 6 presented a complete sigmoid obstruction. Thirty six patients had a left colonic occlusive (33) or perforated (3) cancer. Anterograde colonic irrigation was carried out with a mean volume of 7.7 l. All patients received a double or triple antibiotic combination. The anastomosis was handsewn in 33 cases and stapled (Knight-Griffen) in 21. Seven patients with severe peritonitis had a proximal transitory stoma which was closed within 4 months. Two patients (3.7%) died postoperatively, one for anastomotic dehiscence and the second for evisceration. We observed 7 cases of hypothermia (&lt; 34 degrees C) during the irrigation. Six patients developed a sepsis of the surgical wound, 2 a septicemia and l an abscess in the right iliac fossa which was percutaneously drained. All complications had a favourable outcome. This study confirms that in selected cases a single stage surgery for colonic emergencies preceded by on-table irrigation grants good results and is a safe and effective alternative to Hartmann's procedure." }, { "id": "pubmed23n0630_24252", "title": "[Surgical treatment of acute diverticulitis. Our experience].", "score": 0.009523809523809525, "content": "The treatment of the acute diverticulitis is still a stimulating and complex problem sustained by several anatomopathological and clinical factors and the possibility of different therapeutic options, being the operative mortality among 5% and 45%. With the modern technologies it is possible to follow the evolution of the illness so to perform more appropriate therapeutic plan. From 1997 to 2007 we have observed 278 patients with acute diverticulitis. In 219 (78,7%) patients the inflammatory and sub-occlusive condition has been faced with medical therapy, with resolution of the disease in 170 (61%) cases. In 49 (17,6%) patients we have gotten the resolution of the inflammatory disease, but not of the sub-occlusion and therefore we liked to submit them to surgical treatment in election. In 1 case we have found a colovesical fistula. A total of 59 (21,2%) patients with signs of acute abdomen have been submitted to surgery in urgency, within the 24 hours from the hospitalization. We have performed a primary resection with anastomosis and without stoma in all the patients, except in 3 cases in which we have done the Hartmann procedure for the cheap general conditions. We have not recorded intra and postoperative mortality and only in 3 cases we have had a leakage, that has not needed a surgical treatment. In 9 cases we observed infection of the wound, treated with antibiotic therapy. In our experience, performing a surgical procedure, without derivative stoma and manual anastomosis, it seems to be the fittest and less expensive procedure, also in situation of emergency-urgency, without increase of mortality and morbidity." }, { "id": "pubmed23n0553_9493", "title": "Elective laparoscopically assisted sigmoidectomy for the sigmoid volvulus.", "score": 0.009433962264150943, "content": "The laparoscopic approach for the treatment of sigmoid volvulus has been a rare surgical indication. This phase 2 study investigated the feasibility and surgical outcomes of elective laparoscopic surgery for sigmoid volvulus. Patients with sigmoid volvulus were first offered colonoscopic decompression for their acute colonic obstruction. If the colonic decompression was successful, complete bowel preparation was performed, followed by elective laparoscopically assisted sigmoidectomy. The details of the laparoscopic procedures are shown in the video. Briefly, the redundant sigmoid colon is totally mobilized by a laparoscopic medial-to-lateral dissection sequence, after which it is exteriorized, transected, and reconstructed by end-to-end anastomosis. In the authors' experience, the medial-to-lateral approach is highly efficient for the laparoscopic mobilization of the redundant sigmoid colon. We believe that the longer the lateral abdominal wall attachment of the sigmoid colon is preserved, the better the exposure and the easier the dissection. If the risk of anastomotic leakage is considered high in a specific case, protective ileostomy is selectively preformed. Before entering the current study, the patients were well informed about the advantages and disadvantages of laparoscopic surgery. The enrollment of patients was selective according to the appropriate eligibility criteria. This study was approved by the Institutional Review Board of the National Taiwan University Hospital. The patients' clinicopathologic data and surgical outcomes were prospectively evaluated. Between August 2001 and April, 2005, a total of 14 patients (10 men and 4 women) with sigmoid volvulus were treated with the described procedure. The age distribution of the patients was 68.4 +/- 12.2 years. The attack of sigmoid volvulus was the first episode for eight patients, the second episode for 4 patients, and the third episode (or more) for two patients. The body mass index (BMI) of the patients was 26.8 +/- 4.4 kg/m(2). The physical status (classification of American Society of Anesthesiology [ASA]) was 1 for five patients, 2 for eight patients, and 3 for 1 patient. During the laparoscopy, all the patients presented with the pathognomonic findings of sigmoid volvulus including redundant sigmoid colon, narrow sigmoid mesenteric pedicle, and mesosigmoiditis with mesenteric fibrosis and scarring, as shown in the video. The length of the resected colon was 32 +/- 6 cm. The operation time was 194.6 +/- 32.4 min, and the blood loss was 44.0 +/- 12.4 ml. The abdominal wound consisted of four 5 to 12 mm working ports and a 5 cm major wound for exteriorization of the sigmoid colon. Some surgeons have shown that a sigmoid volvulus can be resected through a 5-cm left lower quadrant incision with very little mobilization of the colon because of its redundancy. In this context, the laparoscopic approach competed with the minilaparotomy method in terms of adequate sigmoid resection, lysis of mesosigmoid adhesion, and tension-free colorectal anastomosis. Protective ileostomy was performed for the only patient with a physical status of ASA 3. There was no mortality in this case series. However, pneumonia developed postoperatively in one patient, acute myocardial infarction in one patient, and wound infection in two patients. Excluding the two patients who experienced postoperative pneumonia and acute myocardial infarction, the duration of the postoperative ileus was 48 +/- 12 h, the postoperative hospitalization was 7 +/- 1 days, and the degree of postoperative pain was 3.5 +/- 0.5 according to the visual analog scale. The return to partial activity required 18 +/- 2.5 days, and the return to full activity required 28.4 +/- 5.6 days. As compared with the overall costs for a conventional sigmoid colectomy, which are completely covered by the National Bureau of Health Insurance of Taiwan, the expenses for the patients undergoing laparoscopic procedures were significantly higher by approximately 24,000.0 NT dollars +/- 2,635.0 (1 U.S. dollar = 32 NT dollars). These higher expenses must be borne by the patients themselves. Considering that patients with sigmoid volvulus often are elderly and chronically ill, laparoscopic elective surgery after a successful colonoscopic decompression may be a good choice for a selected group of patients in terms of minimized surgical complications and quick convalescence." }, { "id": "pubmed23n0876_2333", "title": "Outpatient treatment in uncomplicated acute diverticulitis: 5-year experience.", "score": 0.009433962264150943, "content": "Most cases of diverticular inflammation are mild and require only medical treatment with liquid diet and antibiotics. Until recently, this treatment required admission to hospitals, which consequently entailed costs. In most cases, treatment was conservative, and less than a quarter of patients admitted actually underwent surgery. In the last year, the outpatient treatment of these patients with uncomplicated diverticulitis has proven effective and safe. The aim of the present study was to describe our experience after 5 years of outpatient treatment with oral antibiotics. We conducted a retrospective revision study between January 2010 and December 2014. We included all patients admitted to the Emergency Department of the University General Hospital of Elche with a diagnosis of uncomplicated acute diverticulitis based on medical history, physical examination and abdominopelvic computed tomography (CT) scanning. Outpatient treatment consisted of oral antibiotics for 10 days (metronidazole 500 mg/8 h and ciprofloxacin 500 mg/12 h), a liquid diet and oral analgesics (acetaminophen 1 g/6 h). During the period from January 2010 to December 2014, 224 patients were treated on an outpatient basis at a success rate of over 92%. Only 18 patients (8%) required admission after outpatient treatment. Outpatient treatment of uncomplicated acute diverticulitis was demonstrated to be safe and effective." }, { "id": "pubmed23n0873_7891", "title": "Psoas muscle abscess simulating acute appendicits: A case report.", "score": 0.009345794392523364, "content": "Psoas abscess is a rare clinical entity with vague symptomatology. We report a psoas abscess that simulated symptoms of acute appendicitis. A twenty-five year old male presented pain irradiating to the right iliac fossa and lumbar region associated with thigh flexion. Laboratorial exams revealed leukocytosis with a neutrophil shift to the left. Abdominal Ultrasound showed significant intestinal distension and a small quantity of free fluid at the right iliac fossa. Laparotomy and an appendectomy were performed. During immediate post-operative, the patient evolved with worsening of the pain and the leukocytosis, therefore, we chose to maintain his antalgic posture. An abdominal Computerized Tomography scan with contrast was solicited, revealing an increase of the iliac and psoas muscles of the right side, and multiple bacterial focuses. A retroperitoneal access was performed and 300ml of purulent secretion was drained. Afterwards, we implanted a Penrose Drain. The patient had a good post-op evolution, being discharged 7days after the drainage. The psoas muscle is a flexor of the thigh. Psoas abscess is an underdiagnosed condition, its main treatment is surgery associated with antibiotic therapy. CT scan seems to be the best choice of diagnostic image exam, although some authors prefer the nuclear magnetic resonance. The psoas muscle abscess is uncommon and poorly characterized in its etiology, clinical associations, and its therapeutic approach. On the other hand, acute appendicitis is the most common abdominal emergency, with a 7% death rate, and surgery is its main treatment." }, { "id": "pubmed23n0603_6433", "title": "Emergency laparoscopic surgery for complicated diverticular disease.", "score": 0.009345794392523364, "content": "The aim of this study was to analyse the outcome of emergency laparoscopic surgical management of complicated diverticular disease. A prospectively collected electronic database of all colorectal laparoscopic procedures between April 2001 and September 2007 has been used to identify outcomes in patients presenting with complicated diverticular disease. Sixty-six patients (28 men), median age 69 years (23-95), ASA grade II (12), III (38), IV (16) have undergone emergency surgery for complicated diverticulitis--Hinchey grades I (27), II (29), III (7) and diverticular bleeding (3) over a 6(1/2)-year period: 43 high anterior resections, 17 Hartmann's resections and seven low anterior resections. Diverticular fistulas were seen in 16 patients: colovaginal (7), colovesical (2), colo-fallopian (4), entero-colic (3). The median operation time was 110 min (45-195 min). There was one conversion to open surgery. Postoperative analgesia was provided by intravenous Paracetamol in 33 patients (50%), patient-controlled analgesia in 24 (36%), oral Paracetamol and Oramorph (12%) and epidural opioid infusion (1.5%). The median time to normal diet was 24 h (4 h-6 days) and median hospital stay 5 days (2-30). There were two deaths (3.3%); anastomotic leak, ventricular fibrillation (VF) cardiac arrest. Other complications included: wound infection eight (12%), anastomotic leak four (8%), port-site hernia one and one case of Clostridium difficile colitis requiring colectomy. There were five (7.5%) returns to theatre and two readmissions (3%). Laparoscopic resectional surgery in complicated diverticular disease is a feasible, safe and a largely predictable operation that allows for early hospital discharge and, in our opinion, improved patient care. We are encouraged to continue to offer our patients the option of an emergency laparoscopic resection." }, { "id": "pubmed23n0791_17413", "title": "[Two cases of curative resection by laparoscopic surgery following preoperative chemotherapy with bevacizumab for locally advanced colon cancer].", "score": 0.009259259259259259, "content": "Here we report 2 cases of curative resection following preoperative chemotherapy with bevacizumab for locally advanced colon cancer. Case 1 was a 62-year-old man admitted with constipation, abdominal distention, and abdominal pain. An abdominal computed tomography(CT)scan revealed an obstructive tumor of the sigmoid colon with invasion into the bladder. A diverting colostomy was performed, and chemotherapy with mFOLFOX6(infusional 5-fluorouracil/Leucovorin+ oxaliplatin) plus bevacizumab was initiated. The tumor shrunk markedly after 6 courses of this treatment. Thereafter, laparoscopy- assisted sigmoidectomy was successfully performed. Case 2 was a 61-year-old woman admitted with diarrhea, abdominal pain, and fever. An abdominal CT scan revealed an obstructive tumor of the sigmoid colon with invasion into the ileum, uterus and retroperitoneum. A diverting colostomy was performed, and chemotherapy with XELOX(capecitabine+ oxaliplatin)plus bevacizumab was initiated. The tumor shrunk markedly after 6 courses of this treatment. Thereafter, laparoscopy- assisted sigmoidectomy was successfully performed. Both cases demonstrated partial clinical responses to chemotherapy; thus, curative resection surgeries were performed. There were no perioperative complications. Therefore, we conclude that oxaliplatin-based chemotherapy plus bevacizumab and laparoscopic resection could be very effective for locally advanced colon cancer." }, { "id": "pubmed23n0090_14341", "title": "[Surgical tactics in complicated sigmoid diverticulitis].", "score": 0.009259259259259259, "content": "Between January 1972 and February 1988 139 admissions (136 patients) for diverticulitis were registered. Treatment remained conservative in 47 cases. 23 cases underwent elective surgery. In 69 patients emergency-laparotomy had to be done. In 41 cases (3 deaths) the abdomen was washed out and drained, followed by a proximal colostomy. In 23 of these patients a free perforation had to be oversewn. 6 patients were treated by Hartmann resection (1 death). Primary resection, anastomosis and proximal colostomy were performed in 15 cases. 3 patients underwent exterritorization and resection. 4 patients with colonic ileus were initially treated by colostomy alone. There were 2 late deaths both from pulmonary embolism. Of the 63 patients who had a colostomy constructed 4 (6.3%) never had the stoma closed. There were 2 persistent stomas in the 41 patients who had a preliminary colostomy alone (4.9%) and the incidence of persistent stoma in 5 patients who had a Hartmann resection was 40% (2 cases). -The three-stage resection makes good results, provided that a free perforation is solidly oversewn to prevent further fecal contamination. Primary resection with anastomosis and proximal colostomy, which is more and more used in suitable cases, considerably shortens duration of treatment. Hartmann resection remains second choice because of the known high incidence of persistent stoma. It is submitted to surgeon's experience to choose at any situation the best procedure regarding age and general state, local findings and extent of peritonitis. With this tactic hospital lethality of emergency operation was 4 of 69 patients (5.8%), overall lethality 6 (8.7%). Intestinal continuity was restored in 94% of surviving patients." }, { "id": "pubmed23n1012_26118", "title": "Chronic abdominal pain after laparoscopic hernia repair due to mesh graft migration to the cecum: a case report.", "score": 0.009174311926605505, "content": "Hernia repair with mesh graft is one of the most common procedures in general surgery. Mesh graft repair is the treatment of choice for umbilical and periumbilical hernias to minimize recurrence. One of the rare but serious complications is mesh graft migration to viscus. These complications can occur months to years after repair and their diagnosis can be challenging as they may present as vague abdominal pain only. A 74-year-old gentleman with multiple medical comorbidities was diagnosed with a para-umbilical hernia after which he underwent a laparoscopic hernia repair at our hospital using a mesh graft with no complications. On postoperative day 10, he presented to the emergency room (ER) complaining of colicky abdominal pain in the right iliac fossa for 1 day associated with diarrhea. A Computed Tomography (CT) scan of the abdomen and pelvis showed diffuse wall thickening of the cecum and terminal ileum with small free air worrisome for perforation. The decision was made in the ER to discharge him home on antibiotics. The patient then returned back multiple times to the ER for the same complaint along with bleeding per rectum for which he underwent further investigations. Months later, the patient presented again with the same symptoms. A CT scan revealed recurrence of a periumbilical hernia and thickening of the medial wall of the cecum with mesh graft material. The patient was then taken to surgery and intra-operative findings revealed migration of almost 50% of the mesh graft size to the cecum and part of the mesh graft was eroding the distal part of ileum just proximal to the ileocecal junction. Adhesolysis and limited right hemicolectomy with ileocolic anastomosis was done. The patient had an uneventful recovery after revisions surgery without any perioperative complications. He was discharged home on postoperative readmission day 5 and followed up at 2 weeks and 3 months without any delayed complications or subjective complaints. It is important to consider mesh graft migration to viscus as a cause of persistent abdominal pain and bleeding per rectum irrespective of the time of presentation post hernia repair." }, { "id": "pubmed23n0106_16251", "title": "Surgical options in acute diverticulitis: value of sigmoid resection in dealing with the septic focus.", "score": 0.009174311926605505, "content": "The outcome of 78 patients hospitalized with acute diverticulitis was analysed to determine the indications for emergency operation and to examine the safety of sigmoid resection. Forty patients improved on medical therapy, but four relapsed soon after discharge. Forty-two (55%) patients had emergency operations for non-resolution of clinical sepsis (25), persistent symptoms or mass (14) and fistula (three). Operations performed were: sigmoid resection and primary anastomosis (23) with covering colostomy (six). Hartmann's operation (10), drainage with/without colostomy (seven) and right hemicolectomy (two). Findings at operation were: abscess (19), phlegmon (14), generalized peritonitis (six), colovesical fistula (three) and chronic diverticulitis (three). Complications included wound infections (six), respiratory complications (five) and one death. Six patients having drainage of the sigmoid inflammation alone as the first operation required subsequent resection, with prolonged and often complicated hospitalization. Minimal morbidity and shorter hospitalization were achieved when sigmoid resection was performed at the initial procedure." }, { "id": "pubmed23n0373_8963", "title": "Intraperitoneal abscess after an undetected spilled stone.", "score": 0.00909090909090909, "content": "Gallbladder perforation with loss of calculi in the abdomen is frequent during laparoscopic cholecystectomy and can cause serious late complications. We report on a 65-year-old woman who underwent laparoscopic cholecystectomy for gallbladder empyema, during which a stone spilled into the peritoneal cavity. The spilled gallstone was not noticed during the initial operation. Three months later, she reported left upper quadrant pain of recent onset without associated symptoms such as fever, nausea, or weight loss. On examination, a palpable 2-cm tender subcutaneous mass was found. Abdominal ultrasound demonstrated an incarcerated hernia, and computed tomography (CT) scan showed an intraperitoneal abscess located in the back of the anterior abdominal wall in the left upper quadrant, which contained a recalcification figure. The patient was brought to surgery, at which time an incision was made over the mass. A chronic abscess in the back of the abdominal wall, also spreading into the subfascial space, was drained, and purulent material was obtained with a large stone, 2.8 cm in diameter, which had become lodged in the rectus abdominis after an undetected stone spillage during laparoscopic cholecystectomy. The patient continued receiving antibiotic treatment for 7 days, recovered well, and was discharged 7 days after drainage of the abscess." }, { "id": "pubmed23n0904_17956", "title": "Laparoscopic resection of a sigmoid colon lipoma in a young female patient: A case report and review of the literature.", "score": 0.009009009009009009, "content": "Lipomas of the sigmoid colon are rare entities. The present case describes a 27-year-old Caucasian woman who underwent a laparoscopic sigmoidectomy following the detection of a giant lipoma. The young patient was referred to the Emergency Department of the University Hospital of Heraklion (Crete, Greece) in May 2013 after experiencing intermittent abdominal cramping during defecation, and altering episodes of diarrhea and constipation. In addition, the patient described the protrusion of a solid tissue mass shaped like a 'champagne bottle cork' from the anus following defecation. These symptoms had been present for 1 month prior to referral. Physical examination was unremarkable. An urgent colonoscopy revealed a polypoid lesion measuring 2.5 cm in diameter in the sigmoid colon, which was located ~12 cm above the anal ring, with a smooth surface and tissue fragility. Tissue samples were obtained and sent for histopathological analysis. Preoperative contrast-enhanced computed tomography was performed urgently and confirmed the presence of a solid mass in the sigmoid colon without enlargement of regional lymph nodes. Following adequate preparation, the patient underwent a laparoscopic sigmoidectomy with intracorporeal termino-terminal colorectal anastomosis, with the use of a circular stapler. The patient had a positive post-operative outcome without complications and was discharged on day 4 post-surgery in an optimal condition. Histopathological examination of the surgical specimen demonstrated a pedunculated lipoma shaped like a 'champagne bottle cork'. The tumor consisted of mature adipose cells. The overlying colonic mucosa showed hyperplastic crypts with regenerative changes. In the lamina propria mild inflammatory infiltration was observed. At 2 years post-surgery, the patient remains asymptomatic without any clinical evidence of recurrence." }, { "id": "pubmed23n1017_16371", "title": "Hot Topics in Surgical Management of Acute Diverticulitiss.", "score": 0.009009009009009009, "content": "In this session different issues for the surgical management of diverticular disease DD) were considered. The first session debated about the antibiotic treatment for acute uncomplicated diverticulitis (AUD), and supports their use selectively rather than routinely in patients with AUD. The second session discussed the best surgical treatment for those patients. Open approach is a valid choice especially in acute setting, while the laparoscopic approach should be individualised according to the level of skills of the surgeon and the risk factors of the patient (such as obesity and state of health at the time of the operation). The third session debated about the peritoneal lavage and drainage, which is still a safe surgical procedure. However, it requires longer follow-up and results of other trials to draw an adequate conclusion. The last session covers the current surgical certainties in managing complicated DD: 1. urgent colectomy has higher mortality in immune-compromised patients, while in elective surgery is comparable with other populations; 2. laparoscopic peritoneal lavage (LPL) should be the choice in young/fit patients; 3. elective resection is safer in an inflammation free interval; 4. laparoscopic resection shows advantages in several outcomes (such as post-operative morbidity and lower stoma and re-operation rate); 5. in Hinchey III/fecal peritonitis, primary sigmoid resection and anastomosis (open or laparoscopic) could be proposed in young/ fit patient; 6. in case of emergency surgery, Hartmann procedure (open or laparoscopic) must be considered in critically ill/unstable patient." }, { "id": "pubmed23n0757_20119", "title": "[Laparoscopic treatment of sigmoid colon intussusception secondary to giant submucosal lipoma].", "score": 0.008928571428571428, "content": "Colonic lipomas have very low frequency, are usually asymptomatic and diagnosis is made incidentally. Seventy-five per cent of lipomas larger than 4 cm are symptomatic, causing abdominal pain, rectal bleeding, obstruction and exceptionally invagination. The resection of invaginated segment is mandatory in cases with invagination and can be performed by laparoscopy when colonic dilation is moderate. We present a 73-year-old man who entered the emergency department complaining of intermitent abdominal pain, rectal bleeding, absence of bowel movements and flatulence, during four days. A CT scan showed a generalized colonic dilation until left lower quadrant. A colo-colonic invagination secondary to an endoluminal lipoma was observed in sigmoid colon. A laparoscopic sigmoidectomy was performed with extracorporeal termino-terminal anastomosis. The postoperative period was uneventful and the patient was discharged from the hospital five days later. A sumbmucous colonic lipoma was diagnosed in the pathological study." }, { "id": "pubmed23n0502_1965", "title": "[Sonographic diagnosis of diverticulitis: the burdensome way to acceptance].", "score": 0.008928571428571428, "content": "Since the middle to the end of the 80 s, the sonographic detection of diverticulitis has been increasingly improved. In a paper including a larger number of patients published in 1992, W. B. Schwerk demonstrated a high sensitivity and specificity. The detection of diverticulitis was the final entry into the chapter of acute abdominal sonography, after the diagnosis of gastrointestinal perforation, acute appendicitis and ureterolithiasis had been achieved with high reliability. Until then, diverticulitis was a classic surgical disease and a contrast enema with water-soluble contrast medium the diagnostic method of choice. Invariably, the radiologist added the well known comment: Cancer of the sigmoid colon cannot be excluded with certainty. What has changed in the 12 years after Schwerk's publication? Many internists practising sonography have discovered the sonographic diagnosis of this condition and, depending on the severity, treat the less complicated cases with intravenous antibiotics and parental nutrition or with oral antibiotics and low-ballast diet. Soon, abscesses were healed with sonographically guided aspiration and drainage. For a long time, the older generation of surgeons stayed with contrast enemas and prolonged parenteral therapy and, in case of complications, surgical interventions, though surgeons early recognized the diagnostic contribution of sonography. Influenced by radiologists and the Anglo-American literature, surgeons increasingly used computed tomography (CT) as standard method for the initial diagnostic work-up for the last five to eight years. A physician dedicated to gastrointestinal sonography cannot accept this approach, in particular, since sonography is easy and reliable, provides a reasonable differential diagnosis and was found to help the surgeons. An exception is the deep-seated diverticulitis in the sometimes barely accessible distal sigmoid colon. Furthermore, an experienced clinician will anyhow proceed to CT in any unexplained discrepancy between clinical and sonographic findings. It reflects the high value given to sonography if our surgical colleagues use this diagnostic method in the primary diagnosis of acute diverticulitis and achieve results that are as good as the results of the expensive and by all criteria more elaborate CT. The extended application of ultrasound for the omentum and in necrotic epiploic appendagitis should be mentioned here as well. Altogether, CT can be easily refrained from in 80 % to 90 % of cases with suspected diverticulitis. In view of the DRG era, this is an important argument, and emphasizes the economic role of sonography, the necessity of correct coding of sonographic procedures and the need of more sonographic training. Only quality will increase the acceptance of sonography as diagnostic tool as repeatedly demanded and presented in this journal. If this fails, it is highly likely that the diagnostic potential of sonography will remain unexploited or, under the best of circumstances, rediscovered after a 5-year expiration date in a new literature search in 10 years." }, { "id": "pubmed23n0803_16339", "title": "Sterile abdominal abscess resulting from remnant laparoscopic clips after sigmoidectomy: a case report and literature review.", "score": 0.008849557522123894, "content": "The occurrence of intra-abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74-year-old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine-needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory-white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery. " }, { "id": "pubmed23n1122_462", "title": "Meckel's diverticulum abscess in the elderly population: A case report.", "score": 0.008849557522123894, "content": "and importance: Meckel's Diverticulum (MD) is the most usual congenital anatomic abnormality of the gastrointestinal tract. It is present in almost 2% of the population and it rarely becomes symptomatic in adults. Herein, we report a rare case of an elderly woman with MD, its diagnostic algorithm and treatment, pointing out the significance of this pathology in the differential diagnosis of right lower quadrant pain. A 75-year-old woman presented in the emergency department due to sudden right lower quadrant abdominal pain and fever. After a comprehensive clinical and imaging evaluation, a diagnostic laparoscopy under general was performed. The appendix presented without inflammation, and a MD abscess was found about 50cm from the ileocaecal valve. The resection of the MD abscess, the appendix and the gallbladder (due to synchronous chololithiasis) were performed. The patient had an uncomplicated post-operative course and she was discharged from hospital on the fifth postoperative day after having been fed and mobilized enough. A complicated MD can be a life-threatening situation. Generally, the MD cannot be easily diagnosed through obtaining patient's medical history, clinical examination and laboratory testing and it is undiagnosed to up to 60% of the cases, while it is usually an incidental finding during a diagnostic laparoscopy or laparotomy. Clinicians should be aware that MD complications in the elderly population can vary. However, having under consideration the very low but true possibility of the MD in the old age may lead to an early and accurate diagnosis." }, { "id": "pubmed23n1052_14884", "title": "Four cases of laparoscopic colectomy for sigmoid colon and rectal cancer with persistent descending mesocolon.", "score": 0.008771929824561403, "content": "Persistent descending mesocolon (PDM) is a congenital anomaly associated with the failure of fixation of the descending colon to the lateral abdominal wall. In the laparoscopic colectomy for colorectal cancer, it has been noticed that there are extensive adhesions and a distinctive anatomy of colonic vessels in cases with PDM. Therefore, it is necessary to have sufficient knowledge about PDM so that it can be appropriately treated during surgery. Case 1-a 79-year-old man underwent laparoscopic intersphincteric resection for rectal cancer. Preoperative barium enema (BE) revealed that the sigmoid colon was located at the right side of the abdomen. An enhanced computed tomography (CT) showed that the common trunk of the left colic artery (LCA) and the first sigmoid colonic artery (S1) branched from the inferior mesenteric artery (IMA). Case 2-a 68-year-old man underwent laparoscopic sigmoidectomy for sigmoid colon cancer and laparoscopic distal gastrectomy for gastric cancer synchronously. BE showed that the descending colon ran from the splenic flexure to medial caudal side. An enhanced CT showed that the distance from the LCA to the marginal artery was 1.0 cm. Case 3-a 68-year-old man underwent laparoscopic low anterior resection for rectal cancer. BE showed that the descending colon ran to the medial caudal side. An enhanced CT showed that the mesentery of the descending colon was comparatively shortened. Case 4-a 60-year-old man underwent laparoscopic sigmoidectomy for sigmoid colon cancer. An enhanced CT showed that the descending colon ran to the medial caudal side and predicted that the LCA and S1 formed a common trunk and branched radially from the IMA. We reported four cases with PDM recognized preoperatively as above. Three cases had a shortening of the mesocolon. While dissecting the vessels, although special attention was required to maintain the blood flow to the intestine, none of these cases developed any complications during the postoperative course. We considered that it is important to have positional awareness of the LCA and the marginal artery to perform the laparoscopic surgery safely when a colorectal cancer with PDM is diagnosed preoperatively using imaging methods." }, { "id": "pubmed23n0776_12137", "title": "Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis.", "score": 0.008771929824561403, "content": "The severity of acute diverticulitis ranges from mild, simple inflammation to pericolic abscesses, or perforation with faeculent peritonitis. Treatment of diverticulitis has evolved towards more conservative and minimally invasive strategies. The aim of this review is to highlight recent concepts and advances in management. A literature review was performed on the electronic databases MEDLINE from PubMed, Embase and the Cochrane Library for publications in English. The keywords 'diverticulitis', 'diverticular' were searched for the past decade (to September 2013). Diverticulitis occurs frequently in the Western world, but only one in five patients develops complications (such as abscess and perforation) during the first acute presentation. The reported perforation rate is 3.5 per 100,000 population. Based on recent data, including the AVOD and DIVER trials, antibiotic therapy for mild episodes may be unnecessary and outpatient management reasonable in most patients. Antibiotics and admission to hospital is required for complicated diverticulitis confirmed on imaging and for patients with sepsis. Diverticular abscesses (about 5 per cent of patients) may require percutaneous drainage if antibiotics alone fail. Laparoscopic management of non-faecal perforated diverticulitis is feasible in selected patients, and peritoneal lavage in combination with antibiotic therapy may avoid colonic resection and a stoma. However, the collective, published worldwide experience is limited to fewer than 800 patients, and results from ongoing randomized trials (LapLAND, SCANDIV, DILALA and LADIES trials) are needed to inform better decision-making. The treatment of diverticulitis continues to evolve with a trend towards a more conservative and minimally invasive management approach. Judicious use of antibiotics in uncomplicated cases, greater application of laparoscopic techniques, and primary resection and anastomosis are of benefit in selected patients." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 0, 318 ] ], "word_ranges": [ [ 0, 48 ] ], "text": "The clinical presentation is strongly suggestive of giant cell arteritis (GCA), with febrile fever, shoulder girdle and pelvic pain, and headache. Age and sex also point to this possibility. Abrupt unilateral visual loss with pale papillary edema is highly indicative of arteritic ischemic optic neuropathy due to GCA." }, "3": { "exist": true, "char_ranges": [ [ 1007, 1049 ] ], "word_ranges": [ [ 160, 170 ] ], "text": "we rule out 3 because the dose is too low," }, "4": { "exist": true, "char_ranges": [ [ 503, 921 ] ], "word_ranges": [ [ 78, 147 ] ], "text": "4 could make us doubt, and it is true that we will have to ask for a temporal artery biopsy, but that is not immediate: the statement makes it very clear that we have to act immediately. The current trend is to use megadoses of intravenous corticosteroids, and although aspirin has traditionally been proposed to reduce ischemic events, the evidence currently indicates that antiplatelet agents do not contribute much." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Request a Doppler ultrasound of temporal arteries.", "2": "Start treatment with prednisone 60mg per day and aspirin 100 mg per day.", "3": "Start treatment with prednisone 10 mg per day.", "4": "Request a temporal artery biopsy.", "5": "Request a brain magnetic resonance imaging." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1100_5465", "title": "Giant Cell Arteritis Presenting as Unilateral Arteritic Anterior Ischemic Optic Neuropathy.", "score": 0.018883049790683174, "content": "Giant cell arteritis (GCA) is a rare inflammatory vasculitis of unknown cause that involves large and medium arteries. Arteritic anterior ischemic optic neuropathy (AAION) is attributed to vascular occlusion of the posterior ciliary arteries (PCAs) which supply the optic nerve head (ONH). AAION is the most common ophthalmic complication of GCA and can cause sudden and irreversible loss of vision with a high risk of involvement of the second eye. A 57-year-old female patient presented with unilateral sudden onset visual loss in the right eye (OD) for two days. It was accompanied by severe right-sided headache and scalp tenderness on the right temple, neck as well as the presence of jaw pain over the past three months. Visual acuity (VA) was hand motion (HM) OD, and 20/20 in the left eye (OS). Fundus examination revealed diffuse swollen optic disc with pallid \"chalky white\" appearance OD and normal healthy optic disc OS. A dramatically elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were found. Therefore, a diagnosis of GCA was made, and immediate IV methylprednisolone was started followed by oral prednisone doses. A right temporal artery (TA) biopsy was done later and was negative. On follow-up, VA has maintained at HM level OD, and no involvement of the second eye occurred. GCA is a rare form of vasculitis that can be difficult to diagnose especially in the setting of negative TA biopsy. We support the evidence that negative TA biopsy does not rule out clinically suspected GCA with elevated ESR and CRP and recommend keeping a low index of suspicion as immediate treatment is required to prevent irreversible vision loss." }, { "id": "pubmed23n0574_18362", "title": "[Temporal arteritis presenting with headache and abducens nerve palsy. Report of a case].", "score": 0.018624393624393623, "content": "A 71-year-old man visited our clinic with a 3-day history of severe throbbing headache and 1-day history of horizontal diplopia. He had had jaw claudication and pain in the neck and shoulder several days previously. His right eye was slightly esotropic and did not move laterally. There was no blepharoptosis, proptosis, lid edema, or conjunctival injection. The pupils were unremarkable. The remainder of the cranial nerve functions was intact. There was no limb weakness or sensory impairment. Superficial temporal arteries were swollen and tender on both sides. Laboratory examination showed elevated CRP level and high erythrocyte sedimentation rate. Cranial MR images were unremarkable. The cerebrospinal fluid was acellular with 45 mg/dl of protein. A diagnosis of temporal arteritis was made. Treatment with 50 mg of prednisolone brought about prompt disappearance of the headache. Right ocular movement fully recovered in 10 days. Temporal artery biopsy findings and response to corticosteroid were consistent with temporal arteritis. The motility pattern of the right eye was consistent with complete abducens nerve palsy, which is a rare manifestation of temporal arteritis. Although temporal arteritis is a rare cause of ophthalmoplegia in the elderly patients, swift diagnosis and treatment is necessary to avoid blindness." }, { "id": "pubmed23n0702_678", "title": "Polymyalgia rheumatica and giant cell arteritis in older patients: diagnosis and pharmacological management.", "score": 0.017711598746081504, "content": "Giant cell arteritis (GCA) is an inflammatory vasculopathy that involves large- and medium-sized arteries and can cause vision loss, stroke and aneurysms. GCA occurs in people aged &gt;50 years and is more common in women. A higher incidence of the disease is observed in populations from Northern European countries. Polymyalgia rheumatica (PMR) is a periarticular inflammatory process manifesting as pain and stiffness in the neck, shoulders and pelvic girdle. PMR shares the same pattern of age and sex distribution as GCA. The pathophysiology of PMR and GCA is not completely understood, but the two conditions may be related and often occur concurrently. A delay in the diagnosis should be avoided because of the risk of vascular ischaemic complications due to GCA. The diagnosis should be considered in patients aged &gt;50 years presenting with symptoms such as new headache, visual disturbances, jaw claudication or symptoms of PMR. GCA can also present as a systemic inflammatory syndrome with fever of unknown origin. Marked elevation of acute-phase reactants, recognizable in higher erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, is often seen in both PMR and GCA. However, some patients can present with a normal ESR. Confirmation of the diagnosis of GCA by temporal artery biopsy is important because clinical findings and laboratory tests are not specific, and because a diagnosis of GCA commits patients to long-term treatment with corticosteroids. The role of imaging techniques for the diagnosis of GCA remains unclear, but these modalities can be helpful in assessing the extent of vascular involvement, especially when extra-cranial disease is present. In PMR, subdeltoid and subacromial bursitis can be identified by imaging techniques, especially ultrasound or MRI. The clinical manifestations of GCA and PMR respond dramatically within 12-48 hours of starting corticosteroid treatment. The initial corticosteroid dosage commonly used in GCA is oral prednisone 40-60 mg/day, and for patients with PMR a dosage of 15-20 mg/day is often sufficient. A prolonged course of treatment is necessary, and corticosteroids are gradually tapered, guided by regular clinical evaluation and ESR (and/or CRP) measurement. Methotrexate is the best studied corticosteroid-sparing agent in GCA, and may be useful for patients with frequent disease relapses and/or corticosteroid-related toxicity. Retrospective studies favour aspirin (acetylsalicylic acid) as an effective adjuvant treatment for reducing the ischaemic complications of GCA. The long-term course of corticosteroid therapy frequently exposes elderly patients with PMR/GCA to various adverse effects, which can be attenuated with appropriate prophylactic measures. Co-morbid diseases and polypharmacy can pose particular challenges in the geriatric population. In general, the life expectancy of patients with GCA does not appear to be shortened, whereas the morbidity associated with the disease and its treatment is well recognized." }, { "id": "pubmed23n1045_469", "title": "A Case of Brucellosis with Possible Ileal Involvement.", "score": 0.01621417797888386, "content": "Brucellosis is a zoonotic disease that can involve different organs and tissues. Fever, fatigue, lymphadenopathy, hepatosplenomegaly, cytopenia, and arthritis are the usual modes of presentation. Gastrointestinal manifestations of human brucellosis are common but documented ileal involvement is extremely rare. A 68-year-old female presented with a history of 10 days of intense temporal migraine, photophobia, and phonophobia with partial response to paracetamol. The patient referred night sweats, anorexia, and colicky abdominal pain after her meals for the past 4 months followed by diarrhea. She denied nausea, vomiting, hypersensitivity of the scalp, blurry vision, melena, or rectal bleeding. She denied travelling or contact with animals. Physical examination revealed fever (38.3°C) and splenomegaly. Laboratory workup revealed Hb 7.8 g/dL, leukopenia (3.47 × 10<sup9</sup/L), C-reactive protein 5.94 mg/dL, and erythrocyte sedimentation rate 23 mm/h. Abdominal ultrasound showed hepatic steatosis and mild homogeneous splenomegaly. Chest radiography was normal. Lumbar puncture; transcranial, carotid, and temporal arteries Doppler, and head computed tomography (CT) did not show any significant changes. Abdominal CT showed diffuse thickening of the ileum and some mildly swollen locoregional lymph nodes. Fecal calprotectin was not elevated. Blood cultures and serologies were positive for <iBrucella</i (positive Rose-Bengal test, ELISA IgM-positive, IgG-negative anti-brucella antibody serology and positive Huddleson reaction - titer 1:320). The patient was started on rifampicin 600 mg/day and doxycycline 100 mg q. 12 h for 10 weeks with good clinical and analytical response. Upper and lower gastrointestinal endoscopy were normal, although the last was done already under antibiotic treatment. Although gastrointestinal manifestations of brucellosis are quite common, ileitis is thought to be extremely rare. In countries where brucellosis is endemic, doctors must consider this diagnosis when faced with patients with systemic symptoms and diarrhea or abdominal pain. Early recognition of brucellosis and institution of appropriate therapy usually leads to a good recovery without complications." }, { "id": "pubmed23n0053_20383", "title": "[Giant-cell arteritis limited to the femoral arteries].", "score": 0.015702631417530515, "content": "A previously healthy 48-year-old woman developed, over several months, increasing pain in her hips, cervical and lumbar spine as well as the shoulders. In addition she developed intermittent claudication after walking 100-200 m. Erythrocyte sedimentation rate (ESR) was 35-43 mm in the first hour; the IgM concentration was raised to 610 mg/dl. Angiography demonstrated symmetrical occlusion of both superficial femoral arteries. An attempt at thrombolysis having failed, a biopsy of the femoral artery wall was obtained. This revealed a florid arteritis, in part as giant-cell arteritis with destruction of the elastic structures, while the adjacent muscle was unchanged. Subsequent biopsy of the temporal artery was normal. Treatment consisted at first of 60 mg prednisolone and 100 mg aspirin, both daily for 4 weeks. The ESR fell and the free-of-pain walking distance rose. There has been no recurrence of pain after stepwise reduction over one year of the steroid dosage until its discontinuation." }, { "id": "pubmed23n0334_10172", "title": "Lessons to be learned: a case study approach--a case of temporal arteritis.", "score": 0.014955849889624725, "content": "A 71-year-old male presented with a history of sudden partial visual loss in the right eye with an inferior visual field defect over the past 3-4 days. He had no history of headache or of facial pain. Clinical examination confirmed that vision on the right side was reduced to 6/18 and on the left to 6/12. The right eye showed a relative afferent pupillary defect. There was no other abnormality of the anterior segment of either eye. The right retina showed a pale swollen optic disc and a provisional diagnosis of anterior ischaemic optic neuropathy (AION) was made. An urgent erythrocyte sedimentation rate (ESR) was ordered and the patient was asked to return to the eye clinic in one month. However, 16 days later--when it was first recognised that his ESR was elevated to 75 mm in the first hour--the patient was recalled immediately in order to commence systemic steroid treatment; but regrettably, by this time, his right eye had become totally blind. In this case, although the attending doctor made a correct clinical diagnosis on presentation, he failed to act upon the result of the blood test." }, { "id": "pubmed23n1076_3428", "title": "[Management of patients with a suspicion of giant cell arteritis: Survey among general practitioners and specialists].", "score": 0.01484585143803021, "content": "Headache, visual disturbances and shoulder and hip girdle pain are frequent symptoms of consultation and the diagnosis of giant cell arteritis (GCA) can be evoked in these situations. However, GCA is a rare disease, and the management modalities of a clinical suspicion of GCA are poorly described, which warranted this study. This is a survey evaluating the management of a suspected case of GCA. The questionnaires were sent to general practitioners (GPs), members of the French Rheumatology Society (SFR) and the French National Society of Internal Medicine (SNFMI) RESULTS: One thousand four hundred and fifty two physicians responded to the survey, including 967 GPs (66.6 %) and 485 other specialists (33.4 %). GPs immediately referred the patient to the emergency room in 42 % of cases, and to a specialist colleague in 72 % of cases in the presence of visual symptoms. GPs and other specialists reported performing temporal artery biopsy (TAB) respectively in 46.7 % and 69.7 % of cases (P&lt;0.05). GPs and other specialists reported using diagnostic imaging in 7.4 % and 16.2 % of cases, respectively (P&lt;0.05). Temporal artery ultrasound was the most used diagnostic imaging. The average prednisone equivalent dose prescribed as initial treatment was 1mg/kg/day for GPs and 0.7mg/kg/day for other specialists (P&lt;0.05). Some suspected GCA patients would be managed by their GPs. Imaging was little used for the diagnosis of GCA and TAB remained the preferred diagnostic examination. The initial prednisone equivalent dose varied between GP and other specialists." }, { "id": "pubmed23n0683_9414", "title": "[Case of temporal arteritis: FDP-PET ((18)F-fluorodeoxyglucose-positron emission tomography) was useful for early diagnosis and treatment].", "score": 0.014693264693264693, "content": "A 61-year-old woman with a continuous left temporal headache and a fever of 39°C for about one month was admitted to our hospital. The physical examination was not remarkable, except for slight tenderness of the left temporal side of her head. Laboratory data on admission revealed an increase of leucocytes (9,700/µl), blood platelets (59.4×10(4)/µl), and serum c-reactive protein (CRP) (10.9 mg/dl). The erythrocyte sedimentation rate (ESR) was also elevated (88 mm/1 h). After gallium scintigraphy, a gallium-67 uptake was weakly detected at the left temporal side of her head. However, after FDG-PET examination, a high FDG uptake was detected in her temporal artery, abdominal aorta, and bilateral femoral arteries. Moreover, Doppler sonography showed a hypoechoic halo around her left temporal artery. After treatment with oral prednisolone (40 mg/day), her headache disappeared and her serum CRP level returned to normal. Finally, the patient had pathological temporal arteritis proven by a biopsy. It is difficult to make an early diagnosis of temporal arteritis if the dilatation or swelling of the temporal arteries is not present. FDG-PET is considered a useful examination not only for the exploration of tumors, but also for the evaluation of the inflammation of large vessels." }, { "id": "InternalMed_Harrison_1439", "title": "InternalMed_Harrison", "score": 0.014617971231085373, "content": "The erythrocyte sedimentation rate (ESR) is often, although not always, elevated; a normal ESR does not exclude giant cell arteritis. A temporal artery biopsy followed by immediate treatment with prednisone 80 mg daily for the first 4–6 weeks should be initiated when clinical suspicion is high. The prevalence of migraine among the elderly is substantial, considerably higher than that of giant cell arteritis. Migraineurs often report amelioration of their headaches with prednisone; thus, caution must be used when interpreting the therapeutic response. Glaucoma may present with a prostrating headache associated with nausea and vomiting. The headache often starts with severe eye pain. On physical examination, the eye is often red with a fixed, moderately dilated pupil. Glaucoma is discussed in Chap. 39." }, { "id": "pubmed23n0479_22722", "title": "Giant Cell Arteritis.", "score": 0.01430976430976431, "content": "Patients with a suspected diagnosis of giant cell arteritis (GCA) should be started on high-dose corticosteroid therapy without delay. A temporal artery biopsy should be performed after initiation of therapy to confirm the diagnosis. Patients with acute visual or neurologic symptoms present a neuro-ophthalmic emergency. Therapy should be initiated immediately with high-dose intravenous methylprednisolone sodium succinate and followed by high-dose oral prednisone. Treatment may begin with high-dose oral prednisone in patients without visual or neurologic symptoms. Calcium, vitamin D, and peptic ulcer prophylaxis should accompany steroid therapy, as indicated. The following treatments should be considered for patients with suspected GCA and acute visual or neurologic signs or symptoms: intravenous methylprednisolone sodium succinate (250 mg intravenously every 6 hours) should be given for 3 days, followed by oral prednisone (80 mg per day or 1 mg/kg) for 4 to 6 weeks. Prednisone should then be tapered by 10 mg per day every month. Most patients require 1 year of therapy to avoid relapse. Taper and duration should be modified according to erythrocyte sedimentation rate, C-reactive protein, and signs and symptoms of GCA. Rheumatologic consultation and follow-up is often helpful for these patients. For patients with suspected GCA and no acute visual or neurologic signs or symptoms, therapy may begin directly with oral prednisone (80 mg per day or 1 mg/kg) with same taper and duration based on laboratory values and clinical signs and symptoms." }, { "id": "pubmed23n0661_4997", "title": "[Dutch College of General Practitioner's practice guideline on polymyalgia rheumatica and temporal arteritis].", "score": 0.014220514052366082, "content": "The practice guideline for general practitioners (GPs) on polymyalgia rheumatica and temporal arteritis was published in February 2010 by the Dutch College of General Practitioners. This guideline provides GPs with recommendations for the diagnosis and treatment of polymyalgia rheumatica. After other disorders have been excluded, the diagnosis of 'polymyalgia rheumatica' is made in patients over the age of 50 who have bilateral pain in the neck and shoulder girdle and/or hip girdle that has lasted for longer than 4 weeks, morning stiffness that lasts longer than 60 minutes and an ESR &gt; 40 mm in the first hour. After the diagnosis is made treatment with prednisone or prednisolone 15 mg per day is started. This dosage is diminished very gradually according to a uniform treatment schedule during a period of 3 months, thereafter depending on the clinical course. The practice guideline pays attention to the diagnosis and management of temporal arteritis only when it occurs concurrently with polymyalgia rheumatica." }, { "id": "pubmed23n0684_20087", "title": "[Dutch College of General Practitioner's practice guideline on polymyalgia rheumatica and temporal arteritis].", "score": 0.01411519514967791, "content": "The practice guideline for general practitioners (GPs) on polymyalgia rheumatica and temporal arteritis was published in February 2010 by the Dutch College of General Practitioners. This guideline provides GPs with recommendations for the diagnosis and treatment of polymyalgia rheumatica. After other disorders have been excluded, the diagnosis of 'polymyalgia rheumatica' is made in patients over the age of 50 who have bilateral pain in the neck and shoulder girdle and/or hip girdle that has lasted for longer than 4 weeks, morning stiffness that lasts longer than 60 minutes and an ESR &gt; 40 mm in the first hour. After the diagnosis is made treatment with prednisone or prednisolone 15 mg per day is started. This dosage is diminished very gradually according to a uniform treatment schedule during a period of 3 months, thereafter depending on the clinical course. The practice guideline pays attention to the diagnosis and management of temporal arteritis only when it occurs concurrently with polymyalgia rheumatica." }, { "id": "wiki20220301en001_181765", "title": "Giant cell arteritis", "score": 0.013949573094961318, "content": "While studies vary as to the exact relapse rate of giant cell arteritis, relapse of this condition can occur. It most often happens at low doses of prednisone (<20 mg/day), during the first year of treatment, and the most common signs of relapse are headache and polymyalgia rheumatica. Associated conditions The varicella-zoster virus (VZV) antigen was found in 74% of temporal artery biopsies that were GCA-positive, suggesting that the VZV infection may trigger the inflammatory cascade. The disorder may co-exist (in about half of cases) with polymyalgia rheumatica (PMR), which is characterized by sudden onset of pain and stiffness in muscles (pelvis, shoulder) of the body and is seen in the elderly. GCA and PMR are so closely linked that they are often considered to be different manifestations of the same disease process. PMR usually lacks the cranial symptoms, including headache, pain in the jaw while chewing, and vision symptoms, that are present in GCA." }, { "id": "pubmed23n1143_5988", "title": "A Case of Giant Cell Arteritis With a Normal Erythrocyte Sedimentation Rate (ESR) Post ChAdOx1 nCoV-19 Vaccination.", "score": 0.013685636856368564, "content": "Giant cell arteritis (GCA) has been reported post the coronavirus disease 2019 (COVID-19) vaccination, especially with the mRNA vaccine. A normal erythrocyte sedimentation rate (ESR) is seen in some GCA patients. This report describes a 68-year-old gentleman who presented with a right-sided temporal headache for three weeks, starting three to five days after his second dose of the ChAdOx1 nCoV-19 vaccine, a viral vector vaccine, which was given seven weeks post the first dose. On presentation, he developed blurred vision in the left eye, and it progressed to complete vision loss four days later. He also had episodes of blurred vision in the right eye. The blood test showed a mildly elevated C-reactive protein of 29 mg/L and a normal erythrocyte sedimentation rate (ESR) of 4 mm/hr. Optical coherence tomography showed anterior ischaemic optic neuropathy in the left eye and retinal ischemia in the right eye. Bilateral giant cell arteritis (GCA) was confirmed on temporal artery biopsy. He was treated with methylprednisolone pulse therapy followed by prednisolone. He re-presented with intermittent blurry vision in the right eye three months later. He was treated with methylprednisolone pulse therapy again, followed by prednisolone, aspirin, and tocilizumab. This case describes a patient who developed GCA post ChAdOx1 nCoV-19 vaccination with a normal ESR. Further studies are needed to investigate this relationship as causal or incidental and the likelihood of low-level inflammatory makers in such a situation." }, { "id": "First_Aid_Step2_572", "title": "First_Aid_Step2", "score": 0.013433787770070956, "content": "ESR > 50 (usually > 100). Ophthalmologic evaluation. Temporal artery biopsy: Look for thrombosis; necrosis of the media; and lymphocytes, plasma cells, and giant cells. High-dose prednisone begun immediately to prevent ocular involvement (or involvement of the remaining eye after onset of monocular blindness). Obtain a biopsy, but do not delay treatment. Conduct a follow-up eye exam. Risk factors include female gender and age > 50. Hx/PE: Presents with pain and stiffness of the shoulder and pelvic girdle musculature with difficulty getting out of a chair or lifting the arms above the head. Other symptoms include fever, malaise, and weight loss. Weakness is generally not appreciated on exam. Dx: Labs reveal a markedly ↑ESR, often associated with anemia. Tx: Low-dose prednisone (10–20 mg/day). Table 2.9-5 outlines the presentation and treatment of common pediatric orthopedic injuries." }, { "id": "pubmed23n0861_3086", "title": "Temporal arteritis with erythrocyte sedimentation rate &lt;50 mm/h: a clinical reminder.", "score": 0.013283305300383835, "content": "Temporal arteritis, also known as giant cell arteritis (GCA), is a systemic vasculitis that predominantly involves the temporal arteries. It is a medical emergency and should be treated promptly as it can lead to permanent loss of vision. It is very commonly associated with a raised erythrocyte sedimentation rate (ESR), usually &gt;50 mm/h, one of the essential criteria defined by the American College of Rheumatology classification of GCA. Here, we describe the case of a 73-year-old male presenting with a 2-day history of a sudden onset of a severe left-sided headache, which had the signs and symptoms consistent with GCA but he had an ESR of only 27 mm/h. The patient was urgently treated with prednisolone 60 mg per day, and his symptoms dramatically improved within 24 hours of therapy. Temporal artery biopsy results were consistent with an inflammatory response, and withdrawal of treatment led to a relapse of the symptoms. The patient was slowly tapered off the high steroid dose and is now currently managed on a low steroid dose. We should keep a high index of suspicion for GCA in patients presenting with clinical symptoms of GCA even though the ESR is &lt;50 mm/h as stated in the criteria for GCA diagnosis. " }, { "id": "pubmed23n1097_13018", "title": "Simultaneous Bilateral Primary Occlusion of the Ophthalmic Artery due to Florid Giant Cell Arteritis.", "score": 0.013200615174299385, "content": "To report a case of simultaneous bilateral ophthalmic artery occlusion in diagnosed giant cell arteritis (GCA). A 77-year-old male patient presented to the emergency department with simultaneous vision loss in both eyes for 3 hours. Headache at both temples and jaw claudication had been present for 3 weeks. Laboratory values demonstrated an initially increased C-reactive protein (CRP) of 202.0 mg/L and an erythrocyte sedimentation rate (ESR) of 100 mm within the first 20 minutes. Duplex sonography of the right and left temporal arteries revealed a \"halo sign.\" A case of GCA was suspected, and intravenous high-dose methylprednisolone therapy was immediately administered. The clinical examination revealed a bilateral central retinal artery occlusion and fluorescein angiography showed a hot optic disc in the right eye and patchy choroidal hypoperfusion in both eyes. Biopsy of the left temporal artery was performed, which confirmed a florid temporal arteritis with complete thrombotic occlusion of the vascular lumen. Despite a good response to the administered therapy (CRP 17.0 mg/L 1 week after initiation), the visual prognosis was significantly limited through retinal and optic nerve involvement. By the follow-up examination 8 weeks later, the near visual acuity was 20/400 in the right and left eye at a distance of 16 inches. We hereby present a simultaneous bilateral ophthalmic artery occlusion as a rare complication of GCA. The combination of central retinal artery occlusion, arteritic anterior ischemic optic neuropathy, and choroidal hypoperfusion suggests an acute inflammatory involvement of the ophthalmic artery. In cases of the slightest suspicion of giant cell arteritis, an immediate high-dose steroid therapy initiation is of utmost importance." }, { "id": "Neurology_Adams_1722", "title": "Neurology_Adams", "score": 0.012381567614125753, "content": "Treatment This disorder is self-limiting, lasting 6 months to 2 years, and responds dramatically to corticosteroid therapy, although this may have to be continued in low dosage for several months or a year or longer. We begin treatment with 20 mg of prednisone if there is no evidence of temporal arteritis (which requires higher doses). The absence of improvement in a day or two should bring the diagnosis into question. The degree of hip and shoulder pain is the best guide to the duration of steroid therapy and the rate at which the drug is withdrawn, usually in very small increments every 2 weeks. The sedimentation rate or C-reactive protein can be used as a guide, but neither alone is adequate to alter the medication schedule. Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy and Causalgia; (See Chap. 7)" }, { "id": "Neurology_Adams_11296", "title": "Neurology_Adams", "score": 0.01231194764892397, "content": "3. When muscle pain is a prominent feature, polymyalgia rheumatica must be differentiated. This latter syndrome is characterized by pain, stiffness, and tenderness in the muscles of the neck, shoulders, and arms, and sometimes of the hips and thighs; even passive motion of the limbs causes pain because of the periarticular locus of this disease. A high sedimentation rate, usually above 65 mm/h, is a diagnostic feature, but more typically the value is close to 100 mm/h, levels higher than in myositis. Biopsy of the temporal artery frequently discloses a giant cell arteritis. CK levels—and, of course, muscle biopsy—are normal. Rapid disappearance of pain with administration of small doses of prednisone is also diagnostic of polymyalgia rheumatica (see Chap. 9)." }, { "id": "pubmed23n0324_6721", "title": "[Clinical thinking and decision making in the practice. A patient with fever of unknown origin].", "score": 0.01220591489047865, "content": "A 75-year-old woman was admitted because of fever of unknown origin (FUO). In the year before the current admission she developed myalgias and was treated for polymyalgia rheumatica with low-dose prednisone. Her complaints persisted and prednisone was discontinued. Five months before the present admission she developed fever (37.7-38.9 degrees C), malaise, fatigue and occipital headache. Laboratory tests showed an elevated erythrocyte sedimentation rate (98 mm in the first hour) and a severe hypochromic, slightly microcytic, anaemia. Although a recent temporal artery biopsy was negative, a second biopsy was taken which showed giant cell arteritis. The patient was treated with high-dose prednisone (60 mg daily) and made a full recovery. It is emphasized that temporal arteritis is a common cause of FUO in the elderly." }, { "id": "wiki20220301en226_33112", "title": "Cerebral vasculitis", "score": 0.012168340713539979, "content": "Diagnostic criteria Three or more of the following five criteria must be met: Age 50 years or more New developed headache Tenderness of the superficial temporal artery Elevated sedimentation rate, at least 50 mm/hour (blood test that reveals inflammatory activity) Giant cell arteritis in a biopsy specimen from the temporal artery Takayasu's arteritis Symptoms Starts with nonspecific symptoms such as: Localized joint pain Fever Fatigue Headaches Rashes Weight loss Diagnosis usually does not happen until the blockage causes deficient blood flow to the extremities or to a stroke." }, { "id": "article-26239_19", "title": "Optic Ischemia -- Treatment / Management", "score": 0.01186954071569456, "content": "AAION: In cases of high suspicion treatment with high dose corticosteroids should be started immediately after drawing samples for CBC, ESR, CRP without waiting for results of investigations. Immediate treatment prevents vision loss in another eye as there are high chances of involvement of the second eye within days to weeks. Temporal artery biopsy can be delayed for 7 to 10 days if immediate facilities are not available. Pathological changes in the temporal artery will not be affected as they take weeks to months to change. High-dose intravenous methylprednisolone (1 g/day) for 3 to 5 days is preferred. Some studies suggest different duration for intravenous steroid use, a three-day course of high-dose IV steroids, suggesting benefit on visual recovery in the same eye and prevention of disease in the second eye is favored. [11] [12] The consensus approach after intravenous therapy is to start a moderate to a high dose of oral prednisone (1 mg/kg/day). Steroids are slowly tapered over 3 to 12 months, depending on the response. ESR and CRP are followed closely throughout the course." }, { "id": "InternalMed_Harrison_25299", "title": "InternalMed_Harrison", "score": 0.011778478593272171, "content": "Source: Reprinted with permission from WHO Expert Consultation on Rheumatic Fever and Rheumatic Heart Disease (2001: Geneva, Switzerland): Rheumatic Fever and Rheumatic Heart Disease: Report of a WHO Expert Consultation (WHO Tech Rep Ser, 923). Geneva, World Health Organization, 2004. single dose of 1.2 million units (600,000 units for children ≤27 kg) IM benzathine penicillin G. These may be used for the treatment of arthritis, arthralgia, and fever, once the diagnosis is confirmed. They are of no proven value in the treatment of carditis or chorea. Aspirin is the drug of choice, delivered at a dose of 50–60 mg/kg per day, up to a maximum of 80–100 mg/kg per day (4–8 g/d in adults) in four to five divided doses. At higher doses, the patient should be monitored for symptoms of salicylate toxicity such as nausea, vomiting, or tinnitus; if symptoms appear, lower doses should be used. When the acute" }, { "id": "pubmed23n0708_5588", "title": "[Temporal arteritis: a confounding diagnosis].", "score": 0.011714480874316941, "content": "Temporal arteritis is a chronic vasculitis of medium and large-size vessels and involves particularly extracranial branches of the aortic arch arteries. Authors report the case of a 73-year-old woman who presented to the hospital after looking for medical counselling three times because of unexplained fever, fatigue, nonproductive cough, and throat pain. She already completed two antibiotic prescriptions. This 3-week history completed in the last days with temporal bilateral headache and visual disturbance. Physical examination was notable for fever and bilateral thickened tender temporal arteries. The erythrocyte sedimentation rate was elevated. A biopsy specimen of the left temporal artery confirmed the diagnosis of giant cell temporal arteritis. The diagnostic suspicion of this disease is clinical and usually simple, but in 10% there are throat pain, non-productive cough and fever which are misunderstood as superior respiratory tract infections leading to diagnosis and treatment delay." }, { "id": "pubmed23n0551_14923", "title": "Giant cell arteritis and polymyalgia rheumatica: pathophysiology and management.", "score": 0.011548143486469478, "content": "Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common and often concurrent diseases in Western countries in individuals aged &gt;50 years. Clinical features of GCA are mainly due to involvement of the cranial arteries. PMR is clinically characterised by pain, aching and morning stiffness involving the neck, shoulder and hip girdles. Both conditions are generally associated with elevation of erythrocyte sedimentation rate and C-reactive protein. A temporal artery biopsy is the gold standard test for the diagnosis of GCA. Some diseases may mimic PMR or present with polymyalgic symptoms. Corticosteroids are the cornerstone of the management of GCA and PMR. An initial dosage of prednisone 10-20 mg/day yields a dramatic improvement of PMR symptoms in most cases. In GCA, the initial prednisone dosage required is higher (40-60 mg/day). However, once established, visual loss, which is the most feared complication of GCA, does not usually improve following corticosteroid therapy. Some patients exhibit a chronic-relapsing course and may need low doses of corticosteroids for several years. Alternative corticosteroid-sparing therapies and some therapeutic agents aimed at restoring balanced bone cell activity in patients taking corticosteroids are potentially useful in the management of GCA and PMR." }, { "id": "InternalMed_Harrison_1431", "title": "InternalMed_Harrison", "score": 0.011286734574405807, "content": "A careful neurologic examination is an essential first step in the evaluation. In most cases, patients with an abnormal examination or a history of recent-onset headache should be evaluated by a computed tomography (CT) or magnetic resonance imaging (MRI) study. As an initial screening procedure for intracranial pathology in this setting, CT and MRI methods appear to be equally sensitive. In some circumstances, a lumbar puncture (LP) is also required, unless a benign etiology can be otherwise established. A general evaluation of acute headache might include cranial arteries by palpation; cervical spine by Pain induced by bending, lifting, cough Pain associated with local tenderness, e.g., region of temporal artery the effect of passive movement of the head and by imaging; the investigation of cardiovascular and renal status by blood pressure monitoring and urine examination; and eyes by funduscopy, intraocular pressure measurement, and refraction." }, { "id": "InternalMed_Harrison_2316", "title": "InternalMed_Harrison", "score": 0.011235671362924811, "content": "FIguRE 39-9 Anterior ischemic optic neuropathy from temporal arteritis in a 67-year-old woman with acute disc swelling, splinter hemorrhages, visual loss, and an erythrocyte sedimentation rate of 70 mm/h. FIguRE 39-11 Optic atrophy is not a specific diagnosis but refers to the combination of optic disc pallor, arteriolar narrowing, and nerve fiber layer destruction produced by a host of eye diseases, especially optic neuropathies." }, { "id": "First_Aid_Step2_571", "title": "First_Aid_Step2", "score": 0.010922796235836373, "content": "Also called giant cell arteritis; due to subacute granulomatous infl ammation of the large vessels, including the aorta, external carotid (especially the temporal branch), and vertebral arteries. The most feared manifestation is blindness 2° to occlusion of the central retinal artery (a branch of the internal carotid artery). Risk factors include polymyalgia rheumatica (affects almost half of TA patients), age > 50, and female gender. Presents with new headache (unilateral or bilateral); scalp pain and temporal tenderness; and jaw claudication. Fever, permanent monocular blindness, weight loss, and myalgias/arthralgias (especially of the shoulders and hips) are also seen. ESR > 50 (usually > 100). Ophthalmologic evaluation. Temporal artery biopsy: Look for thrombosis; necrosis of the media; and lymphocytes, plasma cells, and giant cells." }, { "id": "pubmed23n0596_4516", "title": "Anterior ischemic optic neuropathy due to giant cell arteritis with normal inflammatory markers.", "score": 0.010312831389183458, "content": "In anterior ischemic optic neuropathy (AION), it is important not to miss the diagnosis of giant cell arteritis (GCA) because this requires immediate steroid treatment to prevent involvement of the second eye and possible blindness. A missed diagnosis also might lead to fatal systemic complications. Observational case report. A 79-year-old woman noticed decreased visual and visual field loss in the right eye. At presentation, right visual acuity was 10/20 (ETDRS chart 2000). There was a right relative afferent pupillary defect of 0.6 log units. Asked for symptoms of GCA she complained about temporal and occipital headache, jaw claudication combined with malaise, and myalgia of the upper limbs. Laboratory tests showed normal inflammatory markers. Repeated tests confirmed ESR and CRP to be within the normal range. GCA being suspected, ultrasound of the superficial temporal arteries and temporal artery biopsy were performed unilaterally on the right side. Histology showed a chronic inflammatory cell infiltrate consistent with active GCA. The patient was treated with high-dose corticosteroids (250 mg methylprednisolone, three times/day, initially) and symptoms rapidly resolved, but visual loss remained unchanged. The case presented here proves that GCA with typical related visual loss (AION) is possible even when both ESR and CRP are in the normal range. Therefore, in the presence of typical symptoms, the clinician must not rely solely on laboratory testing, but start steroid therapy immediately and order a temporal artery biopsy." }, { "id": "Neurology_Adams_11603", "title": "Neurology_Adams", "score": 0.009852395182468533, "content": "The major consideration in elderly and middle-aged patients with pain in proximal muscles of the limbs is polymyalgia rheumatica. This subject is mentioned briefly in other sections of this book in relation to back and extremity pain (see Chap. 10) and to temporal arteritis, to which it is closely connected (see Chap. 9). The muscular soreness may be diffuse or asymmetrical, particularly in the proximal arms and shoulders. Every movement is reported as stiff and painful. The periarticular tissues and their muscular attachments are affected primarily and may be tender, but this is difficult to interpret, because tenderness in these regions may be found in healthy individuals. The sedimentation rate is elevated in the majority of patients, and a 48-h trial of prednisone, by completely alleviating muscle pain, confirms the diagnosis. In the context of muscle pain, systemic symptoms such as weight loss, headache, and fatigue, as well as mild anemia, are particularly suggestive of" }, { "id": "pubmed23n0598_23177", "title": "[Polymyalgia rheumatica and giant cell arteritis: recent data and current situation].", "score": 0.00980392156862745, "content": "Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are two frequently linked inflammatory diseases of the elderly. The diagnosis of GCA is based on temporal artery biopsy, but results must not delay steroid therapy because of the potential sudden ocular and neurologic ischemic complications. PET-scan and MRI angiography can be helpful in difficult cases. The diagnosis of PMR is essentially clinical, centred on subacute onset of morning aching and stiffness in the shoulder and hip girdles. The treatment of both entities is still based on glucocorticoids (10-20 mg/j of prednisone for PMR, and 40-60 for GCA). Methotrexate, though, now appears a sometimes-useful corticosteroid-sparing agent, both in PMR and GCA. There also appears to be a role for low dose aspirin to decrease ischemic events in GCA." }, { "id": "pubmed23n1102_22675", "title": "Case 294: Catastrophic Antiphospholipid Syndrome.", "score": 0.009708737864077669, "content": "History A 50-year-old woman presented to the emergency department of our hospital with a 2-day history of lower limb pain associated with unusual asthenia and diffuse arthralgia over the past 3 weeks. She was a native of Guinea and had lived in France for most of her life, working as a personal care assistant. Her only medical history of note was an occurrence of fetal death at 12 weeks gestation when she was 35 years old. She had bilateral lower limb swelling, without changes in skin temperature or color. All proximal and distal arterial pulses were felt. General physical examination findings were otherwise unremarkable. Her laboratory tests showed a decreased hemoglobin concentration of 8.9 g/dL (normal range, 12-16 g/dL), a decreased platelet count of 45 × 10<sup9</sup/L (normal range, [150-400] × 10<sup9</sup/L), a C-reactive protein level of 158 mg/L (normal range, &lt;5 mg/L), and a d-dimer level of 2000 mg/L (normal range, &lt;500 mg/L]). Compression US of the lower limbs revealed bilateral calf vein thrombosis involving the fibular and posterior tibial veins. Curative anticoagulation using low-molecular-weight heparin (enoxaparin, subcutaneous injection of 100 units per kilogram of body weight twice a day) was started. The day after the start of anticoagulation therapy, the patient reported dyspnea and acute chest and abdominal pain. Her vital signs were assessed, and she had elevated blood pressure and increased heart rate and respiratory rate, but she remained afebrile. Her cardiac auscultation was unremarkable, besides tachycardia. Skin examination revealed small areas of necrosis on the fingertips of her right hand. Laboratory studies were repeated and showed an increase in serum creatinine level from a baseline value of 0.49 mg/dL to a new value of 1.01 mg/dL (normal range, 0.6-1.1 mg/dL), an apparition of low-grade proteinuria of 0.43 g per day (normal range, &lt;0.3 g/ day), and a high serum troponin level of 1066 ng/L (normal range, &lt;14 ng/L), whereas electrocardiography showed no ST segment modification and echocardiography revealed a moderately altered left ventricular ejection fraction (45%). There was no coronary occlusion seen at emergency coronarography. Contrast-enhanced CT of the chest, abdomen, and pelvis was performed (Figs 1, 2) together with cardiac MRI (Figs 3, 4)." } ] } } }

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{ "1": "Placental bed tumor.", "2": "Atypical endometrial hyperplasia.", "3": "Endometrial polyp.", "4": "Choriocarcinoma.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0810_22919", "title": "A case of placental polyp after normal vaginal delivery.", "score": 0.019230769230769232, "content": "Placental polyp is retained placental tissue within the endometrial cavity, which forms a nidus for inflammation and bleeding. There are very few reported cases of the clinical placental polyp. Here, we report a case of 34-year-old G4L3Ab1 woman with the chief complaint of intermittent vaginal bleeding since her last normal vaginal delivery 3 months ago. Serum human chorionic gonadotropin (hCG) titer was slightly elevated. A polypoid mass was detected within the endometrial cavity by imaging studies. History of the patient, mass lesion within the endometrial cavity and slightly elevated serum hCG titer raised the suspicion of trophoblastic neoplasms. Endometrial curettage yielded unsatisfactory specimen containing only fibrin deposition and was followed by total hysterectomy. The uterus showed slight global enlargement resulting from the presence of a polypoid mass within the endometrial cavity. The red-colored mass had a smooth outer surface and fragile consistency without any permeation into the myometrium. Pathology reported it as the placental polyp. Although very rare, placental polyp should be kept in mind as one of the reasons of abnormal uterine bleeding in parous women. Definite diagnosis is made by pathology examination. " }, { "id": "wiki20220301en047_30939", "title": "Endometrial polyp", "score": 0.013725490196078431, "content": "Cause No definitive cause of endometrial polyps is known, but they appear to be affected by hormone levels and grow in response to circulating estrogen. Risk factors include obesity, high blood pressure and a history of cervical polyps. Taking tamoxifen or hormone replacement therapy can also increase the risk of uterine polyps. The use of an intrauterine system containing levonorgestrel in women taking tamoxifen may reduce the incidence of polyps. Diagnosis Endometrial polyps can be detected by vaginal ultrasound (sonohysterography), hysteroscopy and dilation and curettage. Detection by ultrasonography can be difficult, particularly when there is endometrial hyperplasia (excessive thickening of the endometrium). Larger polyps may be missed by curettage." }, { "id": "pubmed23n0349_9450", "title": "Endometrial adenocarcinoma in pregnancy.", "score": 0.012876008804108583, "content": "The coexistence of endometrial adenocarcinoma and pregnancy is rare. Most cases are discovered in the first trimester due to irregular bleeding or spontaneous abortion. A 44-year-old woman, gravida 3, para 2, was admitted due to abnormal vaginal bleeding. After complete history, physical examination, and laboratory evaluation, she was diagnosed with spontaneous abortion and underwent a suction curettage. Pathological examination of the tissue included chorionic villi and an area of atypical hyperplasia and endometrial cancer. Recent association between first-trimester spontaneous abortions and subsequent endometrial cancer makes these rare cases of concurrent endometrial cancer and first trimester of pregnancy attractive in that they may disclose insights into the pathophysiology of hormone-dependent cancers." }, { "id": "wiki20220301en434_28905", "title": "Early pregnancy bleeding", "score": 0.012824139556812825, "content": "Early pregnancy bleeding refers to vaginal bleeding before 24 weeks of gestational age (during the first and second trimester). If the bleeding is significant, hemorrhagic shock may occur. Concern for shock is increased in those who have loss of consciousness, chest pain, shortness of breath, or shoulder pain. Common causes of early pregnancy bleeding include ectopic pregnancy, threatened miscarriage, and pregnancy loss. Most miscarriages occur before 12 weeks gestation age. Other causes include implantation bleeding, gestational trophoblastic disease, polyps, and cervical cancer. Tests to determine the underlying cause usually include a speculum examination, ultrasound, and hCG." }, { "id": "wiki20220301en168_15946", "title": "Endometrial biopsy", "score": 0.01258204034721592, "content": "Transvaginal ultrasonography is generally done before obtaining an endometrial biopsy as it may help in the gynecologic diagnosis, or even make the taking of a biopsy superfluous if the lining is thin. If the endometrial lining is less than 5 mm thick on sonography, it is highly unusual to encounter endometrial cancer. The test is usually done in women over age 35. A more thorough histologic evaluation can be obtained by a dilatation and curettage, which requires anesthesia. Contraindications The procedure is contraindicated in pregnancy. Therefore, women in the reproductive years may need a pregnancy test before a biopsy is taken to assure that the test is not done during a pregnancy. Other contraindications are pelvic inflammatory disease and coagulopathies." }, { "id": "pubmed23n0971_8170", "title": "Management of placental site trophoblastic tumor: Two case reports.", "score": 0.012307808831326213, "content": "Placental site trophoblastic tumor (PSTT) is a very rare malignant tumor, belonging to a family of pregnancy-related illnesses, called gestational trophoblastic diseases (GTD). Less than 300 cases of PSTT have been reported in literature, with an incidence of ≈ 1/50,000-100,000 pregnancies representing only 0.23% to 3.00% of all GTDs. Our report describes 2 additional cases of PSTT outlining their main diagnostic features and the subsequent management. The first case presented contemporary to a persistent hydatidiform mole in a 37-year-old woman, para 2042; whereas the second one originated 5 years after a miscarriage in 43-year-old woman, para 1031 with a previous diagnosis of breast cancer, and shared some features with placental site nodule (PSN), a benign condition. The first case had a difficult diagnosis because there was an amenorrhea of 11th week with high serum beta-human chorionic gonadotropin (beta-HCG) and an initial ultrasound image of vesicular mole. After the Dilatation and Curettage, histology confirmed the previous hypothesis. However, the final histology of PSTT was obtained after major surgery. On the contrary, the diagnosis of the second case was less challenging but surprising, thanks to a routine trans-vaginal ultrasound showing a suspicious endometrial thickness positive for PSTT at a subsequent hysteroscopic guided biopsy. The treatment consisted of hysterectomy and subsequent follow up. Lymphadenectomy or lymph node sampling were not performed due to the initial stage of the disease. In the first case, there were high values of serum beta-HCG that plummeted after the surgery, whereas in the second one they had been always negative. Hereafter, both went through a follow up with periodic serum oncological markers, imaging studies and clinical evaluation, which have showed negative result for 3 years and 15 months, respectively. A detailed gynecological ultrasound examination could be extremely helpful to understand the next diagnostic step of echo-guided D&amp;C or hysteroscopic biopsy and for a pre-operative staging assessment. On the contrary, determining the serum beta-HCG's curve is crucial just in case of an initial positive value to pursue clinical evaluation and follow-up. In case of good prognostic factors, the main therapy remains hysterectomy." }, { "id": "Gynecology_Novak_3123", "title": "Gynecology_Novak", "score": 0.01199706738352847, "content": "Threatened Abortion Threatened abortion is defined as vaginal bleeding before 20 weeks of gestation. It occurs in at least 20% of all pregnancies (15). The distinction from missed or inevitable abortion requires ultrasound documentation of an intrauterine embryo or fetus with cardiac activity. The bleeding is usually light and may be associated with mild lower abdominal or cramping pain. The differential diagnosis in these patients includes consideration of possible cervical polyps, vaginitis, cervical carcinoma, gestational trophoblastic disease, ectopic pregnancy, trauma, and foreign body. On physical examination, the abdomen usually is not tender, and the cervix is closed. Bleeding can be seen coming from the os, and usually there is no cervical motion or adnexal tenderness." }, { "id": "article-21104_15", "title": "Endometrial Hyperplasia -- History and Physical", "score": 0.010629811335806311, "content": "The majority of patients first present with symptoms of abnormal uterine bleeding. The change in the menstrual bleeding pattern alarms the woman to seek medical help early. This is the reason that most of the cases of endometrial cancer (more than 70%) are diagnosed early in stage I as opposed to other cancer where the symptoms are indolent for many years allowing cancer to spread to regional and distant sites.  The importance of a detailed history and physical examination is of utmost importance in the evaluation." }, { "id": "article-21105_7", "title": "Endometrial Polyp -- History and Physical", "score": 0.010628836684670614, "content": "Patients with endometrial polyps may be asymptomatic, or the most common symptom is abnormal uterine bleeding. [1] Other associated symptoms include abdominal pain, pelvic pain, or infertility. One in four reproductive-aged women with abnormal bleeding will have endometrial polyps within the cavity. For any patient with abnormal uterine bleeding, it is important to identify the underlying cause, severity, any associated symptoms, and comorbidities. Obtaining a comprehensive medical and surgical history is crucial to exclude other causes of abnormal uterine bleeding. Although there is not a diagnostic bleeding pattern for endometrial polyps, a detailed history of the patient’s bleeding pattern should be obtained. The most commonly reported patterns include menorrhagia and intermenstrual spotting." }, { "id": "Gynecology_Novak_2037", "title": "Gynecology_Novak", "score": 0.010483718288527073, "content": "Endometrial polyps are a cause of intermenstrual bleeding, heavy menstrual bleeding, irregular bleeding, and postmenopausal bleeding and are associated with the use of tamoxifen and with dysmenorrhea and infertility. As with leiomyomas, most endometrial polyps are asymptomatic. The incidence of endometrial polyps increases with age throughout the reproductive years (162). The diagnosis may be suspected on the basis of endometrial thickening on transvaginal pelvic ultrasound, and patterns of feeder blood vessels may aid in distinguishing endometrial polyps from intracavity fibroids and from endometrial malignancy (162,165,166). Visualization with hysteroscopy or sonohysterography or the microscopic assessment of tissue obtained by a biopsy done in the office or a curettage specimen is required for confirmation. Whether and when to recommend removal is not well established, particularly if a polyp is asymptomatic and is found incidentally. One study of randomly selected Danish women" }, { "id": "wiki20220301en047_30938", "title": "Endometrial polyp", "score": 0.010326340326340326, "content": "An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps. Signs and symptoms They often cause no symptoms. Where they occur, symptoms include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual bleeding (menorrhagia), and vaginal bleeding after menopause. Bleeding from the blood vessels of the polyp contributes to an increase of blood loss during menstruation and blood \"spotting\" between menstrual periods, or after menopause. If the polyp protrudes through the cervix into the vagina, pain (dysmenorrhea) may result." }, { "id": "pubmed23n1037_16989", "title": "Endometrial polyp filled with gestational tissues remained undiscovered in an infertile woman for years: a case report.", "score": 0.01003996003996004, "content": "Recurrent pregnancy loss (RPL) is a common disease, which presents as two, three or more failed pregnancies. It is attributed to many risk factors, yet half of the cases are idiopathic. In this report, we present a case of a 44-year-old woman with a complaint of secondary infertility for 10 years and a history of three spontaneous abortions. Blood tests and images showed no abnormalities, except for hysteroscopy which showed a polyp-like mass. Pathology revealed an endometrial stroma showing severe decidualization with a lot of gestational villi showing fibrosis and hyaline degeneration, features of old gestational product death, with no glands crowding or cellular atypia. In this case, the conception products were not preceded with a miscarriage and did not cause any symptoms indicating its existing. The asymptomatic endometrial polyp filled with fibrotic gestational villi without a prior miscarriage is an unprecedented case in the medical literature." }, { "id": "wiki20220301en161_3617", "title": "Endometrial hyperplasia", "score": 0.009900990099009901, "content": "Diagnosis Diagnosis of endometrial hyperplasia can be made by endometrial biopsy, which is done in the office setting or through curettage of the uterine cavity to obtain endometrial tissue for histopathologic analysis. A workup for endometrial disease may be prompted by abnormal uterine bleeding, or the presence of atypical glandular cells on a pap smear. Prognosis Endometrial hyperplasia can progress to cancer, particularly when there are atypical cells. If untreated with hysterectomy, endometrial hyperplasia progresses to adenocarcinoma within 20 years in: 28% of cases with atypia (95% CI, 8.6% to 42.5%), and about 5% of cases without atypia. The rates are more favorable in cases with simple rather than complex hyperplasia, but as mentioned above this terminology was phased out of the WHO classification in 2014." }, { "id": "pubmed23n0259_14818", "title": "MRI of placental polyps.", "score": 0.009900990099009901, "content": "Placental polyp is intrauterine polypoid placental tissue retained after delivery or abortion and may cause life-threatening bleeding. We studied the value of MRI in diagnosing placental polyps. Two women, 26 and 32 years old, with histologically proven placental polyp were included in this study. These patients were treated with local injections of methotrexate or transcatheter arterial embolization. The MR images before and after these treatments were studied retrospectively. High intensity pedunculated masses of 3-4 cm in size were observed in the expanded uterine cavity on T2-weighted and contrast-enhanced T1-weighted SE images. Bloody contents were observed around the masses. Placental polyps were more intensely enhanced than the myometrium by the contrast media, and the enhanced T1-weighted images indicated the retained placental tissues with an adherent part to the myometrium. Magnetic resonance imaging was also useful in following up the reduction in the size of the lesions and in the blood flow after the treatments. Magnetic resonance imaging may be useful in diagnosing and following up placental polyps." }, { "id": "article-128649_33", "title": "Sonography Female Pelvic Pathology Assessment, Protocols, and Interpretation -- Clinical Significance -- Abnormal Uterine Bleeding", "score": 0.009888828746304701, "content": "In the case of premenopausal females, endometrial hyperplasia, leiomyoma, adenomyosis, endometrial polyps, endocervical polyps, cervical carcinoma, endometrial carcinoma, some pregnancy-related complications like gestational trophoblastic diseases, and retained products of conception are common causes of AUB. TVS is the primary line of investigation for AUB, in which if the uterine cavity is found normal, further evaluation is usually not required, and medical treatment is commenced. [14] Power Doppler along with grey scale TVS has high specificity and negative predictive value for evaluation of AUB comparable to hysteroscopy. [15]" }, { "id": "pubmed23n0325_17956", "title": "[Cervical pregnancy: an obstetric emergency. A clinical case].", "score": 0.00980392156862745, "content": "Cervical implantation could develop in three different ways. The gestational sac can grow up to external os and interruption may simulate an abnormal menstruation. Theoretically the gestational sac could reach the uterine cavity, with a normal evolution of the pregnancy, even if the implantation of the placenta would be on internal uterine os. Lastly, the ectopic gestational sac developes all in cervical channel with an \"obstetrical catastrophe\". The incidence of cervical pregnancy presents great differences between authors, from 1:1,000 to 1:95,000 pregnancies; this is due to the variability of diagnostic criteria. A 36 year-old woman, para 1001, came to the emergency unit with painless vaginal bleeding. She was pregnant at 8 weeks of amenorrhoea, and previously undergone a cesarean section. The portio was swollen and bluewish, the external os was opened. The uterus was slightly increased, expecially in the peri-isthmic area; no adnexal mass. The urinary hCG was &lt; 15,000 I.U. An ultrasound examination showed the endometrium in decidual transformation, without identification of embrional or extraembrional structures. The diagnosis was retained miscarriage. During the cervical dilatation, an impressive and uncontrollable haemorrhage occurred. It was decided to perform a total hysterectomy via laparotomy. The macroscopic examination of the uterus showed the cavity empty and the sopravaginal cervical area enlarged, invaded by an ectopic trophoblastic proliferation. The majority of obstetricians will never see a cervical pregnancy; the minority who has to treat this pathology wishes to have never seen one." }, { "id": "Obstentrics_Williams_1052", "title": "Obstentrics_Williams", "score": 0.009756264548815556, "content": "• Sonographic Recognition of Pregnancy Transvaginal sonography has revolutionized early pregnancy imaging and is commonly used to accurately establish gestational age and conirm pregnancy location. A gestational sac-a small anechoic luid collection within the endometrial cavityis the irst sonographic evidence of pregnancy. It may be seen with transvaginal sonography by 4 to 5 weeks' gestation. A luid collection, however, can also be seen within the endometrial cavity with an ectopic pregnancy and is termed a pseudogestational sac or pseudosac (Fig. 19-4, p. 375). Thus, further evaluation may be warranted if this is the only sonographic inding, particularly in a woman with pain or bleeding. A normal" }, { "id": "wiki20220301en043_17457", "title": "Vaginal bleeding", "score": 0.009708737864077669, "content": "Postmenopausal bleeding In postmenopausal vaginal bleeding, the primary goal of any diagnostic evaluations is to exclude endometrial hyperplasia and malignancy. Transvaginal ultrasonography and endometrial sampling are common methods for an initial evaluation. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) recommend transvaginal ultrasonography as an appropriate first-line procedure to identify which patients are at higher risk of endometrial cancer. Endometrial sampling is indicated if having the following findings and/or symptoms: Endometrial thickness greater than 4 mm Diffuse or focal increased echogenicity (heterogeneity) Failure to visualize the endometrium Persistent or recurrent bleeding regardless of endometrial thickness Endometrial sampling can be obtained either by an endometrial biopsy using an endometrium sampling device such as a pipelle or by dilation and curettage (D&C) with or without a hysteroscopy. FIGO classification" }, { "id": "article-21105_10", "title": "Endometrial Polyp -- Evaluation", "score": 0.00957042957042957, "content": "Transvaginal ultrasound is the most common and efficient technique in imaging pelvic structures. Findings on ultrasound may appear nonspecific with diffuse or localized, echogenic endometrial thickening. [14] In patients with symptoms of postmenopausal bleeding, an endometrial thickness of less than 4 mm is associated with an atrophic endometrium. However, increased endometrial thickness greater than 4 mm is related to endometrial pathology, including polyps. [13] The location of the polyp, number, and diameter does not correlate with the reported symptoms. [15]" }, { "id": "wiki20220301en168_15945", "title": "Endometrial biopsy", "score": 0.009523809523809525, "content": "Medical uses There are a number of indications for obtaining an endometrial biopsy in a non-pregnant woman: Women with chronic anovulation such as the polycystic ovary syndrome are at increased risk for endometrial problems and an endometrial biopsy may be useful to assess their lining specifically to rule out endometrial hyperplasia or cancer. In women with abnormal vaginal bleeding the biopsy may indicate the presence of abnormal lining such as endometrial hyperplasia or cancer. In patients with suspected uterine cancer, the biopsy may discover the presence of cancer cells in the endometrium or cervix. In female infertility the assessment of the lining can determine, if properly timed, that the patient ovulated, however, the same information can be obtained by a blood test of the progesterone level." }, { "id": "pubmed23n1004_14538", "title": "Placental polyp: a rare cause of iron deficiency anemia.", "score": 0.009501241254795758, "content": "Placental polyps are defined as pedunculated or polypoid fragments of placenta or ovular membranes retained for an indefinite period of time into the uterus after abortion or child birth. An important cause of retention is placental accretism, an abnormal adherence of the placenta into the uterine wall. Chronic cases are rarely reported in the literature. In these cases, the placental retention in the immediate postpartum is not followed by heavy bleeding what makes the diagnosis challenging. We report a rare case of iron-deficiency anemia in a multiparous 29-year-old female patient two years after the last delivery. She sought medical care with clinical symptoms of anemia and recent menses alterations. There was no history of abortion. On gynecological examination, there was a twofold enlarged uterus, and the pelvic ultrasound revealed an image compatible with an endometrial polyp. She underwent open hysterectomy because of uncontrollable bleeding followed by hypotension after curettage. The histolopathologic examination revealed a partially hyalinized and necrotic placental polyp." }, { "id": "wiki20220301en003_102935", "title": "Breast cancer", "score": 0.009433962264150943, "content": "Hormonal therapy Some breast cancers require estrogen to continue growing. They can be identified by the presence of estrogen receptors (ER+) and progesterone receptors (PR+) on their surface (sometimes referred to together as hormone receptors). These ER+ cancers can be treated with drugs that either block the receptors, e.g. tamoxifen, or alternatively block the production of estrogen with an aromatase inhibitor, e.g. anastrozole or letrozole. The use of tamoxifen is recommended for 10 years. Tamoxifen increases the risk of postmenopausal bleeding, endometrial polyps, hyperplasia, and endometrial cancer; using tamoxifen with an IntraUterine System releasing levonorgestrel might increase vaginal bleeding after 1 to 2 years, but reduces somewhat endometrial polyps and hyperplasia, but not necessarily endometrial cancer. Letrozole is recommended for five years." }, { "id": "article-21105_9", "title": "Endometrial Polyp -- History and Physical", "score": 0.009433962264150943, "content": "A general physical exam should be performed along with a bimanual exam and sterile speculum exam during the clinic visits. The cervix and vaginal vault should be fully examined to rule out other structural causes for the patient’s symptoms. A pedunculated endometrial polyp may be visualized from the external os." }, { "id": "pubmed23n0895_22670", "title": "Epithelioid trophoblastic tumor: a case report and literature review.", "score": 0.009345794392523364, "content": "Epithelioid trophoblastic tumor (ETT) is a very rare case of malignant trophoblastic tumor, which can occur particularly during the fertile age of women with a long history of abortion and delivery. ETT originates from the intermediate trophoblastic cells of chorion laeve. The main features of this tumor include lack of vessels within the tumor, nuclear hyperchromasia and pleomorphism and a large zone of necrosis and hyalinization. The clinical features of ETT are specific to each case and often consist of vaginal bleeding or amenorrhea in the absence of other complains. The beta-human chorionic gonadotropin (β-hCG) serum level cannot be an absolute criterion useful in defining diagnosis. The right diagnosis can only be established by a histopathological examination of the tissue picked-up via intrauterine curettage. This paper describes the case of a 35-year-old woman who required gynecological investigation for amenorrhea. The diagnosis established by biopsic curettage and the clinical evolution have influenced the physician's decision to perform hysterectomy. The only method to differentiate between the microscopic diagnosis of ETT and choriocarcinoma was the immunohistochemical staining of trophoblastic cells for cytokeratin AE1÷AE3, p63, Ki67. Despite the diagnosis of malignity, this tumor does not usually require a recommendation for chemotherapy and does not seem to have a bad prognostic. However, these data do not rule out that clinical behavior is sometimes difficult to predict. We analyzed the clinical and histology criteria in line with the data published in literature." }, { "id": "wiki20220301en038_68225", "title": "Tamoxifen", "score": 0.009259259259259259, "content": "Dysmenorrhea Tamoxifen has been used effectively to improve blood flow, reduce uterine contractility and pain in dysmenorrhea patients. Breast cancer Tamoxifen is used for the treatment of both early and advanced estrogen receptor-positive (ER-positive or ER+) breast cancer in pre- and postmenopausal women. Tamoxifen increases the risk of postmenopausal bleeding, endometrial polyps, hyperplasia, and endometrial cancer; using tamoxifen with an intrauterine system releasing levonorgestrel might increase vaginal bleeding after 1 to 2 years, but reduces somewhat endometrial polyps and hyperplasia, but not necessarily endometrial cancer.[137] Additionally, it is the most common hormone treatment for male breast cancer. It is also approved by the FDA for the prevention of breast cancer in women at high risk of developing the disease. It has been further approved for the reduction of contralateral (in the opposite breast) cancer. The use of tamoxifen is recommended for 10 years." }, { "id": "article-22233_14", "title": "Gestational Trophoblastic Disease -- History and Physical", "score": 0.009259259259259259, "content": "On physical exam, in more than 50% of cases, there is a discrepancy between uterine size and dates. In a complete mole, the uterus is usually larger than the expected gestational date of the pregnancy, whereas, in partial moles, the uterus can be smaller than the suggested date. Adnexal enlargement due to theca lutein cysts may be present on pelvic examination, and fetal heart tones will be absent in patients with complete moles. [11]" }, { "id": "wiki20220301en043_17450", "title": "Vaginal bleeding", "score": 0.009174311926605505, "content": "Malignancy (pre-cancer and cancer): The Malignancy and Hyperplasia category of the PALM-COEIN system includes malignancies of the genital tract, including cancers of the vulva, the vagina, the cervix, and the uterus. Endometrial hyperplasia, included in this PALM category of abnormal bleeding, is more common in women who are obese or who have a history of chronic anovulation. When endometrial hyperplasia is associated with atypical cells, it can progress to cancer or occur concurrently with it. While endometrial hyperplasia and endometrial canceroccur most commonly among post-menopausal women, most patients with endometrial cancer have abnormal bleeding, and thus the diagnosis must be considered in women during the reproductive years." }, { "id": "pubmed23n0692_8350", "title": "A placental polyp arising from an exaggerated placental site.", "score": 0.009174311926605505, "content": "There are very few reported cases of the clinical course of exaggerated placental site, and a case of a placental polyp arising from an exaggerated placental site has not been reported previously. Here, we report a case of a 43-year-old woman whose chief complaint was of massive genital bleeding. She had undergone an operation for induced abortion in the first trimester 41 days previously. A placental polyp measuring 45 mm with an abundant blood flow could be detected by transvaginal color Doppler ultrasonography and enhanced magnetic resonance imaging. We performed a transabdominal simple total hysterectomy. At the anterior wall of the uterus, a protruding lesion into the uterine cavity was observed and a placental polyp was attached to the protruding lesion. The histological specimen of the protruding lesion, which was considered to be the implantation site, showed intermediate trophoblastic cells infiltrated into the myometrium. An exaggerated placental site was diagnosed, which might lead to a placental polyp." }, { "id": "wiki20220301en024_103792", "title": "Heavy menstrual bleeding", "score": 0.00909090909090909, "content": "Surgery Dilation and curettage (D&C) is not recommended for cases of simple heavy menstrual bleeding, having a reserved role if a spontaneous abortion is incomplete Endometrial ablation is not recommended for women with active or recent genital or pelvic infection, known or suspected endometrial hyperplasia or malignancy. Uterine artery embolization (UAE): The rate of serious complications is comparable to that of myomectomy or hysterectomy; however, UAE presents an increased risk of minor complications and requiring surgery within two to five years. Hysteroscopic myomectomy to remove fibroids over 3 cm in diameter Hysterectomy" }, { "id": "pubmed23n0290_15911", "title": "Pyomyoma after uterine instrumentation. A case report.", "score": 0.00909090909090909, "content": "Since 1945, only 10 cases of pyomyoma have been described in the literature. Four were related to pregnancy but none to elective abortion or uterine instrumentation. A 32-year-old woman was admitted to the hospital with a history of lower abdominal pain, nausea, vomiting and low grade fever with a past medical history significant for uterine leiomyomata and a second-trimester elective abortion 10 weeks prior to admission. Pelvic sonography demonstrated an enlarged uterus with a mass consisting of cystic and solid components. Uterine curettage revealed blood clots and scanty endometrial tissue. After no improvement following antibiotic therapy and nondiagnostic uterine curettage, an exploratory laparotomy was performed. It revealed peritonitis with multiple pyomyomas draining purulent material. Although rarely reported, pyomyoma should be considered in the setting of a recent history of uterine instrumentation, signs of infection and a uterine myoma." }, { "id": "Gynecology_Novak_6584", "title": "Gynecology_Novak", "score": 0.009031816626753335, "content": "Symptoms Endometrial carcinoma most often occurs in women in the sixth and seventh decades of life, at an average age of 60 years; 75% of cases occur in women older than 50 years of age. About 90% of women with endometrial carcinoma have vaginal bleeding or discharge as their only presenting symptom. Most women recognize the importance of this symptom and seek medical consultation within 3 months. Some women experience pelvic pressure or discomfort indicative of uterine enlargement or extrauterine disease spread. Bleeding may not have occurred because of cervical stenosis, especially in older patients, and may be associated with hematometra or pyometra, causing a purulent vaginal discharge. This finding is often associated with a poor prognosis (69). Less than 5% of women diagnosed with endometrial cancer are asymptomatic. In the absence of symptoms, endometrial cancer usually is detected as the result of investigation of abnormal Pap test results, discovery of cancer in a uterus" }, { "id": "wiki20220301en240_16100", "title": "Uterine clear-cell carcinoma", "score": 0.009009009009009009, "content": "Uterine clear-cell carcinoma (CC) is a rare form of endometrial cancer with distinct morphological features on pathology; it is aggressive and has high recurrence rate. Like uterine papillary serous carcinoma CC does not develop from endometrial hyperplasia and is not hormone sensitive, rather it arises from an atrophic endometrium. Such lesions belong to the type II endometrial cancers. Diagnosis The lesion is found in patients who present typically with abnormal or postmenopausal bleeding or discharge. Such bleeding is followed by further evaluation leading to a tissue diagnosis, usually done by a dilatation and curettage (D&C). A work-up to follow would look for metastasis using imaging technology including sonography and MRI. The median age at diagnosis in a large study was 66 years. Histologically the lesion may coexist with classical endometrial cancer. Treatment Prognosis of the CC is affected by age, stage, and histology as well as treatment" } ] } } }

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{ "1": "Ulcerative colitis is only associated with an increased risk of colorectal cancer in smokers.", "2": "In her case, given that she is in long-term remission, the screening advised to the general population is considered appropriate.", "3": "In cases such as yours, it is considered appropriate to undergo periodic colonoscopies with multiple biopsies staggered along the entire colon.", "4": "In cases such as yours, screening with periodic fecal occult blood tests is considered appropriate, but with a higher frequency than that used in screening the general population.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0249_20615", "title": "[Effectiveness and costs of screening colonoscopy].", "score": 0.018137254901960782, "content": "Screening colonoscopy is always indicated when rectosigmoidoscopy reveals an adenoma, since this lesion roughly doubles the patient's risk of contracting colonic cancer. Follow-up should be performed at intervals of about three years after endoscopic removal of all colorectal polyps. Repeated screening examinations are recommended for the following genetic diseases that carry an increased risk of colorectal carcinoma: familial adenomatous polyposis (FAP) and its genetic variant, hereditary non-polyposis colorectal cancer syndrome (HNPCC) and hamartomatous polyposis syndromes (e.g. Peutz-Jeghers). Also in the case of familial \"sporadic\" carcinoma of the colon, regular screening colonoscopies for first degree relatives are recommended. Although the use of regular screening colonoscopies in patients with a long history of extensive ulcerative colitis is controversial, the recent results support such examinations. While the benefit of screening colonoscopy or sigmoidoscopy of the general population from the age of 50 onward must be affirmed, it should be weighed against the costs involved in such an undertaking. At the present time, the American Cancer Society recommends that from the age of 50 onward, the annual fecal test for occult blood should be supplemented by sigmoidoscopy performed every three to five years." }, { "id": "pubmed23n0320_15595", "title": "[Prevention and early detection of colorectal carcinoma by endoscopic examinations].", "score": 0.017905459175553078, "content": "People at average risk for colorectal cancer (asymptomatic, age &gt; or = 45 years, no risk factors) are offered fecal occult blood testing each year and sigmoidoscopy every five years. In case of a positive fecal occult blood test, examination of the whole colon by colonoscopy should be performed. Colorectal cancer risk is significantly lowered by endoscopic polypectomy in patients with adenomas. After complete removal of adenomatous polyps a control colonoscopy is advised three years after the initial examination. People with a positive family history of colorectal cancer or adenomatous polyps, of inherited polyposis syndromes, of a hereditary non-polyposis colorectal cancer, after polypectomy, after resection of colorectal cancer and with inflammatory bowel disease possess an increased risk for the development of colorectal cancer. Surveillance recommendations in these cases are detailed. In order to increase the cost-benefit ratio in surveillance after curative resection of colorectal cancer the frequency of the surveillance procedures can be reduced. In patients with total or extensive ulcerative colitis colonoscopy with multiple biopsies should be performed after a disease duration of eight to ten years, further recommendations depend on the histopathologic results." }, { "id": "pubmed23n0345_19750", "title": "Screening for colorectal cancer and other GI cancers.", "score": 0.017869964100518547, "content": "Most of the major advances in the screening for gastrointestinal cancers this year were in the area of colorectal cancer screening. Currently, screening is recommended for the prevention of colorectal cancer in average and high-risk populations. For average risk populations, large randomized trials support the use of screening fecal occult blood testing, and case-control studies support the use of screening sigmoidoscopy. This year, several investigators have addressed issues related to the probability of identifying advanced lesions in the proximal colon following a positive screening flexible sigmoidoscopy. Similarly, two studies identified that villous histology in an index polyp was associated with an increased risk of recurrent colonic polyps. Additionally, two large trials provided new insight about the prevalence of mutations in the MLH1 or MSH2 mismatch-repair genes among patients with colorectal cancer. Lastly, a case-control study from Sweden provided the best evidence to date that surveillance colonoscopies for patients with long-standing ulcerative colitis may reduce cancer-related mortality. Although further work is needed, these studies have served to advance our knowledge of colorectal cancer screening substantially." }, { "id": "pubmed23n0321_21116", "title": "[Evaluation of various screening and surveillance methods in colorectal carcinoma].", "score": 0.017588325652841783, "content": "Colorectal cancer is a common disease which is almost wholly preventable by early removal of adenomatous polyps. Screening should be offered to all persons without risk factors from the age of 50. Selection of the appropriate screening programme should take into account personal preference, local expertise and insurance coverage. Endoscopic screening and surveillance investigations should be strongly encouraged in all persons wit risk factors such as (1) previous treatment of colorectal adenomatous polyps or cancers, (2) ulcerative colitis, (3) patients with hereditary colorectal cancer syndromes and (4) first degree relatives of patients with colorectal cancer. The following four strategies are available for candidates &gt; 50 years without risk factors: (1) faecal occult blood testing (annually), (2) flexible sigmoidoscopy (every 5 years), (3) a combination of both (1 + 2) strategies and (4) coloscopy (every 10 years). Coloscopy should be performed after a positive test result in strategy programs 1-3. Results from prospective randomized trials are available only for faecal occult blood testing, showing an approximately 15% reduction of mortality in the screening group. The potential for reduction of colorectal cancer mortality has been estimated at 30-70% and 60-90% for flexible sigmoidoscopy and coloscopy respectively. However, no results from prospective randomized trials are presently available. Cost-effectiveness analysis has not shown relevant differences between the four different screening strategies." }, { "id": "pubmed23n0366_1181", "title": "Screening for early colorectal cancer.", "score": 0.01665774685576666, "content": "There is now solid evidence from randomized trials suggesting that it is possible to reduce mortality from colorectal cancer by 15% to 25% by screening with fecal occult blood tests (FOBTs). The major benefit results from detection of early cancer in average-risk persons above 50 years of age who have a positive test followed by colonoscopy. However, it has to be demonstrated that the same acceptability can be reached in the general population as that obtained in trials. Many countries must establish a screening organization in a limited area to learn how satisfactory quality assurance can be obtained before a country-wide screening program is set up. So far, screening has not resulted in a reduced incidence of colorectal cancer in true population studies despite removal of two to three times as many possible precursors compared to controls. Cost-effectiveness will probably be as good as that known from screening for breast cancer with mammography and better than that for cervical cancer. However, the calculations are based on the unhydrated Hemoccult-II test in randomized trials. More sensitive methods would be attractive, but none has yet been evaluated properly in average-risk persons. There is no general agreement how to screen high risk groups such as patients with previous colorectal adenomas and carcinomas, one or two first-degree relatives with colorectal neoplasia, or ulcerative colitis. Families with familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer, however, are presented with firm guidelines. Genetic screening has been helpful in no more than these two small groups in the colorectal carcinoma universe." }, { "id": "pubmed23n0653_1559", "title": "[Screening and early diagnosis of colorectal cancer].", "score": 0.016488651535380507, "content": "Screening and early diagnosis of colorectal cancer Colorectal cancer, major health problem in industrialised countries, fulfils the conditions required for mass screening. Data from controlled studies indicate that it is possible to reduce colorectal cancer mortality at a population level using faecal occult blood testing. Population-based studies rely on biennial testing in subjects between 50 and 74 and total colonoscopy in case of positive test. The colorectal cancer mortality decrease in this case varies between 15 and 28% in the general population, 33 and 39% among participants to screening. In order to decrease significantly colorectal cancer mortality compliance has to be over 50%. On the basis of available data, the European Commission recommended to organise colorectal cancer screening in the EU. Epidemiological studies allow us to define subjects at high risk for colorectal cancer. Colonoscopy screening is recommended in first degree relatives of patients with colorectal cancer diagnosed before 60 or 65 or with two affected first-degree relatives, in subjects with an extended ulcerative colitis or Crohn disease or with a personal history of large bowel cancer or large adenoma." }, { "id": "pubmed23n0386_10787", "title": "[Individual screening for colorectal cancer: which strategy for which patient?].", "score": 0.01628707627118644, "content": "Currently, more than 4,000 newly colorectal cancer are diagnosed each year in Belgium. The individual average-risk for developing colorectal cancer is about 5%. 90% of colorectal cancer occurred after the age of 50, and in 70% of the cases in patients without particular risk factors (average-risk population). Personal and/or familial history of colorectal adenoma, colorectal cancer, inflammatory bowel disease localised to the colon, familial polyposis syndrome or Hereditary Non Polyposis Colorectal Cancer (HNPCC) increase the risk of colorectal cancer. An individual appropriate screening of high-risk patients and average-risk asymptomatic patients older than 50, together with endoscopic resection of adenoma decrease the incidence and the mortality of colorectal cancer. Usual screening methods are fecal occult blood testing which is not proven to be efficient alone for individual screening (but still recommended for general population's screening), sigmoidoscopy (which has to be completed by a colonoscopy, if lesions founded), and colonoscopy. Virtual colonoscopy and genetic testing need further evaluation. Currently, colonoscopy seems to be the goldstandard method providing complete examination of the whole colon and being the most cost-effective method. Screening strategy should be decided on an individual basis considering the patient's benefit with respect to the informed consent." }, { "id": "pubmed23n0255_13990", "title": "[Screening coloscopy: when and how?].", "score": 0.016025641025641024, "content": "Screening colonoscopy aims at a reduction of colorectal cancer mortality. The efficacy is undetermined due to lack of controlled trials. However, screening colonoscopy is generally accepted in asymptomatic patient with a considerably increased risk for carcinoma in particular in case of familial adenomatous polyposis coli, hereditary nonpolypous colorectal cancer syndrome and adenomas detected by sigmoidoscopy. A positive cost/benefit ratio can also be expected in first-degree relatives of patients with familial sporadic colorectal carcinoma. To date the efficacy of colonoscopic surveillance of patients with extensive ulcerative colitis remains undetermined in spite of an increased risk of cancer in the long-term course. In people with an average risk for colorectal cancer the probability of a development of carcinoma might be reduced by about 45% by once-only sigmoidoscopy performed at the age of 50-60 years. Further reduction can theoretically be expected from routine colonoscopy. However, before a general recommendation can be given, the efficacy must be proved in a randomised controlled trial." }, { "id": "wiki20220301en010_160838", "title": "Colorectal cancer", "score": 0.01449342685929298, "content": "Pathogenic Escherichia coli may increase the risk of colorectal cancer by producing the genotoxic metabolite, colibactin. Inflammatory bowel disease People with inflammatory bowel disease (ulcerative colitis and Crohn's disease) are at increased risk of colon cancer. The risk increases the longer a person has the disease, and the worse the severity of inflammation. In these high risk groups, both prevention with aspirin and regular colonoscopies are recommended. Endoscopic surveillance in this high-risk population may reduce the development of colorectal cancer through early diagnosis and may also reduce the chances of dying from colon cancer. People with inflammatory bowel disease account for less than 2% of colon cancer cases yearly. In those with Crohn's disease, 2% get colorectal cancer after 10 years, 8% after 20 years, and 18% after 30 years. In people who have ulcerative colitis, approximately 16% develop either a cancer precursor or cancer of the colon over 30 years." }, { "id": "wiki20220301en014_100819", "title": "Colonoscopy", "score": 0.014328808446455506, "content": "Fecal occult blood is a quick test which can be done to test for microscopic traces of blood in the stool. A positive test is almost always an indication to do a colonoscopy. In most cases the positive result is just due to hemorrhoids; however, it can also be due to diverticulosis, inflammatory bowel disease (Crohn's disease, ulcerative colitis), colon cancer, or polyps. Colonic polypectomy has become a routine part of colonoscopy, allowing quick and simple removal of polyps during the procedure, without invasive surgery. Colon cancer screening Colonoscopy is one of the colorectal cancer screening tests available to people in the US who are 45 years of age and older. The other screening tests include flexible sigmoidoscopy, double-contrast barium enema, computed tomographic (CT) colongraphy (virtual colonoscopy), guaiac-based fecal occult blood test (gFOBT), fecal immunochemical test (FIT), and multitarget stool DNA screening test (Cologuard)." }, { "id": "pubmed23n0394_8170", "title": "High prevalence of undetected ulcerative colitis: data from the Nottingham fecal occult blood screening trial.", "score": 0.014300254452926209, "content": "Inflammatory bowel disease (IBD) is usually diagnosed as a result of symptoms but occasionally is found during investigation for other conditions. An earlier report from Nottingham had found a high prevalence of previously undetected \"asymptomatic\" IBD detected as a result of colorectal cancer screening, and the aim of this study was to reassess the prevalence, symptoms, and outcome in these patients. We investigated subjects found to be fecal occult blood (FOB) positive in a randomized trial of FOB screening for colorectal cancer. All FOB-positive subjects were investigated by colonoscopy or flexible sigmoidoscopy and barium enema. Subjects with IBD were referred back to their general practitioner for any further investigation and treatment. Seventy-five thousand two hundred fifty-three subjects (aged 45-74) were sent FOB tests and 44,838 (60%) completed a series of tests on one or more occasions. Of 133,000 test series, 1.5% were positive. During investigation 53 cases of previously undetected IBD (52 of ulcerative colitis) were found; 52% (27/52) had proctosigmoiditis only, whereas 25% (13/52) had pancolitis. Only 17% (9/52) were completely asymptomatic, with a half or more reporting some rectal bleeding (54%) or diarrhea (50%). The overall prevalence of undetected ulcerative colitis was 69/10(5) (95% CI = 50-88/10(5)) in people offered screening and 116/10(5) (95% CI = 85-147/10(5)) in people accepting screening and was higher in men. Of 32 subjects followed up 2-12 yr after diagnosis, 91% (29) continued to have few or no symptoms, with only 12 currently receiving any treatment for their colitis. In comparison with detected disease, undetected ulcerative colitis is relatively common but does usually cause some symptoms. It generally appears to follow a benign course, but a significant proportion have extensive colitis and may therefore be at an increased risk of colorectal cancer." }, { "id": "wiki20220301en003_40041", "title": "Ulcerative colitis", "score": 0.014286955011290603, "content": "Colorectal cancer The risk of colorectal cancer is significantly increased in people with ulcerative colitis after ten years if involvement is beyond the splenic flexure. People with backwash ileitis might have an increased risk for colorectal carcinoma. Those people with only proctitis usually have no increased risk. It is recommended that people have screening colonoscopies with random biopsies to look for dysplasia after eight years of disease activity, at one to two year intervals. Mortality People with ulcerative colitis are at similar or perhaps slightly increased overall risk of death compared with the background population. However, the distribution of causes-of-death differs from the general population. Specific risk factors may predict worse outcomes and a higher risk of mortality in people with ulcerative colitis, including: C. difficile infection and cytomegalovirus infection (due to reactivation)." }, { "id": "wiki20220301en010_160867", "title": "Colorectal cancer", "score": 0.013839926883405143, "content": "Several screening methods are recommended including stool-based tests every 2 years, sigmoidoscopy every 10 years with fecal immunochemical testing every two years, and colonoscopy every 10 years. It is unclear which of these two methods is better. Colonoscopy may find more cancers in the first part of the colon, but is associated with greater cost and more complications. For people with average risk who have had a high-quality colonoscopy with normal results, the American Gastroenterological Association does not recommend any type of screening in the 10 years following the colonoscopy. For people over 75 or those with a life expectancy of less than 10 years, screening is not recommended. It takes about 10 years after screening for one out of a 1000 people to benefit. The USPSTF list seven potential strategies for screening, with the most important thing being that at least one of these strategies is appropriately used." }, { "id": "pubmed23n0316_8443", "title": "Cancer and inflammatory bowel disease: bias, epidemiology, surveillance, and treatment.", "score": 0.013657407407407408, "content": "Individuals with chronic ulcerative colitis are at increased risk of developing colorectal carcinoma, particularly if there is long-standing disease or extensive colitis. It is generally accepted that the risk of colorectal cancer does not begin until 8 to 10 years after the time of diagnosis of ulcerative colitis. Thereafter it increases by approximately 0.5% to 1.0% per year. In patients with Crohn's disease, the risk of malignancy is smaller and less well defined. The most significant predictor of the risk of malignancy in patients with inflammatory bowel disease is the presence of dysplasia in colonic biopsies. There is considerable controversy in the literature regarding the efficacy of colonoscopic surveillance programs and the role of prophylactic surgery to prevent colorectal cancer. Surveillance certainly fails to detect carcinoma in some patients who are having regular colonoscopy. Concerns have also been raised as to the cost-benefit of colonoscopic surveillance in patients with colitis. Randomized controlled trials of surveillance programs are highly unlikely in view of the low prevalence of IBD in the population, the long period of observation required, and the probability of contamination of surveillance programs by colonoscopy for assessment of disease activity. Despite the lack of clear guidelines, surveillance colonoscopy and biopsy continues to be widely practiced. Research is proceeding to identify genetic and biochemical markers that may prove clinically useful for predicting cancer risk. At present, however, surveillance programs are likely to continue according to institutional practice. It is important for those participating in such programs to be aware of the limitations of colonoscopy and biopsy as a means of reducing the risk of cancer in inflammatory bowel disease." }, { "id": "pubmed23n0311_6874", "title": "Evaluation of surveillance programmes for colorectal cancer in ulcerative colitis patients by case-control studies: methodological considerations.", "score": 0.013474025974025973, "content": "The evaluation of the efficacy of colonoscopy screening in patients with ulcerative colitis for colorectal cancer is associated with methodological difficulties. Case-control studies can, however, be used to determine the efficacy of such a programme and the outline of the methodology in such a programme is presented. The randomised controlled trial provides perspective for case-control studies of screening efficacy. Cases are selected from persons who have ulcerative colitis with manifestations of colorectal cancer: for example, those who have died of colorectal cancer or have symptomatic metastases. Controls are selected from persons who have ulcerative colitis, who had been alive when the case died of colorectal cancer, and who had been subject to the risk of dying from, but had not had, colorectal cancer diagnosed when the case was diagnosed with colorectal cancer. The relevant screening history for cases begins with the case's diagnosis of ulcerative colitis and ends with the cases diagnosis of colorectal cancer; that for controls should be comparable to that for cases to avoid bias. Cases and controls are compared with respect to their \"exposure\" to colonoscopy during their screening histories: the occurrence of any screening, which took place during the period of time that an occult tumour (or an identifiable lesion) may plausibly have been present. The proposed methodology can evaluate the efficacy of a screening programme rapidly, practically, and ethically." }, { "id": "wiki20220301en010_160864", "title": "Colorectal cancer", "score": 0.013386531434111417, "content": "The three main screening tests are colonoscopy, fecal occult blood testing, and flexible sigmoidoscopy. Of the three, only sigmoidoscopy cannot screen the right side of the colon where 42% of cancers are found. Flexible sigmoidoscopy, however, has the best evidence for decreasing the risk of death from any cause. Fecal occult blood testing (FOBT) of the stool is typically recommended every two years and can be either guaiac-based or immunochemical. If abnormal FOBT results are found, participants are typically referred for a follow-up colonoscopy examination. When done once every 1–2 years, FOBT screening reduces colorectal cancer deaths by 16% and among those participating in screening, colorectal cancer deaths can be reduced up to 23%, although it has not been proven to reduce all-cause mortality. Immunochemical tests are accurate and do not require dietary or medication changes before testing." }, { "id": "pubmed23n0934_5997", "title": "Colorectal Cancer Screening and Surveillance in Individuals at Increased Risk.", "score": 0.01332819722650231, "content": "Individuals at increased risk of developing colorectal cancer include those with a personal or family history of advanced adenomas or colorectal cancer, a personal history of inflammatory bowel disease, or genetic polyposis syndromes. In general, these persons should undergo more frequent or earlier testing than individuals at average risk. Individuals who have a first-degree relative with colorectal cancer or advanced adenoma diagnosed before 60 years of age or two first-degree relatives diagnosed at any age should be advised to start screening colonoscopy at 40 years of age or 10 years younger than the earliest diagnosis in their family, whichever comes first. In individuals with ulcerative colitis or Crohn disease with colonic involvement, colonoscopy should begin eight to 10 years after the onset of symptoms and be repeated every one to three years. Individuals who have a first-degree relative with hereditary nonpolyposis colorectal cancer should begin colonoscopy at 25 years of age and repeat colonoscopy every one to two years. In persons with a family history of adenomatous polyposis syndromes, screening should begin at 10 years of age or in a person's mid-20s, depending on the syndrome; repeat colonoscopy is typically required every one to two years. Screening colonoscopy should begin at eight years of age in individuals with Peutz-Jeghers syndrome. If results are normal, colonoscopy can be repeated at 18 years of age and then every three years. Persons with sessile serrated adenomatous polyposis should begin annual colonoscopy as soon as the diagnosis is established." }, { "id": "wiki20220301en024_32220", "title": "Fecal occult blood", "score": 0.012935729847494554, "content": "Colorectal cancer screening An estimated 1–5% of large tested populations have a positive fecal occult blood test. Of those, about 2–10% have cancer, while 20–30% have adenomas. Screening methods for colon cancer depend on detecting either precancerous changes such as certain kinds of polyps or on finding early and thus more treatable cancer. The extent to which screening procedures reduce the risk of gastrointestinal cancer or deaths depends on the rate of precancerous and cancerous disease in that population. gFOBT (guaiac fecal occult blood test) and flexible sigmoidoscopy screening have each shown benefit. Other colon cancer screening tools such as iFOBT (immunochemical fecal occult blood test) or colonoscopy are also included in guidelines." }, { "id": "pubmed23n0373_19568", "title": "Asymptomatic inflammatory bowel disease with special reference to ulcerative colitis in apparently healthy persons.", "score": 0.012923203963666391, "content": "We examined cases of asymptomatic inflammatory bowel diseases, particularly asymptomatic ulcerative colitis, which were found in apparently healthy Japanese persons who underwent general health screening. Patients with positive immunological fecal occult blood test (IFOBT) among approximately 236,000 persons participating in the health screening program at the Aichi Prefectural Center for Health Care for the past 9 yr underwent total colonoscopy. In patients with ulcerative colitis, we investigated the sex and age distributions, extent of lesion, endoscopic activity, incidence rate, and clinical course. In all, 35 cases of inflammatory bowel disease were detected, and 274 cases of colorectal cancer (not discussed here) were detected in the same population. The 35 cases of inflammatory bowel disease consisted of 19 cases of ulcerative colitis (12 of asymptomatic and minimally symptomatic ulcerative colitis, and seven of symptomatic or with past history of ulcerative colitis); five of intestinal tuberculosis; two of Crohn's disease; two of amebic colitis; and seven of endoscopic colitis. The 12 patients with asymptomatic and minimally symptomatic ulcerative colitis consisted of 11 men and one woman aged 36-63 yr (mean 46.2 yr). We classified these cases into three grades of severity according to endoscopic findings: four cases were mild, eight moderate, and none severe. Of these 12 cases, three were found endoscopically because of positive IFOBT, although barium enema was normal. Anatomic types of colitis cases included three of total colitis, three left-sided colitis, two proctitis, and four right-sided or segmental colitis. In one case, the disease extended proximally during the course of observation. We found 35 cases of inflammatory bowel disease because of positive IFOBT performed as part of a general health screening. Of these, 19 cases were ulcerative colitis. These included many asymptomatic and minimally symptomatic cases, which could be very important in helping to elucidate the natural history of ulcerative colitis; thus, long-term follow up is necessary." }, { "id": "wiki20220301en186_40074", "title": "Colorectal polyp", "score": 0.012879514221796102, "content": "Inflammatory polyp These are polyps that are associated with inflammatory conditions such as ulcerative colitis and Crohn's disease. Prevention Diet and lifestyle are believed to play a large role in whether colorectal polyps form. Studies show there to be a protective link between consumption of cooked green vegetables, brown rice, legumes, and dried fruit and decreased incidence of colorectal polyps. Diagnosis Colorectal polyps can be detected using a faecal occult blood test, flexible sigmoidoscopy, colonoscopy, virtual colonoscopy, digital rectal examination, barium enema or a pill camera. Malignant potential is associated with degree of dysplasia Type of polyp (e.g. villous adenoma): Tubular Adenoma: 5% risk of cancer Tubulovillous adenoma: 20% risk of cancer Villous adenoma: 40% risk of cancer Size of polyp: <1 cm =<1% risk of cancer 1–2 cm=10% risk of cancer >2 cm=50% risk of cancer Normally an adenoma that is greater than 0.5 cm is treated. Gallery" }, { "id": "wiki20220301en010_160863", "title": "Colorectal cancer", "score": 0.01241327905510005, "content": "There is tentative evidence for calcium supplementation, but it is not sufficient to make a recommendation. Vitamin D intake and blood levels are associated with a lower risk of colon cancer. Screening As more than 80% of colorectal cancers arise from adenomatous polyps, screening for this cancer is effective for both early detection and for prevention. Diagnosis of cases of colorectal cancer through screening tends to occur 2–3 years before diagnosis of cases with symptoms. Any polyps that are detected can be removed, usually by colonoscopy or sigmoidoscopy, and thus prevent them from turning into cancer. Screening has the potential to reduce colorectal cancer deaths by 60%." }, { "id": "wiki20220301en003_40035", "title": "Ulcerative colitis", "score": 0.012233185662505034, "content": "The risk of cancer arising from a ileal pouch anal anastomosis is low. However, annual surveillance with pouchoscopy may be considered in individuals with risk factors for dysplasia, such as a history of dysplasia or colorectal cancer, a history of PSC, refractory pouchitis, and severely inflamed atrophic pouch mucosa. Bacterial recolonization In a number of randomized clinical trials, probiotics have demonstrated the potential to be helpful in the treatment of ulcerative colitis. Specific types of probiotics such as Escherichia coli Nissle have been shown to induce remission in some people for up to a year. A probiotic called VSL#3 may be effective in inducing remission in active ulcerative colitis, and may be as effective as 5-ASAs in preventing relapse of quiescent UC." }, { "id": "pubmed23n0540_24457", "title": "Strategies for detecting colon cancer and/or dysplasia in patients with inflammatory bowel disease.", "score": 0.01207590569292697, "content": "Patients with longstanding ulcerative colitis and colonic Crohn's disease have an increased risk of colorectal cancer compared with the general population. This review assesses the evidence that endoscopic surveillance may prolong life by allowing earlier detection of colon cancer or its pre-cursor lesion, dysplasia, in patients with inflammatory bowel disease. To assess the effectiveness of cancer surveillance programs in reducing the death rate from colorectal cancer in patients with ulcerative colitis and colonic Crohn's disease. The following strategies were used to identify relevant studies:1. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from 1966 to August 2005. The medical subject headings \"Ulcerative Colitis\", \"Crohn Disease\" or \"Inflammatory Bowel Disease\" and \"Surveillance\" or \"Cancer\" were used to perform key-word searches of the databases.2. Hand searching of reference lists from papers. Potentially relevant articles were reviewed independently and unblinded by three authors to determine if they fulfilled the selection criteria. Each article was rated as being eligible, ineligible, or without sufficient information to determine eligibility. Any disagreement between reviewers was resolved by consensus. Any trials published in abstract form were only considered if it was possible to obtain full details of the protocol and results from the authors. Eligible articles were reviewed in duplicate and the results of the primary research trials were abstracted onto specially designed data extraction forms. The proportion of patients dying from bowel cancer or other causes in the control and surveillance groups of each study was derived from life tables, survival curves or where possible, by calculating life tables from the data provided. Data from the original research articles were converted into 2x2 tables (survival versus death x surveillance versus control) for each of the individual studies for comparable follow-up intervals. The presence of significant heterogeneity among studies was tested by the chi-square test. Because this is a relatively insensitive test, a P value of less than 0.1 was considered statistically significant. Provided statistical heterogeneity was not present, the fixed effects model was used for the pooling of data. The 2x2 tables were combined into a summary test statistic using the pooled relative risk (RR) and 95% confidence intervals as described by Cochrane and Mantel and Haenszel. Karlen 1998a in a nested case-control study comprising 142 patients from a study population of 4664 UC patients, found that 2/40 patients dying of colorectal cancer had undergone surveillance colonoscopy on at least one occasion compared with 18/102 controls (RR 0.28, 95% CI 0.07 to 1.17). One of 40 patients who died from colorectal cancer had undergone surveillance colonoscopies on two or more occasions compared with 12/102 controls (RR 0.22, 95% CI 0.03 to 1.74) in contrast to a more modest effect observed for patients who had only one colonoscopy (RR 0.43, 95% CI 0.05 to 3.76). Choi 1993 found that carcinoma was detected at a significantly earlier stage in the surveilled patients; 15/19 had Duke's A or B carcinoma in the surveilled group compared to 9/22 in the non-surveilled group (P = 0.039). The 5-year survival rate was 77.2% for cancers occurring in the surveillance group and 36.3% for the no-surveillance group (P = 0.026). Four of 19 patients in the surveillance group died from colorectal cancer compared to 11 of 22 patients in the non-surveillance group (RR 0.42, 95% CI 0.16 to 1.11). Lashner 1990 found that four of 91 patients in a surveillance group died from colorectal cancer compared to 2 of 95 patients in a non-surveilled group (RR 2.09, 95% CI 0.39 to 11.12). Colectomy was less common in the surveillance group, 33 compared to 51 (P &lt; 0.05) and was performed four years later (after 10 years of disease) in the surveillance group. For the pooled data analysis 8/110 patients in the surveillance group died from colorectal cancer compared to 13/117 patients in the non-surveillance group (RR 0.81, 95% CI 0.17 to 3.83). There is no clear evidence that surveillance colonoscopy prolongs survival in patients with extensive colitis. There is evidence that cancers tend to be detected at an earlier stage in patients who are undergoing surveillance, and these patients have a correspondingly better prognosis, but lead-time bias could contribute substantially to this apparent benefit. There is indirect evidence that surveillance is likely to be effective at reducing the risk of death from IBD-associated colorectal cancer and indirect evidence that it may be acceptably cost-effective." }, { "id": "pubmed23n0073_16114", "title": "Knowledge of colorectal cancer and use of screening tests among higher-risk persons.", "score": 0.011696306429548563, "content": "Colorectal cancer is a major cause of cancer mortality in the United States, and certain risk factors have been identified. Random samples (N = 893) of residents between 40 and 74 years old in two areas (ie, Long Island, New York and the state of Connecticut) with relatively high rates of colorectal cancer were surveyed by telephone in 1988. Prevalence of certain risk factors for colorectal cancer was estimated, including family history of colorectal cancer and personal history of \"ulcerative colitis\" and \"polyps.\" Knowledge of dietary risk factors for cancer (ie, cured meat and low fiber intake), daily use of fiber cereals, and frequency of medical checkups did not differ significantly among those in higher-risk groups v other respondents. In multivariate analyses a family history of colorectal cancer was a significant independent predictor of knowledge of the frequency of colorectal cancer relative to stomach cancer, and of ever having heard of a fecal occult blood test, but not of having had an occult blood test or procto(sigmoido)scopy. Persons reporting a history of \"ulcerative colitis\" had a lower assessment of the curability of colorectal cancer, and the frequency of recent procto(sigmoido)scopic examination was not increased. Findings are discussed with reference to potential educational programs in the primary and secondary prevention of colorectal cancer." }, { "id": "wiki20220301en456_4715", "title": "Cancer prevention", "score": 0.011614781368821292, "content": "Colorectal cancer Colorectal cancer is most often screened with the fecal occult blood test (FOBT). Variants of this test include guaiac-based FOBT (gFOBT), the fecal immunochemical test (FIT), and stool DNA (sDNA) testing. Further testing includes flexible sigmoidoscopy (FS), total colonoscopy (TC), or computed tomography (CT) scans if a TC is non-ideal. A recommended age at which to begin screening is 50 years. However, this is highly dependent on medical history and exposure to CRC risk factors. Effective screening has been shown to reduce CRC incidence by 33% and CRC morality by 43%." }, { "id": "wiki20220301en268_18829", "title": "Cancer screening", "score": 0.011595238095238094, "content": "The US Preventive Services Task Force recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. For people over 75 or those with a life expectancy of less than 10 years screening is not recommended. A new enzyme method for colorectal cancer screening is the M2-PK Test, which is able to detect bleeding and non-bleeding colorectal cancers and polyps. In 2008, Kaiser Permanente Colorado implemented a program that used automated calls and sends fecal immunochemical test kits to patients who are overdue for colorectal cancer screenings. The program has increased the proportion of all eligible members screened by 25 percent. Multi-Target Stool DNA Test (Cologuard) and Plasma SEPT9 DNA Methylation Test (Epi proColon) have been FDA-approved." }, { "id": "wiki20220301en022_19849", "title": "Rectal examination", "score": 0.011406454783748361, "content": "Although the DRE is commonly used as a way to obtain a stool sample for a FOBT (fecal occult blood test) in an office based setting, this is an insufficient way of screening for colorectal cancer and is not recommended. A single office-based FOBT (fecal occult blood test) performed following a digital rectal examination (DRE) is not an adequate screen due to low sensitivity for advanced tumor and colorectal cancer. Screening for colon cancer this way does not meet HEDIS, Medicare or American Cancer Society standards. The FOBT has never been validated for any purpose other than as a take home colon cancer screening test. A paper published in the Journal of General Internal Medicine states, \"While FOBT done appropriately (taken home and used according to the instructions) is an important screening option, in-office FOBT may be worse than no screening at all because it misses 95% of cases of advanced tumor, giving many patients a false sense of reassurance.\"" }, { "id": "wiki20220301en024_32223", "title": "Fecal occult blood", "score": 0.010316040548598688, "content": "The American College of Gastroenterology has recommended the abandoning of gFOBT testing as a colorectal cancer screening tool, in favor of the fecal immunochemical test. Though the FIT test is preferred, even the guaiac FOB testing of average risk populations may have been sufficient to reduce the mortality associated with colon cancer by about 25%. With this lower efficacy, it was not always cost-effective to screen a large population with gFOBT. If colon cancer is suspected in an individual (such as in someone with an unexplained anemia), fecal occult blood tests may not be clinically helpful. If a doctor suspects colon cancer, more rigorous investigation is necessary, whether or not the test is positive." }, { "id": "InternalMed_Harrison_7000", "title": "InternalMed_Harrison", "score": 0.010121606230941622, "content": "540 SCREENING The rationale for colorectal cancer screening programs is that the removal of adenomatous polyps will prevent colorectal cancer, and that earlier detection of localized, superficial cancers in asymptomatic individuals will increase the surgical cure rate. Such screening programs are particularly important for individuals with a family history of the disease in first-degree relatives. The relative risk for developing colorectal cancer increases to 1.75 in such individuals and may be even higher if the relative was afflicted before age 60. The prior use of proctosigmoidoscopy as a screening tool was based on the observation that 60% of early lesions are located in the rectosigmoid. For unexplained reasons, however, the proportion of large-bowel cancers arising in the rectum has been decreasing during the past several decades, with a corresponding increase in the proportion of cancers in the more proximal descending colon. As such, the potential for proctosigmoidoscopy to" }, { "id": "wiki20220301en010_160831", "title": "Colorectal cancer", "score": 0.01006296827674159, "content": "Colorectal cancer (CRC), also known as bowel cancer, colon cancer, or rectal cancer, is the development of cancer from the colon or rectum (parts of the large intestine). Signs and symptoms may include blood in the stool, a change in bowel movements, weight loss, and fatigue. Most colorectal cancers are due to old age and lifestyle factors, with only a small number of cases due to underlying genetic disorders. Risk factors include diet, obesity, smoking, and lack of physical activity. Dietary factors that increase the risk include red meat, processed meat, and alcohol. Another risk factor is inflammatory bowel disease, which includes Crohn's disease and ulcerative colitis. Some of the inherited genetic disorders that can cause colorectal cancer include familial adenomatous polyposis and hereditary non-polyposis colon cancer; however, these represent less than 5% of cases. It typically starts as a benign tumor, often in the form of a polyp, which over time becomes cancerous." }, { "id": "wiki20220301en563_18525", "title": "Wendy Atkin", "score": 0.00988235294117647, "content": "From 1994 she worked with Jane Wardle on a trial of flexible sigmoidoscopy that included endoscopic examination of the colon, reporting that 40% of colorectal cancers could be prevented by this intervention. She compared the screening to a Faecal occult blood (FOB) test. In 2008 she moved to St Mary's Hospital, London, where she established the Cancer Screening and Prevention Research Group. The group researches bowel cancer and, ultimately, aims to reduce the number of people who die from the disease. Their 2010 paper outlining the results of the UK Flexible Sigmoidoscopy Screening Trial was the most frequently cited paper in The Lancet that year. The landmark study was a randomised controlled trial of almost 400,000 adults across 14 areas in the UK. If there were any polyps, people were referred for a colonoscopy. The strategy was rolled out by the UK National Screening Committee in 2011 and was expected to achieved complete population coverage in 2016. This was achieved with a £60" }, { "id": "wiki20220301en014_100823", "title": "Colonoscopy", "score": 0.009692105510184925, "content": "Medicare coverage In the United States, Medicare insurance covers the following colorectal-cancer screening tests: Colonoscopy: average risk — every 10 years beginning at age 50, high risk — every 2 years with no age restriction Flexible sigmoidoscopy — every 4 years beginning at age 50 Double-contrast barium enema: average risk — every 4 years beginning at age 50, high risk — every 2 years (CT) colongraphy: not covered by Medicare gFOBT: average risk — every year beginning at age 50 FIT: average risk — every year beginning at age 50 Cologuard: average risk — every 3 years beginning at age 50 Risks About 1 in 200 people who undergo a colonoscopy experience a serious complication. Perforation of the colon occurs in about 1 in 2000 procedures, bleeding in 2.6 per 1000, and death in 3 per 100,000, with an overall risk of serious complications of 0.35%." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 589, 772 ] ], "word_ranges": [ [ 93, 124 ] ], "text": "As the Gram stain indicates that the bacteria are grouped in chains, as this is typical of enterococcus, we suggest the need to cover this group of bacteria with antibiotic treatment." }, "4": { "exist": true, "char_ranges": [ [ 773, 966 ] ], "word_ranges": [ [ 124, 151 ] ], "text": "Staphylococci are typically seen on Gram stain as Gram-positive cocci forming clusters and yeasts, although with the same staining, have a different typical morphology than Gram-positive cocci." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Continue with cefuroxime while awaiting the definitive result, since the patient has undergone multiple treatments and we should not make a mistake in his current treatment.", "2": "Change to ertapenem, considering the possibility of multiresistant microorganisms.", "3": "Switch to a broad-spectrum antimicrobial treatment that covers Enterococcus spp.", "4": "Switch to broad-spectrum antimicrobial therapy containing imipenem, considering the possibility of Staphylococcus aureus, since our hospital has a high incidence of methicillin-resistant S. aureus (MRSA).", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0689_22648", "title": "[Spectrum of microbial colonisation and resistance of a surgical ICU in a systematic comparison of the 10-year time period 1996-2005 using routine microbiological testing].", "score": 0.016597796143250687, "content": "Knowledge on potentially pathogenic microbes including characteristics of their antibiotic resistance in septic patients as well as on the ward- and department-specific microbial spectrum can be considered essential for an efficient initiation of an adequate antimicrobial treatment, which turns out to become pivotal for patient outcome. Permanent changes in microbial patterns and antibiotic resistance can only be identified by a continuous investigation of various microbiological specimens. Based on the retrospective evaluation of prospectively collected data on microbiological investigations of the surgical ICU in 1996, 2002, 2004 and 2005, the short- and long-term changes by trend of microbial spectrum and antibiotic resistance following reorganisation and restructuring of the University Hospital from the more traditional pavillon-based system to a multidisciplinary complex building in 2003 were investigated. Twice a week, routine microbiological testing of blood and urinary cultures as well as swabs from wound areas and endotracheal swabs were initiated in septic patients (suspect, manifestation) or in case of their clinical impairment. The microbial spectrum was sub-divided according to Gram-staining (Gram-positive/ -negative), various species and fungi with descriptive absolute and relative data values. -Various groups and time periods were statistically compared using χ² test as appropriate. P values &lt; 0.05 were considered statistically significant. In total (n (Total) = 4 899), microbiological testing resulted in the detection of microbes in 699 and 833 blood and urinary cultures (14.3 % and 17 %, respectively) as well as 1 232 wound swabs (25.1 %) together with 2 135 samples from the endotracheal sites (43.6 %). During the short- (2002 vs. 2004) and long-term analyses (1996 vs. 2005), the proportion of Gram-positive microbes increased. Al-though Gram-positive bacteria can be considered the most frequent microbes for bacteriemia, there was a shift onto urinary and wound infections as well as pneumonias through the observation period. Despite the decreasing incidence of Enterococcus and the consistent proportion of MRSA, the increase of resistant Enterococcus strains (0 % vs. 43.2 %; P &lt; 0.05) is critical. However, in the Gram-negative microbial spectrum there was an increase of the bacteraemia rate but a fall of the detection rate in wound and endotracheal swabs. In parallel, an increase of the detection rate of E. coli in blood (6.5 % vs. 45.5 %; P &lt; 0.05) and endotracheal swabs (9.2 % vs. 16.2 %; P &lt; 0.05) is associated with an increase of multiresistant Enterobacteriaceae strains (0 % vs. 30.7 %; P &lt; 0.05). The portion of multiresistant strains of Pseudomonas with 31 % stayed the same through the 10-year time period. While Candida-based colonisation showed a decreased incidence (25 % vs. 15 %; P &lt; 0.05) during the whole investigation period, there was a relative rise in the frequency of candidemia. ICU relocation from the pavillon-based system to a new complex clinic building was not associated with any significant alteration of the microbial spectrum on the surgical ICU. Increasing incidences of resistant Enterococcus and Gram-negative problematic microbes may indicate a general spread of multi-resistant microbes under the steady selecting pressure of a not always adequately initiated antibiotic / antimicrobial therapeutic regimen and underline the required but specific and selected microbiological screening." }, { "id": "pubmed23n0107_4336", "title": "Use of microbiology reports by physicians in prescribing antimicrobial agents.", "score": 0.01596159615961596, "content": "The purpose of this study was to examine the use of microbiologic reports by physicians in prescribing antimicrobial agents in a community hospital setting. Patients were identified by daily review of all blood, urine, and sputum cultures that grew pathogen(s) during a 7-week period. Appropriateness of antibiotic therapy was based on results of antibiotic susceptibility testing of isolated pathogen(s). The physician response to culture results was evaluated on changes made in antimicrobial therapy. Seventy-one patients with 73 cultures (infections) were identified; 70% of the infections were community acquired. The frequency of each infection during the study period was: bacteremia (N = 12), pneumonia (N = 18), definite urinary tract infection (N = 26) and probable urinary tract infection (N = 17). Initial treatment was appropriate in 49 of 73 (67%) episodes; the organism(s) isolated were resistant to initial therapy in 24 of 85 (33%) episodes. After culture results were available, 34 of 73 (47%) regimens were changed, but only 50% of the changes were considered appropriate. Overall, there was no significant difference in the proportion of all treatment regimens considered appropriate before (67%) and after (56%) culture results were known. We conclude that results of cultures and antibiotic susceptibility data had little influence on appropriateness of antibiotic prescribing in the hospital setting." }, { "id": "pubmed23n0755_12180", "title": "Considerations in the choice and administration of agents for empiric antimicrobial therapy.", "score": 0.014391447368421052, "content": "Infections remain a common problem for critically ill patients and often are responsible for early mortality, especially following inadequate antibiotic therapy. The choice of empiric therapy has become increasingly difficult because of the increasing incidence of antibiotic-resistant bacteria. A retrospective review of the literature over the last two decades was conducted to assess the importance of adequate empiric antibiotic therapy and which factors should be considered in choosing the \"best\" empiric therapy. Current diagnostic and treatment guidelines suggest that all seriously ill patients in whom infection is suspected undergo a comprehensive work-up (e.g., blood, urine, sputum cultures) to confirm the etiology prior to initiation of antibiotic therapy. Whereas the selection of the most appropriate antimicrobial agent(s) must consider the likely etiologies and anticipated resistance patterns, the lack of rapid and sensitive culture techniques has made this process difficult. Recent literature has concluded that empiric therapy for many nosocomial infections must be directed at multi-drug-resistant, gram-negative bacilli and methicillin-resistant Staphylococcus aureus (MRSA), especially in patients with a history of prolonged hospitalization and recent antibiotic use. There is also growing evidence that inadequate or prolonged antibiotic administration may encourage the emergence of resistant bacteria. New antibiotics directed against multi-drug-resistant, gram-positive pathogens include daptomycin, linezolid, and tigecycline. Initial empiric broad-spectrum antibiotic therapy is necessary for treatment of patients with serious infections following a thorough evaluation of possible sources, including culture and susceptibility testing. Clinicians may need to tailor antibiotic therapy based on the patient's initial response after the organism is confirmed, and susceptibility test results are available." }, { "id": "pubmed23n0867_6581", "title": "A CLEAR CASE OF MRSA SEPSIS, OF AN UNEXPECTED ORIGIN.", "score": 0.01407147726166131, "content": "A 56-year-old man with a history of uncontrolled type 2 diabetes mellitus, benign prostatic hypertrophy and history of recent knee and elbow abscess presented to the emergency department with nausea, vomiting, and fevers. Two days prior, he presented to the ER and was diagnosed with acute presumed prostatitis and urinary retention. He was discharged on ciprofloxacin and an indwelling Foley catheter with urology follow-up. After being unable to tolerate oral medications, he presented again to the emergency department, at which time, he was febrile and tachycardic. Physical exam was benign except for a boggy and tender prostate and bilateral CVA tenderness. Labs demonstrated leukocytosis, elevated HbA1C, and pyuria on urinalysis. Urine cultures collected at the patient's earlier emergency department visit demonstrated no growth. Computed tomography indicated an enlarged prostate with patchy areas of low density. He was admitted with sepsis secondary to prostatitis. Blood cultures on day one showed gram-positive cocci , methicillin resistant staph aureus (MRSA isolate) and persistent bacteremia for three days despite therapy with vancomycin. After adequate dosing of vancomycin, sterilization of the blood was achieved, yet urine culture demonstrated growth of MRSA. Transthoracic rchocardiogram (TTE) showed no signs of endocarditis with good visualization of valves. He was successfully treated with 14 days of vancomycin. " }, { "id": "pubmed23n1080_7304", "title": "[The distribution of microorganisms and antibiotic resistance profile in pulmonary critical care unit patients: A single-centre study].", "score": 0.013789324688370394, "content": "The patients in the intensive care unit have a higher risk of infections because of the poor general condition of these patients and the frequent application of invasive procedures with longer hospitalization length. Also, this group of patients tend to have resistant infections due to empirically widespread and uncontrolled use of broad-spectrum antibiotics. Hence, data are needed to determine appropriate empirical antibiotic therapy in intensive care patients. In this study, it was aimed to assess the distribution of microorganisms and antibiotic resistance profile from the samples taken from the patients in the intensive care unit. Patients who were hospitalized in Ankara University Faculty of Medicine Chest Diseases Intensive Care Unit for more than 24 hours between December 2016 and December 2017 were included in our study. Demographic characteristics, comorbid diseases, clinical findings, results of sputum, tracheal aspirate, blood, urine, gaita and pus culture samples and antibiotic susceptibility test results were recorded prospectively. A total of 287 patients, 150 males and 137 females, were included in the study. The mean age of all patients was 69.96 ± 14.4 years. Two hundred twenty-three positive cultures were detected in 1053 samples taken from 287 patients. Gram-negative bacilli constituted 55.1% of the 223 positive cultures. The most common microorganisms were Acinetobacter (16.6%), Staphylococcus (14.8%) and Klebsiella (10.8%). Colistin resistance was found to be 8.3% in the Acinetobacter strains and resistance rates of 97-100% were observed to other antibiotic groups. Thirty-three staphylococcus were isolated, 17 were S. aureus and 16 were coagulase-negative Staphylococcus. While 29.4% of S. aureus were resistant to methicillin (MRSA), vancomycin resistance was not detected. Meanwhile, the MRSA ratio was 62.5%, there was no vancomycin resistance among the coagulase-negative Staphylococcus. Klebsiella was the third most common microorganism and beta-lactamase producing Klebsiella strain was 62.5%. Gentamycin was found to be the most susceptible antibiotic in Klebsiella strains with a resistance rate of 20.8%. Pseudomonas aeruginosa constituted 9.4% of the cultures. While the resistance to colistin was not detected, resistance to piperacillin/tazobactam 42.8%, tobramycin, imipenem and meropenem 50% and ceftazidime 61.9%. The duration of hospitalization in patients with Acinetobacter isolated (23 [10-34] days vs 12.5 [5-24] days, p= 0.011) and the mortality rate (62.5% vs 37.5%, p= 0.008) were significantly higher than those who were not Acinetobacter isolated. In conclusion, gram-negative bacilli constitute the majority of the patients in intensive care unit. Acinetobacter, the most common microorganism, has a high resistance rate and has been associated with prolonged hospitalization and mortality." }, { "id": "wiki20220301en070_12487", "title": "Antibiotic sensitivity testing", "score": 0.013063775318123635, "content": "Specimens for antibiotic sensitivity testing are ideally collected before treatment is started. A sample may be taken from the site of a suspected infection; such as a blood culture sample when bacteria are suspected to be present in the bloodstream (bacteraemia), a sputum sample in the case of a pneumonia, or a urine sample in the case of a urinary tract infection. Sometimes multiple samples may be taken if the source of an infection is not clear. These samples are transferred to the microbiology laboratory where they are added to culture media, in or on which the bacteria grow until they are present in sufficient quantities for identification and sensitivity testing to be carried out." }, { "id": "wiki20220301en002_144462", "title": "Pneumonia", "score": 0.012396909907088423, "content": "In people managed in the community, determining the causative agent is not cost-effective and typically does not alter management. For people who do not respond to treatment, sputum culture should be considered, and culture for Mycobacterium tuberculosis should be carried out in persons with a chronic productive cough. Microbiological evaluation is also indicated in severe pneumonia, alcoholism, asplenia, immunosuppression, HIV infection, and those being empirically treated for MRSA of pseudomonas. Although positive blood culture and pleural fluid culture definitively establish the diagnosis of the type of micro-organism involved, a positive sputum culture has to be interpreted with care for the possibility of colonisation of respiratory tract. Testing for other specific organisms may be recommended during outbreaks, for public health reasons. In those hospitalized for severe disease, both sputum and blood cultures are recommended, as well as testing the urine for antigens to" }, { "id": "wiki20220301en041_56061", "title": "Pyelonephritis", "score": 0.010485603781693168, "content": "Diagnosis Laboratory examination Analysis of the urine may show signs of urinary tract infection. Specifically, the presence of nitrite and white blood cells on a urine test strip in patients with typical symptoms are sufficient for the diagnosis of pyelonephritis, and are an indication for empirical treatment. Blood tests such as a complete blood count may show neutrophilia. Microbiological culture of the urine, with or without blood cultures and antibiotic sensitivity testing are useful for establishing a formal diagnosis, and are considered mandatory." }, { "id": "pubmed23n0977_11634", "title": "Clinical, etiological and antimicrobial susceptibility profile of pediatric urinary tract infections in a tertiary care hospital of Nepal.", "score": 0.009900990099009901, "content": "Urinary tract infection (UTI) is one of most common pediatric infections. The study was designed to assess the clinical profile, common bacterial microorganisms causing UTI and their antimicrobial susceptibility patterns at B. P. Koirala Institute of Health Sciences (BPKIHS) hospital. This is a prospective cross-sectional study conducted at Department of Microbiology and Infectious Diseases for 6 months (January to June 2018). A total of 1962 non-repetitive urine specimens (midstream, nappy pad, catheter aspirated) of pediatric patients (0-14 years age) suspected of UTI were obtained in the Microbiology laboratory. Clinical data was obtained from requisition form and hospital software. Culture and bacterial identification was done by using standard microbiological guidelines. Antimicrobial susceptibility testing was done by Kirby-Bauer disc diffusion method following clinical and laboratory standards institute (CLSI) guidelines. Resistance to methicillin and vancomycin were confirmed by calculating minimum inhibitory concentration using broth dilution method. Among 1962 samples, 314 (16%) were positive for bacterial infection. Fever, irritability and poor feeding was the most common symptoms in neonates while older children presented with fever and urinary symptoms. E. coli was reported the most common etiological agent (53%), followed by Enterococcus faecalis (22%), Klebsiella pneumoniae (7%) and Staphylococcus aureus (7%). Multidrug resistant (MDR) isolates accounted for 32% of isolates, while 5% were extensively drug resistant (XDR). Fourty percentage of gram-negative bacilli were ESBL producer, 38% of S. aureus were methicillin resistant Staphylococcus aureus (MRSA) and 5% E. faecalis were vacomycin resistant enterococci (VRE). E coli was highly resistant to Ampicillin (87%), Ceftriaxone (62%) and Ofloxacin (62%). Amikacin (11% resistance) and Nitrofurantoin (5% resistance) are the most effective drugs for gram-negative bacilli (GNB) while vancomycin and linezolid are functional against gram-positive cocci. High-level antimicrobial resistance was observed in pediatric UTI with alarming incidence superbugs like MDR, XDR, ESBL and MRSA. Regular surveillance should be carried out to determine the local prevalence of organisms and antimicrobial susceptibilities in order to guide the proper management of children." }, { "id": "InternalMed_Harrison_6528", "title": "InternalMed_Harrison", "score": 0.009826288824847903, "content": "The initial antibacterial regimen should be refined on the basis of culture results (Fig. 104-2). Blood cultures are the most relevant basis for selection of therapy; surface cultures of skin and mucous membranes may be misleading. In the case of gram-positive bacteremia or another gram-positive infection, it is important that the antibiotic be optimal for the organism isolated. Once treatment with broad-spectrum antibiotics has begun, it is not desirable to discontinue all antibiotics because of the risk of failing to treat a potentially fatal bacterial infection; the addition of more and more antibacterial agents to the regimen is not appropriate unless there 491 is a clinical or microbiologic reason to do so. Planned progressive therapy (the serial, empirical addition of one drug after another without culture data) is not efficacious in most settings and may have unfortunate consequences. Simply adding another antibiotic for fear that a gram-negative infection is present is a" }, { "id": "pubmed23n1156_4856", "title": "A 30-Day-Old Infant with Necrotizing Fasciitis of the Perineal Region Involving the Scrotum Due to Methicillin-Resistant Staphylococcus aureus (MRSA) and Extended-Spectrum β-Lactamase (ESBL)-Producing Klebsiella pneumoniae: A Case Report.", "score": 0.00980392156862745, "content": "BACKGROUND Fournier's gangrene is an idiopathic form of necrotizing fasciitis involving the genital and perineal regions; it is associated with high complication and mortality rates. Rarely, perineal infection may be caused by hospital-acquired antimicrobial-resistant bacteria. This report is of a 30-day-old infant with methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum ß-lactamase (ESBL)-producing Klebsiella pneumoniae necrotizing fasciitis involving the perineal region. CASE REPORT A 30-day-old male infant presented to the Emergency Department with rapidly progressive white discoloration of scrotal skin since 3 days prior to admission, progressing from 2-3 white spots to covering two-thirds of the scrotal skin. Pain upon urination was noted, with normal appetite and bowel movements. He had a history of diaper rash 6 days earlier accompanied by fever, and the rash was treated with topical antifungal and corticosteroid ointment. He was born at term by caesarean delivery, with birth weight 2900 g. Laboratory examinations revealed leukocyte count 23 000/µL and CRP 26.8 mg/dL. Hemoglobin was 10.6 g/dL, serum sodium was 134 mEq/L, blood glucose was 80 mg/dL, serum urea was 15 mg/dl, and creatinine was 0.27 mg/dL. Chest and abdominal X-rays were normal. He received broad-spectrum antibiotics and underwent surgical debridement, and necrotic tissue was obtained for biopsy and culture. Histology examination showed non-specific granulation tissue consistent with Fournier gangrene. Soft- tissue culture isolated MRSA and ESBL-K. Antibiotics were changed according to the sensitivity report. Blood and urine cultures were negative. CONCLUSIONS Immediate surgery and antibiotics are essential in treating Fournier gangrene to avoid life-threatening complications. Initial symptoms are non-specific. Diagnosis remains primarily clinical, confirmed by intraoperative macroscopic findings." }, { "id": "pubmed23n1025_8901", "title": "Yield and clinical impact of blood cultures in patients admitted to an internal medicine ward.", "score": 0.00980392156862745, "content": "The purpose of this prospective observational study was to evaluate the yield and clinical impact of blood cultures in a 78-bed Internal Medicine ward of a medium-sized Italian acute care hospital. During a two-month study period, 154 (mean age: 75.2 ++ 12.2 years; 94 males) out of 620 (24.8%) hospitalized patients underwent 174 blood cultures and were enrolled in the study. The rate of true-positive cultures was 11.5% (20/174) and the rate of false-positive (contaminants) was 5.7% (10/174). A total of 23 microorganisms (5 multidrug resistant strains), most frequently Escherichia coli (n = 10), Klebsiella pneumoniae (n = 3) and Staphylococcus aureus (n = 3), were isolated. The positivity rate was significantly higher in patients with urinary tract infection (31%) and abdomen infection (26.1%) than in patients with pneumonia (4.9%; p&lt;0.01). Although the positivity rate in patients exposed to antibiotics was lower than in those not exposed, the difference was not statistically significant. Therapy changes due to blood culture positivity were observed in 7.1% of the patients overall. In-hospital death was observed in nine of the 136 patients with negative blood cultures (6.6%) and in none of the 18 patients with positive blood cultures. These results indicate that the yield and clinical impact of blood cultures is quite low in patients admitted to an Internal Medicine ward and suggest the need to improve the adequacy of the indications to perform the test." }, { "id": "pubmed23n0012_7593", "title": "[Blood culture results from 1967 to 1975 and drug sensitivity of bacteria isolated by blood culture in the last three years (1974-1976) (author's transl)].", "score": 0.009708737864077669, "content": "The blood culture results of patients of S. M. Nuova Hospital of Florence (Italy) have been examined in a period of nine years (1967-1976). We can attest from this results that in the last years of this period we have had an increase of the number of Enterobacteriaceae from blood culture. In the meanwhile we have had a decrease of positive results that is not due to an increase of the number of blood culture; in fact it has been doubled, but this decrease is mostly due to a larger number of examinated patients that to an increase of blood culture for each patient. Introduction in the routine of a diphasic culture system (Castañeda) commercially available has allowed contaminants' decrease. Antibiotic resistance of most important bacteria isolated in the last three years (1974-1976) were carry out." }, { "id": "pubmed23n0760_3829", "title": "Bacterial spectrum and antimicrobial susceptibility pattern of bloodstream infections in children with febrile neutropenia: experience of single center in southeast of Turkey.", "score": 0.009615384615384616, "content": "Empirical antimicrobial therapy is usually started in febrile neutropenic patients without having culture results. The aim of this study was to help determine the policies of empirical antibiotic usage in febrile neutropenic children by detecting the antimicrobial susceptibility profile in this group of patients. In this study 811 blood cultures taken from neutropenic children hospitalized at the Department of Oncology of Gaziantep Children Hospital November 2007 and February 2010 were retrospectively evaluated. Blood cultures were routinely collected in aerobic and anaerobic media and incubated using the BACTEC system. Identification and antimicrobial susceptibility testing of the isolates to antimicrobial agents was performed using the Vitek2(®) system according to the recommendations of the Clinical and Laboratory Standards Institute. Of 811 isolates analyzed, 128 (56.4%) were gram positive cocci, 43 (18.9%) were gram negative bacilli and fungi accounted for 56 (24.7%). The main isolated Gram-positive bacteria from blood were coagulase-negative staphylococcus (56.7%), followed by methicillin-resistant Staphylococcus aureus (14.1%). S. aureus and Streptococcus spp. were all susceptible to linezolid, vancomycin and teicoplanin. S aureus was still susceptible to few other antimicrobial agents such as tetracycline (82.4%), chloramphenicol (55.6%). Seven E. faecium, 7 E. fecalis and 1 E. hirae was isolated from blood cultures. Vancomycin resistance was detected in 6 out of 15 (40%) Enterococcus spp. isolates. Among gram-negative bacteria E. coli (30.2%) was followed by Klebsiella pneumoniae (20.9%) and Proteus spp. (18.6%). Imipenem (89.2%), meropenem (86.6%), chloramphenicol (88.9%), amicasin (82.4%) and fosfomycin (81.3%) showed highest susceptibility in vitro activity against all Gram-negative isolates. To know the antimicrobial susceptibility profile of the pathogens frequently isolated from febrile neutropenic children and to consider this profile before starting an empirical antibiotic therapy would help the clinics which have any role in the treatment of these patients to determine the empirical antibiotic usage policies." }, { "id": "article-22388_16", "title": "Gram-Positive Bacteria -- History and Physical", "score": 0.009615384615384616, "content": "It is important to identify patients with sepsis and order necessary blood cultures and labs." }, { "id": "pubmed23n0974_1926", "title": "Intravenously administered cloxacillin-induced neutropenia with eosinophilia in a patient with infective endocarditis: a case report.", "score": 0.009523809523809525, "content": "Bacteremia following Staphylococcus aureus is a serious clinical condition which is often associated with distant metastatic infections. One of the most dreaded complications of Staphylococcus aureus bacteremia is infective endocarditis. Cloxacillin is a common antibiotic prescribed for suspected staphylococcal infections and confirmed methicillin-sensitive Staphylococcus aureus infections. Prolonged use of cloxacillin may lead to neutropenia. A 38-year-old Sinhalese man presented to Teaching Hospital Kurunegala, Sri Lanka, complaining of a 3-week history of fever; he was found to have a pansystolic murmur over the apex of his heart. He had leukocytosis with predominant neutrocytosis. His C-reactive protein was 231 mg/l and erythrocyte sedimentation rate was 100 mm/first hour. Transthoracic two-dimensional echocardiography revealed prolapsed mitral valve with 7 × 13 mm vegetation over the posterior mitral valve. On the following day, three blood cultures became positive and were subsequently identified as Staphylococcus aureus. Intravenously administered cloxacillin 3 g 6 hourly was started. Following day 24 of intravenously administered cloxacillin, our patient developed high spike fever. His total white blood cells were: 990/mm<sup3</sup with 34% neutrophils and 22% eosinophils. His hemoglobin concentration was 9.5 g/dL and platelet count remained normal (202 × 10<sup6</sup/mm<sup3</sup). His C-reactive protein was 78 mg/l, erythrocyte sedimentation rate was 95 mm/first hour, and he was otherwise comfortable, showing no signs of sepsis beside the high grade fever. His serum was negative for filarial and Toxoplasma antibodies while stool was negative for oocytes and amoebic cysts. Further, his serum was negative for dengue virus, Epstein-Barr virus, cytomegalovirus, and hepatitis B antibodies. He was clinically well on day 6 after stopping cloxacillin with 44% neutrophils and 18% eosinophils. His C-reactive protein and erythrocyte sedimentation rate became normal, and there was no further plan for cardiothoracic intervention or administration of antimicrobials. He was discharged from hospital and remained well 6 months later. This case report signifies the potential fatal adverse effect of cloxacillin in methicillin-sensitive Staphylococcus aureus infections. Leukopenia is associated with prolonged use of high doses of cloxacillin. In addition to transthoracic two-dimensional echocardiography and inflammatory markers, sequential white blood cells and differential counts would help clinicians to assess the prognosis of patients with infective endocarditis." }, { "id": "pubmed23n0659_8492", "title": "[Specifics of urinary tract infection investigated in hospitalized patients].", "score": 0.009523809523809525, "content": "Urinary tract infections investigated in hospital show a series of clinical and etiological features, especially concerning antibiotic sensitivity, determined by the recurrent pattern of these disease, which often determines severe urinary or general complications. We considered 36,136 urine samples belonging to patients admitted in hospital with history or symtomatology of urinary infection. We noted the following: Urine bacteriological investigation is one of the most asked for laboratory examinations in hospital, having a diagnostic significance (more than 10(5) cfu/ml) in only 15,45% of cases. The etiological patterns, though similar to those registered in ambulatory investigations, present a series of characteristics like: decreased percent of isolation of Enterobacteriaceae - 76.14%, compared to 98.90%, increased proportion of some groups of Gram-negative bacilli highly-resistant to antibiotics, such as Pseudomonas and Acinetobacter and of some groups of Gram-positive cocci--especially group D streptococcus. Accordingly, the sensitivity patterns denote the decrease of the proportion of strains that are sensitive to \"regular\" antibiotics, this phenomenon implying the use of recent antibiotics, more costly. Once again we point out to the necessity of conducting antibiotherapy by means of evaluating sensitivity during therapy." }, { "id": "pubmed23n1068_24389", "title": "COVID-19 Coinfection with <i>Mycobacterium abscessus</i> in a Patient with Multiple Myeloma.", "score": 0.009433962264150943, "content": "Coronavirus disease (COVID-19) is a worldwide pandemic causing multiple fatalities and morbidities worldwide. We report a case of severe pneumonia causing acute respiratory distress syndrome due to a coinfection with SARS-CoV-2 and <iMycobacterium abscessus</i in an elderly patient with multiple myeloma in Florida, USA. <iCase Presentation</i. An 84-year-old male with a medical history significant for multiple myeloma not in remission was sent to the emergency department to rule out COVID-19 infection prior to continuing his chemotherapy sessions. At presentation, he had nonspecific mild symptoms and an unremarkable physical examination. He had significant blood test findings including serum lactate dehydrogenase 373 U/L, high sensitive C-reactive protein 17.40 mg/l, and ferritin 415 ng/ml. Xpert-SARS-CoV-2 was positive. Chest radiograph revealed patchy areas of interstitial infiltrates in mid to lower lung zones. During his hospitalization course, his oxygenation deteriorated, requiring mechanical intubation. Repeat chest radiograph showed worsening bilateral infiltrates. He was started on broad-spectrum antibiotics and eventually weaned off mechanical intubation and extubated. On the 11<supth</sup day of admission, he was found to be bradycardic and in shock, and he was reintubated. His labs showed worsening inflammatory markers along with kidney dysfunction to the point of requiring renal replacement therapy. He received both convalescent plasma and remdesivir for treatment of COVID-19 pneumonia. Eventually, repeat blood cultures came back positive for the growth of acid-fast beaded bacilli. While awaiting final culture and sensitivity reports, his antibiotics were upgraded to cover possible nocardia infection. Repeat blood and sputum cultures resulted in growth of AFB bacilli <iMycobacterium abscessus</i 1 week after. This case report highlights the importance of keeping a broad differential and considering multiple coinfections, including atypical ones during this COVID-19 pandemic, such as the one that was discussed above, <iMycobacterium abscessus</i, in order to provide goal-directed therapy." }, { "id": "pubmed23n0521_23001", "title": "[Study on bacteremia in the service of Internal Medicine of a group 2 hospital. Analysis of recent three years].", "score": 0.009433962264150943, "content": "Bacteremia remains one of the most relevant problems in infectious disease. The interest of this study was to know the presentation and development pattern of bacteremia in our environment, in order to best prevent and treat this entity. A retrospective, no interventional study, on significant bacteremia detected in the Service of Internal Medicine of a secondary level hospital over three years was carried out. Through the study length, from January 1 2001 until December 31 2003, 4,719 blood cultures were processed by the Service of Microbiology; of these, 1964 (41.6%) were submitted by the Service of Internal Medicine. Results were positive in 336 (17.1%); of these, 18 (24.1%) correlated with episodes of true bacteremia, and 255 (75.9%) were deemed as contaminations. Overall, 81 episodes of true bacteremia were studied, from 77 patients (4 patients presented with 2 episodes). An incidence rate of 28.25 episodes per 1000 hospital admissions was estimated. Mean age was 72 years (95% CI: 68.62-75.38). Males over 60 years-old were predominant (51.9%). Bacteremia was community-acquired in 75.3% of cases, and nosocomial in 24.7%. Commonest baseline diseases were elevated arterial blood pressure and diabetes mellitus. Bacteremia development was mostly related to genitourinary and vascular handling. Most of them were nephrourological (42.0%), respiratory (19.8%) and abdominal (13.6%) in origin. In our environment, Escherichia coli (33.0%) and Staphylococcus coagulase-negative (15.9%) were the most commonly isolated pathogens. Empiric antibiotic therapy was correct in 86.2% of cases; third generation cephalosporins were the most used. Overall mortality rate was 16% (13 patients), and bacteraemia-related mortality was 61%. A high incidence of bacteremia episodes is noteworthy, as compared with series from other centers. The percentage of episodes due to Staphylococcus coagulase-negative was significant, as it is the rule in recent years; thus, a thoroughly assessment of potential contaminants, as well as staff training in extraction techniques becomes necessary." }, { "id": "pubmed23n0600_7562", "title": "[Microbiologic study of the bile culture and antimicrobial susceptibility in patients with biliary tract infection].", "score": 0.009345794392523364, "content": "Bacterial infection of biliary tract may cause severe inflammatory response or sepsis. An immediate bile culture and appropriate antibiotic administration are important to control the biliary tract infection. The objective of the study was to identify organisms in bile and the features of antibiotic susceptibility in patients with biliary tract infection. We retrospectively reviewed the clinical records of 212 patients whose bile had been cultured for variable biliary tract diseases at Inje University Ilsan Paik Hospital from Jan. 2000 to Feb. 2007. Bile samples were obtained from percutaneous transhepatic biliary drainage (PTBD, n=89), percutaneous transhepatic gallbladder drainage (PTGBD, n=14) or endoscopic naso-biliary drainage (ENBD, n=49). The overall positive rate of bile culture was 71.7% (152 cases). The organisms cultured were Escherichia coli (25.0%), Enterococcus spp. (13.4%), Klebsiella spp. (11.1%), Pseudomonas spp. (11.1%), and coagulase-negative Staphylococcus (9.7%) in decreasing order. Effective antibiotics for Gram-negative organisms were amoxicillin/clavulanic acid, amikacin, imipenem, and piperacillin/tazobactam in order of effectiveness. Of the cultured blood samples from 160 patients, fifty (31.2%) showed positive bacterial growth. The organisms isolated from blood were similar to those found in the bile. A broad spectrum penicillin/beta-lactamase inhibitor is a recommendable antimicrobial for empirical treatment for biliary tract infection. However, Gram-positive bacteria such as Enterococcus spp. or methicillin-resistant Staphylococcus aureus are emerging as causative microorganisms. If these organisms are isolated, antimicrobial drugs should be replaced by narrower-spectrum antimicrobials." }, { "id": "pubmed23n0678_2820", "title": "[Blood cultures when fever?].", "score": 0.009345794392523364, "content": "A 78-year-old man was referred from his residency where he lives to the emergency division due to general deterioration and frequent falls in the last week. His personal history is remarkable for arterial hypertension and diabetes. Two weeks before he needed a vesical catheterism that was traumatic and profilactic ciprofloxacin was prescribed. On physical exploration he appears disoriented, blood pressure is 9/40 mm Hg, cardiac rythm 120 beats per minute, temperature 37,3 °C and 24 respirations per minute. He appears to have pain on his upper left abdomen cuadrant. When the nurse gets a peripheral vein she asks, ¿should I obtain hemocultures?" }, { "id": "pubmed23n0794_235", "title": "[Saccharomyces cerevisiae fungemia in an elderly patient following probiotic treatment].", "score": 0.009259259259259259, "content": "Saccharomyces cerevisiae, known as baker's yeast, is also used as a probiotic agent to treat gastroenteritis by modulating the endogenous flora and immune system. However, since there have been increasing reports of fungemia due to S.cerevisiae and its subspecies S.boulardii, it is recommended that probiotics should be cautiously used in immunosuppressed patients, people with underlying diseases and low-birth weight babies. To emphasize this phenomenon, in this report, a case of S.cerevisiae fungemia developed in a patient given probiotic treatment for antibiotic-associated diarrhea, was presented. An 88-year-old female patient was admitted to our hospital with left hip pain, hypotension, and confusion. Her medical history included hypertension, chronic renal failure, left knee replacement surgery, and recurrent urinary tract infections due to neurogenic bladder. She was transferred to the intensive care unit with the diagnosis of urosepsis. After obtaining blood and urine samples for culture, empirical meropenem (2 x 500 mg) and linezolid (1 x 600 mg) treatment were administered. A central venous catheter (CVC) was inserted and after one day of inotropic support, her hemodynamic parameters were stabilized. The urine culture obtained on admission yielded extended-spectrum beta-lactamase-producing Klebsiella pneumoniae and Escherichia coli. Urine culture was repeated after three days and no bacteria were isolated. On the 4th day of admission she developed diarrhea. Toxin A/B tests for Clostridium difficile were negative. To relieve diarrhea, S.boulardii (Reflor 250 mg capsules, Sanofi Aventis, Turkey) was administered twice a day, without opening capsules. Two days later, her C-reactive protein (CRP) level increased from 23.2 mg/L to 100 mg/L without fever. Her blood culture taken from the CVC yielded S.cerevisiae. Linezolid and meropenem therapies were stopped on the 13th and 14th days, respectively, while prophylactic fluconazole therapy was replaced with caspofungin 1 x 50 mg on the fifth day. After seven days of therapy CRP and serum creatinine levels decreased to 9.1 mg/L and 1.2 mg/dl, respectively; and she was discharged from the hospital with improvement. The probiotic capsules were used unopen, thus, it was proposed that S.cerevisiae fungemia originated from translocation from the intestinal mucosa. Since it was not possible to investigate the molecular genetics of the strain isolated from the blood culture and the strain present in the probiotic, a definite conclusion about the origin of the strain could not be reached. It was thought that old age and underlying disease of the patient were the related predisposing factors for S.cerevisiae fungemia. This case emphasized that clinicians should be cautious in case of probiotic application even though in encapsulated form, even in immunocompetent patients with a history of long-term hospital stay and use of broad-spectrum antimicrobials since there may be a risk of S.cerevisiae fungemia development." }, { "id": "pubmed23n0212_11203", "title": "[Changes in antibiotic resistance of organisms isolated from blood cultures in a recently built hospital].", "score": 0.009259259259259259, "content": "The change in antimicrobial resistance of organisms isolated from blood cultures was studied in a university hospital that opened in July 1977 and had 550 beds by December 1982. Minimal inhibitory concentrations (MIC) were studied by an automatic microdilution technique. Analysis of MICs in the different groups of organisms in relation with time demonstrated no enhancement of resistance during these first 5 1/2 years, except for Pseudomonas aeruginosa that became significantly more resistant (p less than 0.05) to five of the seven antibiotics tested. However, comparison of the two periods July 1977-December 1980 and january 1981-December 1982 evidenced a trend towards a decrease in Enterobacteriaceae (p. less than 0.001) and increase in P. aeruginosa (p less than 0.01) and S. aureus (p less than 0.001). This suggests that the selective pressure from hospital use of antibiotics caused no increase in resistance of different organisms but rather a modification of their relative frequency." }, { "id": "wiki20220301en022_61054", "title": "Hematuria", "score": 0.009174311926605505, "content": "The first step in evaluation of red or brown colored urine is to confirm true hematuria with urinalysis and urine microscopy, where hematuria is defined by three of more red blood cells per high power field. Although a urine dipstick test may be used, it can give false positive or false negative results. In gathering information, it is important to inquire about recent trauma, urologic procedures, menses, and culture-documented urinary tract infection. If any of these are present, it is appropriate to repeat a urinalysis with urine microscopy in 1 to 2 weeks or after treatment of the infection. If the results of the urinalysis and urine microscopy reveal a glomerular origin of hematuria (indicated by proteinuria or red blood cell casts), consultation of a nephrologist should be made. If the results of the urinalysis indicate a non-glomerular origin, a microbiological culture of the urine should be performed, if it has not been done already. If the culture is positive, treatment of the" }, { "id": "pubmed23n0344_19146", "title": "[Trends in resistant bacteria isolated from a tube smear in intubated patients in intensive care].", "score": 0.009174311926605505, "content": "Long standing antibiotics therapy has resulted in growing bacteria resistance. We took a tube smear and prepared culture with antibiogram from the fifty intubated patients in the Intensive care unit in the war period. Gram-negative germs were the dominant ones in total sum, and among them the Acinetobacter calcoaceticus (No 21), Pseudomonas aeruginosa (No 18), Klebsiella pneumoniae (No 18), were isolated most frequently. Pseudomonas aeruginosa showed high resistance to Gentamicin (64%), Amikacin (35%), Trimethoprim (66%), Pefloxacin (20%), Ofloxacin (25%), Ciprofloxacin (25%). Klebsiella pneumoniae is resistant to Gentamicin (68%), Amikacin (22%), Cephalosporin (100%), Trimethoprim (31%), but it showed no resistance to chinolones. Acinetobacter calcoaceticus is resistant to Gentamicin (73%), Amikacin (36%), Cephalosporin (100%), Trimethoprim (63%), Pefloxacin (33%), Ofloxacin (67%), Ciprofloxacin (46%). Staphylococcus aureus was the most frequent among Gram-positive germs and it was resistant to Penicillin (100%), Gentamicin (40%), Lincocin (18%), Trimethoprim (5%), Pefloxacin (13%), Methicillin (21%), Cephalosporin (8%). The appearance of resistance on the antibiotics demands attentive follow-up aiming to influence the empirical application of antibiotics schemes depending on resistance." }, { "id": "pubmed23n0602_21991", "title": "Enteric fever: a retrospective 6-year analysis of 82 paediatric cases in a teaching hospital.", "score": 0.00909090909090909, "content": "To evaluate the clinical and laboratory properties, to see the response to therapy, incidence of antimicrobial resistance and complications of Enteric Fever in children. This is a retrospective study of 82 cases of enteric fever admitted in department of pediatrics, Manipal Teaching hospital, Pokhara, Nepal. Study period was six years from (Jan 2000 to Dec 2005). Total of 82 cases of Salmonella infections were admitted .There were 50 (60%) males and 32 (40%) females. Most of the patients were above the age of five. The leading clinical feature were Fever (100%) , GI symptoms (73%), followed by splenomegaly (60%), hepatomegaly (58%), chills &amp; rigor (41%), headache(33%),coated tongue(17%), lymphadenopathy (13%), Respiratory signs (13%), toxic look (7%). The laboratory reports revealed leucopenia in 26% and leukocytosis in 16%. Widal test was positive in 83%, Blood culture was positive in 37 %.Bone marrow was done in 8 cases, out of which 5(62.5%) were culture positive. Out of 35 culture positive cases 32 were Salmonella typhi and 3 were Salmonella paratyphi A. Regarding the treatment 55% were treated with ciprofloxacin, 29 % with ceftriaxone, 7% with ampicillin, 6% with cefotaxime and 2.4 % with chloramphenicol. Response to therapy was assessed by day of defervescence after antibiotics. Best response was observed with ciprofloxacin (4.7 days) followed by ceftriaxone (5 days), ampicillin (5.5 days), cefotaximee (6.4 days), chloramphenicol (10 days) respectively. In the antibiogram resistance was 43% with chloramphenicol, 37% with ampicillin, 31% with trimethoprim- sulfamethoxazole, 5.7%with ciprofloxacin and 4% with cefotaxime. Resistance was 0% with ceftriaxone, cefuroxime, and ofloxacin. Gentamycin was found to show high sensitivity (91%). The complications observed were anemia in 10%, 5% had neurologic signs like clouding of consciousness and 3.7% had CNS irritability. It is important to include Enteric fever in the differential diagnosis of febrile patients with abdominal symptoms. Though blood culture is the definite test, Widal test plays supportive role in diagnosis of enteric fever, especially when patients come after a course of antibiotics. Sometimes when both blood culture and Widal tests are negative Bone marrow can be the diagnostic tool for the diagnosis. Based on this analysis ciprofloxacin is still a good drug for the treatment of Enteric Fever. Ceftriaxone, Cefuroxime and Ofloxacin can be considered as first line treatment for Enteric fever since resistance was nil with these drugs on culture reports." }, { "id": "pubmed23n0309_15246", "title": "[Changes in the spectrum of the causative agents of community-acquired pneumonias (1982-1992)].", "score": 0.00909090909090909, "content": "The picture of pneumonia acquired out of hospital is continually changing. Microbial aetiology as well as predisposing factors, course and prognosis of this disease were prospectively analysed over a period of 10 years. In three prospective studies, undertaken between 1982 and 1992, data from 448 patients with out-of-hospital acquired pneumonia were analysed. Microbiological evidence was obtained through blood cultures, from purulent sputum or bronchial secretions, as well as by determining serum antibodies or antigens in urine. Proof of causative organism was achieved in 282 patients (64.1%), with identification of 337 different ones. The spectrum of causative microbes shifted during the study period from predominantly gram-positive bacteria to largely atypical organisms (from 12.5% during 1982/1983, to 36.7% in 1991/1992). Although pneumococci continued to dominate, Chlamydia pneumoniae appeared as an important cause of pneumonia, at 11.4% the most important atypical organism in 1991/1992. -Most patients (74.3%) had a chronic underlying disease. The death rate remained relatively constant at 12.9% during the 10-year period. The observed changes in microbial spectrum should be taken into account when specific antibiotic treatment is given. History as well as clinical, radiological and laboratory findings are of only limited value as pointers to the possible microbial cause." }, { "id": "pubmed23n1055_18239", "title": "A Clinical Challenge in the Emergency Department: A Case of Klebsiella Infective Endocarditis Presenting With Splenic Abscess.", "score": 0.009009009009009009, "content": "Infective endocarditis (IE) is a serious bacterial infection of the endocardium and/or heart valves that carries considerable morbidity and mortality. Often presenting with very non-specific symptoms, this disease presents many challenges to the emergency medicine practitioner. A 47-year-old male with no pertinent medical history presented to the emergency department complaining of shortness of breath. He stated that his symptoms had been persistent for the last three weeks and were associated with malaise and fatigue. CT of the abdomen/pelvis with IV contrast revealed a 7-cm hypodensity of the spleen concerning for abscess versus infarct. He denied any trauma or IV drug use. Follow-up ultrasound was ordered, which characterized the hypodensity as a splenic abscess. An echocardiogram was recommended for possible IE, and cardiology was consulted. The transthoracic echocardiogram was performed on hospital day 2, which showed minimal mitral valve thickening with mild mitral regurgitation. The interventional radiology (IR) service was consulted for the splenic abscess in order to perform CT-guided drainage. An IR drain was successfully placed on hospital day 3. On the same day, blood cultures grew Klebsiella pneumoniae. On hospital day 5, that patient was transferred to the ICU for possible empyema formation with signs of respiratory distress. The patient underwent CT of the chest that showed the development of a left-sided effusion. The patient had also been persistently tachycardic and febrile, with high leukocytosis since admission and worsening respiratory status. Transesophageal echocardiogram (TEE) was scheduled but put on hold due to worsening respiratory status. Repeat TEE was scheduled five days later, which showed mitral regurgitation and increased size of the vegetation despite antibiotic therapy. Two days later, he was scheduled for mitral valve repair. When reviewing our case, the patient had both common and uncommon aspects of splenic abscess or IE. First, despite having respiratory symptoms for two weeks, the primary reason he came to the hospital was due to the new onset of fevers. He was febrile, tachycardic, and with significant leukocytosis. He continued to have fevers despite antibiotic therapy and IR drainage of the abscess. With no history of IV drug use history, negative transthoracic echocardiography, lack of immunocompromising condition, and blood cultures with gram-negative rods, IE became less likely of a diagnosis.  Establishing the diagnosis of IE proved to be exceptionally complicated, especially in the setting of a COVID-19 pandemic. The most notable challenge was having a high index of suspicion despite any risk factors. The patient was a previously healthy 47-year-old male with no medical problems. IE continues to be a clinical challenge for physicians, especially in the emergency department, due to the lack of diagnostic criteria such as positive blood cultures or vegetations visualized on echocardiographic studies. IE has a wide gamut of presentations with different levels of acuity. Diagnosis is more straightforward when patients present with obvious risk factors, but, in many cases, such as this one, those risk factors may be absent. A high index of suspicion is required, especially in patients with additional findings such as splenic abscess, embolic phenomenon, focal neurologic deficit, mycotic aneurysm, decompensated heart failure, new murmurs, or pleural effusions." }, { "id": "pubmed23n0105_7441", "title": "[Gram-negative bacteria in a medical resuscitation unit. Distribution of species and antibiotic sensitivity].", "score": 0.009009009009009009, "content": "The distribution of Gram-negative bacilli species and their susceptibility to various antibiotics were surveyed over a 18-month period in an intensive care unit. Gram-negative bacilli were isolated from blood cultures (65), urine cultures (191), respiratory tract samples (176) or miscellaneous samples (69). The bacilli most frequently isolated from blood cultures were enterobacteriaceae (95%), including Escherichia coli (46%), Proteus (22%) and Klebsiella pneumoniae (12%). Pseudomonas aeruginosa was predominant in respiratory tract samples, and Serratia marcescens was more frequently isolated from urine cultures than from other samples. Antibiotic susceptibility testing was performed using a standard disc diffusion method. In view of the susceptibility of blood isolates to the second-generation cephalosporins we consider that these are preferable to third-generation cephalosporins for first-line antibiotic therapy of septicaemia due to Gram-negative bacilli, except for hospital-acquired infections. More than 50% of the bacilli were resistant to ampicillin; ticarcillin and mezlocillin were not very active against Klebsiella. Nalidixic acid was very active on urine isolates and therefore seems to be a good first-line antibacterial for lower urinary tract infections." }, { "id": "wiki20220301en419_7255", "title": "Omadacycline", "score": 0.008928571428571428, "content": "Omadacycline, sold under the brand name Nuzyra, is a broad spectrum antibiotic medication belonging to the aminomethylcycline subclass of tetracycline antibiotics. In the United States, it was approved in October 2018, for the treatment of community-acquired bacterial pneumonia and acute skin and skin structure infections. In vitro studies In vitro studies have shown that omadacycline has activity against a broad range of Gram-positive and select Gram-negative pathogens. Omadacycline has potent in vitro activity against Gram-positive aerobic bacteria including methicillin-resistant Staphylococcus aureus (MRSA), penicillin-resistant and multi-drug resistant Streptococcus pneumoniae, and vancomycin-resistant Enterococcus. Omadacycline also has antimicrobial activity against common Gram-negative aerobes, some anaerobes, and atypical bacteria such as Legionella and Chlamydia. This activity translated to potent efficacy for omadacycline in an in vivo systemic infection model in mice." }, { "id": "pubmed23n0557_3826", "title": "[A case of septic pulmonary embolism showing the rapid appearance of multiple cavities in both lung fields induced by urinary tract infection].", "score": 0.008928571428571428, "content": "A 69-year-old man who had benign prostatic hypertrophy and hypertension was admitted to our hospital because of urinary retention and high grade fever. Chest radiograph showed the appearance of multiple cavitating nodules in both lung fields within a few days after admission. Staphylococcus aureus was isolated in blood and sputum cultures, though there were no pathogens in urine culture. Abdominal CT demonstrated bilateral hydronephrosis. Since we could not detect any other infectious focuses such as bacterial endocarditis, septic thrombophlebitis etc., we reached the diagnosis of septic pulmonary embolism (SPE) induced by urinary tract infection (UTI). After diagnosis, the patient was given intravenous meropenem, ciprofloxacin, sulbactam/ampicilin, and recovered. Although several cases of SPE induced by UTI in diabetes mellitus patients have been reported, the present case who had no severe underlying disorder is very rare." }, { "id": "pubmed23n0672_3654", "title": "[Interest of real-time PCR Xpert MRSA/SA on GeneXpert(®) DX System in the investigation of staphylococcal bacteremia].", "score": 0.008849557522123894, "content": "Recently, a rapid, fully automated real-time PCR test has become available for detection of Staphylococcus aureus in positive blood cultures, Xpert MRSA/SA blood culture. This study was defined to evaluate the use of this product in our hospital setting to assist in optimizing antibiotic treatment. Over a period of 18months (from February 2008 to July 2009), 51 positive blood cultures were examined for Staphylococcus using the Xpert MRSA/SA assay on the GeneXpert(®) System. The PCR results were transferred to the clinician as soon as available. The presence of empirical antibiotic therapy was noted and modified if necessary after discussions between the clinician and the infectious disease specialist. Twenty-three blood bottles were positive for S. aureus, two were resistant to methicillin. Twenty-eight were coagulase negative staphylococci. No discrepancy between identification (S. aureus) and methicillin resistance was observed. Thirty-two samples had clinically significant bacteremia (23 S. aureus and nine coagulase negative staphylococci). Sixteen (50%) of these patients had received inappropriate antibiotic therapy (11 without antibiotic therapy, five with betalactam antibiotics). For these patients, an appropriate antibiotic therapy was prescribed according to these results. Sixteen patients had adequate empirical antibiotic therapy at the time of receiving the PCR result. Among these 16 patients, eight switches were performed from broad-spectrum treatment to a more restrictive antistaphylococcal treatment. Of the 19 patients with a nonclinically relevant coagulase negative staphylococci infection, four were already on antibiotics for other infections and these treatments were not modified. Empirical treatment could be avoided in 13 patients who had a clinical presentation consistent with staphylococcal bacteremia (multiple sores, history of carrying methicllin-resistant or susceptible S. aureus infection, presence of intravascular material or prosthesis). The real-time PCR Cepheid Xpert MRSA/SA on GeneXpert(®) DX System has become an essential tool in our laboratory enhancing the reports of positive blood cultures for staphylococci. This test is fast (50min) and reliable. It allows optimization of antibiotic therapy in hospital." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 2241, 2534 ] ], "word_ranges": [ [ 321, 365 ] ], "text": "Conversive or dissociative disorder is ruled out because these are usually related to psychological factors, associated with the symptom or deficit (not deliberate). The onset or exacerbation of the condition is preceded by conflicts or other triggers, which is not mentioned in the statement." }, "2": { "exist": true, "char_ranges": [ [ 2535, 2795 ] ], "word_ranges": [ [ 365, 406 ] ], "text": "Neither would it be a hypochondriacal disorder because this implies a preoccupation and fear of having, or the conviction of having, a serious illness based on the personal interpretation of somatic symptoms. But it does not involve physical signs or symptoms." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 2241, 2534 ] ], "word_ranges": [ [ 321, 365 ] ], "text": "Conversive or dissociative disorder is ruled out because these are usually related to psychological factors, associated with the symptom or deficit (not deliberate). The onset or exacerbation of the condition is preceded by conflicts or other triggers, which is not mentioned in the statement." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Conversive disorder.", "2": "Hypochondriac disorder.", "3": "Somatization disorder.", "4": "Dissociative disorder.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en337_37313", "title": "Somatic symptom disorder", "score": 0.018070818070818073, "content": "In people who have been diagnosed with a somatic symptom disorder, medical test results are either normal or do not explain the person's symptoms (medically unexplained physical symptoms), and history and physical examination do not indicate the presence of a known medical condition that could cause them, though the DSM-5 cautions that this alone is not sufficient for diagnosis. The patient must also be excessively worried about their symptoms, and this worry must be judged to be out of proportion to the severity of the physical complaints themselves. A diagnosis of somatic symptom disorder requires that the subject have recurring somatic complaints for at least six months." }, { "id": "wiki20220301en337_37315", "title": "Somatic symptom disorder", "score": 0.0160378517881283, "content": "History Somitisation disorder was first described by Paul Briquet in 1859 and was subsequently known as Briquet's syndrome. He described patients who had been sickly most of their lives and complained of multiple symptoms from different organ systems. Symptoms persist despite multiple consultations, hospitalisations and investigations. Definition Somatic symptom disorders are a group of disorders, all of which fit the definition of physical symptoms similar to those observed in physical disease or injury for which there is no identifiable physical cause. As such, they are a diagnosis of exclusion. Somatic symptoms may be generalized in four major medical categories: neurological, cardiac, pain, and gastrointestinal somatic symptoms." }, { "id": "wiki20220301en189_3786", "title": "Medical explanations of bewitchment", "score": 0.015147265077138851, "content": "Hysteria and psychosomatic disorders The symptoms displayed by the afflicted in Salem are similar to those seen in classic cases of hysteria, according to Marion Starkey and Chadwick Hansen. Physicians have replaced the vague diagnosis of hysteria with what is essentially its synonym, psychosomatic disorder. Psychological processes known to influence physical health are now called \"psychosomatic\". They include: \"several types of disease known as somatoform disorders, in which somatic symptoms appear either without any organic disorder or without organic damage that can account for the severity of the symptoms. ... A second type, conversion disorders, involves inexplicable malfunctions in motor and sensory systems. The third type, pain disorder, involves sensation either in the absence of an organic problem or in excess of actual physical damage.\"" }, { "id": "wiki20220301en337_37320", "title": "Somatic symptom disorder", "score": 0.013379273313048147, "content": "Controversy Somatic symptom disorder has been a controversial diagnosis, since it was historically based primarily on negative criteria; that is, the absence of a medical explanation for the presenting physical complaints. Consequently, any person suffering from a poorly understood illness can potentially fulfill the criteria for this psychiatric diagnosis, even if they exhibit no psychiatric symptoms in the conventional sense. Misdiagnosis In the opinion of Allen Frances, chair of the DSM-IV task force, the DSM-5's somatic symptom disorder brings with it a risk of mislabeling a sizable proportion of the population as mentally ill. “Millions of people could be mislabeled, with the burden falling disproportionately on women, because they are more likely to be casually dismissed as ‘catastrophizers’ when presenting with physical symptoms.”" }, { "id": "wiki20220301en031_24976", "title": "Factitious disorder", "score": 0.013114895080839354, "content": "Differential diagnosis Factitious disorder should be distinguished from somatic symptom disorder (formerly called somatization disorder), in which the patient is truly experiencing the symptoms and has no intention to deceive. In conversion disorder (previously called hysteria), a neurological deficit appears with no organic cause. The patient, again, is truly experiencing the symptoms and signs and has no intention to deceive. The differential also includes body dysmorphic disorder and pain disorder." }, { "id": "Neurology_Adams_12023", "title": "Neurology_Adams", "score": 0.012769958747876729, "content": "Hysteria in its fullest form is a polysymptomatic disorder, implicating at some time and in some patients, almost every organ system. In a study of 50 unmistakable cases of hysteria (as compared with a control group of 50 healthy women), the most frequent symptoms reported by Purtell and colleagues were headache, blurred vision, lump in the throat, loss of voice, dyspnea, palpitation, anxiety attacks, anorexia, nausea and vomiting, abdominal pain, unusual food allergies, severe menstrual pain, urinary retention, painful intercourse, paresthesias, dizzy spells, nervousness, and easy crying." }, { "id": "wiki20220301en282_18236", "title": "ICHD classification and diagnosis of migraine", "score": 0.012729285262492094, "content": "Menstrual migraines may also be linked to oestrogen withdrawal. Under the category of headache attributed to a substance or its withdrawal, the ICHD specifies the diagnostic criteria for oestrogen-withdrawal headache (8.4.3, and ), and suggests that both that diagnosis and one of the menstrual migraine diagnoses be used in case of migraines related to oestrogen withdrawal occurring mainly at menstruation. Abdominal migraine Abdominal migraine is a recurrent disorder of unknown origin, principally affecting children. Sometimes early on, it can be misdiagnosed in an ER setting as appendicitis. Episodes feature nausea, vomiting, and moderate-to-severe central, abdominal pain. The child is well between episodes. The International Classification of Headache Disorders definition is: Most children with abdominal migraines will develop migraine headache in adult life; the two propensities might co-exist during the child's adolescence." }, { "id": "pubmed23n1012_12382", "title": "Somatic symptom disorder: a diagnostic dilemma.", "score": 0.012544547398431933, "content": "Somatic symptom disorder (SSD) is a diagnosis that was introduced with publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013. It eliminated the diagnoses of somatisation disorder, undifferentiated somatoform disorder, hypochondriasis and pain disorder; most of the patients who previously received these diagnoses are now diagnosed in DSM-5 with SSD. The main feature of this disorder is a patient's concern with physical symptoms for which no biological cause is found. It requires psychiatric assessment to exclude comorbid psychiatric disease. Failure to recognise this disorder may lead the unwary physician or surgeon to embark on investigations or diagnostic procedures which may result in iatrogenic complications. It also poses a significant financial burden on the healthcare service. Patients with non-specific abdominal pain have a poor symptomatic prognosis with continuing use of medical services. Proven treatments include cognitive behavioural therapy, mindfulness therapy and pharmacological treatment using selective serotonin reuptake inhibitors or tricyclic antidepressants. The authors describe the case of a 31-year-old woman with an emotionally unstable personality disorder and comorbid disease presenting to the emergency department with a 3-week history of left-sided abdominal and leg pain. Despite a plethora of investigations, no organic cause for her pain was found. She was reviewed by the multidisciplinary team including surgeons, physicians, neurologists and psychiatrists. A diagnosis of somatoform symptom disorder was subsequently rendered. As patients with SSD will present to general practice and the emergency department rather than psychiatric settings, this case provides a cautionary reminder of furthering the need for appropriate recognition of this condition." }, { "id": "Gynecology_Novak_1626", "title": "Gynecology_Novak", "score": 0.01185693560986497, "content": "Epidemiology Somatization is believed to be among the most common and most difficult psychological conditions in office practice. It is estimated that 60% to 80% of the general population experiences one or more somatic symptoms in a given week, providing an ample substrate for the patient preoccupied with her health (167). Somatization disorder occurs almost exclusively in women; menstrual symptoms may be an early sign. Lifetime prevalence in women is 0.2% to 2.0%. Conversion disorder occurs 2 to 10 times more frequently in women than in men (there is no difference for gender in children), and it is more common in rural and disadvantaged populations with little medical sophistication (167). Cases have become relatively rare. Conversion disorder may develop into somatization disorder. Reported rates of somatization disorder range from 11 to 300 per 100,000. Pain disorder is extremely common in both genders. Hypochondriasis is equally distributed between men and women; prevalence in" }, { "id": "wiki20220301en337_37316", "title": "Somatic symptom disorder", "score": 0.011636363636363636, "content": "Diagnostic and Statistical Manual of Mental Disorders Somatic symptom disorders used to be recognized as Somatoform disorders in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. The following were conditions under the term Somatoform Disorders: Conversion disorder: A somatic symptom disorder involving the actual loss of bodily function such as blindness, paralysis, and numbness due to excessive anxiety Somatization disorder Hypochondriasis Body dysmorphic disorder: wherein the afflicted individual is concerned with body image, and the disorder is manifested as excessive concern about and preoccupation with a perceived defect of their physical appearance. Pain disorder Undifferentiated somatic symptom disorder – only one unexplained symptom is required for at least six months. In the newest version of DSM-5 (2013) somatic symptom disorders are recognized under the term somatic symptom and related disorders:" }, { "id": "article-21573_10", "title": "Factitious Disorder -- History and Physical", "score": 0.01076721883173496, "content": "Patients with factitious disorder may present to any specialty with self-induced, feigned, or exaggerated symptoms. Some patients with factitious disorder present with simple but serious symptoms such as chest pain, as they know this is more likely to result in hospital admission. [1] Other patients may present with much more complex and elaborate symptoms. A good history and physical exam is essential in making the diagnosis. Many clues may raise a clinician's suspicion, including: [3] [4]" }, { "id": "article-69_7", "title": "Somatic Symptom Disorder -- History and Physical", "score": 0.010461965084767127, "content": "The presence of SSD may be suggested by a vague and often inconsistent history of present illness, symptoms that are rarely alleviated with medical interventions, patient attribution of normal sensations as medical illness, avoidance of physical activity, high sensitivity to medication adverse effects, and medical care from multiple providers for the same complaints." }, { "id": "wiki20220301en084_38796", "title": "Menstrual disorder", "score": 0.010143141530002845, "content": "Dysmenorrhea Especially painful or persistent menstrual cramping that occurs in the absence of any underlying pelvic disease. Pain radiating to the low back or upper thighs with onset of menstruation and lasting anywhere from 12–72 hours. Headache, nausea, vomiting, diarrhea, and fatigue may also accompany the pain. Pain may begin gradually, with the first several years of menses, and then intensified as menstruation becomes regular. Patients who also have secondary amenorrhea report symptoms beginning after age 20 and lasting 5–7 days with progressive worsening of pain over time. Pelvic pain is also reported." }, { "id": "wiki20220301en015_59816", "title": "Somatization disorder", "score": 0.010138888888888888, "content": "DSM-IV-TR The DSM-IV-TR diagnostic criteria are: A history of somatic complaints over several years, starting prior to the age of 30. Such symptoms cannot be fully explained by a general medical condition or substance use or, when there is an associated medical condition, the impairments due to the somatic symptoms are more severe than generally expected. Complaints are not feigned as in malingering or factitious disorder. The symptoms do not all have to occur at the same time, but may occur over the course of the disorder. A somatization disorder itself is chronic but fluctuating that rarely remits completely. A thorough physical examination of the specified areas of complaint is critical for somatization disorder diagnosis. Medical examination would provide object evidence of subjective complaints of the individual." }, { "id": "wiki20220301en166_16837", "title": "DSM-5", "score": 0.009900990099009901, "content": "Somatic symptom and related disorders Somatoform disorders are now called somatic symptom and related disorders. Patients that present with chronic pain can now be diagnosed with the mental illness somatic symptom disorder with predominant pain; or psychological factors that affect other medical conditions; or with an adjustment disorder. Somatization disorder and undifferentiated somatoform disorder were combined to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms. Somatic symptom and related disorders are defined by positive symptoms, and the use of medically unexplained symptoms is minimized, except in the cases of conversion disorder and pseudocyesis (false pregnancy). A new diagnosis is psychological factors affecting other medical conditions. This was formerly found in the DSM-IV chapter \"Other Conditions That May Be a Focus of Clinical Attention\"." }, { "id": "Neurology_Adams_12024", "title": "Neurology_Adams", "score": 0.009900990099009901, "content": "The mental examination of the patient with hysteria demonstrates a lack of precision in relating the details of the illness. Questions regarding the chief complaint usually elicit a narration of a series of incidents or problems, many of which prove to have little or no relevance to the question. Memory defects (amnesic gaps) are apparent while the history is being taken; the patient appears to have forgotten important segments of the history, some of which he had clearly described in the past and are part of the medical record. The description of symptoms is dramatic and not in accord with the facts as elicited from other members of the family. Often, a rather casual demeanor is manifest, the patient insisting that everything in her life is quite normal and controlled, when, in fact, her medical record is checkered with instances of dramatic and unexplained illness. This calm attitude toward a turbulent illness and seemingly disabling physical signs is so common that it has been" }, { "id": "wiki20220301en109_6670", "title": "Somatic anxiety", "score": 0.00980392156862745, "content": "Somatic anxiety, also known as somatization, is the physical manifestation of anxiety. It is commonly contrasted with cognitive anxiety, which is the mental manifestation of anxiety, or the specific thought processes that occur during anxiety, such as concern or worry. These different components of anxiety are especially studied in sports psychology, specifically relating to how the anxiety symptoms affect athletic performance. \"Symptoms typically associated with somatization of anxiety and other psychiatric disorders include abdominal pain, dyspepsia, chest pain, fatigue, dizziness, insomnia, and headache.\" These symptoms can either happen alone or multiple can happen at once. Although commonly overlooked, scientists are starting to study somatic anxiety more. Studies are actually starting to show that some medically overlooked cases that could not relate physical pain to any type of organ dysfunction typically could have been somatic anxiety." }, { "id": "Neurology_Adams_12025", "title": "Neurology_Adams", "score": 0.00980392156862745, "content": "her medical record is checkered with instances of dramatic and unexplained illness. This calm attitude toward a turbulent illness and seemingly disabling physical signs is so common that it has been singled out as an important characteristic of hysteria, la belle indifference. Other patients, however, are obviously tense and anxious and report frank anxiety attacks. Emotional reactions are superficial and scenes that are disturbing to others are quickly forgotten. Claims of early life sexual or physical abuse are common and often prove to be true, or sometimes are not valid; when present, they probably play a role in the genesis of some cases (see further on)." }, { "id": "wiki20220301en329_17082", "title": "Chronic fatigue syndrome", "score": 0.009708737864077669, "content": "In 1970, two British psychiatrists, McEvedy and Beard, reviewed the case notes of 15 outbreaks of benign myalgic encephalomyelitis and concluded that it was caused by mass hysteria on the part of patients, or altered medical perception of the attending physicians. Their conclusions were based on previous studies that found many normal physical test results, a lack of a discernible cause, and a higher prevalence of the illness in females. Consequently, the authors recommended that the disease should be renamed \"myalgia nervosa\". This perspective was rejected in a series of case studies by Dr. Melvin Ramsay and other staff of the Royal Free Hospital, the center of a significant outbreak. The psychological hypothesis posed by McEvedy and Beard created great controversy, and convinced a generation of health professionals in the UK that this could be a plausible explanation for the condition, resulting in neglect by many medical specialties. The specialty that did take a major interest in" }, { "id": "wiki20220301en251_31185", "title": "New daily persistent headache", "score": 0.009615384615384616, "content": "Notes: Headache may be unremitting from the moment of onset or very rapidly build up to continuous and unremitting pain. Such onset or rapid development must be clearly recalled and unambiguously described by the patient. Otherwise it is coded as 2.3 chronic tension-type headache. History and physical and neurological examinations do not suggest any of the disorders listed in groups 5-12 (including 8.2 medication overuse headaches and its subforms), or history and/or physical and/or neurological examinations do suggest such disorder but it is ruled out by appropriate investigations, or such disorder is present but headache does not occur for the first time in close temporal relation to the disorder. Criteria revision" }, { "id": "wiki20220301en075_14316", "title": "Accessory pancreas", "score": 0.009523809523809525, "content": "Accessory pancreas is a small cluster of pancreas cells detached from the pancreas and sometimes found in the wall of the stomach or intestines. Diagnosis Pancreatic disorders are often accompanied by weakness and fatigue. The past Medical history may reveal previous disorders of the biliary tract or duodenum, abdominal trauma or surgery, and metabolic disorders such as diabetes mellitus. The medication history should be detailed and specifically include the use of thiazides, furosemide, estrogens, corticosteroids, sulfonamides, and opiates. Note a family history of pancreatic disorders. In the review of systems, obtain a complete description of any pain in the upper abdomen or epigastric area. Symptoms that may be important in relation to pancreatic disorders are pruritus, abdominal pain, dyspnea, nausea, and vomiting. The functional assessment includes data about the patient’s dietary habits and use of alcohol." }, { "id": "wiki20220301en386_23018", "title": "Abdominal migraine", "score": 0.009433962264150943, "content": "Abdominal migraine is a psychogenic pain disorder. It primarily affects children. It mainly causes episodes of abdominal pain without an accompanying headache. It is caused by psychological stress, with risk factors including other mental disorders and psychological trauma from abuse. It is difficult to confirm the diagnosis, as its symptoms are not specific, and it can take time before a diagnosis is made. Short term treatment involves analgesia and avoiding bright light. Long term treatment involves treating the underlying psychogenic cause. The condition is rare in adults. The mean age of diagnosis is 7 years. Signs and Symptoms Symptoms of abdominal migraine may include: Abdominal pain. Nausea. Vomiting. Headache. Photosensitivity. Loss of appetite. Pallor. These occur in distinct episodes. This can have a significant effect on day-to-day life. It usually does not occur with a headache. Body mass index is usually unaffected, and physical development is normal." }, { "id": "Neurology_Adams_12058", "title": "Neurology_Adams", "score": 0.009433962264150943, "content": "There is a significant overlap of hysteria and other medical and neurologic diseases. On record are numerous studies in which patients with an initial diagnosis of hysteria by general physicians were followed for many years. Up to one-third of them (far less in most series) turned out eventually to have an “organic condition” that, in retrospect, explained the initial symptoms (Couprie et al). This emphasizes that the original clinical diagnosis of hysteria is sometimes erroneous, although numerous other surveys emphasize the opposite, as noted below. When the diagnostic criteria in these cases are closely analyzed, it becomes apparent that the diagnosis was made solely by the “discrepancy method”—that is, the patient’s symptoms or signs were not deemed to be credible manifestations of disease, based mainly on the clinical experience of the examiner. Of course, this assumes that the examiner has a wide experience; unfortunately for the novice, many syndromes are unknown or" }, { "id": "wiki20220301en002_198637", "title": "Eating disorder", "score": 0.009345794392523364, "content": "their diet, choose to consume their trigger foods to promote weight loss. On the other hand, individuals with good dietary management may develop anxiety, food aversion and eating disorders because of concerns around cross contamination of their foods. Some authors suggest that medical professionals should evaluate the presence of an unrecognized celiac disease in all people with eating disorder, especially if they present any gastrointestinal symptom (such as decreased appetite, abdominal pain, bloating, distension, vomiting, diarrhea or constipation), weight loss, or growth failure; and also routinely ask celiac patients about weight or body shape concerns, dieting or vomiting for weight control, to evaluate the possible presence of eating disorders, specially in women." }, { "id": "pubmed23n0069_9677", "title": "[The importance of the anamnesis and the clinical and paraclinical examination methods in the diagnosis of internal diseases].", "score": 0.009345794392523364, "content": "Data are available on the studies into the significance of case history, clinical and paraclinical examinations for a valid diagnosis of internal diseases. Clinical cases are presented where neglect of the disease history and detailed clinical examination brought about misdiagnosis. The role of paraclinical methods in diagnostic investigations is considered. It is emphasized that students should be better trained in patients' interviewing and clinical examination." }, { "id": "wiki20220301en302_17894", "title": "Anorexia nervosa", "score": 0.009259259259259259, "content": "the importance of strictly following their diet, choose to consume their trigger foods to promote weight loss. On the other hand, individuals with good dietary management may develop anxiety, food aversion and eating disorders because of concerns around cross contamination of their foods. Some authors suggest that medical professionals should evaluate the presence of an unrecognized celiac disease in all people with eating disorder, especially if they present any gastrointestinal symptom (such as decreased appetite, abdominal pain, bloating, distension, vomiting, diarrhea or constipation), weight loss, or growth failure; and also routinely ask celiac patients about weight or body shape concerns, dieting or vomiting for weight control, to evaluate the possible presence of eating disorders, especially in women." }, { "id": "pubmed23n0235_15122", "title": "Factitious illness in gynecology.", "score": 0.009259259259259259, "content": "Factitious or self-induced illness has rarely been mentioned in gynecologic literature. Described herein are 4 nonpregnant women, 3 of whom had vaginal bleeding of unknown origin and 1 who had recurrent fevers and an acute abdomen. In gynecologic practice, factitious illness should be suspected whenever a patient presents with a protracted illness that has eluded diagnosis. Furthermore, the index of suspicion for factitious illness should be high whenever a patient has an abnormal psychiatric history or has worked in a paramedical field." }, { "id": "article-69_8", "title": "Somatic Symptom Disorder -- History and Physical", "score": 0.009230484646688865, "content": "In addition to a thorough history, a full review of systems (not only at the location of the symptom) and a comprehensive physical exam is required to evaluate physical causes of somatic complaints. Given frequent comorbid psychiatric disease, a mental status examination should be performed, noting appearance, mood, affect, attention, memory, concentration, orientation, the presence of hallucinations or delusions, and suicidal or homicidal ideation. [8] Ultimately, the physical examination may provide a baseline for monitoring over time, assure patients that their complaints are acknowledged, and help validate the primary care provider’s concern that the patient does not have a physical medical illness. If a disease is present, the exam may provide information on severity." }, { "id": "wiki20220301en100_46724", "title": "Medically unexplained physical symptoms", "score": 0.009205004355055824, "content": "The term medically unexplained symptoms is in some cases treated as synonymous to older terms such as psychosomatic symptoms, conversion disorders, somatic symptoms, somatisations or somatoform disorders; as well as contemporary terms such as functional disorders, bodily distress, and persistent physical symptoms. The plethora of terms reflects imprecision and uncertainty in their definition, controversy, and care taken to avoid stigmatising sufferers. Risk factors for medically unexplained symptoms are complex and include both psychological and organic features, and such symptoms are often accompanied by other somatic symptoms attributable to organic disease. As such it is recognised that the boundary defining symptoms as medically unexplained is increasingly becoming blurred." }, { "id": "wiki20220301en494_12384", "title": "Functional neurologic disorder", "score": 0.009174311926605505, "content": "Patients with functional movement disorders and limb weakness may experience symptom onset triggered by an episode of acute pain, a physical injury or physical trauma. They may also experience symptoms when faced with a psychological stressor, but this isn't the case for most patients. Patients with functional neurological disorders are more likely to have a history of another illness such as irritable bowel syndrome, chronic pelvic pain or fibromyalgia but this cannot be used to make a diagnosis. FND does not show up on blood tests or structural brain imaging such as MRI or CT scanning. However, this is also the case for many other neurological conditions so negative investigations should not be used alone to make the diagnosis. FND can, however, occur alongside other neurological diseases and tests may show non-specific abnormalities which cause confusion for doctors and patients." }, { "id": "pubmed23n0098_3130", "title": "Excess medical care of women with somatization disorder.", "score": 0.009174311926605505, "content": "We compared 50 women with somatization disorder to 25 women with major depression. The somatizers had three times as many operations and hospitalizations as the depressed women. Hospitalizations for headache and backache, abdominal and pelvic operations, and radiologic studies for abdominal complaints occurred frequently in the somatizers. Important factors in the excess medical care of these women were the difficulty in diagnosis and the unwillingness of physicians to use the diagnosis of somatization disorder to limit medical care. Even though somatization disorder has been well described in the medical literature for 30 years, somatizers still receive excess medical care." }, { "id": "wiki20220301en029_45760", "title": "Conversion disorder", "score": 0.00909090909090909, "content": "Sensory symptoms or deficits: Impaired vision (hysterical blindness), double vision Impaired hearing (deafness) Loss or disturbance of touch or pain sensation Conversion symptoms typically do not conform to known anatomical pathways and physiological mechanisms. It has sometimes been stated that the presenting symptoms tend to reflect the patient's own understanding of anatomy and that the less medical knowledge a person has, the more implausible are the presenting symptoms. However, no systematic studies have yet been performed to substantiate this statement. Diagnosis Definition Conversion disorder is now contained under the umbrella term functional neurological symptom disorder. In cases of conversion disorder, there is a psychological stressor. The diagnostic criteria for functional neurological symptom disorder, as set out in DSM-5, are:" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 186, 386 ] ], "word_ranges": [ [ 28, 62 ] ], "text": "angiotensin II receptor blockers have demonstrated their efficacy in this field for type 2 DM, which together with the side effects that IECAS produce in the patient makes an ARAII the drug of choice." }, "2": { "exist": true, "char_ranges": [ [ 186, 386 ] ], "word_ranges": [ [ 28, 62 ] ], "text": "angiotensin II receptor blockers have demonstrated their efficacy in this field for type 2 DM, which together with the side effects that IECAS produce in the patient makes an ARAII the drug of choice." }, "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": "Angiotensin converting enzyme inhibitor.", "2": "Angiotensin receptor blocker.", "3": "Calcium antagonist.", "4": "Alpha-blocker.", "5": "Beta-blocker." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0407_6951", "title": "Effects of dual blockade of the renin-angiotensin system in primary proteinuric nephropathies.", "score": 0.01537744641192917, "content": "Blockade of the renin-angiotensin system (RAS) with angiotensin converting enzyme (ACE) inhibitors or with angiotensin II type 1 (AT1) receptor blockers has been shown to reduce proteinuria and to slow down the progression of renal disease in diabetic and non-diabetic primary proteinuric nephropathies. Additionally, this beneficial effect is not dependent on blood pressure control. To assess and compare the effects of lisinopril (up to 40 mg/day), candesartan (up to 32 mg/day) and combination therapy (lisinopril up to 20 mg/day plus candesartan up to 16 mg/day) on urinary protein excretion, 45 patients with primary proteinuric nephropathies (urinary protein/creatinine ratio 3.8+/-2.4 g/g) and normal or slightly reduced renal function (CCr 95+/-33 mL/min) were enrolled in a six month multicenter, prospective, open, randomized, active-controlled and parallel-group trial with 1:1:1 allocation. Blood pressure goal was set at or below 125/75 mm Hg for all patients, with additional antihypertensive medication prescribed if required. Renal function, estimated by creatinine clearance, remained stable throughout the study. Hyperkalemia (K&gt;5.5 mmol/L) was detected in 3.1% of all measurements in follow-up, and was more frequent in patients treated with lisinopril alone or lisinopril plus candesartan (P&lt;0.001) than in those on candesartan alone. No other relevant adverse event was recorded. The blood pressure goal (&lt;125/75 mm Hg) was achieved by week 4 in all treatment groups (P&lt;0.005 when compared to baseline), and afterwards the mean systolic and diastolic blood pressure remained below these values until the end of the trial with no statistically significant differences between groups. Urinary protein/creatinine ratio (percentage reduction 95% confidence intervals CI) decreased in patients treated with lisinopril alone to -33% (CI -12-56) to -31% (CI 0-68) and to -50% (CI -9-90), in patients treated with candesartan to -28% (CI -12-45), to -41% (CI -30-52) and to -48% (CI -32-63), in patients treated with the combination of both to -60% (CI -44-77) to -54% (CI -38-69) and to -70% (CI -57-83) at two, three, and six months, respectively. All comparisons with baseline achieved statistical significance and treatment with combination therapy was statistically more effective in proteinuria reduction than treatment with candesartan alone at two and six months (P=0.004 and P=0.023, respectively) and than treatment with lisinopril only at two months (P=0.03). Dual blockade of the renin-angiotensin system with ACE inhibitors and AT1 receptor blockers produces a beneficial antiproteinuric effect that could not be explained only by the systemic blood pressure reduction. All treatments were well tolerated." }, { "id": "pubmed23n0410_4125", "title": "Pharmacologic management of diabetic nephropathy.", "score": 0.0152485836818976, "content": "Diabetes mellitus and hypertension are leading causes of end stage renal disease in the United States. Drug therapy that focuses on tight glycemic control and blood pressure control reduces the progression of nephropathy and cardiovascular complications. Angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce the progression of renal disease in patients with diabetes. The angiotensin II receptor blockers (ARBs) losartan and irbesartan have also been shown to reduce microalbuminuria compared with placebo. The nondihydropyridine calcium channel blockers (CCBs) verapamil and diltiazem have been shown to be as effective as an ACE inhibitor in reducing urinary albumin excretion. This paper reviews the pathophysiology and diagnosis of diabetic nephropathy and recent clinical trials assessing the most appropriate therapeutic options for delaying the progression of nephropathy in patients with diabetes. Primary and review articles that addressed the pathophysiology, diagnosis, and therapeutic options for attenuating the progression of diabetic nephropathy were retrieved through a MEDLINE search (January 1990 to August 2002) and the bibliographies of identified articles were reviewed. English-language sources were searched using the following search terms: diabetes mellitus, nephropathy, proteinuria, ACE inhibitors, and ARBs. Studies published in peer-reviewed journals that were determined to be methodologically sound, with appropriate statistical analysis of the results, were selected for inclusion in this review. Patients with type 1 diabetes mellitus and evidence of nephropathy should be started on an ACE inhibitor unless contraindicated. The ARBs and ACE inhibitors are viable choices for patients with type 2 diabetes mellitus and evidence of proteinuria. Patients who experience adverse events such as dry cough with ACE inhibitors can be switched to ARBs. Clinical literature suggests that if monotherapy with an ACE inhibitor or ARB does not provide an adequate response, a nondihydropyridine CCB should be added to the regimen. Nondihydropyridine CCBs should also be considered when ACE inhibitors and ARBs are contraindicated. ACE inhibitors and ARBs should be considered first-line therapy for patients with type 2 diabetes mellitus and nephropathy. The ACE inhibitors are still the drug of choice for patients with type 1 diabetes mellitus and evidence of incipient or overt nephropathy. If therapeutic goals are not achieved with an ACE inhibitor or ARB, then the addition of a nondihydropyridine CCB should be considered." }, { "id": "pubmed23n0396_10871", "title": "Current recommendations for the treatment of hypertension: are they still valid?", "score": 0.01414858514148585, "content": "Recent trials have helped to clarify indications for the initial pharmacological therapy of hypertension. Both the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) and World Health Organization-international Society of Hypertension (WHO-ISH) recommendations should be revised. The more recent trials indicate that: (1) diuretics and beta-blockers appear to be as effective in reducing overall morbidity/ mortality as other agents (Swedish Trial in Old Patients with Hypertension [STOP-2], United Kingdom Prospective Diabetes Study [UKPDS], Intervention as a Goal in Hypertension Treatment [INSIGHT], Nordic diltiazem [NORDIL]); (2) the use of an a-blocker results in more cardiovascular events, especially congestive heart failure, when compared with a diuretic (Antihypertensive Therapy and Lipid Lowering Heart Attack Trial [ALLHAT]); (3)the use of an angiotensin-converting enzyme (ACE) inhibitor results in fewer myocardial infarctions and episodes of heart failure than calcium channel blockers in the elderly and in diabetic patients (Fosinopril vs. Amlodipine Cardiovascular Events Randomized Trial [FACET], Appropriate Blood Pressure Control in Diabetes [ABCD], STOP-2) - other data (Captopril Prevention Project [CAPPP]) suggest that the use of an ACE inhibitor is preferred in diabetic patients; (4) overall cardiovascular events are similar with calcium channel blockers compared with a diuretic - however, there are fewer strokes with non-dihydropyridine calcium channel blockers (NORDIL) and a trend towards an increase in heart failure and myocardial infarctions with either a dihydropyridine or non-dihydropyridine calcium channel blockers compared with a diuretic (INSIGHT, NORDIL); (5) angiotensin receptor blockers (ARBs) will decrease proteinuria and slow progression of renal disease in type 2 diabetic patients when compared with regimens that do not include an ARB or an ACE inhibitor (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan [RENAAL], Irbesartan Type II Diabetic Nephropathy Trial [IDNT], Irbesartan Type II Diabetes with Microalbuminuria [IRMA Il]). The debate over initial therapy may be moot. High-risk hypertensive patients should probably be treated initially with combination therapy, one of which should be a diuretic. The use of diuretics and beta-blockers as well as ACE-inhibitors alone or with a diuretic should be considered as initial therapy (a change from JNCVI). Alpha-blockers should be reserved for special situations, i.e. prostatic hypertrophy (in contrast to WHO-ISH recommendations). An ACE-inhibitor or ARB, usually along with a diuretic, can be considered as preferred therapy in hypertensive diabetic patients. Some data suggest equal or greater reduction in strokes with a calcium channel blocker than other medications." }, { "id": "pubmed23n0419_17151", "title": "[Renoprotective effect of triple therapy with low-dose angiotensin receptor blocker, low-dose diuretic and Ca-antagonist in hypertensive type 2 diabetic patients with overt nephropathy].", "score": 0.014034068912117692, "content": "Combination therapy with angiotensin receptor antagonist(ARB) plus angiotensin converting enzyme inhibitor(ACE-I) (ARB/ACE-I) was efficacious in reducing proteinuria in patients with progressive renal disease. However, this therapy may be associated with the worsening of anemia and hyperkalemia. The present study addressed whether or not triple therapy with low-dose ARB, low-dose diuretic (D) and calcium channel blocker(CCB) (ARB/D/CCB) is as effective as therapy with low-dose ARB/ACE-I in retarding the progression of overt diabetic nephropathy. In the triple therapy, the patients were initially subjected to monotherapy with CCB for 24 weeks. Low-dose ARB and low-dose D were added to the treatment for an additional 24-week period. In parallel, patients undergoing double therapy were initially treated with low-dose ACE-I alone for 24 weeks, and then low-dose ARB was added for an additional 24-week period. The results were as follows: 1) In the triple therapy, blood pressure was reduced by 9 mmHg in systole and 5 mmHg in diastole (not significant) compared to monotherapy with CCB. There was a significant decline in proteinuria (3.3 +/- 1.2 g/day in the CCB-treated period vs. 2.1 +/- 1.0 g/day in the ARB/D/CCB-treated period, n = 12, p = 0.0143). Furthermore, a significant improvement in the slope of reciprocal serum creatinine concentration(1/Cr) was found in response to triple therapy(1/Cr: -0.0118 +/- 0.0009 in the CCB-treated vs. -0.0035 +/- 0.0028(I/mg/dl/month) in the ARB/D/CCB-treated period, n = 12, p &lt; 0.001). There was neither a worsening of anemia nor an increase in the serum potassium(K) concentration. 2) In the double therapy, blood pressure was reduced by 12 mmHg in systole(p = 0.0079, n = 11) and 6 mmHg in diastole(n = 11, p = 0.0037) compared to the monotherapy with ACE-I. A significant improvement in the slope of 1/Cr was found in the double therapy(1/Cr: -0.0095 +/- 0.0052 in the ACE-I treated period vs. -0.0029 +/- 0.0028(I/mg/dl/month) in the ARB/ACE-I, n = 11, p &lt; 0.001). In addition, there was a substantial reduction in hematocrit and increase in serum K concentration. The present result suggests that triple therapy consisting of ARB/D/CCB is as efficacious as double therapy with ARB/ACE-I in protecting the kidney from the progression in patients with diabetic overt nephropathy. The former may be expected to have less adverse effects." }, { "id": "wiki20220301en043_69825", "title": "Diabetic nephropathy", "score": 0.01402067095899695, "content": "Blood pressure control: Multiple randomized clinical trials have demonstrated a benefit of decreasing systolic blood pressure to <140 mmHg in patients with diabetic nephropathy. High blood pressure is associated with accelerated development of microalbuminuria, over proteinuria and declining kidney function. Angiotensin-converting-enzyme inhibitors, as well as angiotensin II receptor blockers, are particularly helpful in patients with diabetes to lower blood pressure and slow the progression of nephropathy. More intensive blood pressure lower (125-130/<80) in patients with diabetic mellitus has been shown to decrease the risk of progression of diabetic nephropathy as well as other diabetic complications. Some patients might require dual therapy to adequately control pressure, in which case calcium channel blockers or diuretics are a good second-line option." }, { "id": "wiki20220301en026_111808", "title": "Angiotensin II receptor blocker", "score": 0.013790370517138894, "content": "Medical uses Angiotensin II receptor blockers are used primarily for the treatment of hypertension where the patient is intolerant of ACE inhibitor therapy primarily because of persistent and/or dry cough. They do not inhibit the breakdown of bradykinin or other kinins, and are thus only rarely associated with the persistent dry cough and/or angioedema that limit ACE inhibitor therapy. More recently, they have been used for the treatment of heart failure in patients intolerant of ACE inhibitor therapy, in particular candesartan. Irbesartan and losartan have trial data showing benefit in hypertensive patients with type 2 diabetes, and may delay the progression of diabetic nephropathy. A 1998 double-blind study found \"that lisinopril improved insulin sensitivity whereas losartan did not affect it.\" Candesartan is used experimentally in preventive treatment of migraine. Lisinopril has been found less often effective than candesartan at preventing migraine." }, { "id": "wiki20220301en024_705", "title": "Antihypertensive drug", "score": 0.013707909942219567, "content": "The ratio of CCBs' anti-proteinuria effect, non-dihydropyridine to dihydropyridine was 30 to -2. ACE inhibitors ACE inhibitors inhibit the activity of angiotensin-converting enzyme (ACE), an enzyme responsible for the conversion of angiotensin I into angiotensin II, a potent vasoconstrictor. captopril enalapril fosinopril lisinopril moexipril perindopril quinapril ramipril trandolapril benazepril A systematic review of 63 trials with over 35,000 participants indicated ACE inhibitors significantly reduced doubling of serum creatinine levels compared to other drugs (ARBs, α blockers, β blockers, etc.), and the authors suggested this as a first line of defense. The AASK trial showed that ACE inhibitors are more effective at slowing down the decline of kidney function compared to calcium channel blockers and beta blockers. As such, ACE inhibitors should be the drug treatment of choice for patients with chronic kidney disease regardless of race or diabetic status." }, { "id": "pubmed23n0045_7837", "title": "Effects of ACE inhibition supplementary to beta blockers and diuretics in early diabetic nephropathy.", "score": 0.013079616893801948, "content": "Angiotensin converting enzyme (ACE) inhibition has shown promising results in diabetic nephropathy, but long-term results on survival are not available. In a cohort of patients receiving antihypertensive treatment predominantly consisting of beta blockers in combination with diuretics, support for an improved survival has been presented. Addition of ACE inhibition to such a combination treatment may be favorable both due to the suggested renoprotective effects of ACE inhibitors and because diuretics activate the renin-angiotensin system. In 10 insulin-dependent diabetic patients with early diabetic nephropathy [urinary albumin excretion rate (UAE) less than 100o micrograms/min], who were receiving continuous therapy with metoprolol and bendroflumethiazide, a double-blind crossover study with four months addition of ramipril 5 mg (Ramace) and placebo was conducted. UAE (radioimmunoassay) and fractional albumin excretion were significantly reduced after the four months of ramipril administration [UAE: 114.1 x/divided by 1.3 (geometric mean x/divided by confidence factor] versus 174.6 x/divided by 1.2 micrograms/min, 2P less than 0.005). Renal plasma flow (clearance of 131I-hippuran) tended to increase [497 +/- 25 (mean +/- SE) vs. 464 +/- 28 ml/min/1.73 m2, 2P = 0.08], while GFR (125I-iothalamate) stayed unchanged (121 +/- 8 vs. 120 +/- 9 ml/min/1.73 m2). Mean arterial pressure during clearance studies fell moderately (95 +/- 3 vs. 101 +/- 1 mm Hg, 2P less than 0.05) and renal resistance was decreased (2P less than 0.03). ACE activity was suppressed in all patients. Twenty-four-hour ambulatory blood pressure measurements were not significantly different after the two periods (daytime averages: 91 +/- 2 vs. 93 +/- 2, nighttime 80 +/- 2 vs. 84 +/- 3 mm Hg).(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0296_21318", "title": "Calcium channel blockers versus other antihypertensive therapies on progression of NIDDM associated nephropathy.", "score": 0.012987540078736962, "content": "Treatment of hypertension with ACE inhibitors in diabetic patients reduces proteinuria and slows progression of nephropathy compared with agents that do not maintain declines in proteinuria. Calcium channel blockers (CCBs) have variable effects on proteinuria; their long-term effects on progression of diabetic nephropathy are not known. The current study examines the hypothesis that CCBs that maintain reductions in proteinuria slow progression of nephropathy associated with non-insulin dependent diabetes mellitus (NIDDM) by a degree comparable to ACE inhibitors, given similar levels of blood pressure control. To test this hypothesis we randomized 52 patients with NIDDM associated nephropathy and hypertension, mean age of 63 +/- 8 years, to either the ACE inhibitor, lisinopril (N = 18), nondihydropyridine CCBs (NDCCBs), verapamil SR (N = 8) or diltiazem SR (N = 10), or the beta blocker, atenolol (N = 16). Goal blood pressure was &lt; or = 140/90 mm Hg. Patients were followed for a mean period of 63 +/- 7 months. The primary end point was change in creatinine clearance (CCr) slope in each group. There was no significant difference in mean arterial pressure reduction among the groups over the study period (P = 0.14). The mean rate of decline in CCr was greatest in the atenolol group (-3.48 ml/min/year/1.73 m2; P &lt; 0.0001). There was no difference in the CCr slopes between lisinopril and NDCCBs groups (P = 0.36). Proteinuria was reduced to a similar extent in the lisinopril and NDCCBs groups (P &gt; 0.99). Therefore, in persons with renal insufficiency secondary to NIDDM, similar levels of blood pressure control with either lisinopril or NDCCBs slowed progression of renal disease to a greater extent than atenolol. Moreover, this enhanced slowing of renal disease progression correlated with sustained and significant reductions in proteinuria, findings not observed in the atenolol group." }, { "id": "pubmed23n0381_8510", "title": "Diabetics with hypertension not controlled with ACE inhibitors: alternate therapies.", "score": 0.012790127492644654, "content": "If hypertension in patients with diabetes mellitus type II is not adequately controlled by angiotensin-converting enzyme inhibitors (ACE-i), a beta-blocker is frequently added as second-line therapy. Recently, large randomized trials demonstrated the beneficial effect of second-generation dihydropyridine calcium-channel blockers in these patients. These compounds are increasingly being used to replace beta-blockers. Withdrawal of beta-blockers may influence diabetic control and may cause rebound hypertension. Any rebound hypertension from beta-blocker withdrawal may not occur if the beta-blocker is replaced with a calcium-channel blocker. A calcium-channel blocker will influence vascular resistance (VR) and blood pressure differently than a beta-blocker. Thirty-four patients with diabetes mellitus type II and a resting diastolic blood pressure above 90 mm Hg despite enalapril 10 mg daily (or equipotent dosages of other ACE-i) for at least 3 months were treated in an open label sequential comparison with the same ACE-i in combination with the beta-blocker metoprolol 100 mg for 3 months, and, subsequently for 3 more months with the same ACE-i in combination with the dihydropyridine calcium-channel blocker lercanidipine 10 mg once daily. After 6 weeks, patients with a diastolic blood pressure above 90 mm Hg were titrated up to 200 mg metoprolol or 20 mg lercanidipine once daily. Patients were examined every 6 weeks during the trial, and after 2 weeks while receiving lercanidipine. In addition to blood pressure measurements, VR was measured by iridium strain gauge plethysmography and expressed in units (1 unit = 1 mm Hg/mL blood/100 mL tissue per minute). Two of 34 patients did not complete the protocol because of non-compliance with the lercanidipine treatment in the first 2 weeks of treatment. Their data are included in the analysis. No rebound hypertension 14 days after the change-over of therapies was observed. (Mean arterial pressures [MAPs] were not significantly different from the point of withdrawal of the beta-blockers.) However, heart rate rose from 69+/-7 to 94+/-10 beats/min (p &lt; 0.001). After 3 months on lercanidipine, MAP fell by 6+/-10 mm Hg (p = 0.002) compared to the point of withdrawal of the beta-blocker. Vascular resistance fell by 6.28+/-11.91 units (p&lt;0.01), while glucosylated hemoglobin (HbA1c) rose by 0.4+/-0.5% (p&lt;0.001) and body weight rose by 0.6+/-0.6 kg (p &lt; 0.01). Multiple regression analysis revealed significant associations between decrease in VR, increase in HbAlc, and decrease in MAP, and partial dependence of these variables on one another. In hypertensive patients with diabetes type II, replacement of ACE-i and metoprolol with ACE-i and lercanidipine does not appreciably influence metabolic control and does not cause rebound hypertension. Lercanidipine was more effective than metoprolol as a second-line antihypertensive drug in these patients. At least two mechanisms may be involved: withdrawal of a pressor effect from the beta-blocker, and calcium-channel-mediated vasodilation." }, { "id": "pubmed23n0527_12033", "title": "[Can angiotensin-converting enzyme inhibitor be used in chronic kidney disease patients with serum creatinine level greater than 266 micromol/L?].", "score": 0.012616674576807468, "content": "Angiotensin-converting enzyme inhibitor (ACEI) has been demonstrated to have protective effect for patients with mild to moderate chronic kidney disease (CKD). However, little evidence is available for the benefit or side-effects of ACEI in treating patients with more severe CKD. A prospective, randomized controlled trial was performed to evaluate the renal protective effect and safety of ACEI in patients whose serum creatinine (Scr) levels were higher than 265 micromol/L. 168 CKD patients took benazepril for two months. 21 patients quitted the trial because of cough. The remaining 147 CKD patients were divided into two groups according to their Scr levels. Patients with Scr 133 - 265 micromol/L were included in group A (n = 55), and those with Scr 266-442 micromol/L were included in group B (n = 92). Furthermore, group B were divided randomly into two subgroups, B1 (n = 47) and B2 (n = 45). Benazepril was given (10 - 20 mg/d) as an intervention for group A and group B1. Additional calcium-channel antagonist and/or beta-blocker and/or vasodilator were used for blood pressure control in those two groups. Patients in group B2 served as controls who take calcium-channel antagonist and/or beta-blocker and/or vasodilator but not Benazepril. The target blood pressure is 125/75 mm Hg or less in all groups. All patients were followed for two years. Doubling of the baseline Scr level or end-stage renal disease with the need for dialysis was regarded as the major end point of the trial. (1) The magnitude of mean arterial pressure reduction was comparable in group A [(12.90 +/- 3.21) mm Hg], group B1 [(13.36 +/- 4.27) mm Hg] and group B2 [(10.38 +/- 3.85) mm Hg]. There was no significant change among them (P &gt; 0.05 in all). (2) The magnitude of urinary protein reduction (Delta) in group A [(0.52 +/- 0.29) g/24 h], group B1 [(0.50 +/- 0.26) g/24 h] were much higher than that in group B2 [(0.19 +/- 0.13) g/24 h] (P &lt; 0.05), but there was no significant difference between group A and B1 (P = 0.94). (3) By the end of two years, the percentages of cases reaching the major end point in group A, group B1 and group B2 were 19.23%, 40.90% and 51.35% respectively. There was significant difference among the three groups (chi(2) = 12.14, upsilon = 2, P = 0.002). (4) After two years of treatment, the left ventricular mass indexes and the percentages of left ventricular hypertrophy in group A, group B1 and group B2 were all decreased significantly. There were no statistical differences among the three groups. (5) The incidence of ACEI related adverse reactions, such as rapid increase of Scr more than 30%, dry cough or hyperkalemia were not different among the three groups. Benazepril slows the progression of CKD in patients with Scr higher than 266 micromol/L, it is safe in these patients." }, { "id": "wiki20220301en024_706", "title": "Antihypertensive drug", "score": 0.01247457627118644, "content": "However, ACE inhibitors (and angiotensin II receptor antagonists) should not be a first-line treatment for black hypertensives without chronic kidney disease. Results from the ALLHAT trial showed that thiazide-type diuretics and calcium channel blockers were both more effective as monotherapy in improving cardiovascular outcomes compared to ACE inhibitors for this subgroup. Furthermore, ACE inhibitors were less effective in reducing blood pressure and had a 51% higher risk of stroke in black hypertensives when used as initial therapy compared to a calcium channel blocker. There are fixed-dose combination drugs, such as ACE inhibitor and thiazide combinations. Notable side effects of ACE inhibitors include dry cough, high blood levels of potassium, fatigue, dizziness, headaches, loss of taste and a risk for angioedema. Angiotensin II receptor antagonists" }, { "id": "wiki20220301en026_111807", "title": "Angiotensin II receptor blocker", "score": 0.012011427087391249, "content": "Angiotensin II receptor blockers (ARBs), formally angiotensin II receptor type 1 (AT1) antagonists, also known as angiotensin receptor blockers, angiotensin II receptor antagonists, or AT1 receptor antagonists, are a group of pharmaceuticals that bind to and inhibit the angiotensin II receptor type 1 (AT1) and thereby block the arteriolar contraction and sodium retention effects of renin–angiotensin system. Their main uses are in the treatment of hypertension (high blood pressure), diabetic nephropathy (kidney damage due to diabetes) and congestive heart failure. They selectively block the activation of the AT1 receptor, preventing the binding of angiotensin II compared to ACE inhibitors. ARBs and the similar-attributed ACE inhibitors are both indicated as the first-line antihypertensives in patients developing hypertension along with left-sided heart failure. However, ARBs appear to produce less adverse effects compared to ACE inhibitors." }, { "id": "pubmed23n0058_1419", "title": "Angiotensin converting enzyme inhibitors versus calcium antagonists in the treatment of diabetic hypertensive patients.", "score": 0.011982922541527642, "content": "Angiotensin converting enzyme inhibitors and calcium antagonists are effective agents for controlling high blood pressure in diabetic patients. We selected 30 type II diabetic patients with proteinuria and evaluated the effect of these drugs on renal function and proteinuria. In a double-blind trial, patients received either 40 mg/day enalapril or 40 mg/day nifedipine during 12 months. They also received a hypoproteic diet with 0.8 g/kg wt/day of protein. In the enalapril group (10 men and eight women), mean arterial blood pressure was 112.0 +/- 12 mm Hg, creatinine clearance was 58.6 +/- 12.4 ml/min, and 24-hour proteinuria was 4.36 +/- 3.23 g/24 hr before treatment. After treatment, mean arterial blood pressure was 82.0 +/- 8.30 mm Hg (p less than 0.001), creatinine clearance was 66.6 +/- 13.8 ml/min (NS), and 24-hour proteinuria was 0.56 +/- 0.78 g/24 hr (p less than 0.001). In the nifedipine group (six men and six women), mean arterial blood pressure was 114.0 +/- 8.0 mm Hg, creatinine clearance was 67.8 +/- 19.6 ml/min, and 24-hour proteinuria was 2.84 +/- 1.31 g/24 hr before treatment. After treatment, mean arterial blood pressure was 86.0 +/- 7.0 mm Hg (p less than 0.001), creatinine clearance was 51.4 +/- 7.9 ml/min (p less than 0.001), and 24-hour proteinuria was 2.66 +/- 0.89 g/24 hr (NS). These results show a similar hypotensive action and different renal effects between these two drugs after 12 months of treatment." }, { "id": "wiki20220301en009_184617", "title": "Beta blocker", "score": 0.011956238603803073, "content": "A 2007 study revealed diuretics and beta blockers used for hypertension increase a patient's risk of developing diabetes mellitus, while ACE inhibitors and angiotensin II receptor antagonists (angiotensin receptor blockers) actually decrease the risk of diabetes. Clinical guidelines in Great Britain, but not in the United States, call for avoiding diuretics and beta blockers as first-line treatment of hypertension due to the risk of diabetes." }, { "id": "wiki20220301en043_69811", "title": "Diabetic nephropathy", "score": 0.011941806425540514, "content": "The status of diabetic nephropathy may be monitored by measuring two values: the amount of protein in the urine - proteinuria; and a blood test called the serum creatinine. The amount of the proteinuria reflects the degree of damage to any still-functioning glomeruli. The value of the serum creatinine can be used to calculate the estimated glomerular filtration rate (eGFR), which reflects the percentage of glomeruli which are no longer filtering the blood. Treatment with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, which dilates the arteriole exiting the glomerulus, thus reducing the blood pressure within the glomerular capillaries, which may slow (but not stop) progression of the disease. Three classes of diabetes medications – GLP-1 agonists, DPP-4 inhibitors, and SGLT2 inhibitors– are also thought to slow the progression of diabetic nephropathy." }, { "id": "pubmed23n0495_20670", "title": "[Are all antihypertensive drugs renoprotective?].", "score": 0.011804158283031524, "content": "Blood pressure, together with proteinuria, represents one of the most important factors in the progression of chronic renal failure (CRF). Antihypertensive therapy is beneficial to slow down the progression of a variety of chronic renal diseases, no matter what the cause. Intraglomerular hypertension, increased glomerular permeability and proteinuria should be identified, since they can be treated to prevent or minimize further glomerular injury. But not all antihypertensive drugs are equally effective to prevent the progression of CRF. Recent large trials indicate that blood pressure lowering obtained by intervention in the renin-angiotensin-aldosterone system (RAAS) has an additive renoprotective effect in diabetic and nondiabetic renal diseases. In nondiabetic patients, the AIPRI and REIN studies support that angiotensin-converting enzyme (ACE) inhibitors have a long-term renoprotective effect. The benefits of ACE inhibitors can be demonstrated even in patients who are not hypertensive. Angiotensin II receptor antagonists are shown to be renoprotective in type 2 diabetics (RENAAL and IDNT). However, whether these renoprotective effects are due to blood pressure reduction or due to the specific pharmacologic RAAS blockade is still a matter of debate. This discussion is still open, because the reduction in blood pressure levels was lower in patients treated with a drug that interferes with the RAAS compared with other antihypertensive regimens. It is concluded that both ACE inhibitors and AT II receptor antagonists are lowering the intraglomerular pressure independent of any change in systemic blood pressure by dilatation of the efferent arteriole of the glomerulus. These additional nonpressure-related effects may protect renal function by their antiproteinuric effect. In addition, beneficial effect of ACE inhibitors are related to reduction of AT II, which has potent proinflammatory effects independent of its hemodynamic influences. Other drugs, such as diuretics, beta blockers, and hydralazine, do not induce efferent dilatation and, therefore, may be less likely to reverse intraglomerular hypertension. For example, hydralazine and nifedipine appear to produce prominent afferent or preglomerular arteriolar dilatation. This will allow more of the systemic pressure to be transmitted to the glomerulus. Therefore, short-acting dihydropyridine calcium channel blockers (CCB) are not recommended. By comparison, long-acting dihydropyridines such as diltiazem and verapamil are less potent vasodilators and may primarily decrease the resistance of the efferent arteriole, similar to the ACE inhibitors. They may have an antiproteinuric activity. Yet, there is lack of large prospective randomized trials.A beta blocker as antihypertensive agent is indicated as second- or third-line drug especially in patients with additional cardiovascular disease. Other antihypertensive drugs can be added as necessary to achieve the treatment goals for arterial hypertension. The use of a diuretic will often be helpful in patients who already have renal insufficiency, since fluid overload is an important cause of hypertension and may also enhance the effectiveness of drugs that interfere with the RAAS. alpha(1)-receptor or sympathetic blockers are further possible drugs for combination antihypertensive therapy." }, { "id": "wiki20220301en477_24834", "title": "Management of hypertension", "score": 0.011391606826827234, "content": "Unacceptable combinations are non-dihydropyridine calcium blockers (such as verapamil or diltiazem) and beta-blockers, dual renin–angiotensin system blockade (e.g., angiotensin converting enzyme inhibitor + angiotensin receptor blocker), renin–angiotensin system blockers and beta-blockers, and beta-blockers and centrally acting medications. Combinations of an ACE-inhibitor or angiotensin II–receptor antagonist, a diuretic, and an NSAID (including selective COX-2 inhibitors and non-prescribed medications such as ibuprofen) should be avoided whenever possible due to a high documented risk of acute kidney failure. The combination is known colloquially as a \"triple whammy\" in the Australian health industry. Tablets containing fixed combinations of two classes of medications are available and, while convenient, may be best reserved for those who have been established on the individual components. Additionally, the use of treatments with vasoactive agents for people with pulmonary" }, { "id": "pubmed23n0334_2993", "title": "[Antihypertensive therapy in diabetes mellitus].", "score": 0.011365103964871497, "content": "Approximately 150 million people worldwide have diabetes mellitus, of whom 90% are type II diabetics. It is therefore of no surprise that diabetic nephropathy has become the leading cause of end-stage renal disease. Opposite to what has been known previously, kidney disease is at least as common in type II as in type I diabetes. However, because the majority of type II diabetics has hypertension for many years before diabetes mellitus becomes clinically relevant, renal lesions are often heterogeneous with frequent exclusive presence of ischemic changes. For the treatment of hypertension in diabetics without nephropathy (no microalbuminuria), drugs that exert beneficial effects or are at least neutral with respect to lipid and glucose metabolism, such as ACE inhibitors, angiotensin II-receptor antagonists, non-dihydropyridine-calcium channel blockers and the thiazide-like indapamide, are to be preferred. Although metabolically neutral, dihydropyridine calcium channel blockers should be used with caution, since an increase in cardiovascular morbidity and mortality in type II diabetics treated with these compounds has most recently been described. Once that diabetic nephropathy is established, blood pressure should be lowered to 120/80 mmHg (measured in seated position). Antihypertensive treatment should primarily be based on ACE inhibitors; angiotensin II-receptor antagonists are a valuable alternative if ACE inhibitors are not tolerated. Both ACE inhibitors and angiotensin II-receptor antagonists should be used with high caution in elderly patients with severe atherosclerosis in whom acute renal failure could occur due to the presence of bilateral renal artery stenosis. Newer studies indicate that non-dihydropyridine calcium channel blockers such as verapamil and diltiazem may be as effective as ACE inhibitors in preserving renal function in diabetic nephropathy. A fix-dose combination of the ACE inhibitor trandolapril with verapamil is now available; it should be reserved for patients whose blood pressure and/or proteinuria can not be adequately controlled with ACE inhibitors. Finally, indapamide is the only antihypertensive diuretic with nephroprotective properties." }, { "id": "wiki20220301en024_723", "title": "Antihypertensive drug", "score": 0.011346237970253718, "content": "Chronic kidney disease. ACE inhibitors or ARBs should be included in the treatment plan to improve kidney outcomes regardless of race or diabetic status. Late-stage Dementia should consider Deprescribing antihypertensives, according to the Medication Appropriateness Tool for Comorbid Health Conditions in Dementia (MATCH-D) Diabetes mellitus. The ACE inhibitors and angiotensin receptor blockers have been shown to prevent the kidney and retinal complications of diabetes mellitus. Gout may be worsened by thiazide diuretics, while losartan reduces serum urate. Kidney stones may be improved with the use of thiazide-type diuretics Heart block. β-blockers and nondihydropyridine calcium channel blockers should not be used in patients with heart block greater than first degree. JNC8 does not recommend β-blockers as initial therapy for hypertension" }, { "id": "wiki20220301en008_72961", "title": "Proteinuria", "score": 0.01132665296334361, "content": "Analysis It is possible to analyze urine samples in determining albumin, hemoglobin and myoglobin with an optimized MEKC method. Treatment Treating proteinuria mainly needs proper diagnosis of the cause. The most common cause is diabetic nephropathy; in this case, proper glycemic control may slow the progression. Medical management consists of angiotensin converting enzyme (ACE) inhibitors, which are typically first-line therapy for proteinuria. In patients whose proteinuria is not controlled with ACE inhibitors, the addition of an aldosterone antagonist (i.e., spironolactone) or angiotensin receptor blocker (ARB) may further reduce protein loss. Caution must be used if these agents are added to ACE inhibitor therapy due to the risk of hyperkalemia. Proteinuria secondary to autoimmune disease should be treated with steroids or steroid-sparing agent plus the use of ACE inhibitors." }, { "id": "wiki20220301en035_40479", "title": "Amiloride", "score": 0.011137897782063646, "content": "minimal efficacy. For people with resistant hypertension, already taking a thiazide diuretic, an angiotensin converting enzyme inhibitor (ACE-i) or an angiotensin II receptor blocker (ARB), and a calcium channel blocker, the addition of amiloride (or spironolactone) was better at reducing blood pressure than adding a beta-blocker (bisoprolol) or an alpha-1 blocker (doxazosin). When combined with hydrochlorothiazide, the addition of amiloride had positive effects on blood pressure and blood sugar tolerance. Amiloride may therefore be useful for preventing the metabolic side effects of thiazide diuretics, allowing for the use of higher thiazide doses (in line with how they were originally studied)." }, { "id": "wiki20220301en024_703", "title": "Antihypertensive drug", "score": 0.011101973684210526, "content": "In the United States, the JNC8 (Eighth Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) recommends thiazide-type diuretics to be one of the first-line drug treatments for hypertension, either as monotherapy or in combination with calcium channel blockers, ACE inhibitors, or angiotensin II receptor antagonists. There are fixed-dose combination drugs, such as ACE inhibitor and thiazide combinations. Despite thiazides being cheap and effective, they are not prescribed as often as some newer drugs. This is because they have been associated with increased risk of new-onset diabetes and as such are recommended for use in patients over 65 where the risk of new-onset diabetes is outweighed by the benefits of controlling systolic blood pressure. Another theory is that they are off-patent and thus rarely promoted by the drug industry." }, { "id": "pubmed23n0379_18290", "title": "Outcome survey in unselected hypertensive patients with type 2 diabetes mellitus: effects of ACE inhibition.", "score": 0.01058467741935484, "content": "Although the benefit of angiotensin converting enzyme (ACE) inhibitors in diabetic nephropathy is well documented in double-blind randomized, controlled clinical trials, it is uncertain whether the benefit extends to unselected patients with diabetes mellitus and arterial hypertension in general practice. In 2504 unselected patients with type 2 diabetes mellitus (mean age 63+/-10 years) blood pressure, cardiovascular, renal, and metabolic parameters were assessed at baseline and during a treatment period of 1 year with the ACE inhibitor cilazapril by primary care physicians. The average dose of cilazapril was 2.5 mg/day. Outcome measures were blood pressure, serum creatinine, proteinuria (dip stick), HbA1c levels, evaluation of edema, and exertional dyspnea. In the study cohort, systolic blood pressure decreased by 24+/-17 mm Hg and diastolic blood pressure by 12+/-11 mm Hg. An increase in serum creatinine (&gt; 0.2 mg/dL) occurred more frequently in patients with than in those without renal involvement (19% v 7%; P &lt; .05). Serum creatinine decreased more frequently in patients with renal involvement than in those without (26%+/-4% v 12%+/-3.8%; P &lt; .05). Overall renal function in patients with diabetic nephropathy (n = 318) improved (2.1+/-1.6 mg/dL v 1.7+/-1.4 mg/dL; P &lt; .05). The frequency of proteinuria was lower after 1 year than at baseline (62%+/-9% v 82%+/-8%; P &lt; .05). Metabolic control of diabetes mellitus improved in parallel (median HbA1c 8.0% v 7.0%; P &lt; .01). Scores for edema formation and exertional dyspnea improved as well (P &lt; .01). In this outcome survey of unselected patients with type 2 diabetes mellitus and arterial hypertension, the ACE inhibitor cilazapril effectively lowered blood pressure, which was associated with an improvement in glucose metabolism, cardiac function, and renal function." }, { "id": "wiki20220301en043_69826", "title": "Diabetic nephropathy", "score": 0.009944559944559945, "content": "RAAS inhibition: Inhibition can be achieved with multiple therapies, mainly ACE inhibitors, angiotensin receptor blockers, direct renin inhibitors, and mineralocorticoid antagonists. RAAS inhibition has been proven to be the most effective therapy to slow the progression of diabetic nephropathy in all stages. Although RAAS blockade using more than one agent may further reduce proteinuria, the risk of adverse events (such as hyperkalemia, acute kidney injury) outweigh the potential benefits. Therefore, it is recommended that only one agent is used in patients with DM who have hypertension or any signs of microalbuminuria or diabetic nephropathy." }, { "id": "wiki20220301en038_62585", "title": "Lisinopril", "score": 0.009887650712458895, "content": "Lisinopril is a medication of the angiotensin-converting enzyme (ACE) inhibitor and is considered to be a gold standard drug in the treatment of high blood pressure, and is also used to treat heart failure and after heart attacks. For high blood pressure it is usually a first line treatment. It is also used to prevent kidney problems in people with diabetes mellitus. Lisinopril is taken by mouth. Full effect may take up to four weeks to occur. Within the ACE Inhibitor class, Lisinopril has shown to have less interindividual variability within the drugs, making it a preferable choice for patients with angina and hypertension. Common side effects include headache, dizziness, feeling tired, cough, nausea, and rash. Serious side effects may include low blood pressure, liver problems, high blood potassium, and angioedema. Use is not recommended during the entire duration of pregnancy as it may harm the baby. Lisinopril works by inhibiting the renin–angiotensin–aldosterone system." }, { "id": "pubmed23n0094_8231", "title": "[Prolonged treatment of hypertension in diabetic patients with enalapril. 1-year follow-up].", "score": 0.00980392156862745, "content": "In view of the pharmacological and chemical reasons for using ACE-inhibitors to treat diabetic hypertension, a group of 40 outpatients were treated with Enalapril. The sample consisted of 20 outpatients, 6 males, 14 females aged 48-76 (mean age 63.75), 18 of whom had type II and 2 type I diabetes and 11 under treatment by diet and hypoglycaemic drugs or insulin. All these patients presented slight or moderate essential arterial hypertension (diastolic pressure less than 115 mmHg). For about one year 17 of the patients were given 20 mg/die Enalapril and the remaining three 10 mg/die in a single morning dose. In 16 cases no other treatment was given. In 4 a non-potassium conserving diuretic was also given. Check-ups before six months into and at the end of treatment showed: a statistically significant reduction in systolic (p less than 0.05) and diastolic (p less than 0.01) pressure. In contrast no significant change was noted in heart beat, glycaemia before or after meals, body weight, glycosylated haemoglobin or any other blood chemical parameter considered. In one case only there was a slight increase in proteinuria that was however present at the start of treatment. As far as side effects are concerned there was one case of cardiac palmus during treatment and one case of coughing that regressed totally when treatment was suspended but nothing else of significance. It should be noted that the antidiabetic treatment remained unchanged throughout the period considered in most cases and at most was subjected to minimal qualitative and quantitative adjustments." }, { "id": "pubmed23n0320_11917", "title": "Is antihypertensive treatment the same for NIDDM and IDDM patients?", "score": 0.009708737864077669, "content": "The prevalence of abnormally elevated albumin excretion rate (&gt; 30 mg/24 h) is approximately 40% in insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetic patients. Diabetes has become the leading cause of end-stage renal failure in the US, Japan and Europe. Approximately 90% of the direct and indirect cost of caring for diabetic patients are spent on the complications of diabetes. Identification of patients at high risk of developing diabetic nephropathy is possible by screening for microalbuminuria (30-300 mg/24 h). Elevated urinary albumin excretion rate indicates a substantially increased mortality risk in diabetic patients. Randomised controlled trials in normotensive IDDM and NIDDM patients with persistent microalbuminuria indicate that ACE inhibitors diminish urinary albumin excretion rate, postpone it and may even prevent progression to clinical overt nephropathy. These findings indicate that screening and intervention programs are likely to have life saving effects and lead to considerable economic savings. Systemic blood pressure elevation to a hypertensive level is an early and frequent phenomenon in diabetic nephropathy. Furthermore, nocturnal blood pressure elevation (non-dippers) occurs more frequently in patients with nephropathy. Systemic blood pressure elevation and to a lesser degree albuminuria accelerate the progression of diabetic nephropathy. Effective blood pressure reduction with non-ACE-inhibitors and/or ACE-inhibitors frequently in combination with diuretics: (a) reduces albuminuria; (b) delays the progression of nephropathy; (c) postpones renal insufficiency; and (d) improves survival in IDDM and NIDDM patients with diabetic nephropathy. A specific renal protective effect of ACE-inhibitors in diabetic nephropathy has been demonstrated in IDDM patients with moderately reduced kidney function (s-creatinine &gt; 133 mumol/l) while the data conflict with NIDDM patients. Antihypertensive treatment for diabetic nephropathy simultaneously extends life and saves money. Finally, reduced risk of fatal and non-fatal cardiovascular events have been demonstrated when diabetic patients with isolated systolic hypertension are treated with blood pressure lowering agents. Absolute risk reduction with active treatment compared to placebo was twice as great for the diabetic versus non-diabetic patients (101/1000 versus 51/1000 randomised participants at the 5-year follow-up), reflecting the higher risk of diabetic patients. In conclusion, early detection and aggressive treatment of arterial hypertension with ACE-inhibitors, long acting calcium antagonist and low dose diuretics as first line drugs are highly warranted in diabetic patients with or without diabetic renal disease." }, { "id": "pubmed23n0755_2282", "title": "2 year followup of patients with diabetes mellitus nephropathy showing albuminuria reversal following angiotensin converting enzyme inhibitors.", "score": 0.009615384615384616, "content": "Two-year follow-up of patients with diabetes mellitus (DM) nephropathy shows albuminuria reversal following angiotensin converting enzyme (ACE) inhibitors. To study about a clinical profile of 2-year follow-up of patients with DM nephropathy showing albuminuria reversal following ACE inhibitors. Twenty patients were taken up for study with duly informed consent and suggested for glycemic profile with HbA1C. Baseline renal function, urine microscopy, albuminuria, and other microvascular complications such as neuropathy and retinopathy. These patients were followed up for a period of 2 years with every month follow-up and monthly dose titration of ACE inhibitors, enalapril (Quote: Dr. M. K. Mani), to a maximum tolerable dose and checked after 1 week for raise in creatinine and potassium. Twenty patients, who have attended a secondary level diabetic clinic with diabetic nephropathy and are on regular follow-up for 2 years, were selected. Sick patients requiring parenteral feeds, IV antibiotics, co-morbid conditions such as autonomic gastroparesis and diabetic foot infections, type 1 diabetes and other known kidney disease, chronic kidney disease on dialysis are excluded from the study. EXPECTED RESULT: Reversal of albuminuria. Enalapril is a safe, cheaper ACE inhibitors and the good dose titration coupled with early screening for DM nephropathy really help in halting the progression of chronic kidney disease from DM nephropathy." }, { "id": "pubmed23n0231_1331", "title": "Antihypertensive treatment inhibiting the progression of diabetic nephropathy.", "score": 0.009523809523809525, "content": "In 6 male insulin-dependent proteinuric long-term diabetics aged 26-35 years the rate of progression of nephropathy was followed for an initial control period of 2.0 years and subsequently for 4.1 years during antihypertensive therapy with a beta-receptor blocker combined with Hydralazine and Furosemide. GFR and urinary albumin excretion was measured 3-4 times before and 9-14 times during treatment. Systolic blood pressure was reduced significantly from 162 +/- 14 (SD) mm Hg before treatment to 146 +/- 9 (SD) as a mean during the whole treatment period (2p = 0.002). Diastolic pressure was also reduced significantly, from 103 +/- 9 (SD) mm Hg to 95 +/- 8 (SD), (2p = 0.025). After 49 days of treatment there was a significant fall in albumin clearance as a per cent of GFR from 0.243 +/- 0.28 (SD) to 0.170 +/- 0.20 (SD), (2p &lt; 0.001 for percentage change) with no change in GFR. In five patients the fall rate of GFR was in the initial control period 1.24 ml/min/month +/- 0.8 (SD). In the period when antihypertensive therapy was given it was reduced to 0.45 ml/min/month +/- 0.5 (SD) (2p = 0.037). In the 6th patient there was no decline in GFR neither before, nor during treatment. Before treatment there was a mean yearly percentage increase in albumin excretion of 107 per cent. During treatment this yearly increase was reduced to--7 per cent (2p = 0.002 for differences in slope). The results indicate that the state of renal insufficiency in diabetic patients with nephropathy and moderately increased blood pressure can be postponed by antihypertensive treatment. Other trials should be carried out to define the optimal scheme of treatment." }, { "id": "pubmed23n0504_7306", "title": "[Lercanidipine in diabetic patients with renal failure].", "score": 0.009462759462759464, "content": "To evaluate the safe use of a new calcium channel blocker, lercanidipine, in diabetic chronic renal failure (CRF) patients. The study recruited 42 diabetic CRF patients (creatinine &gt; 1.4 mg/dl for males, creatinine &gt; 1.2 mg/dl for females, or creatinine clearance &lt; 70 ml/min). Mean age was 68.2 +/- 9.1 years. 53.8% were males and 46.2% females. Three patients were type 1 diabetics and 39 ones were type II. All patients were receiving ACE inhibitors (67.4%) or angiotensin II antagonist (32.6%) therapy but they had higher blood pressure than recommended for CRF patients (130/85 mmHg). No patients were under diuretic treatment. Patients were clinically evaluated 1, 3 and 6 months after starting treatment with lercanidipine. Samples for urine and blood examination were taken during the examination. When needed, a third drug was added to treatment, excluding diuretics. Creatinine clearance was measured using 24 h urine collection. BP significantly decrease from 163 +/- 18/90 +/- 8 mmHg to 134 +/- 12/77 +/- 9 mmHg. One half of patients showed significant reduction of blood pressure, 26.7% reached the target blood pressure (&lt; 130/85 mmHg) and 20.0% gets optimal BP control (&lt; 130/85 mmHg). No one patient showed untoward effects. No edema was detected nor adverse effects related to vasodilatation were found. Plasmatic creatinine did not change (1.9 +/- 0.5 baseline vs 1.8 +/- 0.5 mg/dl) and creatinine clearance increased at the end visit (40.1 +/- 14.5 baseline vs 45.4 +/- 18.2 ml/min) but the difference was not significant. Proteinuria was unchanged. Lercanidipine showed a good antihypertensive effect in diabetics CRF patients. It has a good tolerability profile and showed neutral effect on plasmatic lipids. Neither impairment of renal function nor increment in proteinuria were detected." }, { "id": "pubmed23n0383_6477", "title": "A clinical trial in type 2 diabetic nephropathy.", "score": 0.009433962264150943, "content": "A prospective, randomized, three-armed, double-blind, placebo-controlled clinical trial has been completed in 210 sites worldwide to determine whether the angiotensin II receptor blocker irbesartan or the calcium channel blocker amlodipine has a renoprotective effect in patients with overt type 2 diabetic nephropathy. A total of 1,715 subjects randomized during a 3-year period were followed a minimum of 2 years. The goal for all treatment groups was to achieve equivalent blood pressure control, with the blinded study drug (irbesartan, amlodipine, or placebo) as primary therapy with additional antihypertensive drugs, excluding angiotensin-converting enzyme inhibitors, calcium antagonists, and angiotensin II receptor antagonists, to achieve seated systolic blood pressure less than 135 mm Hg and diastolic blood pressure less than 85 mm Hg. The primary outcome was the combined endpoint of time to doubling of entry serum creatinine, end-stage renal disease, or death. Secondary outcomes included fatal and nonfatal cardiovascular events. A Clinical Management Committee monitored the conduct of the study. An Outcome Confirmation Committee classified all study outcome events in blinded fashion. An external Data Safety Monitoring Committee monitored unblinded data for interim safety and efficacy analyses of the study. Eligibility criteria included informed consent, age 30 to 70 years, adult-onset diabetes, hypertension, urine protein excretion greater than 900 mg/24 hours, and serum creatinine values of 90 to 265 micromol/L in women and 110 to 265 micromol/L in men. Baseline characteristics were age, 59 +/- 8 years; body mass index, 31 +/- 7 kg/m(2); 67% male; 73% white, 14% black, and 13% other; duration of diabetes, 15 +/- 9 years; retinopathy, 66%; neuropathy, 48%; congestive heart failure, 7.5%; screening seated systolic blood pressure, 156 +/- 18 mm Hg, and diastolic blood pressure, 85 +/- 11 mm Hg; urine protein excretion, 4.0 +/- 3.5 g/24 hours; serum creatinine, 150 +/- 53 micromol/L; serum potassium, 4.6 +/- 0.5 mEq/L; total cholesterol, 229 +/- 58 mg/dL; and hemoglobin A(1c), 8.1 +/- 1.7%. This large-scale international trial should help define the clinical course and standards of care for hypertensive adults with type 2 diabetes mellitus and nephropathy. Results available on May 19, 2001, will help in defining the current controversy of the risks and benefits of blockade of the renin-angiotensin system versus calcium channel blockade versus standard antihypertensive therapy in this large patient population." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 1201, 1350 ] ], "word_ranges": [ [ 181, 205 ] ], "text": "we found that it had neuroectodermal and embryonal elements in several of the histological preparations, so we consider that the correct answer is 2." }, "3": { "exist": true, "char_ranges": [ [ 1201, 1350 ] ], "word_ranges": [ [ 181, 205 ] ], "text": "we found that it had neuroectodermal and embryonal elements in several of the histological preparations, so we consider that the correct answer is 2." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

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

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0622_6174", "title": "Adenocarcinoma arising from the respiratory ciliated epithelium in a benign cystic teratoma of the ovary.", "score": 0.015838509316770187, "content": "Benign cystic teratoma of the ovary (BCTO) is the most common benign ovarian tumor, accounting for 15-20% of all ovarian tumors. It is usually diagnosed in the third and fourth decades of life. Malignant transformation is rare, occurring in approximately 1-2% of reported cases, with squamous cell carcinoma being the most common form. Adenocarcinoma arising from mature cystic teratoma is extremely rare. We present the patient with a BCTO, where a malignant transformation of respiratory ciliated epithelium resulted in well differentiated adenocarcinoma. Although respiratory epithelium is often found in BCTOs, adenocarcinoma arising from this cell type is uncommon. To our knowledge, this is the fourth reported case of adenocarcinoma arising from the respiratory epithelium of a BCTO." }, { "id": "pubmed23n0721_21912", "title": "Malignant transformation of ovarian mature cystic teratoma with a predominant pulmonary type small cell carcinoma component.", "score": 0.015751937984496124, "content": "A 68-year-old woman was diagnosed with mature cystic teratoma of the left ovary when she was 44 years old. The tumor recently enlarged rapidly, and abdominal magnetic resonance imaging revealed an intrapelvic cystic lesion, which measured 123 × 120 × 107 mm and contained a mural nodule. Under a clinical diagnosis of malignant transformation of mature cystic teratoma, bilateral salpingo-oophorectomy with total hysterectomy and omentectomy were performed. The resected specimen showed a unilocular cystic lesion containing a well-demarcated mural nodule measuring 35 × 30 × 25 mm in the left ovary. A microscopic examination revealed various types of carcinoma in the mural nodule: pulmonary type small cell carcinoma (65%), adenocarcinoma (25%), squamous cell carcinoma (5%), and transitional cell carcinoma (5%). Small cell carcinoma was positive for CD56, synaptophysin, and chromogranin A. The adenocarcinoma component showed intestinal phenotypes; i.e. cytokeratin (CK) 7(-), CK20(+), CDX2(+), estrogen receptor(-), and progesterone receptor (-). Interestingly, CDX2 positivity was retained in all of the carcinomas. It was assumed that the adenocarcinoma had arisen from an intestinal epithelium in the mature cystic teratoma and then differentiated into the diverse histological types mentioned above." }, { "id": "pubmed23n0902_19530", "title": "Ovarian Teratoma in Routine Biopsy Material During a Five-Year Period.", "score": 0.015003030915336432, "content": "Teratomas are tumors derived from germ cells, most frequently arising in the gonads. The aim of this study was to determine the number of ovarian teratomas diagnosed in the routine biopsy material at Ljudevit Jurak Clinical Department of Pathology, Sestre milosrdnice University Hospital Center during a 5-year period, as well as their clinical, gross and microscopic characteristics. Teratomas accounted for 48.6% (n=166) of primary ovarian tumors. The patient mean age was 34.74±12.37 years. Difference in the incidence of teratoma between the left and right ovary was not significant; bilateral teratoma was found in 13 patients. Teratomas were detected by ultrasonography in 115 (69.27%) cases and the rest were found during surgery performed for other indications. Most teratomas (n=161; 96.9%) were mature and cystic (dermoid cysts). Mature and solid teratomas were diagnosed in 5 (3.01%), ovarian struma in 2 (1.8%) cases and strumal carcinoid in 1 (1.2%) case. Mature cystic teratomas contained sebaceous material in 123 (76.8%) cases, and a total of 16 teeth were found; 157 (94.5%) teratomas measured &lt;10 cm in largest diameter. Microscopically, mature cystic teratomas most frequently contained ectodermal (skin with appendages, mature glia and nerve ganglia) and mesodermal (fi brous, fat tissue, cartilage and bone) tissues. Frequently found tissues of endodermal origin were respiratory and intestinal epithelia. Small foci of thyroid tissue were found in 20 (12%) teratomas. Chronic granulomatous foreign body reaction in the wall of mature cystic teratomas was found in 11 (6.8%) tumors." }, { "id": "pubmed23n0555_19922", "title": "A case of ovarian mature cystic teratoma presenting as a pedunculated ileal tumor.", "score": 0.014742524916943521, "content": "We report on a 34-year-old Japanese woman who presented with a pedunculated ileal tumor and who was finally diagnosed as having a right ovarian mature cystic teratoma penetrating and protruding into the ileum. She had undergone laparoscopic left ovarian cystectomy, whose specimen was diagnosed as dermoid cyst when she was 27 years old. The colon fiberscope revealed an ileal polyp, diagnosed as mature teratoma. Because of adhesion to the necrotic nodule between the tumor and the right ovary, ileocecal resection and right ovarian cystectomy were performed. The ileal tumor contained tissues of skin, neuroglia, ganglion, choroid, retina, smooth muscle, as well as fibrous and adipose tissues, cartilage, bone, mucous epithelium, and bronchial structures with bronchial glands. The necrotic nodule showed abscess, granulation tissue, foreign body reaction, hairs, normal ileal epithelium, and the ovary with ovums." }, { "id": "pubmed23n0572_20287", "title": "A case of concomitant occurrence of struma ovarii and malignant transformation of cystic teratoma.", "score": 0.014550656012627011, "content": "A 77-year-old woman received a total abdominal hysterectomy and bilateral salpingo-oophorectomy because of a tumor in the left ovary. The surgical specimen measured 8.5x4.5x4.0 cm, and the solid lesion measured 4.0x3.5x3.5 cm. The solid lesion was diagnosed as struma ovarii. The cyst wall partially comprised squamous epithelium-like and ciliated columnar epithelium-like cells. The tumorous lesion of the cyst wall revealed a poorly differentiated adenocarcinoma. Immunohistochemically, the tumor cells were positive for cytokeratin7, and were negative for cytokeratin20 and thyroid transcription factor-1. The authors diagnosed that struma ovarii and other parats coexisted as a poorly differentiated adenocarcinoma that had arisen from a mature ovarian cystic teratoma. As for the identification of the origin of adenocarcinomas arising from mature ovarian cystic teratomas, more cases need to be identified and investigated." }, { "id": "pubmed23n1138_23523", "title": "Well-differentiated cerebellum in an ovarian mature cystic teratoma: a case report and review of the literature.", "score": 0.014090796328454478, "content": "Mature teratoma is the most common germ cell tumor as it represents 95% of germ cell tumors. Although common in children and young adults, ovarian teratoma can occur at any age. Mature teratomas are composed of mature tissues representing elements derived from more than one embryonic germ layer (ectoderm, mesoderm, and endoderm), with ectodermal derivatives being the usual predominant component; however, the finding of a well-differentiated cerebellum is extremely rare. A 20-year-old Saudi female presented to the emergency department with severe abdominal pain of 1-day duration. Pelvic ultrasound showed a large ovoid- to bilobed-shaped cystic pelvic structure extending to the lower abdomen. The patient underwent left ovarian cystectomy. Microscopic examination showed a cyst wall with skin tissue, including adnexal structures (sebaceous glands), a well-differentiated cerebellum, and mature glial tissue. After extensive sampling, no immature component was identified. Thus, the final diagnosis of a mature cystic teratoma with well-differentiated cerebellum was established. The patient was well postoperatively and was discharged in a stable condition. We report this case of well-differentiated cerebellum within ovarian teratoma to expand the pool of cases reported in literature of this extremely rare entity, as only 22 cases with such findings have been reported in literature to the best of our knowledge. This finding poses a diagnostic challenge to the pathologist due to its rarity and its similarity to immature teratoma. We thus emphasize that thorough sampling of ovarian teratoma is of paramount importance and to keep the aforementioned diagnosis in mind and not confuse it with immature elements, especially in intraoperative consultation and frozen sections." }, { "id": "wiki20220301en013_56033", "title": "Teratoma", "score": 0.013770913770913771, "content": "Malignant transformation A \"benign\" grade 0 (mature) teratoma nonetheless has a risk of malignancy. Recurrence with malignant endodermal sinus tumor has been reported in cases of formerly benign mature teratoma, even in fetiform teratoma and fetus in fetu. Squamous cell carcinoma has been found in a mature cystic teratoma at the time of initial surgery. A grade 1 immature teratoma that appears to be benign (e.g., because AFP is not elevated) has a much higher risk of malignancy, and requires adequate follow-up. This grade of teratoma also may be difficult to diagnose correctly. It can be confused with other small round cell neoplasms such as neuroblastoma, small cell carcinoma of hypercalcemic type, primitive neuroectodermal tumor, Wilm's tumor, desmoplastic small round cell tumor, and non-Hodgkin lymphoma." }, { "id": "pubmed23n0352_14243", "title": "[Malignant transformation of thyroid tissue in an ovarian dermoid cyst: case report].", "score": 0.012962962962962964, "content": "Mature cystic teratoma is the most common type of ovarian teratomas and also the most frequent tumor originating from germ cells. Usually unilateral, it is, by definition, composed of well-differentiated derivates which originate from all three layers. It is most frequently diagnosed in the female reproductive period; in its pure form, it is generally benign, but occasionally it may undergo malignant transformation in one of its elements. The authors report a case of a 43-year-old woman who underwent a thyroid regulation substitutive therapy 12 years after thyroidectomy which had been performed because of Basedow's disease. On the occasion of her fourth delivery by cesarean section, bilateral cystical formations in both ovaries were found. Upon ending the delivery, the right ovary with the cyst was surgically removed, as well as part of the cystically changed left ovary. The pathohistological analysis of the samples taken from the left ovary cyst pointed to the following diagnosis: dermoid cyst of the ovary a mature cystic teratoma, whereas the samples from the cystic tumor of the right ovary were diagnosed as: ovarian teratoma malignant a papillary carcinoma of the thyroid tissue and cystadenoma papillare serosum ovarii. The histological type of the malignant thyroid tissue neoplasm in the teratoma was a papillary carcinoma consisting of papillary proliferations lined by cuboidal, cylindrical and pseudostratified epithelium with charasteristic \"ground glass\" nuclei, but without invasion into the blood vessels. Malignant transformation of the ectopic thyroid tissue, which is one of the elements of the ovarian cystic teratoma, is extremely rare: it is diagnosed on basis of the histological picture and criteria which are the same as for the tumor of the thyroid gland. One should not exclude a pssibility that the identical or different pathological alterations characteristic of the thyroid gland may also be detected in the ectopic thyroid tissue of a dermoid cyst. The reported case was chosen due to its complex and rich clinical and pathohistological picture characterized by the occurrence of a bilateral dermoid cyst with the malignant transformation of the thyroid tissue. The malignant neoplasm in the mature ovarian cystic teratoma was papillary carcinoma of the thyroid tissue with all histological properties typical for the thyroid gland carcinoma. The possibility of the malignant transformation of the endodermal thyroid tissue in the mature ovarian cystic teratoma and changes in the thyroid gland of the Basedow's disease type diagnosed before are without clear causation." }, { "id": "pubmed23n0602_9674", "title": "Adenocarcinoma arising from respiratory ciliated epithelium in benign cystic teratoma of the ovary: a case report with analyzes of the CT, MRI, and pathological findings.", "score": 0.012894092439546985, "content": "The malignant transformation of mature cystic teratoma is rare, thus occurring in only 1-2% of all cases. The most common malignancy arising in mature cystic teratoma is squamous cell carcinoma. Adenocarcinoma occurs with less frequency. We herein present a patient with an ovarian mature cystic teratoma who demonstrated a malignant transformation to well-differentiated adenocarcinoma. Malignant transformation was diagnosed preoperatively by contrast enhanced computed tomography (CT) and magnetic resonance imaging (MRI). Microscopically and immunohistochemically, the adenocarcinoma was considered to have arisen from the ciliated respiratory epithelium. After a 28-month of follow-up period, she remains free of the disease. This is the third reported case of adenocarcinoma arising in the respiratory epithelium of an ovarian mature cystic teratoma. Contrast enhanced CT and MRI are useful for making a preoperative diagnosis and an immunohistochemical study is helpful for defining its origin." }, { "id": "wiki20220301en017_65513", "title": "Ovarian cancer", "score": 0.012882238126219909, "content": "Immature, or solid, teratomas are the most common type of ovarian germ cell tumor, making up 40–50% of cases. Teratomas are characterized by the presence of disorganized tissues arising from all three embryonic germ layers: ectoderm, mesoderm, and endoderm; immature teratomas also have undifferentiated stem cells that make them more malignant than mature teratomas (dermoid cysts). The different tissues are visible on gross pathology and often include bone, cartilage, hair, mucus, or sebum, but these tissues are not visible from the outside, which appears to be a solid mass with lobes and cysts. Histologically, they have large amounts of neuroectoderm organized into sheets and tubules along with glia; the amount of neural tissue determines the histologic grade. Immature teratomas usually only affect one ovary (10% co-occur with dermoid cysts) and usually metastasize throughout the peritoneum. They can also cause mature teratoma implants to grow throughout the abdomen in a disease" }, { "id": "wiki20220301en195_23573", "title": "Immature teratoma", "score": 0.012641289183725764, "content": "An immature teratoma is a teratoma that contains anaplastic immature elements, and is often synonymous with malignant teratoma. A teratoma is a tumor of germ cell origin, containing tissues from more than one germ cell line, It can be ovarian or testicular in its origin. and are almost always benign. An immature teratoma is thus a very rare tumor, representing 1% of all teratomas, 1% of all ovarian cancers, and 35.6% of malignant ovarian germ cell tumors. It displays a specific age of incidence, occurring most frequently in the first two decades of life and almost never after menopause. Unlike a mature cystic teratoma, an immature teratoma contains immature or embryonic structures. It can coexist with mature cystic teratomas and can constitute of a combination of both adult and embryonic tissue. The most common symptoms noted are abdominal distension and masses. Prognosis and treatment options vary and largely depend on grade, stage and karyotype of the tumor itself." }, { "id": "pubmed23n0787_21579", "title": "[Pelvic retroperitoneal teratoma. A case report].", "score": 0.012438574938574939, "content": "Teratomas are congenital tumors comprising of tissues arising from pluripotent embryonic cells. Their common sites of occurrences are ovary, testis, mediastinum and retroperitoneum. Retroperitoneal teratomas are extremely rare in adults but occur in 3% of children. The presence of a cystic or complex adnexal mass during pregnancy is common with mature teratoma reported in approximately 30-50% of pregnancies. The ultrasound is the number one method of detection. The use of tumor markers is limited because it alters its value during pregnancy. We report a case of a 18 year old female patient who came to the General Hospital Dr. Miguel Silva in Morelia, Michoacán with a gestation age of 10.2 weeks and a recent diagnosis of an asymptomatic adnexal mass. Using the transvaginal approach, the ultrasound reported an irregular gestational sac with the absence of cardiac activity in the embryo. A diffusely echogenic adnexal mass with oval appearance, wall regularity and homogeneous internal echos of 12.96 x 8.99 cm. Exploratory laparotomy was performed finding normal uterus and ovaries, with the posterior retroperitoneal resection of the 15 cm multi-lobed tumor. The surgical specimen measured 13 x 12 x 8 cm, had a brownish color, wall irregularity, soft consistency, multi-lobed, and a yellowish interior greasy material. Microscopically the tumor is delimited with a firm capsule composed of a hyaline-fibrous tissue, lined by squamous keratinized epithelium, with multiple layers of keratin. This anato-pathologic finding is diagnostic of retroperitoneum mature teratoma." }, { "id": "pubmed23n0600_18102", "title": "[Benign mature teratomas of the mediastinum].", "score": 0.012016251205068173, "content": "Mature teratomas of the mediastinum are rare. However, they represent the most common mediastinal germ cell tumours. The aim of this study is to describe their clinical and pathological characteristics. Fourteen cases of mediastinal mature teratoma, diagnosed between January 1992 and December 2006, were reviewed retrospectively, noting the clinical, radiological, surgical, and pathological findings. The patient population consisted of 10 females and 4 males with mean age of 29 years (5-56 years). Chest pain was the main symptom. Imaging features comprised a heterogeneous anterior mediastinal mass containing soft-tissue, fluid, fat, or calcium attenuation, or any combination of the four. Macroscopically all the tumours were cystic, or predominantly cystic, containing mostly grumous material. The mean size was 9 cm (5-12 cm). Histological examination constantly revealed skin with or without appendages. Other components identified were bronchial mucosa (12 cases), fat (12 cases), muscle (10 cases), cartilage (8 cases), bone (7 cases), gastrointestinal mucosa (7 cases), pancreas (5 cases), urothelial epithelium (3 cases), nervous and prostatic tissues (one case each). All the teratomas were mature, and 7 of them were intrathymic. Every form of teratoma occurs in the mediastinum (mature, immature and with malignant transformation) but, in our study, they were exclusively mature. The histology is essentially similar to that of teratomas of gonads. However, pancreatic tissue occurs frequently in mediastinum (54% in literature, 25% in our study) but not in the gonads. On the other hand, thyroid follicles have not yet been seen in mediastinal teratomas." }, { "id": "wiki20220301en574_16633", "title": "Ovarian germ cell tumors", "score": 0.012006564740433618, "content": "Teratomas Teratoma are most common germ cell tumor of ovary. Teratomas can be divided into two types: mature teratoma (benign) and immature teratoma (malignant). Immature teratomas contain immature or embryonic tissue which significantly differentiates them from mature teratomas as they carry dermoid cysts. It is commonly observed in 15 to 19-year-old women and rarely in women after menopause. Immature teratomas are characterized with a diameter of 14–25 cm, encapsulated mass, cystic areas, and occasional appearance of hemorrhagic areas. The stage of immature teratomas is determined depending on the amount of immature neuroepithelium tissue detected. Yolk sac tumor" }, { "id": "wiki20220301en022_99046", "title": "Dermoid cyst", "score": 0.011519707436001624, "content": "A dermoid cyst is a teratoma of a cystic nature that contains an array of developmentally mature, solid tissues. It frequently consists of skin, hair follicles, and sweat glands, while other commonly found components include clumps of long hair, pockets of sebum, blood, fat, bone, nail, teeth, eyes, cartilage, and thyroid tissue. As dermoid cysts grow slowly and contain mature tissue, this type of cystic teratoma is nearly always benign. In those rare cases wherein the dermoid cyst is malignant, a squamous cell carcinoma usually develops in adults, while infants and children usually present with an endodermal sinus tumor. Location Due to its classification, a dermoid cyst can occur wherever a teratoma can occur. Vaginal and ovarian dermoid cysts" }, { "id": "pubmed23n0408_4863", "title": "Adenocarcinoma arising from respiratory ciliated epithelium in mature ovarian cystic teratoma.", "score": 0.010934744268077601, "content": "Malignant transformation of a mature cystic teratoma of the ovary is rare, that of an adenocarcinoma is extremely rare. A 32-year-old woman was suspected as having a malignant transformation of her mature cystic teratoma of the ovary because the preoperative level of carcinoembryonic antigen (CEA) was extremely high. Resections of her ovarian cysts were performed, and this particular tumor was histopathologically diagnosed as an adenocarcinoma arising from a mature cystic teratoma of the left ovary. Because adenocarcinomas arising from mature cystic teratomas of the ovary are extremely rare, we report this case with a review of some of the literature." }, { "id": "wiki20220301en195_23575", "title": "Immature teratoma", "score": 0.01092015753669889, "content": "Ovarian cancer is staged using the FIGO staging system and uses information obtained after surgery, which can include a total abdominal hysterectomy via midline laparotomy, unilateral (or bilateral) salpingo-oophorectomy, pelvic (peritoneal) washings, assessment of retroperitoneal lymph nodes and/or appendectomy. The AJCC staging system, identical to the FIGO staging system, describes the extent of tumor (T), the presence of absences of metastases to lymph nodes (N), the presence or absence of distant metastases (M). Pathology An immature teratoma contains varying compositions of adult and embryonic tissue. The most common embryonic component identified in immature teratomas is the neuroectoderm. Occasionally, tumors may present neuroepithelium that resemble neuroblasts. Tumors may also present embryonic components such as immature cartilage and skeletal muscle of mesodermal origin. Immature teratomas composed of embryonic endodermal derivatives are rare." }, { "id": "Pathology_Robbins_4347", "title": "Pathology_Robbins", "score": 0.009992350353796137, "content": "Benign (mature) cystic teratomas are marked by the presence of mature tissues derived from all three germ cell layers: ectoderm, endoderm, and mesoderm. Usually these tumors contain cysts lined by epidermis replete with adnexal appendages—hence the common designation dermoid cysts. Most are discovered in young women as ovarian masses or are found incidentally on abdominal radiographs or scans because they contain foci of calcification produced by toothlike structures contained within the tumor. About 90% are unilateral, with the right side more commonly affected. Rarely do these cystic masses exceed 10 cm in diameter. On cut section, they often are filled with sebaceous secretion and matted hair that, when removed, reveal a hair-bearing epidermal lining ( Fig. 19.18 ). Sometimes there is a nodular projection from which teeth protrude. Occasionally, foci of bone and cartilage, nests of bronchial or gastrointestinal epithelium, or other tissues are present." }, { "id": "wiki20220301en013_56020", "title": "Teratoma", "score": 0.009900990099009901, "content": "Types Mature teratoma A mature teratoma is a grade 0 teratoma. They are highly variable in form and histology, and may be solid, cystic, or a combination of the two. A mature teratoma often contains several different types of tissue such as skin, muscle, and bone. Skin may surround a cyst and grow abundant hair (see dermoid cyst). Mature teratomas generally are benign, with 0.17-2% of mature cystic teratomas becoming malignant. Immature teratoma Immature teratoma is the malignant counterpart of the mature teratoma and contains immature tissues which typically show primitive or embryonal neuroectodermal histopathology. Immature teratoma has one of the lowest rates of somatic mutation of any tumor type and results from one of five mechanisms of meiotic failure." }, { "id": "pubmed23n0541_8717", "title": "[Laparoscopic extirpation of retroperitoneal bronchogenic cyst].", "score": 0.00980392156862745, "content": "The retroperitoneal bronchogenic cyst is an extremely rare anomaly. During the examination of an 18-year-old female patient due to her extreme thinness, the abdominal ultrasound and later the CT indicated as an accidental finding--a left side adrenal/suprarenal adenoma, which turned out to be hormonally inactive. But while we were doing a laparoscopic surgical intervention we found a 6-8-cm cyst in the retroperitoneum, between the greater curvature and the spleen. It contained light grey, mucinous liquid. The left suprarenal gland had normal size and appearance. During the microscopic examination the removed terime showed cystic structures, which were covered inside with multilayer ciliated columnar epithelium, mucous excretory glands, a whole layer of connective/interstitial and smooth muscle tissue. Neither cartilage, nor gastrointestinal epithelium was found. Only a few publications have reported about retroperitoneal bronchogenic cyst so far. These lesions occur very rarely at the greater curvature. Although this alteration is really unusual, bronchogenic cysts have to be expected in the differential diagnostics of the retroperitoneal tumors." }, { "id": "pubmed23n0043_4765", "title": "Pulmonary blastoma. Comparison between its epithelial components and fetal bronchial epithelium.", "score": 0.009708737864077669, "content": "Three cases of pulmonary blastoma exhibiting biphasic epithelial and stromal patterns, and a case of fetal lung-type adenocarcinoma, were examined by immunohistochemistry and electron microscopy (EM) and compared with fetal bronchial epithelium in order to explore the multidirectional differentiation of their epithelial components. The glandular cells of all four tumors resembled fetal bronchial epithelial cells in the pseudoglandular stage. Neuroendocrine (NE) cells were also present; they were argyrophilic and expressed pan-NE markers, neurosecretory granules and peptide hormones. The neural cell adhesion molecule (NCAM) was strongly expressed on the cell membranes of glandular cells, as in the case of proximal bronchial epithelial cells at the pseudoglandular stage in fetal lung. Sialosylated Lewis X was also expressed, indicating that the epithelial cells were possibly of endodermal origin. Two of the four cases showed considerable immunoreactivity for alpha-fetoprotein (AFP). The epithelial cells of pulmonary blastomas may occasionally de-differentiate into cells functionally resembling fetal hepatic, foregut and yolk sac cells expressing AFP. Tumor examination by immunohistochemistry and EM suggested that the glandular cells of the tumors may differentiate to some extent like those of fetal large bronchi at the pseudoglandular stage, but there was concordance and discordance in the expression of neuroendocrine and oncofetal markers between blastomatous tumors and fetal bronchial epithelium." }, { "id": "pubmed23n1069_8899", "title": "Primary Mature Teratoma of the Rectum: A Case Report.", "score": 0.009615384615384616, "content": "BACKGROUND Teratomas are embryonal neoplasms that contain tissues derived from 1 or more of the 3 germ layers. They commonly are found in the sacrococcygeal-gonadal location, sometimes in midline locations such as the mediastinum, retroperitoneum, and head and neck region. Primary rectal teratomas are extremely rare. Extragonadal teratomas can originate from pluripotent germ cells present in abnormal embryonic rests. CASE REPORT Here, we report a rare case of a primary mature, solid teratoma of the rectum. A 68-year-old woman presented with hematochezia and denied any history of abdominal pain or a change in bowel habits. Colonoscopy revealed a 4-cm pedunculated polyp in the rectum. No hair was present on its surface. The polyp was completely removed by polypectomy. Histologically, the tumor consisted of mature components from all 3 germ layers. Its surface was covered by squamous epithelium with hair follicles and sweat glands. Adipose tissue, blood vessels, bone, and glandular epithelium were present inside the mass. No evidence was found of immature elements or malignant features. CONCLUSIONS When polypoid lesions are found in the rectum, teratoma should be considered in the differential diagnosis. Histopathological confirmation is necessary to diagnose teratoma. Primary rectal teratomas should be distinguished from other neoplastic polyps as well as from local spread of teratomas arising in adjacent organs. These neoplasms are usually mature (benign) but may undergo malignant transformation. Therefore, complete resection is recommended to alleviate symptoms and avoid the risk of malignancy." }, { "id": "pubmed23n1132_5448", "title": "Clinicopathological observation of mature teratoma with malignant transformation, a single center retrospective study.", "score": 0.009615384615384616, "content": "To investigate the clinicopathological features of mature teratoma with malignant transformation. Retrospectively analysis of 1179 cases mature teratoma was done from August 1999 to December 2019 in Institution. 14 cases of mature teratoma with malignant transformation were discussed mainly for the pathological characteristics and clinical manifestations. 4 of them were less than 40 years old. All but one occurred in the ovaries, and the one was in the left anterior mediastinum which was the only male. The clinical manifestations of the patients were atypical. Imaging showed cystic solid mass. Surgery was performed. Polypoid mass, solid nodule and thickened area of cyst wall can be seen on the section of tumor. Pathological results show that there were 5 cases of squamous cell carcinoma, 3 cases of carcinoid, 2 cases of serous carcinoma and 2 cases of thyroid papillary carcinoma, 1 case of carcinosarcoma and 1 case of strumal carcinoid. Two cases of squamous cell carcinoma had pelvic and abdominal metastasis. Immunohistochemistry of case 14 showed that AE1/AE3, CD56, SYN, NSE, PSAP, CDX2 were positive in carcinoid. EMA and CK20 were positive in mucinous glands around carcinoid. Calretinin and inhibin were positive in the mesenchyme adjacent to intestinal mucinous gland. Teratoma with malignant transformation is a rare malignancy, although teratoma is a common germ cell tumor. And it's more common in patients over 40 years, especially those patients who were in menopause. Squamous cell carcinoma is the most common type and prone to metastasis. Strumal carcinoid was well-defined, but as an endocrine tumor, it may cause a series of digestive, respiratory or hormonal disorders. Therefore, the mature teratomas should be removed in time after detection." }, { "id": "article-29964_19", "title": "Testicular Teratoma -- Histopathology", "score": 0.009549274255156608, "content": "Microscopy : Any epithelial, mesenchymal, or neural-derived tissue can be seen. Less common are tissues derived from the respiratory, gastrointestinal, or genitourinary tract. Skin-derived structures such as epithelial-derived (epidermoid cyst) or appendages is a quite common finding, especially in prepubertal-type teratomas, while postpubertal-type teratomas tend to appear as multiloculated cysts lined by other tissue types such as glandular epithelium and contain solid areas formed by parenchymal structure or mesenchymal tissues. A certain element of immature tissues can also be encountered, consisting of ectodermal, endodermal, or mesenchymal structures. Neuroectodermal tissue is the most common immature type and often has several differentiation stages of embryonic/fetal nervous system tissue. Historically teratoma has been differentiated into mature and immature, but this distinction is not recommended any more due to the lack of a prognostic significance. Teratoma can occur paired with other histotypes of germ cell neoplasia, such as yolk sac tumor or embryonal carcinoma." }, { "id": "wiki20220301en063_44842", "title": "International Classification of Diseases for Oncology", "score": 0.009523809523809525, "content": "M9064/3 Germinoma Germ cell tumor, NOS M9065/3 Germ cell tumor, nonseminomatous M9070/3 Embryonal carcinoma, NOS Embryonal adenocarcinoma M9071/3 Yolk sac tumor Endodermal sinus tumor Polyvesicular vitelline tumor Orchioblastoma Embryonal carcinoma, infantile Hepatoid yolk sac tumor M9072/3 Polyembryoma Embryonal carcinoma, polyembryonal type M9073/1 Gonadoblastoma Gonocytoma M9080/0 Teratoma, benign Adult cystic teratoma Adult/cystic teratoma, NOS Teratoma, differentiated Mature teratoma M9080/1 Teratoma, NOS Solid teratoma M9080/3 Teratoma, malignant, NOS Embryonal teratoma Teratoblastoma, malignant Immature teratoma, malignant or NOS M9081/3 Teratocarcinoma Mixed embryonal carcinoma and teratoma M9082/3 malignant teratoma, undifferentiated Malignant teratoma, anaplastic M9083/3 Malignant teratoma, intermediate M9084/0 Dermoid cyst, NOS Dermoid, NOS" }, { "id": "pubmed23n0359_12455", "title": "An intrapulmonary teratoma associated with bronchiectasia containing various kinds of primordium: a case report and review of the literature.", "score": 0.009523809523809525, "content": "An intrapulmonary teratoma (IPT), multiloculated and bronchiectatic, with two polyps inside a 23-year-old man is reported. The IPT, a very rare benign cystic lesion, was communicating with segmental bronchus and was removed by a segmental resection from the upper lobe of the left lung. The teratoma contained various kinds of primordial derivatives, such as mesoderm, ectoderm, and endoderm. Though 65 cases of IPT have been reported in the literature (1839-1996), in the present case there were over 15 germ derivatives, the largest number reported to date. The tumor contained thymic tissue, apart from mediastinum, which may be significant in relation to the pathogenesis of IPT. Clinical manifestations, age, and gender distributions and the kind of germ cell derivatives are discussed." }, { "id": "pubmed23n0546_2919", "title": "[Mature cystic teratoma of the ovary with a small ganglioneuroma].", "score": 0.009433962264150943, "content": "A case of ganglioneuroma arising within a cystic mature teratoma of the ovary in a 34-year-old woman is reported. Patient underwent right adnexectomy. The ovary was completely replaced by a bilocular cystic lesion, measuring 8 cm in diameter and filled with adipose tissue and pilosebaceous material. Microscopically the cyst was composed by a mature cystic teratoma containing skin with dermal appendages, fatty tissue and bronchial epithelium. Furthermore a nodule (0.5 cm in size) composed of mature ganglion cells, axons and Schwann cells, was identified. Ganglion cells were positive for NSE and synaptophysin, while Schwann cells stained positively with S100 protein and GFAP. To the best of our knowledgment this is the first reported cases of ganglioneuroma arisen within a cystic mature teratoma of the ovary." }, { "id": "article-29963_3", "title": "Cystic Teratoma -- Introduction", "score": 0.00942330241978467, "content": "Ovarian teratomas are broadly classified histologically into monodermal teratomas (carcinoid tumors, neural tumors, struma ovarii), immature teratomas, and mature cystic teratomas. The most common type among these tumors is mature cystic teratoma, also known as \"Dermoid cyst.\" Cystic teratomas constitute about 20% of ovarian germ cell tumors. The most common site of occurrence is in the ovaries and testes. However, they can rarely be seen in the anterior mediastinum, sacrococcygeal region, or neck. Mature cystic teratoma is always benign with a slow growth rate of 1.8 mm/year; however, in rare circumstances, it can undergo malignant transformation." }, { "id": "pubmed23n0812_4036", "title": "Retroperitoneal bronchogenic cyst: a case report.", "score": 0.009345794392523364, "content": "Bronchogenic cysts are among developmental disorders of the primitive foregut which are typically found above the diaphragm. Bronchial cysts discovered in the abdominal cavity or retroperitoneum are extremely rare. We present a rare case of a retroperitoneal bronchogenic cyst which was incidentally detected after a wrestling injury in a 23-year-old man who had a negative medical history. Although initial imaging studies suggested an adrenal tumor, histopathological analysis provided a definite diagnosis of bronchogenic cyst. Though rare, bronchogenic cysts must be considered in the differential diagnosis of retroperitoneal cystic lesions. This is the first case of a retroperitoneal bronchogenic cyst reported in Iran. " }, { "id": "pubmed23n0636_16507", "title": "Benign cystic teratoma of the parotid gland: a case report.", "score": 0.009259259259259259, "content": "Mature cystic teratomas of the major salivary glands are rare. This report describes a case of a mature cystic teratoma of the left parotid gland, including the cytologic and histopathologic findings. A 17-year-old young woman presented with a slow-growing left parotid mass that had been present for 4 years. Preoperative fine needle aspiration cytology showed the presence of acinar and ductal cells, foamy cells and multinucleated giant cells. Imprint cytology of the surgical material showed the presence of some squamous cells and sebaceous gland-like cells with hair shafts. Cellular atypia was inconspicuous. Grossly, the 3-cm lesion was unicystic and embedded within the parotid gland parenchyma. Microscopically, the inner surface of the cyst was lined with keratinized squamous epithelium. The cyst wall contained skin adnexa such as sebaceous, eccrine and apocrine glands, as well as hair follicles. Some mature cartilage tissue was also detected. Foreign body granulomatous change was seen focally. No immature tissue or malignant transformation was found. There is no previous report describing the cytologic findings of a mature cystic teratoma of the parotid gland. Mature cystic teratomas should therefore be considered in the differential diagnosis of a cystic lesion of the parotid" }, { "id": "pubmed23n0724_11860", "title": "A bronchogenic cyst, presenting as a retroperitoneal cystic mass.", "score": 0.009259259259259259, "content": "Bronchogenic cysts are mostly benign, congenital abnormalities originating from the remnants of the primitive foregut. A retroperitoneal location is rare. Due to the mostly asymptomatic behavior and the historical confusion regarding histology, an exact prevalence is not known. We present here a case report of a retroperitoneal bronchogenic cyst. A literature review was performed for cases of retroperitoneal bronchogenic cysts written in English. Anatomopathological criteria for inclusion were pseudo stratified, ciliated, columnar epithelium together with the presence of at least one of the following: cartilage, smooth muscle or seromucous glands. In addition, the embryology, pathogenesis, radiological, clinical and suggested treatment modalities are reviewed. We report the surgical excision of a retroperitoneal bronchogenic cyst that presented as a non-functioning left adrenal mass. Our review of literature revealed only 62 potential cases of retroperitoneal bronchogenic cysts. After applying the strict anatomopathological criteria, only 30 cases of true retroperitoneal bronchogenic cysts could be identified. Retroperitoneal location of a bronchogenic cyst is rare. Despite the rarity of this pathologic entity, bronchogenic cysts should be considered in the differential diagnosis of retroperitoneal cystic lesions. Only histology can confirm definitive diagnosis. Surgery remains the recommended treatment of choice." }, { "id": "pubmed23n0547_18353", "title": "[Bronchogenic cyst of the tongue].", "score": 0.009174311926605505, "content": "Bronchogemc cyst is a rare aberration secondary to abnormal detachment of accessory lung buds from the primitive foregut. Through one case of bronchogenic cyst of the tongue, the authors made a review of this exceptional localisation. We report one case of bronchogenic cyst of the tongue treated in the Ibn Sina Hospital. Our patient was a new born admitted in our formation for a voluminous cystic mass ot the tongue, responsible of difficulty for mouth occlusion and feeding The radiology I confirms the liquid nature of this mass. The treatment was surgical, and the diagnosis of bronchogenic cyst was histological. Bronchogenic cysts are generally intrathoracic. The localization in the cervico-facial area is rare, and only 4 cases of bronchogenic cyst of the tongue were described in the literature. The clinical presentation is non specific, depending on the volume of the cyst. Radiology permits to confirm the nature of the mass. The certitude diagnosis is histological: bronchogenic cysts are lined by pseudostratified ciliated columnar epithelium with accessory tissues in the cyst wall, smooth muscle, seromucinous glands and cartilage, simulating a bronchus. Complete surgical excision is the base of the treatment." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 124 ] ], "word_ranges": [ [ 0, 17 ] ], "text": "Typical smoker's pancoast, probably an epidermoid, with Horner's sdr. Best would be chemoradio followed by surgical salvage." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 125, 168 ] ], "word_ranges": [ [ 17, 27 ] ], "text": "In the old days it was just RT and surgery." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Neoadjuvant chemotherapy with combined chemoradiotherapy, followed by surgery.", "2": "Neoadjuvant chemotherapy without surgery, followed by radiotherapy.", "3": "Surgery followed by combined chemoradiotherapy.", "4": "Radiotherapy without chemotherapy, followed by surgery.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0399_10965", "title": "[A case of large-cell lung cancer successfully treated with docetaxel in combination with carboplatin and radiotherapy].", "score": 0.012202380952380952, "content": "A 64-year-old male was referred to our hospital in September, 2000 for further examination of an abnormal chest shadow discovered in a regular health check-up. Chest X-P and CT revealed a large tumor in the left upper lobe, in association with hilar lymphadenopathy and costal invasion. Serum CEA was increased, and lung biopsy revealed a large-cell carcinoma. We performed chemoradiotherapy before surgery. Radiation (total 48 Gy) and 3 courses of chemotherapy with docetaxel (60 mg/m2) in combination with carboplatin (AUC = 6,600 mg) resulted in a remarkable reduction in the size of the mass, to less than 50%, and normalized serum CEA. Left upper lobectomy, lymphadenectomy and costectomy were performed. However, no tumor cells were detectable in the ablative specimen pathologically. These findings suggest the efficacy of chemoradiotherapy including docetaxel with carboplatin in patients with large-cell lung cancer." }, { "id": "wiki20220301en000_290529", "title": "Lung cancer", "score": 0.011686874740675857, "content": "The vast majority (85%) of cases of lung cancer are due to long-term tobacco smoking. About 10–15% of cases occur in people who have never smoked. These cases are often caused by a combination of genetic factors and exposure to radon gas, asbestos, second-hand smoke, or other forms of air pollution. Lung cancer may be seen on chest radiographs and computed tomography (CT) scans. The diagnosis is confirmed by biopsy, which is usually performed by bronchoscopy or CT-guidance. The major method of prevention is the avoidance of risk factors, including smoking and air pollution. Treatment and long-term outcomes depend on the type of cancer, the stage (degree of spread), and the person's overall health. Most cases are not curable. Common treatments include surgery, chemotherapy, and radiotherapy. NSCLC is sometimes treated with surgery, whereas SCLC usually responds better to chemotherapy and radiotherapy." }, { "id": "pubmed23n0512_4834", "title": "[Guideline on 'non-small cell lung carcinoma; staging and treatment'].", "score": 0.01166584585077567, "content": "A national, evidence-based guideline on the staging and treatment of patients with non-small cell lung carcinoma (NSCLC) has been compiled by the various disciplines involved. The initial diagnostic measures in patients with suspected lung cancer include history taking, physical examination and chest x-ray. Additional examinations include CT scan of the chest and upper abdomen, bronchoscopy, and 18F-fluorodeoxyglucose-positron-emission-tomography(FDG-PET)-scintigraphy, if curative therapy is planned. Cervical mediastinoscopy or endoscopic echography with fine needle aspiration can be performed for mediastinal tissue staging. The preferred treatment in stage I, II or limited III is radical resection. Postoperative radiotherapy is recommended in cases of incomplete resection and can be considered in patients in whom mediastinal lymph-node metastases are unexpectedly encountered. Chemoradiotherapy is recommended in locally advanced NSCLC. In patients with NSCLC stage I-III and poor performance status, palliative radiotherapy may be the only feasible treatment. Some patients with NSCLC stage III and stage IV can be offered palliative chemotherapy and supportive care. In cases of doubt about operability, resectability, significant pulmonary or cardiac comorbidity or combined treatment, a specialist centre should be consulted. Diagnostics should be completed within 3-5 weeks. Ensuing surgery or radiotherapy should be carried out within 2 weeks. Follow-up of patients with NSCLC includes history taking, physical examination and an optional chest x-ray. In the first year after treatment patient visits are planned quarterly, in the second year half-yearly and then yearly for at least five years." }, { "id": "wiki20220301en299_12100", "title": "Chemoradiotherapy", "score": 0.009900990099009901, "content": "Chemoradiotherapy (CRT, CRTx, CT-RT) is the combination of chemotherapy and radiotherapy to treat cancer. Synonyms include radiochemotherapy (RCT, RCTx, RT-CT) and chemoradiation. It is a type of multimodal cancer therapy. Chemoradiation can be concurrent (together) or sequential (one after the other). The chemotherapy component can be or include a radiosensitizing agent. Chemoradiotherapy as neoadjuvant therapy before surgery has been shown to be effective in esophageal cancer. References Further reading External links Chemotherapy and chemoradiotherapy for rectal cancer. (Macmillan/NHS) Radiation therapy" }, { "id": "pubmed23n0697_23577", "title": "[Radical resection following to concurrent chemoradiotherapy for eighty-five year-old patient with superior sulcus tumor].", "score": 0.009900990099009901, "content": "An 85-year-old male with superior sulcus tumor was referred to our hospital complaining right brachial pain and omalgia. Chest computed tomography showed right apical lung tumor involving the 1st rib, and bronchoscopy established a diagnosis of squamous cell carcinoma, cT3NOM0. After concurrent chemoradiotherapy [cisplatin (CDDP) + 60 Gy], functional examination indicated him to be tolerable to lobectomy, and he underwent right upper lobectomy + chest wall resection (1st-3rd ribs) + lymph-node dissection. Pathological examination revealed that the effect of chemoradiotherapy was Ef. 3. The postoperative course was uneventful. He is free from recurrence for 7 years after the surgery." }, { "id": "wiki20220301en010_160876", "title": "Colorectal cancer", "score": 0.00980392156862745, "content": "Radiation therapy While a combination of radiation and chemotherapy may be useful for rectal cancer, for some people requiring treatment, chemoradiotherapy can increase acute treatment-related toxicity, and has not been shown to improve survival rates compared to radiotherapy alone, although it is associated with less local recurrence. The use of radiotherapy in colon cancer is not routine due to the sensitivity of the bowels to radiation. As with chemotherapy, radiotherapy can be used as a neoadjuvant for clinical stages T3 and T4 for rectal cancer. This results in downsizing or downstaging of the tumour, preparing it for surgical resection, and also decreases local recurrence rates. For locally advanced rectal cancer, neoadjuvant chemoradiotherapy has become the standard treatment. Additionally, when surgery is not possible radiation therapy has been suggested to be an effective treatment against CRC pulmonary metastases, which are developed by 10-15% of people with CRC." }, { "id": "pubmed23n0556_769", "title": "[Complete resection of Pancoast tumor while receiving preoperative concurrent chemoradiotherapy (CCRT) as an induction therapy--report of a case].", "score": 0.00980392156862745, "content": "A 60-year-old man complaining of right shoulder pain and numbness of right arm was diagnosed with Pancoast tumor (invasive right apical lung cancer). Chest CT scan showed a tumor, 5 cm in diameter, in the right apex invading the right posterior chest wall. The patient received preoperative CCRT (RT: 40 Gy/20 Fr, cisplatin: CDDP and etoposide: ETP), resulting in tumor regression (PR). The patient underwent right upper lobectomy (ND 2a), partial resection of the 1st-3rd ribs and Th 1 nerve. Pathological examination demonstrated no live cancer cells and organization of necrotic tissue in the lung and intercostal region (Ef. 3). The patient received postoperative chemotherapy (CDDP+ETP) and was discharged. He did well without any tumor recurrence for 1 year postoperatively. CCRT seems effective and is one of the standard treatments for Pancoast tumor." }, { "id": "wiki20220301en013_76284", "title": "Sarcoma", "score": 0.009708737864077669, "content": "Treatment Surgery is the most common form of the treatment for most sarcomas that have not spread to other parts of the body. Limb-sparing surgery, as opposed to amputation, can now be used to save the limbs of patients in at least 90% of extremity (arm or leg) sarcoma cases. Additional treatments, including chemotherapy, radiation therapy (also called \"radiotherapy\") and proton therapy, may be administered before surgery (called \"neoadjuvant\" chemotherapy or radiotherapy) or after surgery (called \"adjuvant\" chemotherapy or radiotherapy). The use of neoadjuvant or adjuvant chemotherapy and radiotherapy significantly improves the prognosis for many sarcoma patients. Treatment can be a long and arduous process, lasting about a year for many patients. Liposarcoma treatment consists of surgical resection, with chemotherapy not being used outside of the investigative setting. Adjuvant radiotherapy may also be used after surgical excision for liposarcoma." }, { "id": "pubmed23n0748_23703", "title": "[The operated case of 89 year-old patient with pleomorphic carcinoma of the lung].", "score": 0.009708737864077669, "content": "A-89-year-old male patient who complained dry cough was detected lung mass of 3 cm size in diameter at the right upper lobe by CT. FDG-PET seemed to show hilar and mediastinum lymph nodes metastasis. After three weeks, the mass showed rapid growth with 5 cm diameter in size at CT. Therefore the original tumor was supposed to be undifferentiated carcinoma, above all, pleomorphic carcinoma. He had been done pulmonary resection after short period. The right upper lobectomy with combined resection of the partial middle lobe was performed. Hilar and mediastinum lymph nodes dissection was added. In pathological examination, the tumor was proved pleomorphic carcinoma, however, no lymph node metastasis was recognized. He did not refer any complications and discharged back home at the post-operative 11th day. Pleomorphic carcinoma of the lung is known to be difficult to obtain definite diagnosis in early stage because of rapid growth. Therefore many cases are detected in advanced stage. In addition, chemotherapy is generally not effective, so only operative resection seems to be useful. Our patient was 89-year-old, he tolerated the operation and was alive with no trouble during 6 months after resection. When complete resection seems to be possible, operation should be regarded as an initial treatment." }, { "id": "pubmed23n0694_447", "title": "A mass of myxofibrosarcoma in the lung.", "score": 0.009615384615384616, "content": "Fibrosarcoma is a mesenchymal tumor constituted by malignant fibroblasts. Myxofibrosarcoma is one of the fibrosarcoma variants that mostly develops from dermal/subcutaneous tissues. The most common locations are the limbs, with rare occurrences in the chest, head, and neck. Since, to best of our knowledge, there is no such report in English literature, we hereby present a case of lung myxofibrosarcoma. A 47-year-old man who had chest pain for 4 months was admitted to our clinic. The chest X-ray revealed a homogeneous density in the left upper lung. His chest computed tomography (CT) scan showed a solid mass lesion of 52 x 58 mm in size at the apical segment of the left upper lobe. There was tumor invasion at the second and third ribs. CT-guided fine-needle tru-cut lung biopsy was performed. Histopathological evaluation result was high grade myxofibrosarcoma. Surgery was conducted. Myxofibrosarcoma is a surgically curable disease. However, local recurrences occur in 50% to 60% of the cases. Therefore, chemotherapy and/or radiotherapy is the suggested approach following surgery." }, { "id": "pubmed23n0934_3568", "title": "[A Case of Resected Superior Sulcus Tumor with Pathological Complete Response after Trimodality Therapy].", "score": 0.009615384615384616, "content": "The current case was 73-year-oldwoman. She was referredto our hospital for an abnormal shadow of chest X-ray in the upper right lung field. Chest CT showed 3.5 cm of tumor located at the apex of right lobe with invasion of the chest wall. The tumor was diagnosed as squamous cell carcinoma using CT guided needle biopsy(superior sulcus tumor, clinical T3N0M0, Stage II B). The neoadjuvant therapy, 4 courses of chemotherapy(CBDCA plus PTX)andconcurrent radiotherapy(45 Gy/25 Fr)was performed. Chest CT revealed that tumor size was decreased to 2.3 cm in a diameter, and therapeutic effect was decided as partial response(34%). Upper right lobectomy combinedwith the chest wall(1th to 3th ribs)andmed iastinal lymph node dissection were performed. The pathological specimens showed no residual cancer cells(Ef3, pathological complete response[pCR]). She discharged without complications at 10 days after surgery. It is important to collect cases which obtainedpCR for development of more effective preoperative therapy." }, { "id": "wiki20220301en209_18155", "title": "Esthesioneuroblastoma", "score": 0.009523809523809525, "content": "Radiotherapy Radiotherapy alone is reserved only for small lesions not appropriate for either surgery or chemotherapy. Both photon and proton radiotherapy have been used effectively to treat esthesioneuroblastoma. Proton radiotherapy has recently been shown to be effective in a 10-person study with Kadish C tumors, while delivering less toxicity to the nervous system. Chemotherapy Chemotherapy is used in a multimodality treatment plan generally for more advanced, unresectable or reoccurring tumors. Cyclophosphamide, vincristine and doxorubicin have been used as neoadjuvant chemotherapy drugs for grade C esthesioneuroblastoma before surgical resection, producing fair outcomes. Cisplatin and etoposide are often used to treat esthesioneuroblastoma as neoadjuvants or adjuvants with radiotherapy or surgery." }, { "id": "pubmed23n0407_19783", "title": "[Surgically treated pancoast tumor].", "score": 0.009523809523809525, "content": "A 40-year-old male was detected his right apical lung tumor by roentgenographic screening on January 1997, but he did not refer to a hospital since he had no symptom. He went a orthopedics because of his right chest, back, and arm pain on October 1997, and he received traction and physical therapy. He went roentgenographic screening again on January 1998 and he was pointed out that the tumor increased. He admitted our hospital. Biopsy using bronchofiberscopy revealed adenocarcinoma and induction radiotherapy (40 Gy) was performed. Right upper lobectomy with chest wall resection and lymph node dissection was performed under hook approach. This approach was useful to dissect the tumor from the invaded plexus brachialis. Postoperative radio-chemotherapy was added but the patient died 7-postoperative months because of multiple metastases. Early detection should be led to early starting of the therapy." }, { "id": "wiki20220301en015_130807", "title": "Pancreatic cancer", "score": 0.009433962264150943, "content": "Chemotherapy After surgery, adjuvant chemotherapy with gemcitabine or 5-FU can be offered if the person is sufficiently fit, after a recovery period of one to two months. In people not suitable for curative surgery, chemotherapy may be used to extend life or improve its quality. Before surgery, neoadjuvant chemotherapy or chemoradiotherapy may be used in cases that are considered to be \"borderline resectable\" (see Staging) in order to reduce the cancer to a level where surgery could be beneficial. In other cases neoadjuvant therapy remains controversial, because it delays surgery." }, { "id": "pubmed23n0119_10965", "title": "[Superior sulcus cancer of the lung--report on 45 patients].", "score": 0.009433962264150943, "content": "From 1960 to 1980, 45 patients with superior sulcus cancer of the lung were seen in our hospital. 39 were male and 6 were female. The youngest was 28 years old and the eldest was 75. The presenting symptoms and signs were back and shoulder pain in 32 patients, compression of the brachial plexus in 17, Horner's syndrome in 12, supraclavicular mass in 11, superior cava vena obstruction in 4, shadow in the apex in 45, destruction of the rib in 19 (10 in the second rib), destruction of the adjacent vertebra in 8 (5 in T3) and destruction of the clavicle in 1. In 18 patients proved by pathology and cytology, 8 were adenocarcinoma, 3 squamous cell carcinoma, 3 undifferentiated and 4 unclassified carcinoma. 27 patients were diagnosed by X-ray films. 40 patients were admitted for treatment. 3 recieved chemotherapy alone and all of them died in one year. Of the 6 treated by radiation plus chemotherapy, 3 survived for one year but all died in two years. 2 were treated by radiation plus operation and none survived for more than 3 years. 29 were treated by radiation only. The 1, 3 and 5 year survival rates were 51%, 13.7% and 6.9%. Destruction of the rib or the adjacent vertebral body was irrelative to the prognosis but the presence of supraclavicular mass reduced the survival rate. Cause of death was local recurrence in 48% (13/27) and distant metastasis in 48% (13/27). The authors suggest that radical en bloc resection together with radiation the worth further study." }, { "id": "wiki20220301en398_13028", "title": "Asbestos-related diseases", "score": 0.009345794392523364, "content": "Malignant mesothelioma is an aggressive and incurable tumour caused by asbestos arising from mesothelial cells of the pleura, peritoneum (the lining of the abdominal cavity) and rarely elsewhere. Pleural mesothelioma is the most common type of mesothelioma, representing about 75 percent of cases. Peritoneal mesothelioma is the second most common type, consisting of about 10 to 20 percent of cases. Mesothelioma appears from 20 to 50 years after the initial exposure to asbestos. The symptoms include shortness of breath, chronic chest pain, cough, and weight loss. Diagnosing mesothelioma is often difficult and can include physical examination, chest X-ray and lung function tests, followed by CT scan and MRI. A biopsy is needed to confirm a diagnosis of malignant mesothelioma. Mesothelioma has a poor prognosis, with most patients dying within 1 year of diagnosis. The treatment strategies include surgery, radiotherapy, chemotherapy or multimodality treatment. Several tumour biomarkers" }, { "id": "pubmed23n0648_12404", "title": "[Complete resection of Pancoast tumor following induction chemoradiotherapy improves survival].", "score": 0.009345794392523364, "content": "Pancoast tumors are some of the most challenging thoracic malignant diseases to treat because of their proximity to vital structures at the thoracic inlet. We retrospectively analyzed 23 patients with pT3-4, N0-3 Pancoast tumors who underwent combined chest wall resection including the 1st rib, and discuss the anatomical considerations, assessment of induction therapy, and surgical approaches for these cancers. Between 1983 and 2006, 23 patients with Pancoast tumors underwent combined resection of the 1st rib at our institute. Of those, 21 were male and 2 were female, with an average age of 58 years. There were 10 each of squamous cell carcinoma and adenocarcinoma, 2 large cell carcinoma, and 1 adenosquamous carcinoma. Over the past decade, induction chemoradiotherapy (&gt;40Gy) was employed before surgery. A posterior approach was employed in 14 patients, an anterior approach in 7, and a combined anterior and posterior approach in 2. Sixteen patients underwent complete resection. One of 7 patients undergoing incomplete resection (4.3%) died on the 45th postoperative day. The 3- and 5-year survival rates were 50 and 22%, respectively, for patients with complete resection. No case survived for more than 8 months out of the 7 patients with incomplete resection. Fourteen patients with pN0 showed significantly better survival than those with pN1-3 (p = 0.0053). Recent literature and our results suggest that patients with pN0 and/or a pathological complete response (pCR) after induction chemoradiotherapy could achieve long-term survival after complete resection." }, { "id": "wiki20220301en185_5746", "title": "Breast cancer management", "score": 0.009259259259259259, "content": "Systemic therapy Systemic therapy uses medications to treat cancer cells throughout the body. Any combination of systemic treatments may be used to treat breast cancer. Standard of care systemic treatments include chemotherapy, endocrine therapy and targeted therapy. Chemotherapy Chemotherapy (drug treatment for cancer) may be used before surgery, after surgery, or instead of surgery for those cases in which surgery is considered unsuitable. Chemotherapy is justified for cancers whose prognosis after surgery is poor without additional intervention. Hormonal therapy Patients with estrogen receptor positive tumors are candidates for receiving endocrine therapy to reduce chance of relapse or of a new primary breast cancer. Endocrine therapy is usually administered after surgery, chemotherapy and radiotherapy have been given, but can also occur in the neoadjuvant or non-surgical setting. Hormonal treatments include:" }, { "id": "pubmed23n0697_20126", "title": "[A radical resection of non-small cell lung cancer invading chest wall with ipsilateral axillary lymph node metastases].", "score": 0.009259259259259259, "content": "A 41-year-old man who had non-small cell lung cancer invading his right 3rd, 4th and 5th ribs with hilum lymph node swelling(cT3N1M0, cStage III A), received chemoradiation therapy, cisplatin(CDDP)/docetaxel, and 2 Gy/Fr of irradiation prior to surgery. But the therapy was discontinued due to interstitial pneumonitis on day 24, during 28 Gy of radiation. At that time, a PET-CT scan revealed the accumulation of FDG in the primary tumor, hilar lymph node, and one of the ipsilateral axillar lymph nodes, in which cancer cell presence was proven by aspiration needle cytology. We organized a radical operation even though the node status was classified to cStage IV, because ipsilateral axillary lymph nodes may be regarded as regional nodes for tumors invading the chest wall. Right upper lobectomy and chest wall resection were performed, and the ipsilateral hilar, mediastinal, and axillary lymphnode were dissected. Pathological findings showed no active cancer cell in the primary lesion and hilar lymph nodes(Ef. 3), but obvious metastasis in one of the axillary lymph nodes(pT0N0M1b, pStage IV). The patient received adjuvant chemotherapy(CDDP/vinorelbine), and is alive and tumor-free 10months after the resection." }, { "id": "pubmed23n0689_4513", "title": "[A case of stage IIIB pulmonary pleomorphic carcinoma that responded well to chemoradiotherapy and surgery].", "score": 0.009174311926605505, "content": "A 44-year-old man was admitted because he had a mass in the right upper lung field showing high uptake of FDG-PET. Although he had already received video-assisted thoracic surgery to remove the mass in another hospital, the procedure had been unsuccessful because of severe adhesion to the superior vena cava. The pathological diagnosis of a specimen obtained in surgery was pleomorphic carcinoma, clinical stage IIIb (c-T4N2M0). We performed concurrent chemoradiotherapy consisting of systemic chemotherapy twice with both cisplatin and vinorelbine, and radiation therapy (60Gy). The tumor size reduced by 46% immediately after chemoradiotherapy. Because there was still no evidence of distant metastasis, we performed a right upper lobectomy and resection of the superior vena cava to remove the tumor completely. We did not detect any microscopic cancer cells in the surgical specimens and the pathological diagnosis was complete response (CR). It is thought that chemotherapy and radiotherapy are ineffective for pulmonary pleomorphic carcinoma. However, in this case, concurrent chemoradiotherapy with surgical therapy was highly effective and no recurrence has been observed 13 months after surgery." }, { "id": "wiki20220301en026_39239", "title": "Thymoma", "score": 0.00909090909090909, "content": "Surgery is the mainstay of treatment for thymoma. If the tumor is apparently invasive and large, preoperative (neoadjuvant) chemotherapy and/or radiotherapy may be used to decrease the size and improve resectability, before surgery is attempted. When the tumor is an early stage (Masaoka I through IIB), no further therapy is necessary. Removal of the thymus in adults does not appear to induce immune deficiency. In children, however, postoperative immunity may be abnormal and vaccinations for several infectious agents are recommended. Invasive thymomas may require additional treatment with radiotherapy and chemotherapy (cyclophosphamide, doxorubicin and cisplatin).. Recurrences of thymoma are described in 10-30% of cases up to 10 years after surgical resection, and in the majority of cases also pleural recurrences can be removed. Recently, surgical removal of pleural recurrences can be followed by hyperthermic intrathoracic perfusion chemotherapy or intrathoracic hyperthermic perfused" }, { "id": "pubmed23n0287_18553", "title": "[Successful multimodal therapy of a locally advanced non-small-cell bronchial cancer].", "score": 0.00909090909090909, "content": "A chest radiogram, performed on a 60-year-old man with unproductive cough for 3 months, showed a space-occupying lesion in the right upper lobe, and breath sounds were diminished in this area. He had been a heavy smoker. His general condition and nutritional state were good. Computed tomography, skeletal scintigraphy, bronchoscopy with biopsy and mediastinoscopy established the diagnosis of a locally advanced non-small-cell bronchial carcinoma (stage IIIB or T2N3M0). Combined adjuvant treatment was begun in the hope of improving the median survival time of 8 months predicted for this tumour stage. After two cycles of a combined chemotherapy scheme (ifosfamide, carboplatin, etoposide) he received hyperfractionated-accelerated radiotherapy (total dose 45 Gy; 1.5 Gy twice daily) together with carboplatin and vindesine. This was followed by a right upper lobectomy with lymphadenectomy. Full remission was confirmed in both the resected specimen and the lymph nodes. The patients remains free of tumour 30 months after the diagnosis. Neoadjuvant treatment can significantly improve the prognosis of non-small-cell bronchial carcinoma in stage III. Such patients should therefore be treated according to the appropriate study protocol, if possible." }, { "id": "pubmed23n0316_20328", "title": "Neoadjuvant concurrent chemoradiotherapy followed by definitive high-dose radiotherapy or surgery for operable thoracic esophageal carcinoma.", "score": 0.009009009009009009, "content": "A prospective clinical trial was undertaken to investigate the feasibility of concurrent chemoradiotherapy for esophageal carcinomas. Between June 1989 and May 1996, forty patients with operable squamous cell carcinoma of the thoracic esophagus (Stage 0 to III: UICC 1987), ages 45 to 78 years (mean: 64), were enrolled in a study of neoadjuvant concurrent chemoradiotherapy followed by definitive high-dose radiotherapy (CRT group) or surgery (CRT-S group). Neoadjuvant chemoradiotherapy consisted of 44 Gy in 40 fractions for 4 weeks (2.2 Gy/2 Fr/day) through 10-MVX rays, with 2 courses of cisplatin (80-100 mg/body, mean: 60 mg/m2, Day 1, bolus injection) and 5-fluorouracil (500-1000 mg/body/day, mean: 400 mg/m2, Days 1-4, continuous infusion). After completion of neoadjuvant chemoradiotherapy, an intermediate clinical response was assessed by barium swallow, esophagoscopy with/without biopsy, EUS in most cases, thoracic and upper abdominal CT scan, and cervical US. Definitive chemoradiotherapy was performed in patients when regression of more than 75% was evident (CRT Group), and esophageal resection was indicated in those who remained at less than 75% (CRT-S Group). In CRT Group, a cumulative dose of 60-70 Gy for Tis, T1 and 65-75 Gy for T2-T4 tumor with high-dose-rate intraluminal brachytherapy and a total of 3 courses of chemotherapy were planned. In CRT-S Group, intraoperative radiotherapy for abdominal lymphatic system and postoperative supraclavicular irradiation were added. At the time of intermediate assessment, complete response (CR) was observed in 16 patients, a partial response (PR) in 22, and no change (NC) in 2. Thirty responding patients (CR, 16; PR, 14) entered the CRT Group, and 10 nonresponding patients (PR, 8; NC, 2) were followed by surgery (CRT-S Group). Radiotherapy was completed satisfactorily, but chemotherapy was suspended in 26 patients (65%) because of acute toxicity. Clinical CR rate at the completion of treatment showed 90% in CRT Group, and pathologic CR rate 10% in CRT-S Group. The overall median survival was 45 months, survival at 1, 2, and 3 years being 100%, 72%, and 56%, respectively. Local-regional failure was observed in 7 patients (all in CRT Group), distant failure in 6 (3 in CRT Group, 3 in CRT-S Group) and local-regional with distant failure in 1 (CRT Group). Four patients with local-regional recurrence in the CRT Group were salvaged by surgery. Overall survival at 2 and 3 years for CRT vs. CRT-S Group was 72%, 64% vs. 75%, 38%, respectively. No treatment-related mortality was observed. The rate of the 'esophagus conservation' was 65% (Stage 0: 1 of 1, 100%; Stage I: 11 of 12, 92%; Stage II: 8 of 17, 47%; Stage III: 6 of 10, 60%). Our results demonstrated that almost all early disease (Stage 0-I) and about half of advanced disease (Stage II-III) could be conserved, their esophagus treated by the multidisciplinary approach centering on high-dose radiotherapy and concurrent chemotherapy." }, { "id": "pubmed23n0325_2919", "title": "[Surgical treatment of lung cancer with chest wall invasion].", "score": 0.009009009009009009, "content": "From January 1986 to May 1998, 45 lung cancer patients with chest wall invasion (P3) underwent resection (40 male, 5 female), (median age 63.2 yrs (30-79)). Histological types were squamous cell carcinoma in 20, adenocarcinoma in 14, large cell carcinoma in 7, adenosquamous cell carcinoma in 2, and unknown in 2. Operative methods of lung resection were total pneumonectomy in 2, bilobectomy in 3, lobectomy in 38, and partial lung resection in 2. Resection was regarded as complete in 35 and incomplete in 10 patients. Thirty one patients had negative lymph nodes (N0), 9 had peribronchial or hilar lymph node metastases (N1), and 5 had mediastinal lymph node metastases (N2). The extent of tumor invasion to chest wall was P3a (invasion within parietal pleura) in 11, P3b-c (invasion to intercostal muscle) in 16, P3d (invasion to rib) in 18, patients. 5-year survival rate was totally 19.7%. Cisplatin based chemotherapy and concurrent thoracic radiation following surgery (CCRT) was performed in latest nine P3d cases. Partial response was observed in 5 of 9 cases (response rate 56%) and viable tumor cell in the primary site was not seen histologically in 5 of 9 cases. Three year survival rate was 46.9% for CCRT(+) 11.1% for CCRT(-). Acturial 5-year survival rate in P3a-d was 19.76%. P3d cases had poor survival, but CCRT improved prognosis of P3d cases." }, { "id": "pubmed23n0551_9237", "title": "Sister Mary Joseph's nodule as a presenting sign of internal malignancy.", "score": 0.008928571428571428, "content": "CASE 1: A 64-year-old, otherwise healthy woman was referred to the surgery clinic for a presumed umbilical hernia. On physical examination, a cutaneous nodule was noted on the umbilical region and the patient was referred to the dermatology clinic. The patient was reexamined and an erythematous nodule was observed in the umbilicus measuring 2.5 cm in diameter. The patient denied pain, change in bowel habits, or weight loss. There were no other abdominal masses, no sign of ascites, and no regional lymphadenopathy. A skin biopsy from the nodule showed mucinous adenocarcinoma. Immunohistochemical staining was positive for carcinoembryonic antigen, and negative for cytokeratin (CK)7 and CK20. These results were consistent with a Sister Mary Joseph's nodule and led to the diagnosis of an occult colon carcinoma. The patient had no risk factors for colorectal carcinoma. The patient underwent surgery in another hospital, and died 3 months after the initial diagnosis of Sister Mary Joseph's nodule. CASE 2: A 73-year-old woman was referred to the dermatology clinic for evaluation of a painful, ulcerated, 3-cm lesion in the umbilicus (Figure 1). She was otherwise asymptomatic. A skin biopsy showed neoplastic glandular cells infiltrating among collagen bundles (Figure 2). Stainings for mucin and for CK7 were positive, while staining for CK20 was negative. An abdominopelvic CT scan demonstrated a 3.5-cm space-occupying lesion in the liver. Results of gastroscopy, colonoscopy, chest computed tomographic (CT) scan, and mammography were normal. Serum levels of the tumor-associated protein CA125 were elevated to 164 units, while those of CA 19-9 and carcinoembryonic antigen were within normal range. A gynecologic examination and a transvaginal ultrasound were normal. The patient had no personal or family history of any malignancy or any risk factors for developing a carcinoma. The patient was scheduled for a palliative resection of the umbilical nodule, combined with a laparoscopic inspection in search of the undetected primary tumor. She refused surgery and was lost to follow-up. She died 4 months after the initial diagnosis of umbilical metastasis. CASE 3: A 51-year-old man was aware of a silent mass in his umbilicus for 2 years without seeking medical advice. Following 2 weeks of increasing pain in this area, he was referred to the emergency room for a suspected incarcerated umbilical hernia. Surgery revealed a mass attached to the fascia and peritoneal fat. The mass was removed and diagnosed as a poorly differentiated adenocarcinoma, staining positively for carcinoembryonic antigen, and negatively for CK20, CK7, prostate-specific antigen, and prostatic acid phosphatase. Both gastroscopy and colonoscopy failed to detect the primary tumor. An abdominopelvic CT scan was normal, but a CT scan of the chest disclosed a nodule measuring 2.5 x 1.5 cm in the lower lobe of the right lung. On bronchoscopy, it was found to be an invasive adenocarcinoma, consistent with a primary tumor of the lung. The patient was a heavy smoker (45 pack-years). The patient received 4 cycles of combined chemotherapy with carboplatine and gemcitabine, with no improvement. A month later, the patient complained of abdominal pain. Following demonstration of intra-abdominal spread of disease by CT scan, a second line chemotherapy was instituted with paclitaxel. A month later the patient's condition deteriorated and he complained of cough, sweating, and pain along the right leg. A bone scan revealed bone metastases in the right femur and left tibia. Two weeks later he was admitted to the hospital with intestinal obstruction and underwent laparotomy. He had massive intra-abdominal spread of cancer and ascites. Only a palliative colostomy was performed. The patient died 3 weeks later, 9 months after the diagnosis of adenocarcinoma of the lung. The clinical data on the three patients are summarized in Table I." }, { "id": "pubmed23n0647_117", "title": "[A 67-year old man with right arm paresthesias].", "score": 0.008928571428571428, "content": "A 63-year-old man was admitted to the emergency room with chest pain. He had experienced a painful, tingling sensation in the right arm for the last three months, as well as pain in the right scapula. ECG and standard blood samples were normal. An X-ray of the thorax showed a mass in the superior sulcus on the right side. Further investigation with CT and MRI identified a large tumour, about 6 cm in size, with infiltrative growth involving the upper costae. Biopsy revealed a non-small cell carcinoma of the lung. The patient underwent a tri-modal treatment regimen with induction chemotherapy (two courses of cisplatin and etopside) and concomitant radiotherapy (50 Gy in 2 Gy fractions) before a right upper lobectomy was performed. 1 year after surgery the patient is alive, with no signs of recurrent or metastatic disease. Pancoast tumours are an infrequent subtype of lung cancers. Diagnostic delay is not uncommon. The peripheral location of the tumour generates symptoms that may easily be attributed to other causes, such as those of a musculoskeletal origin. Pre-operative chemo-radiotherapy has showed improved survival outcomes compared to pre-operative radiotherapy alone." }, { "id": "pubmed23n0890_5083", "title": "[A Patient with Primary Intraventricular Gliosarcoma and Long-term Survival - a Case Report].", "score": 0.008849557522123894, "content": "Gliosarcoma is a rare, malignant CNS tumor with a very poor prognosis. Gliosarcoma is a variant of glioblastoma multiforme, which is characterized by the presence of both glial and mesenchymal components. The treatment strategy for gliosarcomas has not yet been determined clearly. This case report presents a 23-year-old female patient who complained of increasing headaches, nausea and vomiting, and slight motor weakness in her left arm. An MRI scan of the brain showed a tumor filling the anterior part of the right lateral ventricle and extending into the right frontal lobe. Tumor extirpation was performed. Histology revealed gliosarcoma. Subsequently, the patient received concomitant chemoradiotherapy with temozolomide in the Stupp regimen. Following the fourth cycle of maintenance temozolomide chemotherapy, at eight months after diagnosis, an MRI scan detected progression of the tumor residue. The patient underwent another surgery and then received 10 cycles of second-line chemotherapy in the ICE (ifosfamide, carboplatin, and etoposide) regimen. She completed oncological therapy with minimal toxicity and follow-up MRI scans showed virtually no residual tumor. Another follow-up MRI scan, performed 28 months after diagnosis, demonstrated progression of the tumor residue again. A third tumor resection was performed 29 months after initial diagnosis. Histology again confirmed gliosarcoma. An early postoperative MRI scan showed subtotal resection with a tumor residue in eloquent areas and also suspected implantation metastasis in the spinal canal at the C2 level. From the neurological perspective, the patient was fully self-sufficient, and had only a very mild motor deficit in her left arm. Currently, at 31 months after initial diagnosis, the patient is in a stable condition and fully self-sufficient. Our case report shows that long-term survival can be achieved in a gliosarcoma patient exhibiting all the unfavorable features in clinical-pathological terms. The minimal recommended treatment is maximal resection followed by adjuvant radiotherapy. Our patient also underwent chemoradiotherapy with temozolomide in the Stupp regimen. Recurrence at eight months after diagnosis was managed by a repeat operation and high-dose combination chemotherapy, which kept the disease in remission for 20 months after the initial relapse. The lack of unequivocal rules for chemotherapy provides an opportunity to test less common treatment regimens.Key words: gliosarcoma - surgery - chemotherapy - radiotherapy - survivalThis study was supported in part by the grant No. NT13581-4/2012(86-91) of the Internal Grant Agency of the Czech Ministry of Health.The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 26. 3. 2016Accepted: 27. 4. 2016." }, { "id": "pubmed23n0678_15726", "title": "Three cases of resected pleomorphic carcinoma.", "score": 0.008849557522123894, "content": "Pleomorphic carcinoma (PC) is a rare malignancy of the lung. We present 3 cases that were resected. Case 1: The patient was a 75-year-old asymptomatic man whose chest roentgenogram showed a cavity at the right apex. A right upper lobectomy was performed, and the pathological stage was IB (pT2N0M0). After 3 courses of adjuvant chemotherapy, he is alive without relapse 56 months after the operation. Case 2: The patient was a 60-year-old man with left high back pain whose chest roentgenogram showed a mass shadow in the left upper lung field. A left upper lobectomy with partial resection of S6 was performed after induction chemotherapy. The pathological stage was IIIA (pT2N2M0). He died of infection 4 months after the operation during adjuvant chemotherapy. Case 3: A 78-year-old man with hemoptysis underwent aortic arch replacement after a diagnosis of impending rupture of an aortic aneurysm. During the operation, a tumor in the left upper lung lobe was detected. A left upper division segmentectomy was performed one month later. The pathological stage was IIB (pT3N0M0). Despite adjuvant radiotherapy, the patient died of cancer 9 months after the segmentectomy. The final pathological diagnoses for all 3 cases were PC. More cases of PC should be reported to establish optimal management." }, { "id": "wiki20220301en426_24543", "title": "Induction chemotherapy", "score": 0.008771929824561403, "content": "Induction chemotherapy is the first-line treatment of cancer with a chemotherapeutic drug. The goal of induction chemotherapy is to cure the cancer. It may be contrasted with neoadjuvant therapy, with consolidation chemotherapy (intended to kill any cancer cells that survived the initial treatment), and with maintenance chemotherapy given at lower doses after the consolidation phase of treatment is over. Induction chemotherapy relies on the principle of spatial cooperation. It is beneficial in the control of malignant lymphomas and head and neck squamous cell carcinomas when followed by radiotherapy or when treated concurrently with chemoradiotherapy. References Chemotherapy" }, { "id": "pubmed23n0274_6122", "title": "[A five-year survivor of small cell lung carcinoma stage IIIB treated with surgical resection and an adjuvant chemoradiotherapy--a case report].", "score": 0.008771929824561403, "content": "A 56-year-old woman was admitted to our hospital with the complaint of cough. She had a rt. supraclavicular lymph node swelling, and her chest X-ray showed masses at the rt. hilum and the mediastinum. On bronchofiberscopy, a tumor was detected at the orifice of the lt. B3b, and the biopsy revealed small cell lung cancer (SCLC). With the peroperative diagnosis of stage IIIB SCLC, a neoadjuvant chemotherapy followed by surgical resection was performed. Because of the presence of malignant cells in the pericardial effusion, the operation turned out to be an absolutely non-curative one. As the recurrence of mediastinal lymph node swelling occurred after the surgery, an intensive chemoradiotherapy was performed successfully. Then the patient has been free from disease for five years. This case indicates the possibility that some of SCLC patients can be long-term survivors by the treatment of an appropriate adjuvant therapy combined with radical resection, even if the clinical stage is advanced. Therefore an extended operative indication for SCLC should be considered." }, { "id": "pubmed23n0995_2077", "title": "[An initial exploration of the application of transanal endoscopic microsurgery in rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy].", "score": 0.008695652173913044, "content": "<bObjective:</b To preliminarily explore the value of transanal endoscopic microsurgery (TEM) in rectal cancer patients with clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT). <bMethods:</b Using descriptive case series method, Clinical data of 13 patients who met the criteria of nCRT and were considered to be cCR after MRI or CT scanning, digital rectal examination and colonoscopic biopsy, as well as no lymph node or distant metastasis were found, then underwent TEM from 2013 to 2016 at the Department of General Surgery of Peking Union Medical College Hospital were collected retrospectively. A 3-course combination of capecitabine and oxaliplatin (XELOX) was used for chemotherapy. Besides, a 6MV-X ray radiation was used as radiotherapy simultaneously. Six to eight weeks after completion of radiotherapy, a preoperative assessment was carried out with intrarectal ultrasound, MRI, or pelvic abdominal CT examination. TEM was performed afterwards with informed consent. Postoperative pathological findings and follow-up results were used to evaluate the value of diagnosis and treatment of TEM on those patients. <bResults:</b There were 8 males and 5 females with a median age of 63 (27-80) years. Preoperative examination showed that the lesions were located in the anterior wall in 3 cases, the posterior wall in 3 cases, the left side wall in 4 cases, and the right side wall in 3 cases. Before nCRT, the distance between tumor and anal margin was (4.8±1.1) (2.0-7.5) cm; after nCRT, this distance was (5.2±1.3) (3.0-7.5) cm. All the 13 patients underwent extended local resection of rectal cancer via TEM with the placement of urethral catheter. The average operative time was (52.2±3.7) (42-70) minutes, and the average intraoperative blood loss was (19.2±2.8) (5-30) ml. All the patients could engage in daily activities on postoperative day 1, and could cater themselves orally on postoperative day 2. The main discomfort was postoperative anal pain and foreign body sensation (<in</i=5), which could be alleviated by non-steroidal anti-inflammatory drugs. One case had postoperative lung infection and was cured by antibiotic treatment. One case had urinary retention after removing urine catheter, and then a urine catheter was re-inserted. Average postoperative hospital stay was (2.8±2.4) (2-12) days. All specimens were completely resected via TEM. Histopathological examination confirmed that 7 specimens had achieved pathologic complete response (pCR) and the other 6 specimens had obtained partial tumor response of CAP grade 2. Seven patients with pCR received a median follow-up of 24 (8-48) months and no local recurrence or distant metastasis was reported during follow-up period. Among these 7 cases, one developed defecation dysfunction after discharge, mainly for defecation pain and even dare to defecate, who returned to normal defecation within 2 months after surgery; One developed severe anal pain within six months after surgery and the pain disappeared after symptomatic pain relief. The other 6 patients with CAP grade 2 refused to undergo further radical operation because of their strong desire in preserving anus, and received remedial adjuvant chemotherapy instead. <bConclusion:</b For rectal cancer patients with cCR after nCRT, TEM does have certain application values if the patient has a strong desire to preserve anus." }, { "id": "pubmed23n0596_21502", "title": "Induction chemoradiation therapy followed by surgical resection for non-small cell lung cancer (NSCLC) invading the thoracic inlet.", "score": 0.008695652173913044, "content": "The role of induction therapy for non-small cell lung cancer (NSCLC) invading the thoracic inlet is unclear. We reviewed our experience with induction chemoradiation followed by surgical resection for NSCLC invading the thoracic inlet. We performed a retrospective review of 44 consecutive patients with NSCLC invading the thoracic inlet, treated with induction chemoradiation (two cycles of cisplatin and etoposide concurrently with 45Gy of radiation) followed by surgical resection between 1996 and 2007. All patients underwent chest wall resection (1-5 ribs, mean 3) with resection of the first rib through an anterior (n=15), a posterior (n=18), or a combined approach (n=11). Lobectomy was performed in 40 cases (90%), pneumonectomy in two (5%), and wedge resection in two (5%). Resection of subclavian vessels or portions of vertebrae was performed in five (11%) and 15 (34%) patients, respectively. Hospital mortality was 5% (n=2). R0-resection was achieved in 39 patients (89%). On pathologic examination, 13 patients (30%) showed complete response (pCR) to induction therapy, and 15 (34%) showed minimal microscopic residual disease (90-99% tumor necrosis). The median follow-up was 2 years (range, 2 month-10 years) with an overall cumulative 5-year survival of 59%. Sixteen patients (36%) developed recurrence, which was local in five cases and distant in 11 patients. The 5-year survival in patients with pCR was 90%; 69% in those with minimal residual disease, and 12% in patients with no relevant response (p=0.0005). Resection of NSCLC invading the thoracic inlet can be performed safely after induction chemoradiation therapy. The response rate after induction therapy is a strong predictor of survival." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 2215, 2319 ] ], "word_ranges": [ [ 389, 409 ] ], "text": "And as for the walls of the orbit, the ones that break most frequently are the inferior and medial wall." }, "2": { "exist": true, "char_ranges": [ [ 2104, 2214 ] ], "word_ranges": [ [ 369, 389 ] ], "text": "Options 2 and 4 can be ignored because they are too far away from the extraocular muscles to produce diplopia." }, "3": { "exist": true, "char_ranges": [ [ 2320, 2359 ] ], "word_ranges": [ [ 409, 415 ] ], "text": "The superior wall ruptures very rarely." }, "4": { "exist": true, "char_ranges": [ [ 2104, 2214 ] ], "word_ranges": [ [ 369, 389 ] ], "text": "Options 2 and 4 can be ignored because they are too far away from the extraocular muscles to produce diplopia." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Fracture of the inferior wall of the floor of the orbit with trapping of the inferior rectus muscle.", "2": "Zygomatic arch fracture.", "3": "Fracture of the superior wall of the orbit with entrapment of the superior rectus muscle.", "4": "Dentoalveolar fracture.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0639_16874", "title": "Clinico-radiologic findings of entrapped inferior oblique muscle in a fracture of the orbital floor.", "score": 0.01869812145041503, "content": "A 51-year old man presented with vertical and torsional diplopia after reduction of a blowout fracture at another hospital one year ago. He had no anormalies of head position and 14 prism diopters (PD) right hypertropia (RHT) in the primary position. In upgaze no vertical deviation was found, and hyperdeviation on downgaze was 35PD. Bielschowsky head tilt test showed a negative response. Distinct superior oblique (SO) and inferior rectus (IR) underaction of the right eye was noted but IO overaction was mild on the ocular version test. Double Maddox rod test (DMRT) revealed 10-degree extorsion, but fundus extorsion was minimal in the right eye.Thin-section coronal CT scan showed that there was no fracture line on the anterior orbital floor, but a fracture remained on the posterior orbital floor. Also, the anterior part of the right inferior oblique muscle was vertically reoriented and the medial portion of the inferior oblique muscle was not traced on the coronal CT scan. The patient underwent 14 mm right IO recession and 3 mm right IR resection. One month after the surgery, his vertical and torsional diplopia were eliminated in the primary position." }, { "id": "wiki20220301en128_11452", "title": "Orbital blowout fracture", "score": 0.018480667688639072, "content": "Signs & Symptoms Some clinically observed signs and symptoms include: Orbital pain Eyes displaced posteriorly into sockets (enophthalmos) Limitation of eye movement Loss of sensation (hypoesthesia) along the trigeminal (V2) nerve distribution Seeing-double when looking up or down (vertical diplopia) Orbital and lid subcutaneous emphysema, especially when blowing the nose or sneezing Nausea and bradycardia due to oculocardiac reflex inability to elevate eye ball, and move eyeball downward due to inferior rectus entrapment Causes Common medical causes of blowout fracture may include: Direct orbital blunt injury Sports injury (squash ball, tennis ball etc.) Motor vehicle accidents" }, { "id": "wiki20220301en128_11460", "title": "Orbital blowout fracture", "score": 0.016632160110420978, "content": "History Orbital floor fractures were investigated and described by MacKenzie in Paris in 1844 and the term blow out fracture was coined in 1957 by Smith & Regan, who were investigating injuries to the orbit and resultant inferior rectus entrapment, by placing a hurling ball on cadaverous orbits and striking it with a mallet. References External links CT Scans of Blowout Fracture from MedPix Bone fractures" }, { "id": "pubmed23n1095_8097", "title": "Anatomical implication of less occurrence of inferior oblique muscle entrapment in orbital floor trapdoor fracture.", "score": 0.015082337249268968, "content": "To examine the anatomy of the inferior oblique (IO) muscle and its surrounding structures to clarify why IO muscle entrapment develops less in orbital floor trapdoor fractures. Computed tomographic (CT) images on the unaffected sides were obtained from 64 patients with unilateral orbital fractures. On coronal planes, presence or absence of an infraorbital groove below the IO muscle was confirmed. At the level of the medial margin of the infraorbital groove/canal, the distance from the orbital floor to the IO muscle (IO-floor distance), the thickness of the orbital floor, and the shortest distance from the inferior rectus (IR) muscle to the orbital floor (shortest IR-floor distance) were measured. On quasi-sagittal planes, the distances from the inferior orbital rim to the inferior margin of the IO muscle (IO-rim distance) and the most anterior point of the infraorbital groove (groove-rim distance) were measured. The infraorbital groove was found below the IO muscle in eight patients (12.5%), and the IO-rim and IO-floor distances were significantly longer than the groove-rim and shortest IR-floor distances, respectively (p &lt; 0.001). The orbital floor below the IO muscle was significantly thicker than that below the IR muscle (p &lt; 0.001). Although the medial margin of the infraorbital groove is the most common fracture site, the IO muscle was not located above the groove in most cases. A longer IO-floor distance and thicker orbital floor below the IO muscle may also contribute to less occurrence of IO muscle entrapment in orbital floor trapdoor fractures." }, { "id": "pubmed23n1044_8135", "title": "An Uncommon Case of Isolated Superior Rectus Palsy.", "score": 0.01501052398360474, "content": "Head injury associated with orbital trauma is commonly encountered in day-to-day practice. We report a rare case of orbital trauma resulting in isolated orbital \"roof blow\" in fracture in a 14-year-old child. The patient presented to us with diplopia and limitation of elevation of right eye after orbital trauma. Computed tomography of the orbits (2 mm sections) did not reveal fracture of the orbital floor. However, there was orbital roof \"blow in\" fracture with fracture fragment impingement on the superior rectus muscle. Patient was treated conservatively and spontaneous recovery of ocular motility was noted after a month." }, { "id": "wiki20220301en225_19300", "title": "Facial trauma", "score": 0.014926189174412248, "content": "Nerves and muscles may be trapped by broken bones; in these cases the bones need to be put back into their proper places quickly. For example, fractures of the orbital floor or medial orbital wall of the eye can entrap the medial rectus or inferior rectus muscles. In facial wounds, tear ducts and nerves of the face may be damaged. Fractures of the frontal bone can interfere with the drainage of the frontal sinus and can cause sinusitis. Infection is another potential complication, for example when debris is ground into an abrasion and remains there. Injuries resulting from bites carry a high infection risk." }, { "id": "pubmed23n0682_15123", "title": "Lateral rectus muscle injury, orbital fracture, mouth locking, and facial palsy resulting from reduction malarplasty.", "score": 0.014913831197525408, "content": "I report here on a patient with serious complications (lateral rectus muscle injury, orbital fracture, mouth locking, and facial palsy) that were caused by reduction malarplasty. A 32-year-old woman was referred to our department with complaints of inability to move her right eyeball laterally and inability to open her mouth. She has undergone reduction malarplasty 30 days previously at a local clinic. On examination, her maximal mouth opening was less than 3 mm. Her upper lip deviated to the left side when whistling. The orbit was displaced laterally and inferiorly. The upward and lateral gaze were limited. Computed tomography revealed fracture of the right orbital floor and lateral orbital wall extending to the orbital roof. The right lateral rectus muscle showed disconnection. The osteotomized segments were displaced inferiorly, and they pressed on the masseter muscle and coronoid process on the left side. On the 43rd postoperative day, a revision operation for the zygoma and orbit was carried out. Four days after the revision operation, surgery was performed for the myorrhaphy of the lateral rectus muscle and transposition of the medial rectus muscle. This case suggests the possibility of orbital fracture that can occur as a result of sawing in the wrong direction when using the intraoral approach. Although orbital fracture is extremely rare, it is hoped that this case will heighten the awareness of surgeons for this potential orbital fracture." }, { "id": "pubmed23n1067_8360", "title": "Resolution of Vertical Gaze Following a Delayed Presentation of Orbital Floor Fracture With Inferior Rectus Entrapment: The Contributions of Charles E. Iliff and Joseph S. Gruss in Orbital Surgery.", "score": 0.01431022029613579, "content": "Orbital floor fractures occur commonly as a result of blunt trauma to the face and periorbital region. Orbital floor fractures with a \"trapdoor\" component allow both herniation and incarceration of contents through a bone defect into the maxillary sinus as the bone rebounds faster than the soft tissue, trapping muscle, fat, and fascia in the fracture site. In children, the fractured floor, which is often hinged on one side, tends to return toward its original anatomical position due to the incomplete nature of the fracture and elasticity of the bone. The entrapment of the inferior rectus muscle itself is considered a true surgical emergency-prolonged entrapment frequently leads to muscle ischemia and necrosis leading to permanent limitation of extraocular motility and difficult to correct diplopia. For this reason, prompt surgical intervention is recommended by most surgeons. In adults, true entrapment of the muscle itself is not as common because the orbital floor is not as elastic and fractures are more complete. We present an adult patient with an isolated orbital floor fracture with clinical and radiologic evidence of true entrapment of the inferior rectus muscle itself. Despite the delayed surgical repair (4 days after the injury), the patient's inferior rectus muscle function returned to near normal with mild upward gaze diplopia. Inferior rectus entrapment in adults may more likely be associated with immobilization of the muscle without total vascular compression/incarceration significant enough to lead to complete ischemic necrosis." }, { "id": "article-23495_22", "title": "Anatomy, Head and Neck: Eye Inferior Rectus Muscle -- Clinical Significance", "score": 0.013414029871876548, "content": "Because the inferior rectus is near the orbital floor, orbital floor fractures may involve this muscle. Inferior rectus muscle paresis can result from trauma to the inferior rectus muscle or nerve. This can occur either at the time of initial injury or during surgical repair of the orbital floor. If inferior rectus muscle paresis is present without entrapment, the patient may display hypertropia in the primary position. If paresis is present with entrapment, the patient may have a slight deviation or hypotropia, which decreases with downgaze. The initial management of inferior rectus paresis is observation for six months. Muscle surgery may be recommended if there is no improvement during this time. [9] [10]" }, { "id": "pubmed23n0092_11119", "title": "[Types and treatments of blow-out fractures].", "score": 0.01298750188224665, "content": "A total of ten cases of blow-out fractures of the orbit was investigated as to the signs and symptoms, image findings of conventional views of Caldwell and Waters' and of coronal CT. According to the locations of fractures, medial, floor and medial-floor types were classified. Fractured bone tips were classified to depressive and trapdoor types. Fractures often occur posterior to the eyeball, the inferior rectus muscle showed dislocation and cylinder-like hypertrophy. Contrary to the reports in the past, the inferior rectus muscle did not show entrapment in the herniated portion. Caldwell view is superior to Waters' view in demonstrating fractures at the medial orbital wall. As to the choice of treatment in the majority of cases, conservative methods are indicated. Images by CT are used in determining surgical methods, the depressive type without clinical improvement after two weeks is the indication for the surgical treatments." }, { "id": "pubmed23n0343_882", "title": "Less common orbital fracture patterns: the role of computed tomography in the management of depression of the inferior oblique origin and lateral rectus involvement in blow-in fractures.", "score": 0.012787624378109453, "content": "During the past decade, advances in radiographic imaging have made it possible for the surgeon managing orbital fractures to adopt a rational therapeutic strategy based on a knowledge of alterations in surgical anatomy secondary to traumatic injury. To illustrate the value of computed tomography in the surgeon's armamentarium for management of orbital fractures, cases are presented in which imaging proved decisive in planning a course of therapy. Two patients presented with two types of isolated lateral blow-in fracture, an uncommon fracture pattern. The other cases underscore the value of defining involvement of the inferior oblique origin and lateral rectus muscles in imaging complex orbital fractures, issues not emphasized in earlier literature. Although diplopia alone does not always warrant surgical intervention, diplopia in the context of computed tomography-defined muscle entrapment or muscle origin displacement justifies operative therapy. These cases demonstrate the value of computed tomography in directing surgical therapy with resolution of diplopia and prevention and correction of enophthalmos." }, { "id": "wiki20220301en052_59239", "title": "Medial rectus muscle", "score": 0.01255510829978915, "content": "Compression The medial rectus muscle lies directly adjacent to the orbit of the skull. This leaves it vulnerable to being compressed (incarcerated) during skull fractures, which can prevent movement of the eye. This usually resolves when skull fractures are fixed. Surgical damage The medial rectus muscle may be damaged during eye surgery or skull surgery, such as functional endoscopic sinus surgery. The damage can be minor, such as bruising, or sever, such as cutting through the muscle partially or completely, and nerve injury. Additional images See also Extraocular muscles References External links () Diagram at howstuffworks.com Muscles of the head and neck Human eye anatomy de:Augenmuskeln#Musculus rectus medialis" }, { "id": "pubmed23n0984_6733", "title": "Intraoperative Findings of Extraocular Muscle Necrosis in Linear Orbital Trapdoor Fractures.", "score": 0.01242747520119783, "content": "Orbital trapdoor fractures can constitute a relative surgical emergency. The reason for poor surgical outcomes in ocular motility disturbances and diplopia is not apparent in these fractures. The purpose of this retrospective study was to analyze the possibility of ischemic necrosis of the orbital contents in linear trapdoor fracture of the orbital floor and to evaluate the recovery period of trapdoor fractures. The study included 11 patients with linear trapdoor fracture of the orbital floor over 5 years with minimum 1-year follow-up. Patients with associated facial bone fractures were excluded. Demographic, etiologic, and radiologic characteristics, interval from trauma to surgery, and surgical techniques were recorded. Patients' age range was 9 to 29 years (mean, 16.3 yr). Mean time to surgical intervention from time of injury was 3.9 days (range, 0 to 11 days). Intraoperatively, macroscopic segmental necrosis of the entrapped inferior rectus muscle was observed in 3 patients. Postoperative review was conducted for a minimum of 12 months at 1-week and 1-, 3-, 6-, and 12-month intervals. At the end of the follow-up period, incomplete recovery was observed in 5 patients, including the 3 patients with intraoperative necrosed muscle, and the other 2 patients were operated on at days 7 and 8 from time of injury. This study showed that segmental necrosis of the entrapped inferior rectus muscle is possible in linear trapdoor fracture of the orbital floor. In addition, incomplete recovery correlated with clinical evidence of inferior rectus muscle necrosis and late surgical intervention." }, { "id": "pubmed23n1007_19980", "title": "Clinical findings and surgical outcomes of patients with traumatic isolated inferior rectus muscle paresis.", "score": 0.01242141360259097, "content": "To evaluate clinical findings and surgical outcomes of patients with traumatic isolated inferior rectus muscle paresis. The medical records of patients with traumatic isolated inferior rectus paresis who underwent strabismus surgery at Farabi Eye Hospital between 2011 and 2018 were reviewed retrospectively. Clinical features, type of surgery, and surgical outcomes were extracted from the record for analysis. A total of 19 patients (14 males [74%]) were included. Mean patient age was 34.8 ± 14.6 years. Left eyes in 13 patients (68%) were involved. Thirteen cases (68%) underwent orbital reconstruction surgery for blow-out fracture. Preoperative limitation of duction in the gaze of the inferior rectus muscle was -2 to -3 in all cases. Four patients (21%) had a paradoxical contralateral compensatory head tilt. Inferior rectus muscle resection alone was the first surgical intervention in 12 patients (63%). At the final follow-up, 12 patients (63%) were orthotropic, without any deviation or diplopia in primary position and downgaze. Three patients (16%) had a residual hypertropia of 3<supΔ</sup at distance and near without diplopia, and 4 patients (21%) required reoperation. In our patients with traumatic isolated inferior rectus paresis with persistent deviation at least 6 months after trauma, a stepwise approach based on size of the vertical deviation was employed, with good outcomes: inferior rectus resection alone for hypertropia of 6<supΔ</sup-20<supΔ</sup and inferior rectus resection and superior rectus recession for hypertropia of ≥20<supΔ</sup or significant hypertropia in the field of the superior rectus muscle." }, { "id": "pubmed23n0223_18117", "title": "[Blow out fracture of the medial orbital wall--plastic repair with tantalum mesh].", "score": 0.012338020402536532, "content": "Two cases of blow out fracture of the medial orbital wall were reported. The one was a 14 year-old boy and the other was a 32 year-old man. After hitting the eye against another man or a hard object, the patients felt diplopia, especially on lateral gaze toward the injured side. The blow out fracture was able to be diagnosed by plain roentgenography or tomography. The fractured bone as well as the entrapped soft tissue were clearly detected by CT scan. The fractures occurred at the thinnest part of the Lamina orbitalis ossis ethmoidalis (Lamina papyracea) in both cases. Objects with diameter larger than that of the bony orbit pressed the eye ball and other soft tissue into the orbital cavity, and the blow out fracture occurred in the medial orbital wall in each case. The skin was incised along the supero-medial margin of the orbit and subperiostial dissection was done. The entrapped medial rectus muscle was observed in one case and unverified in the other. Entrapment of the orbital soft tissue other than medial rectus muscle may also have caused diplopia. Tantalum mesh, used for repair is quite thin material. It has much plasticity and little possibility of damaging the orbital tissue and of causing postoperative bleeding. No complication occurred after operation and diplopia disappeared completely or nearly completely in the cases reported." }, { "id": "pubmed23n0520_3853", "title": "Incarceration of the inferior oblique muscle branch of the oculomotor nerve in two cases of orbital floor trapdoor fracture.", "score": 0.012140320359498441, "content": "Incarceration of the inferior oblique muscle (IO) branch of the oculomotor nerve may occur in cases of orbital floor trapdoor fracture. Two orbital floor trapdoor fracture cases, with lesions located just outside of the inferior rectus muscle but without its incarceration, were examined pre- and postoperatively for visual acuity, intraocular details, the nine diagnostic ocular positions of gaze, binocular single vision field with the Hess chart, and by computed tomography (CT). One case was also examined by magnetic resonance imaging (MRI; T1-weighted images). A forced duction test was conducted intraoperatively. Each case presented good visual acuity and neither globe showed any injury. Motility disturbance of the IO was shown in each case by binocular single vision field testing and the Hess chart. The possibility of the incarceration of the IO branch of the oculomotor nerve, which runs from the incarcerated lesion to the superior belly of the IO, in an orbital floor trapdoor fracture was shown on CT and MRI. Intraoperative forced duction testing revealed a restriction due to the incarceration of the connective tissue septa. As inferred from the CT and MRI analyses conducted in this study, IO palsy may be one of the causes of ocular motility disturbance of the IO in an orbital floor trapdoor fracture, in addition to the ocular motility disturbance due to the connective tissue septa." }, { "id": "pubmed23n0950_25438", "title": "Incidence of diplopia after division and reattachment of the inferior oblique muscle during orbital fracture repair.", "score": 0.012093352192362093, "content": "Wide surgical access to the orbital floor and medial wall is often impaired by the course of the inferior oblique muscle. There is no current consensus on the optimal surgical approach for exposure, and techniques involving inferior oblique division are generally shunned for concern of possible complications. To determine the safety and outcomes of inferior oblique division and reattachment for surgical access to the orbital floor and medial wall during orbital fracture repair. Retrospective, single-center, review of 85 patients that underwent orbital floor, medial wall or combined fracture repair with division and reattachment of the inferior oblique near its origin. Measured characteristics include surgical approach, type of surgery, time to surgery, pre- and post-operative diplopia, enophthalmos, and complications. Forty-five patients (52.9%) with no pre-operative diplopia were followed up for a mean of six months. Of these, six patients (13.3%) developed post-operative binocular diplopia that resolved in all patients on an average of three months (range 2-6 months). No patients developed torsional diplopia. One patient developed a hematoma two years later attributable to capsular contraction around the implant. Division and reattachment of the inferior oblique muscle is a safe method that allows for panoramic surgical visualization of the inferior and medial orbit." }, { "id": "article-133080_10", "title": "Extraocular Muscle Management With Orbital and Globe Trauma -- Anatomy and Physiology", "score": 0.012052555348644734, "content": "The oblique muscles course inferior to their corresponding rectus muscles and insert laterally onto the globe. The superior oblique muscle arises from the periosteum of the sphenoid bone body, but its functional origin is the trochlea. The trochlea acts as a pulley for the superior oblique and is situated on the superomedial aspect of the frontal bone, rendering it prone to trauma from penetrating hook injuries in the medial canthus. [10] The inferior oblique originates from the orbital portion of the maxillary bone, crosses the inferior rectus laterally, and inserts over the macula. Incarceration of the inferior oblique muscle or its branch of the oculomotor nerve (CN III) can occur with \"trapdoor\" fractures. [11] Additionally, the lateral inferior oblique runs with pupillomotor preganglionic parasympathetic nerves. Damage here can result clinically in a dilated pupil. Intraoperative considerations, such as a broad arc of contact with the globe and the possibility of the inferior oblique having more than one muscle belly, are likewise important. [12] [13]" }, { "id": "wiki20220301en056_40400", "title": "Superior orbital fissure", "score": 0.011947056774642983, "content": "Superior orbital fissure syndrome Superior orbital fissure syndrome, also known as Rochon-Duvigneaud's syndrome, is a neurological disorder that results if the superior orbital fissure is fractured. Involvement of the cranial nerves that pass through the superior orbital fissure may lead to diplopia, paralysis of extraocular muscles, exophthalmos, and ptosis. Blindness or loss of vision indicates involvement of the orbital apex, which is more serious, requiring urgent surgical intervention. Typically, if blindness is present with superior orbital syndrome, it is called orbital apex syndrome. See also Foramina of skull Inferior orbital fissure References External links () (#2) Foramina of the skull Medical mnemonics" }, { "id": "pubmed23n0932_5808", "title": "Complete inferior rectus muscle transection secondary to orbital blowout fracture.", "score": 0.011847375925045828, "content": "Complete extraocular muscle transection is uncommon in the setting of blunt trauma. We report a case of a 53-year-old male that developed diplopia after hitting his face directly on a concrete slab after a fall. On examination, he had a right hypertropia with a complete infraduction deficit. A CT scan of the face showed an orbital floor blowout fracture with complete inferior rectus transection. On surgical exploration, the distal and proximal ends of the muscle were identified and sutured together, and the floor fracture was repaired. At his post-operative visits, the patient had a persistent infraduction deficit, but subjectively had improved diplopia." }, { "id": "pubmed23n0855_19158", "title": "Morphological characteristics and clinical manifestations of orbital emphysema caused by isolated medial orbital wall fractures.", "score": 0.011774832156997763, "content": "To investigate the morphological characteristics and clinical manifestations of orbital emphysema in patients with isolated medial orbital wall fractures. This was a retrospective observational case series of 348 orbits of 348 patients with isolated medial orbital wall fractures. Medical charts were reviewed, and computed tomographic (CT) images were examined to determine the morphological characteristics of orbital emphysema. Orbital emphysema was detected in 70 orbits (20.1%). Large and communited type fracture was related with the presence of orbital emphysema (P&lt;0.05). Orbital air pockets were detected in medial or superior extraconal orbital segment in all cases with orbital emphysema. Swollen eyelid with crepitus (90.0%) and supraduction limitation (31.4%) were developed with orbital emphysema. All cases with supraduction limitation accompanied with superior extraconal orbital emphysema and superior rectus muscle deviation, and these eyes were fully recovered with conservative management without surgery. Orbital emphysema can be a cause of ocular motility restriction following orbital wall fracture. If supraduction limitation is noted with isolated medial wall fracture and superior orbital emphysema with superior rectus muscle deviation is detected by CT scan, conservative management can be a good choice for spontaneous recovery delaying the surgery." }, { "id": "pubmed23n0849_12572", "title": "Image analysis of the inferior rectus muscle in orbital floor fracture using cine mode magnetic resonance imaging.", "score": 0.011482529446601303, "content": "The main cause of diplopia induced by orbital floor fracture is strangulation or damage of the extraocular muscles, and the outcome varies depending on the severity of trauma. In this study, we evaluated the dynamics of the eyeball and inferior rectus muscle based on cine magnetic resonance (MR) images acquired before surgery. The preoperative images and outcomes were retrospectively investigated. The subjects were 20 patients with orbital floor fracture. The patients repeated upgaze and downgaze, and images of these were acquired using cine mode magnetic resonance imaging (MRI). Image series were obtained in the sagittal direction including the eyeball and long axis of the optic nerve. The eyeball rotation angle, strangulation, and morphology of the inferior rectus muscle were evaluated in each phase. On cine mode MRI, the outcome was poor in cases with a maximal inferior rectus muscle thickness of 5 mm or greater on extension (two or more times thicker than on the healthy side). Our results suggest that the development of sequelae can be predicted by preoperative image analysis using cine MRI, which may be beneficial to help surgeons understand the mechanism of contracture." }, { "id": "pubmed23n0327_4289", "title": "A protocol for extraocular muscle surgery after orbital floor fracture (\"blow-out\")", "score": 0.011347875425545328, "content": "If, after primary repair of an orbital fracture by maxillo-facial surgeons, diplopia persists, extraocular muscle surgery may be necessary. It was the purpose of this study to examine proposed surgical treatment in these cases to determine their efficacy. We analyzed, retrospectively, the files of 14 patients who were treated in our strabismological department for persistent diplopia caused by injury to the extraocular muscles and/or to the surrounding structures. The aim of our treatment protocol was to restore comfortable binocular single vision in primary position and downgaze. The selection of the surgical procedure depended on the deviation in primary position and on the degree of ocular muscle imbalance. Surgery consisted of recession of the inferior rectus muscle of the affected eye in 4 cases, resection of the inferior rectus muscle of the affected eye in 4 other cases, and large recessions of the vertical muscles of the contralateral normal eye in 6 cases. In all 14 patients, we obtained the desired comfortable field of binocular single vision, considered \"good\" (20 degrees up to 30 degrees downgaze) or \"satisfactory\" (a useful field). In 11 cases this was achieved in one procedure. Two patients needed a reintervention because of initial overcorrection, and one patient for an initial undercorrection. All 14 patients had a \"good\" or \"satisfactory\" final result (useful binocular single vision). When extraocular muscle surgery is necessary, we recommend in patients with limited forced elevation, recession of the taut rectus inferior muscle; in patients with the clinical characteristics of an inferior rectus palsy, a resection of this muscle; and in cases with a normal or only slightly limited forced duction test, weakening the contralateral synergists." }, { "id": "article-133080_11", "title": "Extraocular Muscle Management With Orbital and Globe Trauma -- Anatomy and Physiology", "score": 0.01129454529718502, "content": "EOM entrapment or flap tears may follow orbital fractures, which comprise the most common cause of traumatic strabismus. [14] The resultant strabismus depends on the fracture location and extent of EOM involvement. The orbit is pyramidally shaped with the apex posteriorly and the base anteriorly. Seven bones form its boundaries (Table 2). Frontal force to the orbit or globe first impacts the orbital rim but can be transmitted posteriorly before buckling downwards. The orbital floor and medial wall are commonly affected, resulting in a blowout fracture. This type of injury usually results in a comminuted fracture pattern in adults. [15]" }, { "id": "pubmed23n0028_6056", "title": "Blunt trauma to the eye.", "score": 0.01125, "content": "1. Blunt trauma to the orbital region may result in a blowout fracture, characteristically found in the orbital floor, which may contain herniated orbital contents including both inferior muscles of the eye. Persistent diplopia continues as a problem in a significant number of patients following the surgical management of a blowout fracture of the orbit. 2. Prompt recognition and treatment of blowout fractures exhibiting diplopia is usually successful. Inferior rectus and inferior oblique muscles incarcerated in a blowout fracture site for periods varying from two months to nine years may fail to function properly even following successful release of the entrapped muscles. There is some presumptive evidence to suggest a myogenic or neurogenic cause for such dysfunction. 3. Vertical diplopia that persists beyond three months following release of entrapped muscle tissue requires surgical correction, depending on the degree of vertical dissociation. 4. Motility surgery was required in 18 of 20 cases of persistent diplopia. Multiple muscle combinations are frequently required to achieve success. The criterion for a successful result was elimination of vertical diplopia in the primary and reading positions." }, { "id": "pubmed23n0136_3524", "title": "Orbital blowout fractures. The prognostic significance of computed tomography.", "score": 0.011244827695126188, "content": "Nineteen patients with orbital floor fractures were examined and underwent computed tomography of both orbits. By evaluating the amount of orbital expansion and soft tissue herniation, we were able to identify a group of patients at high risk for developing enophthalmos (3/7 in the group with the largest amount vs. 0/7 and 0/5 in the two other groups). By studying the appearance of the inferior rectus muscle, we were also able to identify a group of patients at high risk for developing persistent diplopia (5/5 with entrapped muscles, 0/2 with hooked muscles and 0/12 of patients with free inferior rectus positions)." }, { "id": "article-26295_14", "title": "Orbital Floor Fracture -- History and Physical", "score": 0.011188185276348177, "content": "Decreased sensation over the inferior orbital rim that may extend nasolabially signifies trigeminal nerve damage Subcutaneous emphysema is a sign of a maxillary sinus fracture Inferior rectus entrapment between inferior orbital fragments may have associated oculomotor nerve palsy Enopthalmos, exophthalmos, or swelling behind the globe indicates displacement of the fractured orbital bones Early referral to an ophthalmologist or orbital specialist may be necessary for further evaluation and treatment planning." }, { "id": "wiki20220301en128_11457", "title": "Orbital blowout fracture", "score": 0.011081402257872845, "content": "Imaging Thin cut (2-3mm) CT scan with axial and coronal view is the optimal study of choice for orbital fractures. Plain radiographs, on the other hand, do not have the sensitively capture blowout fractures. On Water's view radiograph, polypoid mass can be observed hanging from the floor into the maxillary antrum, classically known as teardrop sign, as it usually is in shape of a teardrop. This polypoid mass consists of herniated orbital contents, periorbital fat and inferior rectus muscle. The affected sinus is partially opacified on radiograph. Air-fluid level in maxillary sinus may sometimes be seen due to presence of blood. Lucency in orbits (on a radiograph) usually indicate orbital emphysema. Treatment" }, { "id": "article-26289_11", "title": "Anatomy, Head and Neck, Orbit -- Muscles", "score": 0.01093051991255584, "content": "The levator palpebrae superioris muscle, which receives nerve supply from CN III, elevates the upper eyelid. It is superior to the superior rectus muscle at the roof of the orbit, and these two muscles join in a common aponeurosis anteriorly. This intimate muscular relationship explains why the eye elevates as the upper eyelid is retracted. The extraocular muscles and their actions are as follows: [2] Superior rectus: Elevates, adducts and rotates medially Medial rectus: Adducts Inferior rectus: Depresses, adducts and rotates laterally Lateral rectus: Abducts Superior oblique: Depresses, abducts, and rotates medially Inferior oblique: Elevates, abducts, and rotates laterally" }, { "id": "wiki20220301en091_4134", "title": "Greater wing of sphenoid bone", "score": 0.010892512240039528, "content": "Orbital surface The orbital surface of the great wing [Fig. 2], smooth, and quadrilateral in shape, is directed forward and medially and forms the posterior part of the lateral wall of the orbit. Its upper serrated edge articulates with the orbital plate of the frontal bone. Its inferior rounded border forms the postero-lateral boundary of the inferior orbital fissure. Its medial sharp margin forms the lower boundary of the superior orbital fissure and has projecting from about its center a little tubercle that gives attachment to the inferior head of the lateral rectus muscle; at the upper part of this margin is a notch for the transmission of a recurrent branch of the lacrimal artery. Its lateral margin is serrated and articulates with the zygomatic bone. Below the medial end of the superior orbital fissure is a grooved surface, which forms the posterior wall of the pterygopalatine fossa, and is pierced by the foramen rotundum." }, { "id": "wiki20220301en128_11449", "title": "Orbital blowout fracture", "score": 0.010864978902953586, "content": "An orbital blowout fracture is a traumatic deformity of the orbital floor or medial wall, typically resulting from impact of a blunt object larger than the orbital aperture, or eye socket. Most commonly the inferior orbital wall i.e. the floor is likely to collapse, because the bones of the roof and lateral walls are robust. Although the bone forming the medial wall is thinnest, it is buttressed by the bone separating the ethmoidal air cells. The comparatively thin bone of the floor of the orbit and roof of the maxillary sinus has no support and therefore it is the inferior wall that collapses mostly. So the medial wall blowout fractures are second most common, whereas superior wall i.e. the roof and lateral wall blowout fractures are uncommon & rare respectively. There are two broad categories of blowout fractures: open door, which are large, displaced and comminuted, and trapdoor, which are linear, hinged, and minimally displaced. They are characterized by double vision, sunken" }, { "id": "pubmed23n0876_21842", "title": "Overcorrection of a Medial Orbital Wall Fracture Using the Endonasal Approach.", "score": 0.010753931544865866, "content": "Although the endonasal approach is frequently used, and the inadvertent displacement of a bone fragment into the orbital cavity is possible, no reports have yet described the overcorrection of medial orbital wall fractures using the endonasal approach. The authors report 2 patients of the overcorrection of a medial orbital wall fracture using an endonasal approach.In the first patient, a 26-year-old Chinese-Korean woman experienced a fracture of the right medial orbital wall without entrapment of the medial rectus muscle. Eleven days after the trauma, endonasal reduction was performed. Postoperative computed tomography revealed overcorrection of the medial orbital wall and lateral displacement of the medial rectus muscle. On postoperative day 19, exophthalmos of the operated side was still observed (o.d. 20 mm/o.s. 17 mm). In the second patient, a 25-year-old Korean man experienced a fracture of the left medial orbital wall without entrapment of the medial rectus muscle. Postoperative computed tomography showed overcorrection of the medial orbital wall and a laterally displaced medial rectus muscle. On postoperative day 4, exophthalmos of the operated side was observed (o.d. 23 mm/o.s. 26 mm).For fractures of the medial wall, surgery should be performed according to the recommended indications. When the endonasal approach is used to treat medial orbital wall fractures, great care is required in reducing the herniated orbital tissue and inserting the sheet to avoid overcorrection." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 163, 308 ] ], "word_ranges": [ [ 23, 41 ] ], "text": "Adenovirus conjunctivitis can be associated with inflammation of the pre-auricular or ipsilateral sub-mandibular lymph node (option 1 discarded)." }, "2": { "exist": true, "char_ranges": [ [ 309, 672 ] ], "word_ranges": [ [ 41, 94 ] ], "text": "Allergic conjunctivitis is a hypersensitivity condition that can occur immediately after contact with the triggering stimulus or after 24-72 hours, and is associated with accompanying signs such as eyelid edema and erythema, changes in periocular skin pigmentation, and a key symptom: itching. What it is not associated with is lymphadenopathy (option 2 correct)." }, "3": { "exist": true, "char_ranges": [ [ 673, 1045 ] ], "word_ranges": [ [ 94, 143 ] ], "text": "The oculoglandular syndrome of Parinaud is a picture that by definition is composed of conjunctivitis of infectious cause associated with ipsilateral pre-auricular or latero-cervical lymphadenopathy (one or several), generally produced by bacteria such as Bartonella henselae (cat scratch disease) or Francisella tularensis (tularemia or rabbit fever): option 3 discarded." }, "4": { "exist": true, "char_ranges": [ [ 1046, 1326 ] ], "word_ranges": [ [ 143, 179 ] ], "text": "Chlamydial conjunctivitis can present as 3 very distinct clinical pictures: trachoma, ophthalmia neonatorum or adult inclusion body conjunctivitis. The latter is considered a sexually transmitted disease and is associated with ipsilateral pre-auricular nodes (option 4 discarded)." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Adenoviral conjunctivitis.", "2": "Allergic conjunctivitis.", "3": "Parinaud's oculoglandular syndrome.", "4": "Chlamydia conjunctivitis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0668_21993", "title": "[Trachoma in patients with allergic conjunctivitis].", "score": 0.018706293706293706, "content": "The aim of this paper was to identify a possible association between allergic conjunctivitis and Chlamydia trachomatis infection. A prospective study was carried out in 104 eyes of 52 patients with diagnosis of vernal conjunctivitis and atopic keratoconjunctivitis. Conjunctival cytology was performed in all the 52 patients, once it can evidence eosinophils presence and inclusions corpuscles in the conjunctival scraping smear, as well as the direct immunofluorescence that is the choice exam for Chlamydia trachomatis infection confirmation. All procedures were approved by the Institutional Review Board Ethics Committee. Of the 52 patients, 41 (78.8%) presented vernal conjunctivitis and 11 (21.2%) atopic keratoconjunctivitis. Forty-one patients (78.8%) were male and 11 (21.2%) female. The ages varied from 3 to 19 years, with an average of 9.8 years. Regarding racial distribution, 16 (30.8%) patients were caucasian, 14 (26.9%) were black and 22 (42.3%) were brown. Regarding systemic allergic diseases, it was observed that 25 (48.1%) patients presented asthma, 20 (38.5%) allergic rhinitis and 5 (9.6%) atopic dermatitis. The main symptoms complained by the patients were coryza (59.6%), ocular itching (98.1%), burning (61.5%), tearing (65.3%) and photophobia (61.5%). The main clinical signs were: ocular hyperemia (100%), bilaterality (100%), superior tarsal papilla (92.3%) and mucous secretion (82.7%). The cytology of the conjunctival scrapings found eosinophil in 86.5% of the cases. Only seven patients did not present eosinophils in the conjunctival scrapings. Three patients (5.8%) presented positive immunofluorescence for Chlamydia, evidencing an association between allergic conjunctivitis and trachoma. It is important to determine the simultaneous coexistence of Chlamydia trachomatis and allergic conjunctivitis, due to the possibility to change the visual prognostic and of symptoms potentiation in case of double attack. Therefore, it is necessary to perform direct immunofluorescence for the correct diagnosis in patients with allergic conjunctivitis." }, { "id": "pubmed23n0069_11915", "title": "Chlamydial conjunctivitis in neonates and adults. History, clinical findings and follow-up.", "score": 0.01743750935488699, "content": "This study presents data from 73 neonatal and 60 adult patients with chlamydial conjunctivitis who were studied by culture, enzyme-linked immunosorbent assay (ELISA) and immunofluorescence (IF) tests. All patients had visited three or more doctors before the diagnosis was established. Fourteen of the adults had consulted an ophthalmological emergency unit complaining of a foreign body sensation in the eye. The symptoms started monocularly in all 133 cases, however, the fellow eye was affected after 2-7 days in 54 of the neonates and in 5-30 days in 20 of the adult patients. The duration of symptoms before the etiological diagnosis was established was 5-198 days (mean 24 and median 15 days) in the neonates and 7-120 (mean 29 and median 22 days) in the adults. The conjunctivitis was mild, moderate and severe in 7, 72 and 48 of the neonatal eyes, when the etiological diagnosis was established. The corresponding figures for severity of conjunctivitis in the adult group were 9, 57 and 14. Nasopharyngeal colonization occurred in 56 (77%) of the children and in 35 (58%) of the adults. In the adults, only two males complained of symptoms of genital infection. In 46 (77%) adults one or more of the chlamydial diagnostic tests performed on genital samples was positive for Chlamydia trachomatis. Forty-five of the neonates were treated with erythromycin 40-50 mg per kg body weight divided in four daily doses for 14 days, while 35 of the adults were given 250 mg x 4 x 14 of erythromycin.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0700_4534", "title": "[Keratoconjunctivitis sicca during folicular conjunctivitis in adult patients with Chlamydia pneumoniae etiology (summarizing twelve years study)].", "score": 0.01721132897603486, "content": "Following the previous study observing keratoconjunctivitis sicca (KCS) after treated follicular conjunctivitis of chlamydial etiology from the years 1999-2002, at this time the authors would like to point out the possible connection between KCS appearance and Chlamydia pneumoniae infection. In the Department of Ophthalmology, during the period of 12 months (in the years 2009 - 2010), there were treated 11 adult patients (6 women and 5 men) in the age of 28 - 81 years (median, 50 years) with follicular conjunctivitis lasting on average 2.5 years and caused by Chlamydia pneumoniae, and simultaneously were diagnosed the symptoms of KCS, out of the total number of 37 examined patients with similar clinical findings. The diagnosis of chlamydial infection in clinical symptoms of follicular conjunctivitis and simultaneous signs of KCS was established partly according to the serologic positivity of chlamydial genus (anti-LPS) and/or species (anti-Ch. pneumoniae and anti-Ch. trachomatis) IgG, IgM, and IgA antibodies together with simultaneous anti-cHSP60 IgG positivity, further using conjunctival prints examined by means of indirect immunofluorescence method using specific monoclonal antibodies; in conjunctival smears and peripheral leucocytes was tested also the presence of Chlamydia pneumoniae DNA. The main subjective complaints of the patients were burning sensation, sticking, or foreign-body sensation; the itching and lacrimation were less common. Among clinical signs dominated the hyperemia and the edema of the lower fornix; the tortuosity of the vessels and the follicles were not always present. The KCS diagnosis was confirmed by Bengal rose staining. In 10 patients, the positive IgA and/or IgM anti-Ch. pneumoniae antibodies were detected. Simultaneously, the positive anti-cHSP60 IgG were confirmed, out of them medium- and high-positive findings were in 7 patients, and anti-LSP antibodies IgA and/or IgM in 8 of them. Positive smears were found in 6 patients. In 2 persons of this group of treated patients, the general serologic findings were not significant, but the Chlamydia pneumoniae infection was confirmed by Chlamydia pneumoniae DNA positivity in peripheral leucocytes; in these 2 patients, the symptoms lasted for one half of the year. As the side findings were the confirmations of active Chlamydia trachomatis infection in other 4 patients of the whole group. The patients with Chlamydia pneumoniae infection were treated systemically by macrolide antibiotic azithromycine for 12 days. After the treatment, above all else the clinical signs of conjunctival inflammation disappeared, but remained KCS symptoms, which were disappearing only slowly. The optimal supporting therapies were lubricant drops with different concentration of sodium hyaluronide without preservatives. Control microbiological examinations during 6 months after the treatment termination confirmed negative smears findings, but the antibody levels were not decreased significantly. This study confirmed the possible connection between the KCS and Chlamydia pneumoniae infection in simultaneous clinical signs of follicular conjunctivitis. Along with that the study pointed out the necessity of simultaneous evaluating of the microbial findings and clinical symptoms to consider the systemic antibiotic treatment." }, { "id": "pubmed23n1118_277", "title": "Adult inclusion conjunctivitis diagnosed by polymerase chain reaction and Giemsa stain.", "score": 0.016195109461016516, "content": "Adult inclusion conjunctivitis, caused by <iChlamydia trachomatis</i, is easily underdiagnosed with nonspecific ocular manifestation. Combined scrape cytology and molecular testing may be a useful strategy for its early diagnosis. A 24-year-old healthy male complained of blurred vision, foreign body sensation, and watery discharge in his right eye for four weeks. His visual acuity was 20/20 bilaterally at his first visit. Allergic conjunctivitis was the first impression, and topical treatment with corticosteroid and anti-histamine was prescribed. However, he returned five days later without symptom improvement, and his right eye vision declined to 20/40. Subepithelial corneal infiltration of his right eye was observed. According to his personal history, his girlfriend was diagnosed with sexually transmitted chlamydial infection and genital gonorrhea. Under the suspicion of sexually transmitted adult inclusion conjunctivitis, we collected his conjunctival lavage to both real-time polymerase chain reaction, which proved chlamydial infection, and Giemsa stain, which demonstrated typical basophilic intracytoplasmic inclusions. To diagnose adult inclusion conjunctivitis, we can use real-time polymerase chain reaction or Giemsa stain to help us obtain a quick and correct diagnosis." }, { "id": "article-19888_48", "title": "Conjunctivitis -- History and Physical", "score": 0.01361875637104995, "content": "While conjunctivitis often presents similarly, a thorough systematic history and physical exam can safely rule out any acute sight-threatening diagnoses and elucidate the likely cause of conjunctivitis. The classic findings of the 3 most common types of conjunctivitis are: Bacterial - Findings include conjunctival redness, having the sensation of a foreign body in the eye, morning matting of the eyes, white-yellow purulent or mucopurulent discharge, conjunctival papillae, and infrequently preauricular lymphadenopathy. [45] Viral - Findings include eye itching, watery discharge, tearing, a history of recent upper respiratory tract infection, inferior palpebral conjunctival follicles, and tender preauricular lymphadenopathy. [46] [47] Allergic: Findings include eye itching and burning, watery discharge, history of allergies/atopy, edematous eyelids, conjunctival papillae, and no preauricular lymphadenopathy. [48]" }, { "id": "pubmed23n0063_4224", "title": "[Persistence of Chlamydia trachomatis in patients with chronic therapy refractory conjunctivitis].", "score": 0.012953579601176855, "content": "We report three patients with recurrent Chlamydia-associated conjunctivitis. The clinical course of the Chlamydial infection was documented by positive conjunctival smears (direct immunofluorescence staining) and the evaluation of the IgA-titer in the sera (immunoperoxidase assay). The recovery of the ocular symptoms after therapy onset correlated well with the negative results of the conjunctival smears and the decrease in IgA level in the sera. The recurrence of the conjunctivitis was accompanied by an increase in the IgA titer in the sera of all three patients and the presence of Chlamydial elementary bodies in the conjunctival scrapings in two cases. Three patients showed immunologic pecularities: two had an allergic diathesis; the third patient developed Wegener disease 3 months after the onset of ocular inflammation. Inclusion bodies or Chlamydial DNA can persist in conjunctival cells. Anderson suggested that a recurrence of active Chlamydial infection may be induced by external causes, which lead to reconstitution of elementary bodies from the persisting DNA. The extraordinary immune situation of our patients might be one cause of the recurrent conjunctivitis." }, { "id": "InternalMed_Harrison_15519", "title": "InternalMed_Harrison", "score": 0.012701936120360094, "content": "acUte HemorrHagic conjUnctivitis Patients with acute hemorrhagic conjunctivitis present with an acute onset of severe eye pain, blurred vision, photophobia, and watery discharge from the eye. Examination reveals edema, chemosis, and subconjunctival hemorrhage and often shows punctate keratitis and conjunctival follicles as well (Fig. 228-2). Preauricular adenopathy is often found. Epidemics and nosocomial spread have been associated with enterovirus 70 and coxsackievirus A24. Systemic symptoms, including headache and fever, develop in 20% of cases, and recovery is usually complete in 10 days. The sudden onset and short duration of the illness help to distinguish acute hemorrhagic conjunctivitis from other ocular infections, such as those due to adenovirus and Chlamydia trachomatis. Paralysis has been associated with some cases of acute hemorrhagic conjunctivitis due to enterovirus 70 during epidemics." }, { "id": "pubmed23n0681_747", "title": "[The secret of red eyes].", "score": 0.01233201581027668, "content": "\"Red eye\" is a sign and the same time a symptom frequently met in the ophthalmological practice. The \"red eye\" is not always the clinical manifestation of a common conjunctivitis. We will present a case report of a patient who accused conjunctival hyperemia, lacrimation, foreign--body sensation; she was also describing recurrent conjunctivitis for the past year. After an detailed ophthalmologic examination and interdisciplinary consultations. She was diagnosed with Basedow Disease and paraselar meningioma with invasion in the pterigoid fossa. The authors are suggesting that there is an indirect left carotid - cavernous fistula." }, { "id": "article-19888_12", "title": "Conjunctivitis -- Etiology -- Chlamydial Conjunctivitis", "score": 0.01228956228956229, "content": "Chlamydia trachomatis is present in 2 forms: the elementary body and the reticular body. Serovars D-K causes chlamydial inclusion conjunctivitis and affects both the eyes and genitals. It is a common infection among sexually active young individuals, with a 5% to 20% prevalence. The infection can spread through genital secretions and has an incubation period of 1 week. Symptoms of the disease include redness, watering, and discharge from one or both eyes. In chronic cases, the infection can last several months, leading to watery or mucopurulent discharge, preauricular lymphadenopathy, follicles in the inferior fornix, and possibly the upper tarsal conjunctiva. After 2 to 3 weeks, superficial punctate keratitis and perilimbal superficial infiltrates can be seen. Follicles and papillae development are prominent in chronic cases, and conjunctival scarring and corneal pannus may occur. [11]" }, { "id": "wiki20220301en017_48769", "title": "Chlamydia trachomatis", "score": 0.012017911310125667, "content": "C. trachomatis is the single most important infectious agent associated with blindness (trachoma), and it also affects the eyes in the form of inclusion conjunctivitis and is responsible for about 19% of adult cases of conjunctivitis. C. trachomatis in the lungs presents as the chlamydia pneumoniae respiratory infection and can affect all ages." }, { "id": "wiki20220301en002_53119", "title": "Conjunctivitis", "score": 0.01198581560283688, "content": "Bacterial Bacterial conjunctivitis causes the rapid onset of conjunctival redness, swelling of the eyelid, and a sticky discharge. Typically, symptoms develop first in one eye, but may spread to the other eye within 2–5 days. Conjunctivitis due to common pus-producing bacteria causes marked grittiness or irritation and a stringy, opaque, greyish or yellowish discharge that may cause the lids to stick together, especially after sleep. Severe crusting of the infected eye and the surrounding skin may also occur. The gritty or scratchy feeling is sometimes localized enough that patients may insist that they have a foreign body in the eye. Common bacteria responsible for nonacute bacterial conjunctivitis are Staphylococcus, Streptococcus, and Haemophilus species. Less commonly, Chlamydia spp. may be the cause." }, { "id": "wiki20220301en000_103656", "title": "Chlamydia", "score": 0.011538461538461539, "content": "Joints Chlamydia may also cause reactive arthritis—the triad of arthritis, conjunctivitis and urethral inflammation—especially in young men. About 15,000 men develop reactive arthritis due to chlamydia infection each year in the U.S., and about 5,000 are permanently affected by it. It can occur in both sexes, though is more common in men. Infants As many as half of all infants born to mothers with chlamydia will be born with the disease. Chlamydia can affect infants by causing spontaneous abortion; premature birth; conjunctivitis, which may lead to blindness; and pneumonia. Conjunctivitis due to chlamydia typically occurs one week after birth (compared with chemical causes (within hours) or gonorrhea (2–5 days))." }, { "id": "pubmed23n0475_14847", "title": "[Chlamydia pneumoniae--the etiologic agent of follicular conjunctivitis followed by keratoconjunctivitis sicca in adult patients].", "score": 0.011215245235863792, "content": "The authors refer to 21 adult patients at the age of 22 to 87 years, who have suffered from a chronic form of follicular conjunctivitis, found to be caused by Chlamydia pneumoniae as the etiological agent. The observation was made in the period from July 1999 to December 2002. Chl. pneumoniae was detected by a direct demonstration of the conjunctiva smears and by means of serological examination. The print preparations on glass were examined by the method of indirect immunofluorescence by means of specific monoclonal antibodies (Medac, Germany). The serological examination included detection of genus-specific IgG, IgA, IgM antibodies, respectively (Medac, Germany) and species-specific anti-Ch. pneumoniae IgG, IgA abd IgM antibodies, respectively (FOCUS Technologies, U.S.A.). The clinical picture included various long-term subjective complaints (within the range of several months to ten years), particularly a pathological secretion or increased lacrimation, cutting, burning or feeling of a foreign body in the eye. The objective examination revealed chronic changes characterized by a mild edema of bulbar conjunctiva with increased meandering in vessels of irregular caliber and edema in the lower transition plica with follicular structure crossing into the tarsal conjunctiva. In the fornix there was an apparent sticking aqueous or mucinous secretion. The therapy was indicated by the positive smears alone in four patients or positive IgA and/or IgM of genus- or species-specific antibodies in 12 patients. The therapy in the remaining five patients was recommended by the combination of suspect-positive smears in combination with positive genus- or species specific antibody reaction. The therapy made use of systemic administration of a macrolide antibiotic, azithromycin, for the period of 12 to 14 days in a single course of treatment. The pretreatment was always followed by control smears after two weeks and by serological examinations after three and six months. The serological findings remained virtually unchanged during that period of time in all patients under observation. In two of them only the species-specific antibodies anti-Ch. pneumoniae IgA antibodies disappeared six months after the therapy. The clinical findings disappeared slowly, particularly the follicular changes occurred after more than six months after the therapy ended. The subjective complaints, accompanied by a transient hyperemia of conjunctives in particular, remained after the therapy in nine patients older than 45 years, who were found to suffer from kieratoconjnunctivitis sicca. The ocular symptomatology was not accompanied by symptoms of autoimmune disease. The general treatment by antibiotics and the results supportive treatment succeeded in 67% of patients who were completely free of subjective complaints and the pathological process in conjunctives was inhibited." }, { "id": "wiki20220301en084_51258", "title": "Neonatal conjunctivitis", "score": 0.010914974992644894, "content": "If left untreated, neonatal conjunctivitis can cause blindness. Signs and symptoms Neonatal conjunctivitis by definition presents during the first month of life. Signs and symptoms include: Pain and tenderness in the eyeball Conjunctival discharge: purulent, mucoid or mucopurulent (depending on the cause) Conjunctival hyperaemia and chemosis, usually also with swelling of the eyelids Corneal involvement (rare) may occur in herpes simplex ophthalmia neonatorum Time of onset Chemical causes: Right after delivery Neisseria gonorrhoeae: Delivery of the baby until 5 days after birth (early onset) Chlamydia trachomatis: 5 days after birth to 2 weeks (late onset – C. trachomatis has a longer incubation period) Complications Untreated cases may develop corneal ulceration, which may perforate, resulting in corneal opacification and staphyloma formation. Cause" }, { "id": "article-19888_69", "title": "Conjunctivitis -- Differential Diagnosis", "score": 0.010734247967479675, "content": "Compared to iritis, patients with infective keratitis often complain of a foreign body sensation and trouble opening or keeping the eye open. These symptoms are consistent with corneal involvement and can present with other corneal disorders such as corneal ulcer, abrasion, or foreign body. [58] Foreign body and orbital trauma can result in hyphema, which can also result in acute and permanent vision loss." }, { "id": "pubmed23n0934_18393", "title": "Bacterial Conjunctivitis in Childhood: Etiology, Clinical Manifestations, Diagnosis, and Management.", "score": 0.010366441658630664, "content": "Bacterial conjunctivitis is a common reason for children to be seen in pediatric practices. A correct diagnosis is important so that appropriate treatment can be instituted. To provide an update on the evaluation, diagnosis, and treatment of bacterial conjunctivitis in children. A PubMed search was completed in Clinical Queries using the key term \"bacterial conjunctivitis\". Patents were searched using the key term \"bacterial conjunctivitis\" from www.freepatentsonline.com and www.google.com/patents. In the neonatal period, bacterial conjunctivitis is rare and the most common cause of organism is Staphylococcus aureus, followed by Chlamydia trachomatis. In infants and older children, bacterial conjunctivitis is most often caused by Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Clinically, bacterial conjunctivitis is characterized by a purulent eye discharge, or sticky eyes on awakening, a foreign body sensation and conjunctival injection (pink eye). The diagnosis is made clinically. Cultures are unnecessary. Some authors suggest a watchful observation approach as most cases of bacterial conjunctivitis are self-limited. A Cochrane review suggests the use of antibiotic eye drops is associated with modestly improved rates of clinical and microbiological remission as compared to the use of placebo. Various investigators have also disclosed patents for the treatment of conjunctivitis. The present consensus supports the use of topical antibiotics for bacterial conjunctivitis. Topical antibiotics shorten the course of the disease, reduce discomfort, prevent person-to-person transmission and reduce the rate of reinfection." }, { "id": "pubmed23n1049_25418", "title": "An Unusual Presentation of Retinal Detachment and Conjunctivitis: A Case Report.", "score": 0.010192697768762677, "content": "Vision loss is an ophthalmologic emergency with broad differential requiring prompt medical attention. We describe a 55-year-old male presenting to the emergency department (ED) with unilateral, painless visual field deficit with ipsilateral conjunctivitis induced by a presumed foreign body. The patient described a foreign body sensation nine days prior to developing visual changes. In the ED, the patient was diagnosed with a retinal detachment using point-of-care ultrasonography, and emergent ophthalmologic consultation was obtained. Concurrent retinal detachment and conjunctivitis in a patient is extremely rare. Healthcare providers should be aware that foreign body-induced conjunctivitis could lead to retinal detachment." }, { "id": "pubmed23n0416_1622", "title": "Self-inflicted (factitious) conjunctivitis.", "score": 0.009982574060243964, "content": "To describe the diagnosis and management of self-inflicted factitious conjunctivitis in conscripted soldiers. Prospective, noncomparative, consecutive case series. Seventeen conscripted soldiers. Soldiers with chronic conjunctivitis (&gt;3 weeks) were referred by ophthalmologists, and cases of shorter duration were referred by primary-care physicians. All cases underwent thorough ophthalmic and systemic history and examination, as well as questioning regarding their military units, military duties, and social background. Exclusion criteria were any condition that may cause conjunctivitis. Inferior fornix specimen microscopy and culture and eye photography were performed in most cases. In cases suspected of self-inflicted conjunctivitis all medication, besides lubricant drops, was stopped. Underlying psychosocial problems were investigated and managed. Cases were followed for at least 3 months after resolution of the conjunctivitis, at which point the diagnosis was confirmed, and the case entered the analysis. Resolution of the conjunctivitis. Seventeen consecutive cases of self-inflicted conjunctivitis, 8 of long duration and 9 of short duration, were studied. All cases demonstrated inconsistent clinical findings. The ocular signs most suggestive of self-inflicted conjunctivitis were purulent discharge purposely left on the lashes and periorbital skin, discharge more severe than in conjunctival hyperemia, less conjunctival chemosis than in hyperemia, mainly inferior conjunctival involvement, and an uninvolved cornea. Five of the 8 chronic cases had significant underlying psychologic or social problems. Their conjunctivitis resolved only after their underlying problems were addressed. Two cases admitted introducing freshly scraped dental plaque into the lower conjunctival sac. In the remaining 15 the similarity of the clinical findings suggested that a similar method was used. In the context of a subject standing to gain by assuming the sick role and after exclusion of ocular pathology, self-inflicted conjunctivitis can be reliably diagnosed by noting the characteristic clinical profile. Effective management includes addressing the underlying psychologic and social problems." }, { "id": "pubmed23n0414_4133", "title": "[Evaluation of the efficacy and safety of lodoxamide in patients with allergic eye diseases].", "score": 0.009900990099009901, "content": "To evaluate the effectiveness of lodoxamide in the therapy and prophylaxis of the ocular allergies. This prospective study included 64 patients divided in 2 groups. In the first group there were 47 symptomatic patients suffering from seasonal allergic conjunctivitis (n = 27), perennial allergic conjunctivitis (n = 16) and giant papillary conjunctivitis (n = 4). The symptomatic patients were examined upon arrival and every 2 weeks until the symptoms were reduced. During the period, lodoxamide drops were administered 4 times a day. In the second group there were 17 patients who had a history of seasonal ocular allergies during previous years but were still not symptomatic upon arrival. In the group of 17 patients who were very likely to develop ocular allergy but up to inclusion into the study had no ocular symptoms, 12 (70%) presented with allergic rhinitis while 5 (30%) had asthma. The symptoms intensity (itching, discomfort, foreign body sensation, pain, tearing) was graded on a 0-3 scale. The clinical signs (follicles, papillae, hyperemia, conjunctival edema, Trantas dots, stromal infiltrates) were detected on a slit lamp examination and graded on a 0-3 scale. In the group of 47 symptomatic patients 2-4 weeks after lodoxamide administration, 70-80% of symptomatic patients examined clinically had less or no follicles, 60-70% had reduced or no edema, the secretion was stopped or greatly reduced in 50-70% of patients. All of the patients reported reduced or no itching, 60% of patients reported less discomfort, photophobia and reduced tearing. In the asymptomatic group two weeks after the initiation of the prophylaxis 88% of patients were still with no ocular signs of allergy while 12% of patients had a conjunctival hyperemia and follicles. After 4 weeks of the prophylaxis 76% of patients patients were still asympthomatic while only 4 developed a mild form of allergic conjunctivitis (conjunctival hyperemia and papillae), but less severe than during previous episodes. Lodoxamide was effective in reduction of symptoms and clinical signs of the ocular allergies. The best results were obtained if the drug was administered as a prophylaxis or very early in the course of the disease." }, { "id": "pubmed23n0991_733", "title": "Chlamydia trachomatis presenting as preseptal cellulitis in a 3-year-old girl.", "score": 0.009900990099009901, "content": "Inclusion conjunctivitis usually presents with lid swelling, red eye, foreign body sensation, and a mucopurulent discharge in association with a follicular reaction involving the palpebral and bulbar conjunctiva and semilunar fold. Similar to epidemic keratoconjunctivitis, it may present with preauricular lymphadenopathy, superficial punctate keratitis, and subepithelial corneal infiltrates, which tend to be more peripheral. We present the case of preseptal cellulitis in a 3-year-old child, caused by nonconsensual sexual contact with chlamydia trachomatis." }, { "id": "InternalMed_Harrison_14099", "title": "InternalMed_Harrison", "score": 0.009829059829059829, "content": "Clinical Manifestations Both endemic trachoma and adult inclusion conjunctivitis present initially as conjunctivitis characterized by small lymphoid follicles in the conjunctiva. In regions with hyperendemic classic blinding trachoma, the disease usually starts insidiously before the age of 2 years. Reinfection is common and probably contributes to the pathogenesis of trachoma. Studies using polymerase chain reaction (PCR) or other NAATs indicate that chlamydial DNA is often present in the ocular secretions of patients with trachoma, even in the absence of positive cultures. Thus persistent infection may be more common than was previously thought." }, { "id": "pubmed23n0696_15659", "title": "Japanese guideline for allergic conjunctival diseases.", "score": 0.009708737864077669, "content": "The definition, classification, pathogenesis, test methods, clinical findings, criteria for diagnosis, and therapies of allergic conjunctival disease are summarized based on the Guidelines for Clinical Management of Allergic Conjunctival Disease (Second Edition) revised in 2010. Allergic conjunctival disease is defined as \"a conjunctival inflammatory disease associated with a Type I allergy accompanied by some subjective or objective symptoms.\" Allergic conjunctival disease is classified into allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis, and giant papillary conjunctivitis. Representative subjective symptoms include ocular itching, hyperemia, and lacrimation, whereas objective symptoms include conjunctival hyperemia, swelling, folliculosis, and papillae. Patients with vernal keratoconjunctivitis, which is characterized by conjunctival proliferative changes called giant papilla accompanied by varying extents of corneal lesion, such as corneal erosion and shield ulcer, complain of foreign body sensation, ocular pain, and photophobia. In the diagnosis of allergic conjunctival diseases, it is required that type I allergic diathesis is present, along with subjective and objective symptoms accompanying allergic inflammation. The diagnosis is ensured by proving a type I allergic reaction in the conjunctiva. Given that the first-line drug for the treatment of allergic conjunctival disease is an antiallergic eye drop, a steroid eye drop will be selected in accordance with the severity. In the treatment of vernal keratoconjunctivitis, an immunosuppressive eye drop will be concomitantly used with the above mentioned drugs." }, { "id": "pubmed23n0311_16155", "title": "[Reddened eyes, what should be done?].", "score": 0.009708737864077669, "content": "Not every patient who consults his physician because of reddening, pain, burning or itching sensation in an eye suffers from a bacterial or viral infection of the anterior eye segments. The sicca-syndrome mainly occurring in the elderly leads often to chronic reddening and a disturbing sensation of a foreign body in the eye. Allergic manifestations are often a cause for swelling and reddening of the conjunctiva. If next to reddening a rapidly progressing deterioration of vision develops, eventually accompanied by nausea and vomiting acute glaucoma has to be considered. In uveitis the patient mainly complains about sensations of dazzling, reduced visual acuity and pain, reddening of the conjunctiva may be variable. If in addition to acute hyperemia also a yellow-whitish infiltrate of the cornea is observed a bacterial ulcer of the cornea may be suspected. In this case an ophthalmologist has to be consulted without delay. Viral inflammations are often a diagnostic and therapeutic challenge. If reduced sensibility of the cornea is observed, herpetic infection should be considered." }, { "id": "wiki20220301en221_36872", "title": "Brimonidine/timolol", "score": 0.009615384615384616, "content": "Adverse effects The most common adverse effects affecting 5 to 15% of the patients include allergic conjunctivitis, conjunctival folliculosis, conjunctival hyperemia, eye pruritus, ocular burning, and stinging. 1 to 5% of the patients in clinical trials experienced asthenia, blepharitis, corneal erosion, depression, epiphora, eye discharge, eye dryness, eye irritation, eye pain, eyelid edema, eyelid erythema, eyelid pruritus, foreign body sensation, headache, hypertension, oral dryness, somnolence, superficial punctate keratitis, and visual disturbance. Contraindications Contraindications of Combigan include the following: reactive airway disease including bronchial asthma, a history of bronchial asthma, severe chronic obstructive pulmonary disease, sinus bradycardia, secondary or third degree atrioventricular block, overt cardiac failure, cardiogenic shock, age less than 2 years, and hypersensitivity to any component of Combigan." }, { "id": "pubmed23n0415_1556", "title": "Efficacy and safety of topical azelastine compared with topical mitomycin C in patients with allergic conjunctivitis.", "score": 0.009523809523809525, "content": "To compare the efficacy and safety of topical azelastine with topical mitomycin C (MMC) in patients with allergic conjunctivitis. Sixty-three patients (29 male, 29 female; 34 in the age range of 6 to 65 years) with allergic conjunctivitis were enrolled in this study. The patients were randomly assigned to receive topical azelastine 0.02% (n = 31) or topical MMC (0.2 mg/10 mL) (n = 31) four times daily for 3 months. Follow-up examinations were done at 2 weeks to examine side effects of the medications and again at 4 weeks to assess the outcome of treatment. The eyes were examined for relief of symptoms, cure of signs, and the appearance of side effects with use of these drugs. The mean age of the patients in this study was 34.8 +/- 17.3 years. The age of patients in the MMC group was significantly higher than patients in the azelastine group (mean +/- SD, 25.2 +/- 13.5 years). More patients in the MMC group had relief of symptoms like redness [25 (80.7%) in the MMC group versus 19 (55.9%) in the azelastine group; p= 0.033], photophobia [11 (35.5%) in the MMC group versus six (17.7%) in the azelastine group; not significant], discharge [17 (54.8%) in the MMC group versus 11 (32.3%) in the azelastine group; not significant], and foreign body sensation [21 (67.7%) in the MMC group versus 16 (47.1%) in the azelastine group; not significant], while more patients in the azelastine group had relief of lacrimation [14 (41.2%) in the azelastine group versus 10 (32.3%) in the MMC group; not significant] and pain [12 (35.3%) in the azelastine group versus eight (25.8%) in the MMC group; not significant]. The MMC group also showed a greater decrease in follicles [31 (100.0%) in the MMC group versus six (17.7%) in the azelastine group; p= 0.0001] and papillae [29 (93.6%) in the MMC group versus four (11.8%) in the azelastine group; p= 0.0001]. Both drugs were found to be equally effective in relieving itching [18 (58.1%) in the MMC group versus 18 (52.9%) in the azelastine group; not significant]. In the MMC group, 27 (87.1%) patients had conjunctival hyperemia, 28 (90.3%) patients had episcleritis, and 29 (93.6%) patients had irritation. The use of topical azelastine did not cause any adverse event. Though this was a short-term study, we found topical MMC to be more effective than topical azelastine in the treatment of allergic conjunctivitis both in terms of relief of symptoms and resolution of signs. The use of topical MMC in low doses does not cause any significant adverse effect." }, { "id": "pubmed23n0069_18107", "title": "[Incidence of Chlamydia ocular infections in patients with conjunctivitis, at a private clinic of Uberaba, MG].", "score": 0.009523809523809525, "content": "780 patients with recurrent conjunctival infections or persistent complaints of itching, burning pain, lacrimation and conjunctival hyperemia were subject to conjunctival smear examination for cytology and the presence of inclusion bodies. Two hundred and forty seven (31.7%) showed cytoplamic inclusions; 235 of them were subject to a direct specific immunofluorescency test with 90 (38.3%) positive results. The importance of the clinical manifestations and laboratory methods (direct immunofluorescence and research cytoplasmic inclusions) were considered. The patients are clients of a private clinic and have a moderate to hightor socioeconomic level." }, { "id": "pubmed23n0827_3444", "title": "Rapidly evolving conjunctivitis due to Pasteurella multocida, occurring after direct inoculation with animal droplets in an immuno-compromised host.", "score": 0.009433962264150943, "content": "The rare descriptions, in the literature, of ocular infections due to Pasteurella multocida include: endophtalmitis, keratitis and corneal ulcers, Parinaud's oculoglandular syndrome, and conjunctivitis. Here, we report a rare case of rapidly evolving conjunctivitis due to Pasteurella multocida, occurring after direct inoculation with animal droplets in an immuno-compromised host. A 69-year-old, Caucasian male was referred to our department with purulent conjunctivitis, occurring five days after chemotherapy for an angioimmunoblastic-T-cell-lymphoma, and thirty-three hours after being struck in his right eye by his sneezing Dachshund dog. Physical examination revealed purulent conjunctivitis of the right eye associated with inflammatory edema of both lids. Direct bacteriological examination of conjunctival secretions showed gram-negative bacilli and regular, grey non-hemolytic colonies appearing the next day on blood agar. The oxidase test was positive for these colonies. An antibiotherapy associating intravenous amoxicillin and amoxicillin/clavulanate was administered. The outcome was favorable in the next three days allowing discharge of the patient with amoxicillin (2 g tid per os). This case report may be of interest for infectious diseases, ophthalmology or oncology specialists, especially nowadays with chemotherapy being administered in day care centres, where unusual home pathogens can be encountered in health related infections. In this case, previous animal contact and conjunctival samples showing Enterobacteriaceae like colonies with positive oxidase test were two important clues which could help clinicians to make the diagnosis of Pasteurella conjunctivitis in every day practice." }, { "id": "article-19891_7", "title": "Bacterial Conjunctivitis -- History and Physical", "score": 0.009419592752926087, "content": "Certain clinical features can indicate a bacterial origin to conjunctivitis; however, findings are often variable, and there is cross-over between conjunctivitis symptoms of different etiologies. [2] Clinically distinguishing bacterial conjunctivitis from other forms is essential as it can help direct therapies and potentially curb unnecessary empiric antibiotic administration. Traditionally, a purulent or mucopurulent discharge has been associated with the diagnosis of bacterial conjunctivitis while watery discharge has been more consistent with viral or allergic conjunctivitis. [2] A 2003 study contested this assertion based on a lack of evidence to support discharge characteristics correlating with the cause of conjunctivitis. [2] [9] A later study by the same authors concluded that three findings were significantly predictive of bacterial conjunctivitis, including glued eyes, lack of itching, and no previous history of conjunctivitis. [2] [9] A 2006 prospective study of children with conjunctivitis described five clinical history and physical examination variables associated with bacterial culture-positive infections. These included a history of gluey or sticky eyelids in the morning, examination findings of mucoid or purulent discharge, eyelids or eyelashes crusting or gluing on examination, absence of burning sensation, and lack of watery discharge. [4] The inconsistencies of these findings concerning discharge as a predictor of bacterial infection might be attributable to the 2003 survey focusing on history, while the 2006 study included in-office physical examination findings. These differences reinforce the idea of variability in the presentation of bacterial conjunctivitis." }, { "id": "pubmed23n1129_23580", "title": "Tele-ophthalmology as an aid tool for primary care physicians in the IDF, during the Covid-19 lockdown.", "score": 0.009345794392523364, "content": "To describe tele-ophthalmology consultations for primary-physicians in the IDF during the Covid-19 lockdown. Retrospective cross-sectional study. Medical records of tele-ophthalmology consultations from March to June 2020 were reviewed. The study included 245 cases in which an ophthalmologist was consulted. In 62.0% cell-phone camera photographs were used. The mean age was 21.5 ± 6.4 years. The most common diagnoses were acute-conjunctivitis (8.6%); conjunctival-hyperemia (non-specific diagnosis, 8.2%); scleritis/episcleritis (7.3%); chronic allergic-conjunctivitis (7.3%); chalazion (7.3%) hordeolum (6.5%); acute allergic-conjunctivitis (4.5%). 37.6% of patients received primary physician-based treatment, 24.9% of patients received specialist-based treatment. 13.1% were referred to the ER. The consult prevented ER referral for 39.2% and changed the physician's treatment plan in 70.6% of cases. Foreign-body sensation complaints were more likely treated by a primary-physician (p = 0.015). Cases with suspected foreign-body diagnosis were referred more to the ER (p &lt; 0.001). For most cases of eyelid complaints and diagnoses, primary physician care was sufficient (p &lt; 0.001). Conjunctival complaints and diagnoses received significantly more ophthalmologist-based treatment (p &lt; 0.001). Corneal disorders were significantly referred more to the ER (p = 0.001). Despite of possible ethical and legal problems and clinical limitations of this instrument, Tele-ophthalmology using objective aids such as smartphone photography can be an efficient tool in aiding the primary-physician, especially for patients with low access to ophthalmologists, with major impact on patient management." }, { "id": "wiki20220301en301_17646", "title": "Parinaud's oculoglandular syndrome", "score": 0.009259259259259259, "content": "Parinaud's oculoglandular syndrome is the combination of granulomatous conjunctivitis in one eye, and swollen lymph nodes in front of the ear on the same side. Most cases are caused by cat-scratch disease, although it is an unusual feature of this condition. Occasionally it may be caused by other infections. It should not be confused with the neurological syndrome caused by a lesion in the midbrain which is also known as Parinaud's syndrome. Both were named after the same person, Henri Parinaud. Causes Bartonella henselae Francisella tularensis herpes simplex virus type 1 Paracoccidioides brasiliensis Diagnosis References External links Infectious diseases Herpes simplex virus-associated diseases Syndromes caused by microbes" }, { "id": "wiki20220301en002_53122", "title": "Conjunctivitis", "score": 0.009210789210789211, "content": "Other Inclusion conjunctivitis of the newborn is a conjunctivitis that may be caused by the bacterium Chlamydia trachomatis, and may lead to acute, purulent conjunctivitis. However, it is usually self-healing. Causes Infective conjunctivitis is most commonly caused by a virus. Bacterial infections, allergies, other irritants, and dryness are also common causes. Both bacterial and viral infections are contagious, passing from person to person or spread through contaminated objects or water. Contact with contaminated fingers is a common cause of conjunctivitis. Bacteria may also reach the conjunctiva from the edges of the eyelids and the surrounding skin, from the nasopharynx, from infected eye drops or contact lenses, from the genitals or the bloodstream. Infection by human adenovirus accounts for 65% to 90% of cases of viral conjunctivitis." }, { "id": "pubmed23n1030_16032", "title": "Ocular manifestation as first sign of Coronavirus Disease 2019 (COVID-19): Interest of telemedicine during the pandemic context.", "score": 0.009174311926605505, "content": "We report here the case of a 27-year-old man who consulted by telemedicine during the Coronavirus disease 2019 (COVID-19) pandemic, due to foreign body sensation and left eye redness. Examination revealed unilateral eyelid edema and moderate conjunctival hyperemia. A few hours later, the patient experienced intense headache and developed fever, cough and severe dyspnea. A nasopharyngeal swab proved positive for SARS-CoV-2. This case demonstrates that conjunctivitis can be the inaugural manifestation of the COVID-19 infection. It illustrates the interest of telemedicine in ophthalmology during the COVID-19 pandemic, since moderate conjunctival hyperemia can be the first sign of a severe respiratory distress." } ] } } }

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{ "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": 0.012401310889319232, "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": "article-19238_16", "title": "Cervical Intraepithelial Neoplasia -- Treatment / Management", "score": 0.01160826032540676, "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": "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": "Surgery_Schwartz_11848", "title": "Surgery_Schwartz", "score": 0.010600946836704647, "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": "pubmed23n0916_11936", "title": "See and treat strategy by LEEP conization in patients with abnormal cervical cytology.", "score": 0.009708737864077669, "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": "wiki20220301en249_5189", "title": "Bethesda system", "score": 0.009657879284235251, "content": "CIN 1 is the most common and most benign form of cervical intraepithelial neoplasia and usually resolves spontaneously within two years. Because of this, LSIL results can be managed with a simple \"watch and wait\" philosophy. However, because there is a 12–16% chance of progression to more severe dysplasia, the physician may want to follow the results more aggressively by performing a colposcopy with biopsy. If the dysplasia progresses, treatment may be necessary. Treatment involves removal of the affected tissue, which can be accomplished by LEEP, cryosurgery, cone biopsy, or laser ablation. HSIL: high-grade squamous intraepithelial lesion High-grade squamous intraepithelial lesion (HSIL or HGSIL) indicates moderate or severe cervical intraepithelial neoplasia or carcinoma in situ. It is usually diagnosed following a Pap test. In some cases these lesions can lead to invasive cervical cancer, if not followed appropriately." }, { "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": "pubmed23n0533_15131", "title": "Abnormal Pap smears: a comparison of total abdominal hysterectomy and cone biopsy in management.", "score": 0.009615384615384616, "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": "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": "pubmed23n0517_21824", "title": "A prospective evaluation of \"see and treat\" in women with HSIL Pap smear results: is this an appropriate strategy?", "score": 0.009523809523809525, "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": "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": "pubmed23n0476_21145", "title": "[Is it necessary to make screening pap smears after hysterectomy?].", "score": 0.009433962264150943, "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": "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": "pubmed23n0746_12707", "title": "Role of vault cytology in follow-up of hysterectomized women: results and inferences from a low resource setting.", "score": 0.009345794392523364, "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": "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": "pubmed23n1098_2733", "title": "Post-Conization FIGO stage IA1 squamous cell cervical carcinoma; is hysterectomy necessary?", "score": 0.009259259259259259, "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": "article-22882_18", "title": "High-Grade Squamous Intraepithelial Lesion of the Cervix -- Treatment / Management", "score": 0.00919674841554147, "content": "Women aged 21 to 24 with HSIL cytology are recommended to undergo colposcopy. If CIN 2 or greater is not diagnosed on biopsy, it is recommended the patient follow up with cytology and colposcopy every 6 months for a 24-month period, as long as exams are adequate and reveal no squamous intraepithelial lesions (or at most LSIL). If HSIL cytology or a high-grade colposcopic lesion is found during this time, a biopsy should be performed. In patients where HSIL cytology persists for 24 months but no high-grade lesion is identified on biopsy, a diagnostic excisional procedure is recommended. If colposcopy is inadequate, CIN 3 is specified on biopsy, or CIN 2 or CIN 3 persists for 24 months, a diagnostic excisional procedure is recommended. If CIN 2 is specified on biopsy, observation for 12 months using both cytology and colposcopy every 6 months is recommended. This guideline exists because CIN 2 has a higher regression rate and less risk of progression to cancer than CIN 3, especially in younger women. Once the patient has 2 consecutive negative results on cytology and no evidence of a colposcopic abnormality, co-testing is recommended a year later. If negative, a second co-test is recommended after three years. If either co-test is abnormal, colposcopy is recommended." }, { "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": "pubmed23n0079_10832", "title": "Colposcopy as a method of management strategy in CIN and microinvasive cancer.", "score": 0.009174311926605505, "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." }, { "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": "pubmed23n0031_3103", "title": "[The value of vaginal cytology after total hysterectomy for benign or malignant lesions (author's transl)].", "score": 0.00909090909090909, "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": "Gynecology_Novak_3037", "title": "Gynecology_Novak", "score": 0.00900974025974026, "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": "wiki20220301en096_22714", "title": "Cartwright Inquiry", "score": 0.009009009009009009, "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_3038", "title": "Gynecology_Novak", "score": 0.008937299259879905, "content": "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. If HPV DNA testing is negative or if two consecutive posttreatment cytology results are negative for intraepithelial lesion or malignancy, routine screening for at least 20 years is recommended, and should be annual for at least 5 years. A negative HPV DNA test is an excellent predictor of a normal posttreatment for CIN 2 or 3. 6. If CIN 2 or 3 is histologically found at the margins of an excised specimen or in an endocervical sample obtained immediately after the procedure, cytologic follow-up with endocervical sampling every 4 to 6 months is preferred. The role of colposcopy in this follow-up option is not clearly defined in the Guidelines, although in practice, cytology and colposcopy will be performed in most clinical settings. 7." }, { "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." } ] } } }

{ "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": [ [ 39, 175 ] ], "word_ranges": [ [ 5, 22 ] ], "text": "Coraliform lithiasis are associated with urea-folding germs: Proteus in the first place, Pseudomonas, Klebsiella and some staphylococci." } }

{ "1": "Escherichia coli.", "2": "Enterococcus faecalis.", "3": "Salmonella typhi.", "4": "Candida albicans.", "5": "Proteus mirabilis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0088_2490", "title": "Urinary tract infections in children.", "score": 0.018653479090751345, "content": "From January 1981 to December 1987, 346 children with urinary tract infections, proved by urine culture, were admitted to the Department of Pediatrics, Mackay Memorial Hospital. The ratio of male to female was 3.0 in children below 2 years, and 0.8 in children above 2 years, of age. The urine specimens were collected from suprapubic punctures in 281 cases (81.2%). Fever was the most common clinical manifestation. In children below two years old, other common symptoms and signs were body weight loss or poor gain, feeding problems, diarrhea, irritability, jaundice, and abdominal distension. In older children, urinary frequency, dysuria, enuresis, loin and abdominal pain were frequently found. Hematuria and edema were occasionally noted in all age groups. Microscopic examination of 329 centrifuged urine specimens revealed: 256 cases (77.8%) had more than 5 leukocytes per high power field, 233 cases (70.8%) had more than 10 leukocytes. Three hundred and seventy positive urine cultures were obtained from these patients. E. coli was isolated in 273 cases (73.6%), followed by Klebsiella spp., 34 cases (9.2%); Proteus spp., 27 cases (7.3%); Enterococcus, 21 cases (5.7%); Enterobacter spp., 9 cases (2.4%); Pseudomonas aeruginosa, 8 cases (2.2%); Citrobacter spp., 7 cases (1.9%); Morganella morganii, 6 cases (1.6%); Acinetobacter spp., 6 cases (1.6%); etc. Candida albicans was isolated from three patients. Two organisms were isolated in 26 cultures; 3 organisms, in 3, and 4 in 1." }, { "id": "pubmed23n0111_15924", "title": "Perinephric abscess. Modern diagnosis and treatment in 47 cases.", "score": 0.016750305167503053, "content": "The records of 47 patients with a perinephric abscess diagnosed from 1975 to 1986 at 8 San Francisco Bay Area hospitals were reviewed. The mean age was 51 years. Fifty-five percent were females and 45%, males. The left kidney was affected in 47% of cases, the right kidney in 40%, both in 4%, and a transplanted pelvic kidney in 9%. Fever (55%), chills or diaphoresis (47%), flank pain (40%), abdominal pain (40%), and nausea or vomiting (32%) were the most common presenting symptoms. About half the patients had symptoms for 1 week or less and 12% had no symptoms. Fever was documented before diagnosis in 88% of patients. Abdominal mass (13%) or tenderness (49%), and flank mass (9%) or tenderness (42%) were seen less frequently, and 11% of patients did not have fever, flank, or abdominal findings. The most frequent underlying conditions included previous urologic surgery (45%), previous urinary tract infection (38%), diabetes mellitus (36%), and urinary tract stones (36%). Cultures of perinephric abscesses yielded gram-negative aerobes in 52% of patients, primarily Escherichia coli. Staphylococcus aureus was isolated in 26% of patients and anaerobes in 17%. A single pathogen was isolated in 71% and multiple isolates in 29%. Of interest and great potential therapeutic importance was culture of anaerobes, primarily Bacteroides spp. in 17%, Enterococcus spp. in 7%, and Candida albicans in 7%. Positive blood and urine cultures identified perinephric abscess organisms exactly in 58% and 37% of cases, respectively. Routine laboratory tests such as the white blood cell count and urinalysis were insensitive and non-specific for perinephric abscess. Leukocytosis and anemia at admission were seen in slightly more than half of the patients. For radiologic diagnosis, computerized tomographic scanning was most helpful. Ultrasound and intravenous pyelography were falsely negative in about one-third of cases. Mortality (13%) was low in this series when compared with earlier studies, and probably reflects modern medical care. Six patients (13%) died during hospitalization, 2 of whom had diagnosis of PNA established only at autopsy. Drainage of the perinephric abscess was carried out by open surgical drainage in 64% of patients, percutaneous drainage in 19%, and both in 13%. The initial procedure, whether open surgical drainage or percutaneous catheter drainage, was usually successful. Late complications included nephrocutaneous fistulas in 3 patients and disseminated candidiasis in 1 patient." }, { "id": "pubmed23n0605_17281", "title": "[Evaluation of the epidemiological, clinical and laboratory findings in continuous ambulatory peritoneal dialysis related peritonitis attacks].", "score": 0.015944498539435248, "content": "The aims of this study were to assess epidemiological features, clinical outcomes, laboratory findings, causative organisms and treatment approach for continuous ambulatory peritoneal dialysis (CAPD) -related peritonitis cases. A total of 50 patients (35 male, 15 female; age range: 18-83 years, mean age: 49 +/-17 years) with CAPD related peritonitis treated in Infectious Diseases and Clinical Microbiology Department of Ankara Training and Research Hospital between February-July 2006 were enrolled into this study. Demographic characteristics, symptoms, physical examination findings and laboratory parameters of patients were recorded and evaluated at the baseline, 48 hours and at the end of treatment. Fifty six peritonitis episodes occurred during the study period, and overall incidence of peritonitis was calculated as 1.6 episodes/patient-year. The most common presenting symptoms were cloudiness of the peritoneal dialysis fluid (100%), abdominal pain (98%), nausea (74%) and vomiting (54%). Abdominal tenderness and rebaund (100%) were the most common physical examination findings. Increased levels of C-reactive protein, erythrocyte sedimentation rate and procalcitonin were detected in 88%, 94% and 42% of the patients, respectively. The mean white blood cell count of peritoneal dialysate fluids was 905/mm3 (170-17900/mm3) in 56 episodes. In direct microscopic examination of peritoneal fluid samples with Gram stain, positivity was detected in 10 (18%) of the attacks, in which eight yielded gram-positive cocci and two gram-negative bacilli. The rate of culture positivity was 74% in the peritonitis episodes, and no microorganism was isolated from the cultures of 26% of the episodes. The most frequently isolated microorganisms were coagulase-positive staphylococci, followed by Staphylococcus aureus (n:4) and E. coli (n:4) with the rates of 7% of each, Enterococcus spp. (n:3), Klebsiella spp. (n:3) and Pseudomonas spp. (n:3) with the rates of 5% of each, and Streptococcus spp. (n:1), diphtheroid bacillus (n:1) and Candida albicans (n:1) with the rates of 2% of each. Eightyfour percent of patients were successfully treated with intraperitoneal cefazolin and gentamicin empirically. Three of the patient's CAPD therapy was converted to hemodialysis, while two patients have died. As a result, since peritonitis is still the major complication of CAPD despite the technological developments, the informations about causative microorganisms and their antimicrobial susceptibilities would be helpful for the early and accurate treatment of peritonitis." }, { "id": "pubmed23n0651_18953", "title": "Succesful [Successful] endovascular repair of an abdominal mycotic aneurysm. A case report.", "score": 0.014021118227453696, "content": "A 73-year-old man was admitted to the emergency department presenting with cramping pain in the left iliac fossa that had persisted for ten days, with diarrhoea and dysuria. A recent onset of high fever had urged him to the hospital. A routine blood sample showed a leukocytosis of 11.9 x 10(3)/mm(3) and an elevated CRP of 16 mg/dl. Haemocultures and a urine sample were taken. A colonoscopy and ultrasound showed no abnormalities. The urine culture contained salmonella enteritidis. On day 5 a CT scan of the abdomen was performed. This showed a saccular aneurysm of the abdominal aorta, approximately 2 cm in length, with clear signs of a contained rupture. An urgent EVAR procedure was performed. An Excluder bifurcation-endoprosthesis was placed under antibiotic coverage. Control CT scan showed a thrombosis of the aneurysm and a type II endoleakage. The endoleakage spontaneously resolved within 3 months. The patient was kept on antibiotics (levofloxacine) for 4 months. We suggest that the use of an endoprosthesis could be a good and safe alternative for the repair of infrarenal mycotic aorta aneurysm." }, { "id": "pubmed23n0619_14822", "title": "Bacteremia coexisting with tophaceous gout of the spine mimicking spondylodiscitis: a case report.", "score": 0.013346814964610718, "content": "A case report and review of the literature. To report a rare case of bacteremia coexisting with spinal gout initially suspected as pyogenic spondylodiscitis. Gouty spine is a rare disease. It is even rare when coexisting with bacteremia. The presentation as pain, fever, and positive blood culture will make it more difficult to distinguish from spinal infection. A 64-year-old woman with type II diabetes mellitus and chronic renal insufficiency was admitted to the emergency department with a fever of 39 degrees C, chills, and back pain. Laboratory studies revealed an elevated white count and neutrophils; her serum glucose level was 279 mg/dL. The C-reactive protein level was 25.55 mg/dL and serum uric acid was in the upper range of normal. Blood cultures revealed Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis. Urine culture revealed 3 separate gram-negative bacilli. Magnetic resonance imaging of the spine revealed contrast enhancement in the L4-L5 and T5-T9 vertebral bodies. Infective spondylodiscitis of the lumbar and thoracic spine was suspected. Because antibiotic treatment had failed, surgical debridement with diskectomy, partial corpectomy, and allogenous strut graft reconstruction (T8-T9) was performed. During the operation, 600 cc of pleural effusion was drained. Chalky white material was noted at the T8-T9 disc and the adjacent vertebral bodies. Cultures for bacteria, tuberculosis, and fungus were all negative. Histologic examination revealed deposition of eosinophilic crystal-like material, and a diagnosis of tophaceous gout of the spine was established. This is, to our knowledge, the first case of bacteremia coexisting with multiple areas of tophaceous gout of the spine. Although uncommon, gouty spine should be added into the differential diagnosis of patients with back pain and bacteremia." }, { "id": "pubmed23n0771_21526", "title": "Urinary tract infection in outpatient febrile infants younger than 30 days of age: a 10-year evaluation.", "score": 0.013218741820085507, "content": "To determine the prevalence of outpatient-diagnosed urinary tract infection (UTI) in consecutive febrile neonates ≤ 30 days of age and correlate demographic, laboratory and radiographic imaging results with infectious etiology. Review of medical records of consecutive febrile infants ≤ 30 days of age presenting to an urban pediatric emergency department during a 10-year period, whose policy is to perform a sepsis evaluation (urine culture obtained by bladder catheterization) and hospitalize for parenteral antibiotic therapy pending culture results. Of 670 febrile neonates ≤ 30 days of age evaluated for sepsis, urine culture was obtained in 651 cases (97%). Of 100 patients with UTI (15.4%), 73% were male; the most common uropathogens were Escherichia coli (71%), Enterococcus (10%) and Klebsiella sp. (10%). In all, 39% had a maximum documented fever ≥ 102 °F, and 40% had CBC total white blood cells count ≥ 15,000/mm(3). Urine dipstick test was positive for leukocyte esterase or nitrite in 79%. Renal ultrasound performed in 95 patients (95%) showed anatomic abnormalities in 47%; 5/26 (24%) with hydronephrosis had vesicoureteral reflux on voiding cystourethrogram. Four patients had urosepsis; none had bacterial meningitis and no patients died. UTI affects approximately 1 in 6 febrile neonates ≤ 30 days of age. Males are affected 2.5-times greater than females. E. coli continues to be the predominant uropathogen. Clinical parameters like height of fever, CBC total white blood cell count and urine dipstick test lack sensitivity in identifying UTI risk in the outpatient setting. Only 4 infants had urosepsis (4%). Nearly half of neonates with UTI have a radiographically identified anatomic abnormality. All febrile young infants should receive performance of a urine culture; those with UTI require imaging." }, { "id": "pubmed23n0334_15158", "title": "[Lumbar puncture in a pediatric emergency department: something more than a diagnostic technic].", "score": 0.012445887445887446, "content": "The aim of this study was to know the incidence of serious bacterial infections (SBI) in children without sepsis or intracranial infection in which spinal puncture (LP) was performed in an Emergency Department. A retrospective study of all 471 previously healthy children between 1 month and 14 years of age in which a lumbar puncture was performed between July 1995 and March 1997 in the Emergency Department of our hospital was performed. Two hundred and three children (43%) had sepsis, meningitis or encephalitis (aseptic meningitis 149, 31.6%; sepsis-bacterial meningitis 26, 5.5%; nonspecific meningitis 26, 5.5%; encephalitis 2, 0.4%) and 14 (5.2%) had pneumonia. Of the other 254 children, 36 (14.1%) had a SBI: 19 urinary tract infections (E. coli), 11 bacteremia (Streptococcus pneumoniae 8, Salmonella enteritidis 1, Proteus mirabilis 1, E. coli 1, the latter two also having a positive urine culture) and 6 bacterial gastroenteritis (salmonella 5, Campylobacter jejuni 1). The incidence of SBI was significantly higher in the group of children younger than 5 years old (32/175, 18.2%) than in the older group (4/79, 5.0%, p = 0.009). Two patients died (one with pneumococcal meningitis and one with meningococcal sepsis). Children with fever and a normal result in the LP must be carefully examined and, especially in younger patients, urine, blood and stool (if stool abnormalities) cultures should be collected. These children must be closely observed in the hospital or at home and must be re-evaluated by their pediatrician in the following 24 hours." }, { "id": "pubmed23n0619_22576", "title": "[Retroperitoneal abscess by suppurative psoas. Case report].", "score": 0.010512910829923863, "content": "A 51 years old male was admitted to our Emergency Department because a severe pain in the right lumbar area irradiating to homolateral thigh, with fever. Abdomen and pelvis TC scan revealed a big retroperitoneal abscess. An urgent laparotomy was performed. It showed a huge retroperitoneal purulent collection extending caudally to right thigh and all around urinary bladder. The fluid collections were drained and a sample was sent for biological examination. There was the evidence of enterococcus faecalis and specific antibiotic treatment was done. The patient was discharged after 33 days in good general conditions. The aim of this study is to emphasize the difficulty in clinical diagnosis of this pathology due to the lack specific symptoms and signs, and the occasional difficulty to find the original cause of the condition. Moreover we remark the utility of CT scan and of selective collection drainage." }, { "id": "Pathoma_Husain_318", "title": "Pathoma_Husain", "score": 0.01041006129782287, "content": "II. CYSTITIS A. Infection of the bladder B. Presents as dysuria, urinary frequency, urgency, and suprapubic pain; systemic signs (e.g., fever) are usually absent. C. Laboratory findings 1. Urinalysis-cloudy urine with > 10 WBCs/high power field (hpf) 2. Dipstick-Positive leukocyte esterase (due to pyuria) and nitrites (bacteria convert nitrates to nitrites) 3. Culture-greater than 100,000 colony forming units (gold standard) D. Etiology 1. E coli (80%) 2. Staphylococcus saprophyticus-increased incidence in young, sexually active women (but E coli is still more common in this population) 3. Klebsiella pneumoniae 4. Proteus mirabilis-alkaline urine with ammonia scent Fig. 12.15 Linear IF, Goodpasture syndrome. Fig. 12.16 lgA nephropathy. (Courtesy ofTony (Courtesy ofTony Chang, MD) Chang, MD) 5. Enterococcus faecalis E. Sterile pyuria is the presence of pyuria (> 10 WBCs/hpf and leukocyte esterase) with a negative urine culture." }, { "id": "wiki20220301en032_27077", "title": "Trimethoprim/sulfamethoxazole", "score": 0.009900990099009901, "content": "Acinetobacter spp. Aeromonas hydrophila Alcaligenes/Achromobacter spp. Bartonella henselae Bordetella pertussis (pertussis) Brucella spp. Burkholderia cepacia Burkholderia mallei (glanders) Burkholderia pseudomallei (melioidosis) Chlamydia trachomatis (chlamydia) Chryseobacterium meningosepticum Citrobacter spp. Enterobacter spp. Enterococcus faecalis Escherichia coli Haemophilus influenzae Hafnia alvei Kingella spp. Klebsiella granulomatis Klebsiella pneumoniae Legionella spp. Listeria monocytogenes (listeriosis) Moraxella catarrhalis Morganella morganii Mycobacterium tuberculosis (tuberculosis) Neisseria gonorrhoeae (gonorrhoea) Neisseria meningitidis (meningococcal disease) Nocardia spp. Plesiomonas shigelloides Pneumocystis jirovecii Proteus mirabilis Proteus vulgaris Providencia rettgeri Providencia stuartii Salmonella typhi (typhoid fever) Non-typhi Salmonella Serratia spp. Shigella spp. Staphylococcus aureus Staphylococcus epidermidis" }, { "id": "wiki20220301en416_13095", "title": "Silane quats", "score": 0.00980392156862745, "content": "Anabaena cylindricia Chlorella Chlorophyta (green) Chrysophyta (brown) Oscillatoria borneti Pleurococcus Protococcus Scenedesmus quadricauda Selenastrum gracile Acinetobacter calcoaceticus Aeromonas hydrophilia Bacillus cereus Bacillus subtilis Bacillus typhimurium Citrobacter diversus Clostridium perfringens Corynebacterium bovis Corynebacterium diphtheriae Cutibacterium acnes Enterobacter aerogenes Enterobacter agglomerans Enterobacter cloacae Enterococcus Enterococcus faecalis Escherichia coli Klebsiella pneumoniae Klebsiella terrigena MHV-A59 MS2 Virus Mycobacterium tuberculosis Phi6 Proteus mirabilis Proteus vulgaris Pseudomonas aeruginosa Pseudomonas cepacia Salmonella enterica Salmonella typhi Salmonella typhimurium SARS-CoV-2 Serratia liquefaciens Serratia marcescens Stachybotrys chartarum Staphylococcus aureus Staphylococcus epidermidis Streptococcus faecaliis Streptococcus pyrogenes Vancomycin-resistant enterococci Alternaria alternata Aspergillus flavus" }, { "id": "wiki20220301en056_70172", "title": "Pine oil", "score": 0.009708737864077669, "content": "Properties as a disinfectant Pine oil is a disinfectant that is mildly antiseptic. It is effective against Brevibacterium ammoniagenes, the fungi Candida albicans, Enterobacter aerogenes, Escherichia coli, Gram-negative enteric bacteria, household germs, Gram-negative household germs such as those causing salmonellosis, herpes simplex types 1 and 2, influenza type A, influenza virus type A/Brazil, influenza virus type A2/Japan, intestinal bacteria, Klebsiella pneumoniae, odor-causing bacteria, mold, mildew, Pseudomonas aeruginosa, Salmonella choleraesuis, Salmonella typhi, Salmonella typhosa, Serratia marcescens, Shigella sonnei, Staphylococcus aureus, Streptococcus faecalis, Streptococcus pyogenes, and Trichophyton mentagrophytes." }, { "id": "pubmed23n0794_11614", "title": "Raised white cell count in renal colic: Is there a role for antibiotics?", "score": 0.009708737864077669, "content": "To determine the use of antibiotics in patients with renal colic and an elevated white cell count (WCC) in the absence of other features of infection. A retrospective audit of patients presenting to an emergency department with renal colic caused by a solitary ureteric stone over a 6 month period. Student's t-test. Fifty patients met the inclusion criteria for this study. In 42 patients (84%) the urinalysis showed hematuria only and all urine culture results were negative for microbial growth. The mean WCC was 11.5 × 10(9) (4-22.1) and was raised in 34 patients (80.9%). The mean neutrophil count was 8.75 × 10(9)/L (2.3-18.6) and C-reactive protein (CRP) 15.9 (1-192). Antibiotics were commenced in 34 patients (80.9%) based solely on the raised WCC. In eight patients (16%) there were leucocytes and/or nitrites on urinalysis and all urine cultures were positive for growth (coliforms in five, streptococcus in two and candida in one specimen). The mean WCC was 10.5 × 10(9)/L (7.7-16.5) and was raised in four patients. The mean neutrophil count was 8.4 × 10(9)/L (4.9-15.2) and CRP 40.79 (3-86). One patient had pyrexia. All eight patients were commenced on antibiotics based on the WCC and/or urinalysis result. Over three-quarters of the patients (80.9%) in this study who presented with renal colic were unjustifiably commenced on antibiotics based solely on an elevated WCC. Antibiotic use in renal colic should be reserved for when there are features of sepsis or the urinalysis is positive. Further work is required to determine the significance of the observed results and the threshold for starting antibiotics." }, { "id": "pubmed23n0811_2779", "title": "The preliminary assessment of anti-microbial activity of HPLC separated components of Kirkia wilmsii.", "score": 0.009615384615384616, "content": "Most communities in developing countries rely on traditional medicines for the treatment of diseases. In South Africa, the Limpopo province, within the Lebowakgomo district, uses tuberous roots of Kirkia wilmsii, after infusion in water for the treatment of a wide range of diseases by Sotho communities. The main objective of the study was to assess the anti-microbial activity of separated aqueous components of the Kirkia wilmsii tuberous roots. The clear aqueous extracts that were obtained after a 0.45 µm membrane filtration (Millipore Millex-HV Hydrophillic PVDF filter), were then injected into a preparative high performance liquid chromatography instrument in which pure components, as shown by peaks, were collected and evaluated for anti-microbial activity against a range of microorganisms. The eight separated components were obtained, out of which four components showed anti-microbial activity (AMA). The freeze dried components were re-dissolved in deionised water and then evaluated for AMA against Vibrio cholerae, Shigella dysenteriae, Aeromonas hydrophilia, Salmonella typhi Proteus mirabilis, Escherichia coli, Staphylococcus aureus, Candida albicans and Enterobacter aerogenes. Component one exhibited antimicrobial activity against Shigella dysenteriae, Aeromonas hydrophilia, Salmonella typhi, Proteus mirabilis, Escherichia coli and Staphylococcus aureus with a minimum inhibitory concentration (MIC), of 3.445 mg/ml. Component five was only active against Proteus mirabilis with a MIC of 0.08 mg/ml. Component 7, was active against Shigella dysenteriae, Staphylococcus aureus and Escherichia coli with a MIC of 0.365 mg/ml against both Shigella dysenteriae and Staphylococcus aureus and 0.091 mg/ml against Escherichia coli. Component 8, was active against Shigella, Aeromonas hydrophilia, Salmonella, Proteus mirabilis, Escherichia coli with a MIC of 155 mg/ml. Only four out of eight aqueous extracts showed AMA against both gram negative and positive bacteria and showed no AMA against Candida albicans, Enterobacter aerogenes and Vibrio cholerae. Therefore the Kirkia wilmsii plant root may be used as a broad spectrum antibiotic." }, { "id": "wiki20220301en100_6023", "title": "List of MeSH codes (B03)", "score": 0.009523809523809525, "content": "– Escherichia – Escherichia coli – Escherichia coli k12 – Escherichia coli o157 – Hafnia – Hafnia alvei – Klebsiella – Klebsiella oxytoca – Klebsiella pneumoniae – Kluyvera – Morganella – Morganella morganii – Pantoea – Pectobacterium – Pectobacterium carotovorum – Pectobacterium chrysanthemi – Photorhabdus – Plesiomonas – Proteus – Proteus mirabilis – Proteus penneri – Proteus vulgaris – Providencia – Salmonella – Salmonella arizonae – Salmonella enterica – Salmonella enteritidis – Salmonella paratyphi A – Salmonella paratyphi B – Salmonella paratyphi C – Salmonella typhi – Salmonella typhimurium – Serratia – Serratia liquefaciens – Serratia marcescens – Shigella – Shigella boydii – Shigella dysenteriae – Shigella flexneri – Shigella sonnei – Wigglesworthia – Xenorhabdus – Yersinia – Yersinia enterocolitica – Yersinia pestis – Yersinia pseudotuberculosis – Yersinia rucker – Gardnerella" }, { "id": "pubmed23n0992_893", "title": "Cervical Spinal Osteomyelitis with Epidural Abscess following an <i>Escherichia coli</i> Urinary Tract Infection in an Immunocompetent Host.", "score": 0.009523809523809525, "content": "Spinal epidural abscess (SEA) is uncommon with an incidence reported as 0.33-1.96 abscesses per 10,000 hospital admissions per year. Two-thirds of the cases were caused by <iStaphylococcus aureus</i. <iEscherichia coli</i (<iE. coli</i) is a less common cause of SEA, and it is usually after urinary tract infection in patient with preexisting risk factor. A 69-year-old male with a past medical history significant for prostatitis was admitted with fever, altered mental status, neck pain, progressive lower extremities weakness, and frequent falls for 7 days. Both blood and urine cultures grew <iE. coli</i. Lumbar puncture showed 94 RBCs, 24 WBCs (16% neutrophils and 46% lymphocytes), and elevated protein level at 1140 mg/dl with no bacteria. C-spine MRI showed epidural abscess along the anterior and right lateral margin of the cord causing cord compression from C5 through C7, anterior perivertebral abscess from C4 through T2, marrow edema involving C6 and C7 vertebral bodies with increased signal in the intervertebral disc space at C6-C7, and consistent with osteomyelitis and discitis. Anterior cervical decompression with evacuation of anterior epidural abscess with fusion was done. The culture from the epidural abscess grew <iE coli</i. A diagnosis of SEA should be considered in patients presenting with progressive weakness and neurological deficits following UTI and is to be confirmed by MRI. <iE. coli</i could be the culprit for epidural abscess and spine osteomyelitis even in immunocompetent patients." }, { "id": "wiki20220301en100_6044", "title": "List of MeSH codes (B03)", "score": 0.009433962264150943, "content": "– Edwardsiella tarda – Enterobacter – Enterobacter aerogenes – Enterobacter cloacae – Enterobacter sakazakii – Erwinia – Erwinia amylovora – Escherichia – Escherichia coli – Escherichia coli k12 – Escherichia coli o157 – Hafnia – Hafnia alvei – Klebsiella – Klebsiella oxytoca – Klebsiella pneumoniae – Kluyvera – Morganella – Morganella morganii – Pantoea – Pectobacterium – Pectobacterium carotovorum – Pectobacterium chrysanthemi – Photorhabdus – Plesiomonas – Proteus – Proteus mirabilis – Proteus penneri – Proteus vulgaris – Providencia – Rahnella – Salmonella – Salmonella arizonae – Salmonella enterica – Salmonella enteritidis – Salmonella paratyphi A – Salmonella paratyphi B – Salmonella paratyphi C – Salmonella typhi – Salmonella typhimurium – Serratia – Serratia liquefaciens – Serratia marcescens – Shigella – Shigella boydii – Shigella dysenteriae – Shigella flexneri – Shigella sonnei" }, { "id": "pubmed23n0702_8448", "title": "Investigation of the antimicrobial activity of Rhaponticum (Rhaponticum carthamoides D.C. Iljin) and shrubby cinquefoil (Potentilla fruticosa L.).", "score": 0.009345794392523364, "content": "The aim of the study was to determine antimicrobial activity of rhaponticum and shrubby cinquefoil extracts. MATERIAL AND METHODS. Ethanol extract from the leaves of rhaponticum (Rhaponticum carthamoides D.C. Iljin) and shrubby cinquefoil (Potentilla fruticosa L.) was produced at the Department of Food Technology, Kaunas University of Technology. The antimicrobial activity of the viscous extract or rhaponticum and shrubby cinquefoil was evaluated using standard microorganism cultures (bacteria Staphylococcus aureus ATCC 25923, Enterococcus faecalis ATCC 29212, Escherichia coli ATCC 25922, Klebsiella pneumoniae ATCC 33499, Pseudomonas aeruginosa ATCC 27853, Proteus mirabilis ATCC 12459, Bacillus subtilis ATCC 6633, Bacillus cereus ATCC 8035 and fungi Candida albicans ATCC 60193). The minimum inhibitory concentration (MIC) of the examined preparations was determined. RESULTS. Both studied preparations - rhaponticum (Rhaponticum carthamoides D.C. Iljin) and shrubby cinquefoil (Potentilla fruticosa L.) - demonstrated similar antimicrobial activity. The highest sensitivity to the studied preparations was observed in microbes with eukaryotic cell structure: Candida albicans, which is a fungus, and a spore-forming prokaryotic bacterium, Bacillus cereus. The highest resistance was observed in Escherichia coli and Klebsiella pneumoniae. CONCLUSIONS. The studied preparations - viscous extracts of rhaponticum and shrubby cinquefoil - are substances with antimicrobial activity against gram-positive (Staphylococcus aureus and Enterococcus faecalis) and gram-negative (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Proteus mirabilis) bacteria, spore-forming bacteria (Bacillus subtilis and Bacillus cereus), and fungi (Candida albicans)." }, { "id": "pubmed23n0679_18816", "title": "Escherichia coli septic arthritis of a lumbar facet joint following urinary tract infection.", "score": 0.009345794392523364, "content": "Septic arthritis of a lumbar facet joint is a rare condition. We report the case of a 77-year-old diabetic woman who developed fever and back pain 15 days after she had been diagnosed with a genitourinary infection for which she had received ciprofloxacin. Physical examination showed fever (38°C) and pain on pressure over the lower lumbar spinous vertebral apophyses and over the lower left paraspinal musculature. Investigations showed a white cell count of 8.4×10⁹/l, neutrophils 85.3%, erythrocyte sedimentation rate of 125 mm/h, and C-reactive protein of ≥9 mg/dl. Two blood cultures were both positive for Escherichia coli resistant to ciprofloxacin. There was no growth of pathogens from the urine cultures. Scintigraphy with gallium citrate Ga⁶⁷ showed vertical lower lumbar (L4-L5) radionuclide uptake lateralized to the left. Magnetic resonance imaging of the lumbar spine demonstrated signal changes and alteration of the structure at the left interapophyseal L4-L5 joint, an adjacent small collection of 1cm in diameter, and infiltration of the surrounding soft tissues, which extended to the epidural area, left conjunction hole, and paraspinal muscles. The patient was treated with intravenous cefotaxime and gentamicin and bed rest for 21 days, and recovered. This is the first report of interapophyseal arthritis caused by E. coli." }, { "id": "wiki20220301en299_37323", "title": "Viable but nonculturable", "score": 0.009259259259259259, "content": "E.M.S Aeromonas salmonicida Agrobacterium tumefaciens Burkholderia cepacia Burkholderia pseudomallei Brettanomyces bruxellensis Campylobacter coli Campylobacter jejuni Campylobacter lari Cytophaga allerginae Enterobacter aerogenes Enterobacter cloacae Enterococcus faecalis Enterococcus hirae Enterococcus faecium Erwinia amylovora Escherichia coli (including EHEC) Francisella tularensis Helicobacter pylori Klebsiella aerogenes Klebsiella pneumoniae Klebsiella planticola Legionella pneumophila Listeria monocytogenes Micrococcus luteus Mycobacterium tuberculosis Mycobacterium smegmatis Pasteurella piscicida Pseudomonas aeruginosa Pseudomonas syringae Ralstonia solanacearum Rhizobium leguminosarum Rhizobium meliloti Salmonella enterica Salmonella Typhi Salmonella Typhimurium Serratia marcescens Shigella dysenteriae Shigella flexneri Shigella sonnei Streptococcus faecalis Vibrio anguillarum Vibrio campbellii Vibrio cholerae Vibrio harveyi Vibrio mimicus Vibrio parahaemolyticus" }, { "id": "pubmed23n0069_17938", "title": "[Comparison of symptoms and clinical and laboratory findings in the first and last weeks of typhoid fever].", "score": 0.009259259259259259, "content": "In this study we examined the clinical and laboratory findings of 80 in-patients. There is an important difference between sexes (p greater than 0.05). Comparison of ages showed that 7-30 age is more vulnerable than the older group. We found clinical symptoms of fever, chills, headache, abdominal pain, disturbances in bowel function, nausea, vomiting, anorexia, and lassitude in the first two weeks more frequently when compared with the 3rd, 4th, 5th weeks of illness (p less than 0.001). Where physical finding of rose spots, discordant pulse rate are important in the first two weeks (p less than 0.001). Abdominal discomfort is an important symptom both in the first two and in the last three weeks (% 40.3 and % 36 respectively). Hepatomegaly and splenomegaly, were found more frequently in the last three weeks. According to laboratory findings of anemia, leukopenia, increased erythrocyte sedimentation rate and positive blood and feces cultures there is no important difference between the first two and last three weeks (p greater than 0.05). Increase in polynuclear leucocytes is important for the first two weeks, and increase in lymphocytes is important in the last three weeks (p less than 0.001). Positivity of group agglutination tests is 57%, in the first two weeks and 83% in the last three weeks. This difference is found to be important." }, { "id": "pubmed23n0564_22447", "title": "A new antibacterial compound produced by an indigenous marine bacteria--fermentation, isolation, and biological activity.", "score": 0.009174311926605505, "content": "The use of microorganisms for biological purpose has become an effective alternative to control pathogens. A marine bacterium Pseudomonas aeruginosa was isolated from Eal fish of Baluchistan coast of Pakistan. This strain produced a bactericidal antibiotic against environmental and clinical isolates. In this study, we purified bactericidal antibiotic from the ethyl acetate extract of the cells of P. aeruginosa and analyzed its chemical structure. Based on spectrometric analysis, this compound 1 is proposed to be 1-methyl-1,4 dihydroquinoline and is active against methicillin-resistant Staphylococcus aureus (MRSA), methicillin-sensitive S. aureus (MSSA), Salmonella typhi, Shigella flexneri, Escherichia coli, Proteus mirabilis, Vibrio aliginolyticus, Micrococcus luteus, Enterococcus faecalis, Enterobacter faecium but it is not active against G streptococci, Candida albicans, Aspergillus niger. Minimal inhibitory concentration for Gram-positive bacteria was between 50 and 75 microg mL(-1) and for Gram-negative bacteria 75-100 microg mL(-1)." }, { "id": "pubmed23n0369_22053", "title": "Two cases of diskitis attributable to anaerobic bacteria in children.", "score": 0.009174311926605505, "content": "Diskitis, an inflammation of the intervertebral disk, is generally attributable to Staphylococcus aureus and rarely Staphylococcus epidermidis, Kingella kingae, Enterobacteriaciae, and Streptococcus pneumoniae. In many cases, no bacterial growth is obtained from infected intervertebral discs. Although anaerobic bacteria were recovered from adults with spondylodiscitis, these organisms were not reported before from children. The recovery of anaerobic bacteria in 2 children with diskitis is reported. Patient 1. A 10-year-old male presented with 6 weeks of low back pain and 2 weeks of low-grade fever and abdominal pain. Physical examination was normal except for tenderness to percussion over the spine between thoracic vertebra 11 and lumbar vertebra 2. The patient had a temperature of 104 degrees F. Laboratory tests were within normal limits, except for erythrocyte sedimentation rate (ESR), which was 58 mm/hour. Blood culture showed no growth. Magnetic resonance imaging with gadolinium contrast revealed minimal inflammatory changes in the 12th thoracic vertebra/first lumbar vertebra disk. There was no other abnormality. A computed tomography (CT)-guided aspiration of the disk space yielded bloody material, which was sent for aerobic and anaerobic cultures. Gram stain showed numerous white blood cells and Gram-positive cocci in chains. Cultures for anaerobic bacteria yielded heavy growth of Peptostreptococcus magnus, which was susceptible to penicillin, clindamycin, and vancomycin. The patient was treated with intravenous penicillin 600 000 units every 6 hours for 3 weeks, and then oral amoxicillin, 500 mg every 6 hours for 3 weeks. The back pain resolved within 2 weeks, and the ESR returned to normal at the end of therapy. Follow-up for 3 years showed complete resolution of the infection. Patient 2. An 8-year-old boy presented with low back pain and low-grade fever, irritability, and general malaise for 10 days. He had had an upper respiratory tract infection with sore throat 27 days earlier, for which he received no therapy. The patient had a temperature of 102 degrees F, and physical examination was normal except for tenderness to percussion over the spine between the second and fourth lumbar vertebrae. Laboratory tests were normal, except for the ESR (42 mm/hour). Radiographs of the spine showed narrowing of the third to fourth lumbar vertebra disk space and irregularity of the margins of the vertebral endplates. A CT scan revealed a lytic bone lesion at lumbar vertebra 4, and bone scan showed an increase uptake of (99m)technetium at the third to fourth lumbar vertebra disk space. CT-guided aspiration of the disk space yielded cloudy nonfoul-smelling material, which was sent for aerobic and anaerobic cultures. Gram stain showed numerous white blood cells and fusiform Gram-negative bacilli. Anaerobic culture grew light growth of Fusobacterium nucleatum. The organism produced beta-lactamase and was susceptible to ticarcillin-clavulanate, clindamycin, metronidazole, and imipenem. Therapy with clindamycin 450 mg every 8 hours was given parenterally for 3 weeks and orally for 3 weeks. Back pain resolved within 2 weeks. A 2-year follow-up showed complete resolution and no recurrence. This report describes, for the first time, the isolation of anaerobic bacteria from children with diskitis. The lack of their recovery in previous reports and the absence of bacterial growth in over two third of these studies may be caused by the use of improper methods for their collection, transportation, and cultivation. Proper choice of antimicrobial therapy for diskitis can be accomplished only by identification of the causative organisms and its antimicrobial susceptibility. This is of particular importance in infections caused by anaerobic bacteria that are often resistant to antimicrobials used to empirically treat diskitis. This was the case in our second patient, who was infected by F nucleatum, which was resistant to beta-lactam antibiotics. The origin of the anaerobic bacteria causing the infection in our patient is probably of endogenous nature. The presence of abdominal pain in the first child may have been attributable to a subclinical abdominal pathothology. The preceding pharyngitis in the second patient may have been associated with a potential hematogenous spread of F nucleatum. P magnus has been associated with bone and joint infections. This report highlights the importance of obtaining disk space culture for aerobic and anaerobic bacteria from all children with diskitis. Future prospective studies are warranted to elucidate the role of anaerobic bacteria in diskitis in children." }, { "id": "pubmed23n0526_1515", "title": "Bacterial flora of leg ulcers in patients admitted to Department of Dermatology, Poznań University of Medical Sciences, during the 1998-2002 period.", "score": 0.00909090909090909, "content": "Venous leg ulcers are an important cause of morbidity in a significant percentage of the world population. The percentage of leg ulceration, either active or healed, in the European population is about 1%-2%. The aim of this study was to analyze the rate of colonization and qualitative composition of the bacterial flora isolated from leg ulcers in patients admitted to Dermatology Department, Poznań University of Medical Sciences, during the 1998-2002 period, with special reference to the infection risk factors. Bacteriological diagnosis of 175 wound swabs was performed in compliance with compulsory laboratory methods. In 173 positive results, the predominant culture composition included Staphylococcus aureus (56.57%), Pseudomonas aeruginosa (37.14%), Enterococcus faecalis (22.29%), Proteus mirabilis (13.71%) and Escherichia coli (12.57%). There was a significant increase in the incidence of Pseudomonas aeruginosa, Enterococcus faecalis and Escherichia coli, along with a decrease in the incidence of Staphylococcus aureus isolation during the study period. The rate of yeast-like fungi strains, mainly Candida albicans, recorded in culture composition showed a systematic increase. Changes in the qualitative and quantitative composition of bacterial flora, presence of multiple isolates, and concomitant diseases that may influence the characteristics of leg ulcer disease were closely monitored." }, { "id": "pubmed23n1050_19446", "title": "Emphysematous Pyelonephritis in a Diabetic Patient with Remarkable Radiological Findings and Excellent Outcome without Surgical Intervention or Drainage.", "score": 0.00909090909090909, "content": "BACKGROUND Emphysematous pyelonephritis (EPN) is a life-threatening infection of the renal parenchyma. The purpose of this report is to present a case of EPN with distinctive imaging. CASE REPORT An 87-year-old man with a history of type 2 diabetes mellitus presented to the ER with fever and shivering, hypotension, and anuria, which is a clinical presentation of septic shock. He had recently been hospitalized at another hospital due to myocardial infarction and ischemic stroke, where a temporary urinary catheter was placed. Upon physical examination, he had right lateral abdominal pain with extension to the right renal region. Laboratory studies showed leucocytosis (WBC: 24 320/μl with 94.4% polymorphonuclear), elevated C-reactive protein 340 mg/l (NV &lt;3.45), and acute renal failure (urea 155mg/dl NV &lt;50 mg/dl, creatinine 4.4 mg/dl NV &lt;1.2 mg/dl). A plain X-ray showed air was present peripheral to the right kidney, while the abdominal CT revealed air inside the right kidney and bilateral nephrolithiasis. The patient was initially put on aggressive hydration, vasoconstrictors, and hydrocortisone to treat the septic shock, and an advanced antibiotic treatment (meropenem) was initiated immediately. Blood culture grew Escherichia coli. After 3 days of treatment, he showed significant improvement in diuresis and renal function (urea 90 mg/dl, creatinine 1.0 mg/dl), with a concomitant decrease in inflammatory markers (CRP 36.7 mg/l). The antibiotic treatment was tapered to cefuroxime and metronidazole. The patient's condition improved, and he was discharged with per os antibiotic treatment. Subsequently, surgical assessment for the nephrolithiasis was suggested. CONCLUSIONS Emphysematous pyelonephritis, although rare, should be included in the differential diagnosis of fever in a diabetic patient with renal pain." }, { "id": "pubmed23n0619_16837", "title": "[Antimicrobial activity of soft and purified propolis extracts].", "score": 0.009009009009009009, "content": "To evaluate the antimicrobial activity of soft and purified propolis extracts. STUDY OBJECT AND METHODS: Antimicrobial activity of soft and purified propolis extracts was determined with reference cultures of Staphylococcus aureus ATCC 25923, Enterococcus faecalis ATCC 29212, Escherichia coli ATCC 25922, Klebsiella pneumoniae ATCC 33499, Pseudomonas aeruginosa ATCC 27853, Proteus mirabilis ATCC 12459, Bacillus subtilis ATCC 6633, Bacillus cereus ATCC 8035, and fungus Candida albicans ATCC 60193. Microbiological tests were performed under aseptic conditions. Minimum inhibitory concentration (MIC)--the highest dilution of preparation (the lowest concentration of preparation) that suppresses growth of reference microorganisms--was determined. Concentration of phenolic compounds in soft propolis extract that possesses antimicrobial activity against gram-positive (Staphylococcus aureus, Enterococcus faecalis) and gram-negative bacteria (Escherichia coli, Pseudomonas aeruginosa, and Proteus mirabilis) is 0.587+/-0.054 mg and 0.587+/-0.054-0.394+/-0.022 mg (P&gt;0.05) and in purified propolis extract--0.427+/-0.044 mg and 0.256+/-0.02 mg (P&gt;0.05). Klebsiella pneumoniae is most resistant to soft propolis extract when the concentration of phenolic compounds is 1.119+/- 0.152 mg and to purified propolis extract when the concentration of phenolic compounds is 1.013+/-0.189 mg (P&gt;0.05). Spore-forming Bacillus subtilis bacteria are more sensitive to soft and purified propolis extracts when the concentration of phenolic compounds is 0.134+/-0.002 mg and 0.075+/-0.025 mg, respectively, and Bacillus cereus--when the concentration is 0.394+/-0.022 mg and 0.256+/-0.02 mg (P&gt;0.05). Sensitivity of fungus Candida albicans to soft and purified propolis extracts is the same as Bacillus subtilis. Encapsulated bacterium Klebsiella pneumoniae is most resistant to antimicrobial action of soft and purified propolis extracts as compared with gram-positive Staphylococcus aureus and Enterococcus faecalis bacteria (P&lt;0.05), gram-negative Escherichia coli, Pseudomonas aeruginosa, and Proteus mirabilis (P&lt;0.05), spore-forming Bacillus subtilis and Bacillus cereus bacteria (P&lt;0.05), and fungus Candida albicans (P&lt;0.05). There is no statistically significant difference between antimicrobial effect of soft propolis extract and purified propolis extract on gram-positive bacteria, gram-negative bacteria, spore-forming bacteria, encapsulated bacteria, and Candida fungus. Soft and purified propolis extracts possess antimicrobial activity. They could be recommended as natural preservatives in the manufacture of pharmaceutical products." }, { "id": "pubmed23n0389_2099", "title": "[Clinical thinking and decision making in practice. 4 times ERCP, 6 times ultrasonography of the upper abdomen and 3 CT-scans for a woman with recurrent fever and bacteremia].", "score": 0.009009009009009009, "content": "A 42-year-old woman was hospitalised due to recurrent fever (40 degrees C) and bacteraemia. A physical examination revealed no abnormalities. Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca and Enterococci were found in blood cultures. Laboratory results revealed liver enzyme levels which were only slightly elevated. An X-ray investigation, ERCPs, CT scans, ultrasounds, a leucocyte scintigram and a gallium scan, all revealed no abnormalities. Due to the results from the blood cultures it was thought that the bile duct system or the digestive tract were the focus of infection. Therefore a liver biopsy was carried out for the purpose of making a diagnosis. The patient was diagnosed as having ductal plate malformation, a microscopic congenital cystic dilatation of the bile ducts. The prognosis is poor and the treatment consists of lifelong antibiotics." }, { "id": "pubmed23n0836_16378", "title": "Antimicrobial activity of silver and gold in toothpastes: A comparative analysis.", "score": 0.008928571428571428, "content": "In this study, we compared the antimicrobial activity of identical toothpastes differing only in silver or gold nanoparticles against the activity of one of the common toothpastes containing a chemical active ingredient. We also compared the active concentrations of the toothpastes. For this study, we selected \"Royal Denta\" toothpastes containing silver and gold particles, and the \"Blend-A-Med Complete\" toothpaste containing zinc citrate as the active ingredient. We used 8 standard microorganism cultures on the basis of their individual mechanisms of protection. The antimicrobial activity of each studied preparation was evaluated at 9 concentrations. Most effective against gram-positive bacteria (Staphylococcus aureus and Enterococcus faecalis) was the \"Silver Technology\" – MIC was 0.004-0.0015 g/mL. Neither \"Silver Technology\" nor \"Orange and Gold Technology\" had any effect on Escherichia coli or Proteus mirabilis. Antimicrobial activity against the motile bacterium Proteus mirabilis was observed in \"Silver Technology\", \"Orange and Gold Technology\", and \"Blend-A-Med Complete\" – the MIC was 0.015 g/mL or lower. No antimicrobial activity against Candida albicans fungus at the studied concentrations was observed in the \"Orange and Gold Technology\". The toothpaste \"Blend-A-Med\" demonstrated the most effective antimicrobial activity - the MIC of 0.0015 g/mL and 0.015 g/mL inhibited Staphylococcus aureus and Enterococcus faecalis, respectively, and the MIC of 0.15 g/mL inhibited the growth of the bacteria Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, and fungus Candida albicans. Silver in toothpaste has a greater antimicrobial effect than gold, but its effect is still inferior to that of a chemical antimicrobial agent." }, { "id": "pubmed23n0523_13419", "title": "[Abscess of the spleen].", "score": 0.008928571428571428, "content": "Splenic abscess is a rare disease but with increasing frequency. The authors present 9 patients with splenic abscess treated at the Institute of Digestive System Diseases, Clinical Centre of Serbia, in a period from January 1, 1986 to May 15, 2004. Splenic abscess was the complication of septic endocarditis in 4, trauma in 2, dental infection in 1, while in 2 cases it was the complication of chemotherapy in myeloproliferative disorders. All 9 patients had fever, 7 - abdominal pain, 4 - left shoulder pain, and 1 patient had nausea and vomiting. Higher white blood count was found in 6 patients, pleural effusion in 4, elevated left hemidiaphragm in 1 and basal pneumonia in 1 patient as well. Ultrasonography and CT were the most reliable diagnostic procedures. CT was superior in diagnosis of multiple small abscesses. Culture of the pus recovered the Enterococcus in 3 cases, Streptococcus a hemolyticus in 1, Staphylococcus epidermidis and Candida albicans in 1, Staphylococcus aureus, E. Coil and Candida albicans in 1, Staphylococcus aureus i Salmonella enteritidis in 1 case. Eight patients underwent splenectomy and 1 was cured by combined antibiotics in high doses. One patient died postoperatively due to septic endocarditis that had been present before surgery. The authors believe that splenectomy and antibiotics administered according to drug susceptibility test as well as management of underlying disease are the method of choice for splenic abscess treatment. Conservative antibiotic treatment is indicated in selected cases only." }, { "id": "pubmed23n0019_3154", "title": "[Spinal subdural abscess-report of a case (author's transl)].", "score": 0.008849557522123894, "content": "A successfully treated case with a spinal subdural abscess in the lumbar region is reported. The patient, a 58-year-old male, had been suffered from fever and pain in the back for 2 months prior to the visit to a hospital, where pus was obtained through a lumbar puncture. He was then admitted to the Neurosurgical Clinic, Gunma University Hospital on September 6, 1974. On admission, neurological examination revealed an alert patient with flaccid paraparesis, sensory disturbance in bilateral lower limbs and urinary retention. Stiffness of the neck and Lasègue's sign were observed. The body temperature was 38.7 degrees C, white blood cell count 18,900/mn3, and erythrocyte sedimentation rate 118 mn per hour. Pus was again obtained from the spinal canal through a lumbar puncture between the fourth and fifth lumbar vertebrae. Cerebrospinal fluid obtained by a cisternal puncture was colorless clear, and the cell count was 60 WBCs/mn3, protein 154 mg/dl, and glucose 90 mg/dl. Plain roentgenograms of the spine were normal. Myelography showed a block at the level of the first thoracic vertebra, being accompanied with irregular subarachnoid defects. A lumbar laminectomy was performed on September 12, and an abscess adhering to the cauda equina was totally extirpated from the subdural space. Smear of the pus contained Gram-positive bacilli, but the culture was negative. Postoperative course was uneventful, and the neurological deficits were gradually improved. Fifteen months later, the patient could walk with a stick. A review of the available literature, including the present report, lists 14 cases with spinal subdural abscesses which have been induced via hematogenous spread. The symptomotology, clinical diagnosis, treatment and prognosis are briefly discussed. It should be emphasized that early diagnosis and emergency treatment are of choice in order to obtain an excellent operative morbidity." }, { "id": "pubmed23n0525_8778", "title": "Bacteria isolated from blood, stool and urine of typhoid patients in a developing country.", "score": 0.008771929824561403, "content": "Blood, stool and urine samples were collected from 100 patients diagnosed as having typhoid in 5 hospitals in Akwa Ibom State and analyzed for the presence of Salmonella species and other bacteria. Of the 100 blood samples screened, 55 (55%) were positive with the Widal test and 39 (39%) were positive on blood culture. Thirteen (14.1%) out of 92 urine samples were positive for bacterial growth, while 22 (26.8%) of the stool cultures were positive out of the 82 samples screened. Those within the age range 11-20 years old were infected most frequently (33%), followed by the age range 21-30 (19%) and 41-50 (18%) years old. Those in the age range of 0-2 years old (4%) were least infected. Female subjects were more infected than males. The commonest organisms isolated from the blood samples were Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus vulgaris, Streptococcus faecalis, Salmonella paratyphi and Salmonella typhi. S. aureus, S. epidermidis, E. coli, K. aerogenes, S. faecalis, Proteus mirabilis and P. aeruginosa were isolated from urine, while those isolated from stool were S. aureus, E. coli, S. typhi, S. paratyphi, Shigella sp, K. pneumoniae, P. vulgaris, P. aeruginosa and Vibrio cholerae 01. The isolates were sensitive to peflacine, ceftazidine, ciprofloxacin, ceftriaxone, cefotaxime and chloramphenicol. These antibiotics are recommended as the drugs of choice in therapy. The results suggest the existence of symptomless carriers of enteric fever bacilli in the state. This is worrisome, since some of the S. typhi isolates exhibited multiple resistance to commonly used antibiotics." }, { "id": "pubmed23n0701_10238", "title": "A multicenter case-control study of diagnostic tests for urinary tract infection in the presence of urolithiasis.", "score": 0.008771929824561403, "content": "Urinary stone disease (USD) alone can cause much morbidity, but when present in conjunction with urinary tract infection, complications and morbidity increase even more. This study investigated the clinical and laboratory findings in patients who had USD with and without infection and evaluated the most suitable diagnostic value for urinary tract infection parameters before urine culture results were available. In a prospective fashion, patients who presented to the emergency department with a complaint of colicky flank pain (with or without hematuria) and who were diagnosed as having urolithiasis with ultrasound were evaluated for 1 year. The gold standard for the diagnosis of urinary tract infection was urine culture. The most suitable diagnostic value for urinary tract infection parameters was determined by receiver operating characteristic (ROC) curves. Logistic regression was used to identify independent variables that predicted a positive urine culture. Of the 192 eligible patients, 177 agreed to participate in the study. Of the clinical and laboratory characteristics analyzed, urine WBC, blood WBC, and fever were significantly different between culture positive and negative patients (p &lt; 0.001, p = 0.04 p = 0.012, respectively). Using ROC curve analysis, pyuria (over 10 WBCs per HPF), fever over 37.9°C, and leucocytosis over 11,300 were the best predictors of a positive culture result. The logistic regression model for leukocytosis &gt;11,300 (OR 2.1), pyuria (OR 2.8), and temperature &gt;37.9°C (OR 3.1) showed a significantly increased risk of having a positive urine culture (correct class 87.9%). While a single physical examination or laboratory finding cannot predict urinary tract infection in USD patients with complete reliability, the presence of pyruria, fever, and leukocytosis significantly increases the odds of a positive urine culture." } ] } } }

{ "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": [ [ 0, 125 ] ], "word_ranges": [ [ 0, 21 ] ], "text": "HbA1c would be useful in this patient for the diagnosis of diabetes but not for the target organ involvement of hypertension." } }

{ "1": "Transthoracic echocardiogram.", "2": "Performance of fundus examination.", "3": "Determination of microalbuminuria.", "4": "Ankle-brachial index.", "5": "Determination of glycosylated hemoglobin." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en002_174482", "title": "Metabolic syndrome", "score": 0.009900990099009901, "content": "IDF The International Diabetes Federation consensus worldwide definition of metabolic syndrome (2006) is: Central obesity (defined as waist circumference# with ethnicity-specific values) AND any two of the following: Raised triglycerides: > 150 mg/dL (1.7 mmol/L), or specific treatment for this lipid abnormality Reduced HDL cholesterol: < 40 mg/dL (1.03 mmol/L) in males, < 50 mg/dL (1.29 mmol/L) in females, or specific treatment for this lipid abnormality Raised blood pressure (BP): systolic BP > 130 or diastolic BP >85 mm Hg, or treatment of previously diagnosed hypertension Raised fasting plasma glucose (FPG): >100 mg/dL (5.6 mmol/L), or previously diagnosed type 2 diabetes If FPG is >5.6 mmol/L or 100 mg/dL, an oral glucose tolerance test is strongly recommended, but is not necessary to define presence of the syndrome. # If BMI is >30 kg/m2, central obesity can be assumed and waist circumference does not need to be measured" }, { "id": "pubmed23n0050_13847", "title": "[Use of heart rate variability and pulse wave velocity for diagnosing cardiovascular autonomic neuropathy].", "score": 0.009900990099009901, "content": "Heart rate (HR) and arterial pulse wave velocity (PWV) were used for the evaluation of cardiovascular autonomic neuropathy. Data were analyzed from 30 patients with diabetes mellitus (aged from 13 to 75 years). Twenty healthy male subjects (aged from 22 to 44 years) were analyzed for computing normal values as well. After 15 minutes rest, electrocardiogram (ECG) of lead II and plethysmogram of finger tip were simultaneously recorded for each subject. The recording was first done in supine position for 120 seconds and subsequently in upright position for 40 seconds. HR was computed on the basis of consecutive pairs of R wave of the ECG. PWV was estimated by transit time from R wave peak to initial rise of pulse wave. Mean and coefficient of variation (CV) were obtained from the HR in the supine and upright positions respectively, and also from the PWVs. The influence of changing the position was evaluated by percentage of the difference (increasing rate). All the parameters were statistically tested for the difference between the patients with neuropathy and those without neuropathy. As the result, two parameters, that is, the CV of HR in the supine position and the increasing rate of PWV were found to be useful for diagnosing the cardiovascular autonomic neuropathy (p less than 0.05)." }, { "id": "wiki20220301en438_11410", "title": "Suboptimal health", "score": 0.00980392156862745, "content": "Another criterion for diagnosis of subhealth was defined as the presence of ≥ 1 of the following abnormalities: body mass index ≥ 25 kg/m2 or waist circumference ≥ 102 cm in men and 88 cm in women; systolic pressure 120-139 mmHg and/or diastolic pressure 80-89 mmHg; serum triglyceride level ≥ 150 mg/dL and/or total cholesterol level ≥ 200 mg/dL and/or high-density lipoprotein cholesterol level < 40 mg/dL in men and 50 mg/dL in women; serum glucose level 110–125 mg/dL; estimated glomerular filtration rate 60-89 ml/min/1.73 m2; levels of liver enzymes in liver function tests between 41-59 U/L, or with fatty liver disease but < 33% of affected hepatocytes; levels of oxidative stress biomarkers beyond the reference range of 95%; or problems with both sleep quality and psychological state. Population Health Status" }, { "id": "pubmed23n0286_15366", "title": "Assessment of noninvasive lower extremity arterial testing versus pulse exam.", "score": 0.00980392156862745, "content": "Palpation of pedal pulses was compared to noninvasive testing in 100 patients referred to a vascular laboratory. Subjects were 65 +/- 13 (mean +/- s.d.) years old. The right dorsalis pedis (DP) artery served as the reference artery for comparison of Doppler studies with physical examination of the pulses. Absolute Doppler pressures in the right DP were 129 +/- 50 mm Hg. The right ankle:brachial index (ABI) was 0.86 +/- 0.32. There were significant differences in ABI in those with (0.68 +/- 0.28) vs without (0.95 +/- 0.31) claudication in either extremity (p &lt; 0.001). Rest pain was also associated with lower ABI (P &lt; 0.04). Diabetics, hypertensives, claudicants and those with ischemic rest pain were less likely to have palpable pulses (P &lt; 0.035). With right DP pressure &gt;/= 118 mm Hg, 63 per cent of subjects had a palpable DP pulse, whereas 68 per cent with ABI &gt; 0.82 had a palpable right DP. Of those (n = 35) with a right DP pressure &lt; 118 mm Hg, only 6 per cent (n = 2) had a palpable pulse, whereas 5 per cent (2/40) with ABI &lt;/= 0.82 had palpable DP pulses. Based on these findings, it was predicted that a pulse would likely not be palpable in the left DP with a pressure &lt; 118 mm Hg or with AB &lt;/= 0.82. The prediction based on systolic ankle pressures was correct, with 66 per cent sensitivity and 91 per cent specificity. The predication that a left DP pulse would not be palpable with AB &lt;/= 0.82 was more accurate (78% sensitive, 97% specific). Presence of a palpable DP pulse suggests the presence of a Doppler pressure &gt;/= 188 mm Hg and ABI &gt; 0.82. The range of ankle pressures with palpable right DP pulses was 64-220 mm Hg, whereas the range with nonpalpable DP was 42-300 mm Hg. Given the frequent disparity of pulse exam and ankle pressures, noninvasive Doppler testing may be necessary for many patients to accurately assess the vascular status of the leg." }, { "id": "wiki20220301en388_15477", "title": "Epidemiology of metabolic syndrome", "score": 0.009708737864077669, "content": "Fasting plasma glucose greater than or equal to 100 mg/dL, or undergoing drug treatment for elevated glucose HDL cholesterol less than 40 mg/dL in men or less than 50 mg/dL in women, or undergoing drug treatment for reduced HDL cholesterol Triglycerides greater than or equal to 150 mg/dL, or undergoing drug treatment for elevated triglycerides Waist circumference greater than or equal to in men or in women (in the United States) Blood pressure greater than or equal to 130 mm Hg systolic or 85 mm Hg diastolic, or undergoing drug treatment for hypertension Approximately 40–46 percent of the world's adult population has the cluster of risk factors that is metabolic syndrome. In 2000, approximately 32% of U.S. adults had the metabolic syndrome. In more recent years that figure has climbed to 34%." }, { "id": "pubmed23n0083_19333", "title": "[Physical properties of the aorta in normotensive insulin-dependent diabetic subjects. Study using Doppler echocardiography].", "score": 0.009708737864077669, "content": "We studied 16 normotensive insulin-dependent diabetic patients (D) (11 males + 5 females) aged of 25-51 years old (mean = 35 +/- 6) with a good glycemic control, without microangiopathy and previous heart disease and 16 healthy control of 25 subjects (C) matched for sex age and body area. We measured: Systolic blood pressure (SBP) with a mercury sphygmomanometer, aortic diameter (AD), end diastolic left ventricular radius (r) and wall thickness (Th) by Echocardiography TM with 2 D echo control, the pulse wave delay (PWD) by measurement of time between the feet of aortic velocity tracings, recorded in the isthmus and near the diaphragm, Sternal length (L). Parameters calculated were: the ratio th/r. The pulse wave velocity PWV = L/PWD and the ratio PWV/AD which represents an indirect index of aortic characteristic impedance. (table; see text) PWV and the radio Th/r are significantly increased in diabetic patients as compared to the control group. Th/r is not significantly correlated with PWV in the 2 groups. This lack of correlation could be explained in the control group by the small rang of values of PWV (5-7.3 ms-1) and Th/r (0.26-0.38). It is not the case in the diabetic group where values are widespread (PWD 5-10 ms-1 and Th/r 0.23-0.53). in normotensive young insulin-dependent diabetic patients studied by doppler echocardiography: aortic rigidity measured by the pulse wave velocity is increased. Th/r ratio is also increased but this change of left ventricular geometry is not related to aortic rigidity in this group of patients." }, { "id": "wiki20220301en259_2285", "title": "Acquired generalized lipodystrophy", "score": 0.009615384615384616, "content": "According to a prospective, open-label clinical study at the NIH, metreleptin decreased the fasting glucose level from 180 mg/dL to 121 mg/dL, HbA1c from 8.4% to 6.4%, total cholesterol from 214 mg/dL to 146 mg/dL, and triglycerides from 467 (200-847)mg/dL to 180 (106-312)mg/dL after 12 months of use (p<0.001). Patients also had decreased use of anti-diabetic medications, lipid-lowering medications, and insulin (p<0.001). In other clinical reports studying 3 patients diagnosed with AGL accompanied by hypoleptinemia, uncontrolled diabetes, and hypertriglyceridemia who were treated with metreleptin for 12–168 weeks, patients had great reduction in HbA1c, from 10.9% to 5.8%, and had normalized serum triglycerides with a mean decline of 90%. Patients reported improved quality of life and reduced need for other medications without significant adverse effects." }, { "id": "pubmed23n0673_4883", "title": "Ankle-brachial index according to pulse pressure and microalbuminuria in hypertensive patients: a prospective study in family medicine.", "score": 0.009615384615384616, "content": "Microalbuminuria, as determined by the urinary albumin to creatinine (AC) ratio, is a marker of target organ damage (TOD) in hypertensive patients. Pulse pressure (PP) predicts arterial elasticity and the ankle-brachial index (ABI) is a marker of cardiovascular morbidity. TOD reduction should be achieved through improvements in these indices. To determine whether ABI, calculated as the ratio between mean PP in the upper and lower limbs, is associated with a reduction in renal damage, as measured by the AC ratio. This was a prospective interventional study based on an intention-to-treat analysis in an opportunity sample of patients treated by three specialists in family medicine, with three-monthly follow-up over a total of six months. Blood pressure was measured in arms and ankles, and PP was calculated and used to determine right and left ABI and mean overall ABI. The AC ratio was determined by urine dipstick test. Descriptive and inferential statistical analysis was performed. A sample of 75 patients were studied (42.4% women), of whom(42.4% women), of whom 27.6% were diabetic, 46.7% overweight/obese and 49.3% dyslipidemic. overweight/obese and 49 dyslipidemic. There were statistical differences for right ABI (as determined by PP) and for mean overall ABI (as determined by mean PP in lower and upper limbs). Bivariate correlation analysis showed that in the group with improved PP between the first and the third observations, n=23 (40%), there was a statistically significant reduction in AC ratio (r = -0.924, two-tailed p &lt; 0.001); the opposite was observed in the group with reduced PP, in which the AC ratio increased. ABI determined by systolic blood pressure is an excellent predictor of hemodynamic alterations. Increased ABI, based on PP, was accompanied by improved urinary AC ratio. These results are in line with the international literature. An improvement in urinary AC ratio--a predictor of TOD--is observed when an improvement in the ankle PP/brachial PP ratio is achieved." }, { "id": "wiki20220301en002_174484", "title": "Metabolic syndrome", "score": 0.009523809523809525, "content": "EGIR The European Group for the Study of Insulin Resistance (1999) requires insulin resistance defined as the top 25% of the fasting insulin values among nondiabetic individuals AND two or more of the following: Central obesity: waist circumference ≥ 94 cm or 37 inches (male), ≥ 80 cm or 31.5 inches (female) Dyslipidemia: TG ≥ 2.0 mmol/L and/or HDL-C < 1.0 mmol/L or treated for dyslipidemia Blood pressure ≥ 140/90 mmHg or antihypertensive medication Fasting plasma glucose ≥ 6.1 mmol/L NCEP The U.S. National Cholesterol Education Program Adult Treatment Panel III (2001) requires at least three of the following: Central obesity: waist circumference ≥ 102 cm or 40 inches (male), ≥ 88 cm or 35 inches(female) Dyslipidemia: TG ≥ 1.7 mmol/L (150 mg/dl) Dyslipidemia: HDL-C < 40 mg/dL (male), < 50 mg/dL (female) Blood pressure ≥ 130/85 mmHg (or treated for hypertension) Fasting plasma glucose ≥ 6.1 mmol/L (110 mg/dl)" }, { "id": "pubmed23n0833_13615", "title": "[Association between urinary microalbumin-to-creatinine ratio and brachial-ankle pulse wave velocity in hypertensive patients].", "score": 0.009523809523809525, "content": "To explore the association between urinary microalbumin-to-creatinine ratio (ACR) and brachial-ankle pulse wave velocity (baPWV) in hypertensive patients. A total of 877 primary hypertension patients were enrolled in this trial from September 2009 to December 2012, and were randomly recruited and patients were divided into normal ACR group (ACR &lt; 30 mg/g, n = 723), micro-albuminuria group (30 mg/g ≤ ACR &lt; 300 mg/g, n = 136) and macro-albuminuria group (ACR ≥ 300 mg/g, n = 18). baPWV was measure by automatic pulse wave velocity measuring system. The baPWV values in patients of micro-albuminuria group and macro-albuminuria group were significantly higher than in the normal ACR group (all P &lt; 0.05). The baPWV value of macro-albuminuria group was significantly higher than in the micro-albuminuria group (P &lt; 0.05). Linear correlation analysis revealed that ACR was positively correlated with baPWV (r = 0.413, P &lt; 0.01). Multiple linear regression analysis showed that ACR independently correlated with baPWV in patients with primary hypertension (β = 0.29, R(2) = 0.112, P &lt; 0.01) after adjusting for age, sex, body mass index, systolic blood pressure, diastolic blood pressure, blood glucose, total cholesterol, low density lipoprotein, high density lipoprotein and triglyceride. Using ACR &lt; 30 mg/g and ACR ≥ 30 mg/g as dichotomous variable, binary logistic regression analysis showed that ACR ≥ 30 mg/g was also a risk factor of the ascending baPWV in primary hypertension patients (OR: 1.73, 95% CI: 1.62-2.98) after adjusting the traditional cardiovascular risk factors. ACR is positively correlated to baPWV in primary hypertension patients, and the ascending baPWV is a risk factor of early renal dysfunction in primary hypertension patients." }, { "id": "wiki20220301en568_20657", "title": "Metabolic Score for Insulin Resistance", "score": 0.009433962264150943, "content": "Derivation and validation METS-IR was generated using linear regression against the M-value adjusted by lean body mass obtained from the glucose clamp technique in Mexican subjects with and without type 2 diabetes mellitus. It is estimated using fasting laboratory values including glucose (in mg/dL), triglycerides (mg/dL) and high-density lipoprotein cholesterol (HDL-C, in mg/dL) along with body-mass index (BMI). The index can be estimated using the following formula:" }, { "id": "pubmed23n0791_14329", "title": "[Characteristics of brachial-ankle pulse wave velocity and its relationship with risk factors of cardiovascular diseases in populations having health check-up programs].", "score": 0.009433962264150943, "content": "To investigate the characteristics of brachial-ankle pulse wave velocity (baPWV)in populations having health check-up and to explore its relationship with risk factors of cardiovascular diseases. 13 841 people who had health check-up were included and their baPWV were tested by automatic arteriosclerosis measurement system. All people were inquired about their diseases history, while height, weight, body mass index(BMI), blood pressure, fasting blood-glucose as well as serum lipid were also measured. With increasing of age, baPWV were increased both in males and females. The baPWV of male aged less than 60 years was significantly higher than that of female less than 60. Multi-variable regressive analysis showed the age, systolic pressure,BMI, fasting blood-glucose, uric acid and triglyceride were the risk factors of baPWV. BaPWV values of health check-up population in Chengdu area demonstrated different characteristics in different age and gender group. Attention should be paid on baPWV measurement among elder people, especially the elder women, in order to prevent cardiovascular events happening in high risk population." }, { "id": "wiki20220301en071_15812", "title": "Glucose test", "score": 0.009345794392523364, "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": "pubmed23n0258_3593", "title": "[Early diagnosis of arteriopathy of the legs using measures adapted to general practitioners: the systolic index and pulse perception].", "score": 0.009345794392523364, "content": "Atherosclerotic lower-limb arteriopathy is a serious disease. Its prevalence often underestimated when relying only on questioning the patient. A simple early detection method is the systolic index, i.e. the ratio of systolic ankle over brachial pressure. This ratio should normally be greater than 0.9. Lower values indicate detectable arterial obstruction as revealed by reduced peripheral perfusion. Under 0.75 patients are considered as suffering from peripheral vascular disease and require further investigations and specialist opinion. With an index between 0.75 and 0.90 patients are classified as stage I or II of the disease. In a survey by 180 General Practitioners, which were trained by angiologists to measure ankle pressure, more than 1,400 patients, between 40 and 75-years old, with at least one vascular risk factor (hypertension, diabetes, lipids, tobacco) were selected. Tobacco was the most prevalent vascular risk factor, then diabetes (particularly in men). 23.8% of patients recorded values between 0.90 and 0.75 and thus suffering from peripheral vascular disease (certainly age dependent). Clinically absent pulses at the posterior tibial and the dorsalis pedis artery were found is 19 and 27% of patients respectively. Most of the patients received a pharmacological substance allowing to check this index sensitivity. Thus systolic index is a simple low cost method for early detection and care and more general utilisation is proposed." }, { "id": "wiki20220301en003_10293", "title": "Glucose tolerance test", "score": 0.009259259259259259, "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": "pubmed23n0635_17778", "title": "Accuracy of ankle-brachial index using an automatic blood pressure device to detect peripheral artery disease in preventive medicine.", "score": 0.009259259259259259, "content": "Previously, we validated determination of ankle-brachial index using an automatic blood pressure device. To test the feasibility and accuracy of the automatic method in assessing pathological ankle-brachial indexes in routine preventive examinations. Two physicians enrolled 354 subjects (74% men) randomly for automatic ankle-brachial index measurements using an OMRON HM 722 device. Ankle-brachial index was calculated by dividing the highest value obtained at each ankle by the highest arm value. Each subject with an abnormal (less than 0.90) automatic index and the six subsequent subjects underwent Doppler index determination. Automatic ankle-brachial index determination was possible in both ankles in 350 subjects (99%; mean time 8.1+/-2.1 minutes). The incidence of abnormal automatic ankle-brachial index was 8% (n=28). Correlations between the automatic and Doppler methods were good in left and right legs (r=0.84 and 0.78, respectively; p&lt;0.001). In subjects with an abnormal automatic index, correlations with Doppler indexes were good in both legs (r=0.67, p&lt;0.001). In terms of detecting an abnormal index in a routine preventive examination, the automatic method had good sensitivity (92%), specificity (98%), positive predictive value (86%), negative predictive value (99%) and accuracy (97% compared with the Doppler method). Good results were obtained in subjects with an abnormal index in terms of agreement and concordance with the Doppler method (kappa=0.87). The use of a commercially available automatic blood pressure device to detect peripheral artery disease appears feasible and quick in routine medical examinations." }, { "id": "wiki20220301en180_32350", "title": "Prediabetes", "score": 0.009174311926605505, "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": "pubmed23n0376_16292", "title": "Original articles prognostic value of combined echocardiography and ambulatory blood pressure monitoring in hypertensive patients at low or medium cardiovascular risk.", "score": 0.009174311926605505, "content": "The clinical value of echocardiography and ambulatory blood pressure monitoring (ABPM) in hypertensive patients at low immediate risk of cardiovascular disease is still unknown. Echocardiography and ABPM were performed in 715 untreated subjects with essential hypertension World Health Organization/International Society of Hypertension stage I or II and low or medium cardiovascular risk defined by the absence of diabetes, previous cardiovascular events, left ventricular (LV) hypertrophy at electrocardiography, proteinuria, stages III-IV retinopathy and creatinine levels &gt; 106.08 mmoll (1.2 mg/dl) and the presence of one or two traditional risk factors. The LV mass was increased in 26.5% of these subjects. Subjects with a limited blood pressure reduction from day to night (non-dippers) were 11.3%. Over 1-13 years of follow-up, 31 subjects developed a first major cardiovascular event. The event rate (per 100 person-years) was 0.60 in the subgroup with a normal LV mass vs 1.63 in that with an increased LV mass (p &lt; 0.017), and 0.74 in dippers vs 3.75 in non-dippers (p &lt; 0.001). On multivariate analysis, the relative risk of cardiovascular events was 1.70 (95% confidence interval-CI 1.23-2.36) for each 11 g/m(2.7) increment in LV mass (p &lt; 0.01), and 2.77 (95% CI 1.12-6.83) in non-dippers vs dippers (p &lt; 0.05). Overall, on the basis of results of combined echocardiography and ABPM, 33% of subjects were at increased risk of future cardiovascular events. At standard first-line work-up performed on hypertensive subjects at low or medium cardiovascular risk, combined echocardiography and ABPM identify an increase in the risk of subsequent cardiovascular disease in one third of subjects." }, { "id": "wiki20220301en000_93360", "title": "Cholesterol", "score": 0.00909090909090909, "content": "More current testing methods determine LDL (\"bad\") and HDL (\"good\") cholesterol separately, allowing cholesterol analysis to be more nuanced. The desirable LDL level is considered to be less than 100 mg/dL (2.6 mmol/L), although a newer upper limit of 70 mg/dL (1.8 mmol/L) can be considered in higher-risk individuals based on some of the above-mentioned trials. A ratio of total cholesterol to HDL—another useful measure—of far less than 5:1 is thought to be healthier. Total cholesterol is defined as the sum of HDL, LDL, and VLDL. Usually, only the total, HDL, and triglycerides are measured. For cost reasons, the VLDL is usually estimated as one-fifth of the triglycerides and the LDL is estimated using the Friedewald formula (or a variant): estimated LDL = [total cholesterol] − [total HDL] − [estimated VLDL]. Direct LDL measures are used when triglycerides exceed 400 mg/dL. The estimated VLDL and LDL have more error when triglycerides are above 400 mg/dL." }, { "id": "pubmed23n0254_14021", "title": "Heart rate-corrected ankle-to-arm index in the diagnosis of moderate lower extremity arterial disease.", "score": 0.00909090909090909, "content": "Although the ratio of ankle-to-arm systolic pressures (AAI) at rest is widely used in the clinical diagnosis of peripheral arterial disease, the heart rate (HR) at which the measurements are performed is rarely reported. The relation of ankle-to-arm index (AAI) to HR was studied in a normal population (n = 65) and in a population of patients (n = 101) suspected of moderate lower extremity arterial disease (LEAD). In the normal population, a significant inverse correlation was found between AAI and HR at rest: AAI = -0.277 x HR/100 + 1.303; r = -0.52, P &lt; 0.001. In the second population suspected of LEAD, the authors recorded AAI and HR at rest on both legs; 80 normal legs, 110 diseased legs. Thereafter, with normal limits as superior to 0.8, 0.9, and 0.95, sensitivity was respectively 16, 39, and 46%, and specificity was 100, 100, and 98%. In defining normal limit as superior to -2 standard deviations of the AAI-HR relation found in the normal population, sensitivity and specificity were 57 and 100%, respectively. In screening for LEAD in the general population with the use of AAI at rest, the authors suggest that the heart rate at which arterial pressure measurements are performed should be reported." }, { "id": "wiki20220301en416_22141", "title": "Diabetes", "score": 0.009009009009009009, "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": "pubmed23n0804_7029", "title": "[Evaluation of peripheral neuropathy in the patients with type 2 diabetes mellitus by laboratory examination: relationship between albuminuria and ankle-brachial index].", "score": 0.009009009009009009, "content": "The aim of this study was to investigate the influence of peripheral neuropathy on laboratory examinations and to evaluate the relationship between nerve conduction velocity (NCV), albuminuria, and ankle-brachial index (ABI) results in patients with type 2 diabetes mellitus (DM). One hundred twenty-six patients with type 2 DM who had undertaken the nerve conduction study for an initial screening test of diabetic complications were included in our study. We divided patients to 4 groups according to the stage of microalbuminuria and ABI results. Two factors negative (2FN) group (n = 75), urinary albumin creatinine ratio (A/C) &lt; 30 mg/gCr and ABI &gt; or = 1.0; A/C group (n = 25), A/C &gt; or = 30 mg/gCr and ABI &gt; or = 1.0; ABI group (n = 14), A/C &lt; 30 mg/gCr and ABI &lt; 1.0; two factors positive (2FP) group (n = 12), A/C &gt; or = 30 mg/gCr and ABI &lt; 1.0. Neuropathy, retinopathy, hypertension, macroangiopathy, and hyperlipidemia were seen in 57.9%, 38.1%, 59.5%, 22.2%, and 56.3%, respectively. Lower leg NCV in 2FP group was significantly lower than other groups. Our study indicated that impaired diabetic peripheral neuropathy may be detected by combining decreased ABI with increased A/C results." }, { "id": "wiki20220301en025_59749", "title": "Gestational diabetes", "score": 0.008928571428571428, "content": "An early age of onset or long-standing disease comes with greater risks, hence the first three subtypes. Two other sets of criteria are available for diagnosis of gestational diabetes, both based on blood-sugar levels. Criteria for diagnosis of gestational diabetes, using the 100 gram Glucose Tolerance Test, according to Carpenter and Coustan: Fasting 95 mg/dl 1 hour 180 mg/dl 2 hours 155 mg/dl 3 hours 140 mg/dl Criteria for diagnosis of gestational diabetes according to National Diabetes Data Group: Fasting 105 mg/dl 1 hour 190 mg/dl 2 hours 165 mg/dl 3 hours 145 mg/dl" }, { "id": "pubmed23n0895_10374", "title": "Association of simultaneously measured four-limb blood pressures with cardiovascular function: a cross-sectional study.", "score": 0.008928571428571428, "content": "Simultaneous measurement of four-limb blood pressures can improve the accuracy of cardiovascular disease diagnosis. This study aims to investigate the association of simultaneously measured four-limb blood pressures with cardiovascular function as the non-invasive diagnostic method of cardiovascular disease in primary care. 229 subjects (62 males, mean age, 63.50 ± 11.13 years; 167 females, mean age, 59.47 ± 7.33 years) were enrolled. Four-limb blood pressure measurements were simultaneously performed using a blood pressure and pulse monitor device in the supine position. Cardiac functional parameters were also measured by using a cardiac hemodynamic detector in the same position. Data were statistically analyzed with SPSS15.0. The mean age of the 229 subjects was 60.56 ± 8.68 years. Cardiovascular functional parameters decreased with age and body mass index (BMI), only the total peripheral resistance (TPR) was in contrast. Age, BMI, left ankle diastolic pressure (LADP), high arm mean arterial pressure (HARMAP), left arm diastolic pressure (LARDP) and right ankle diastolic pressure (RADP) were significantly correlated with cardiovascular functional parameters. Cardiovascular functional parameters have significant differences with inter-arm difference in systolic blood pressure (SBP) between ≥10 and &lt;10 mmHg, inter-ankle difference in SBP between ≥15 and ≥20 mmHg, inter-ankle difference in SBP between ≥15 and &lt;10 mmHg and right ankle brachial index (RABI) between ≤0.9 and ≥1.0. After excluding 99 hypertensive patients, a part of cardiovascular functional parameters has still significant differences with inter-arm difference in SBP between ≥10 and ≥15 mmHg and RABI between ≤0.9 and ≥1.0. Age, BMI, LADP, HARMAP, LARDP and RADP were the determinants of cardiovascular functional parameters. In addition, a part of cardiovascular functional parameter is associated with inter-arm difference in SBP ≥10 mmHg, inter-ankle difference in SBP ≥15 mmHg and RABI ≤0.9, while these differences still existed after excluding 99 hypertensive patients. Hence, simultaneous measurement of four-limb blood pressures has become feasible and useful approach to the non-invasive diagnostic method of cardiovascular disease in primary care." }, { "id": "wiki20220301en008_126419", "title": "Type 2 diabetes", "score": 0.008849557522123894, "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": "pubmed23n1081_11680", "title": "The risk of micro and macrovascular disease in Egyptian patients with diabetes and peripheral arterial disease.", "score": 0.008849557522123894, "content": "<bAim</b: The aim of this study was to assess the prevalence of micro- and macrovascular disease in Egyptian patients with diabetes mellitus (DM) and peripheral arterial disease (PAD). <bMethods</b: The study included 161 Egyptian patients with DM and PAD (91.3% had type 2 DM and 67.1% were females). Mean diabetes duration was 14.2 ± 5.2 years. Full history, clinical and fundus examination as well as laboratory investigations were done. PAD was diagnosed through assessment of ankle/brachial index (ABI) by Doppler ultrasonography. <bResults</b: ABI was &lt;0.9 in 33.5% and &gt;1.3 in 66.5% of patients. A significant positive correlation was found between abnormal ABI and diabetes duration, ischemic heart disease (IHD), diabetic retinopathy and neuropathy, foot ulcers, elevated blood pressure (BP), creatinine, urine albumin/creatinine ratio (ACR) and triglycerides and a significant negative correlation with HDL. Multivariate regression analysis revealed that the independent predictors for PAD in patients with ABI&lt; 0.9 were neuropathy, creatinine, triglyceride, LDL, urine ACR and low HDL, and in patients with ABI &gt;1.3 were IHD, neuropathy, elevated diastolic BP and triglyceride. <bConclusion</b: The risk of micro- and macrovascular disease is high in Egyptian patients with diabetes and PAD. Early diagnosis and good control of risk factors could reduce PAD progression." }, { "id": "wiki20220301en013_79143", "title": "Blood sugar level", "score": 0.008771929824561403, "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": "pubmed23n0506_6930", "title": "[Prevalence of micro and macroangiopatic chronic complications and their risk factors in the care of out patients with type 2 diabetes mellitus].", "score": 0.008771929824561403, "content": "Type 2 diabetes (DM2) has been related to the development of macroangiopatic [coronary heart disease (CHD), peripheral vascular disease (PVD) and stroke] and microangiopatic [retinopathy, nephropathy, and distal sensory neuropathy (DSN)] complications. The aims of this study were to analyze prevalence of complications in DM2 patients and to estimate their associated risk factors. Cross-sectional study, including 927 out patients with DM2 from three medical centers in Rio Grande do Sul: Hospital de Clinicas de Porto Alegre (n = 475), Grupo Hospitalar Conceicao (n = 229) and Hospital Sao Vicente de Paula (n = 223). Of the patients 42% were male, mean age was 59 +/- 10 years and the median known duration of DM2 was 11 (5-43) years. Retinopathy was identified by direct fundoscopy; CHD by WHO questionnaire and/or abnormal ECG and/or perfusion abnormalities on myocardial scintigraphy; DSN by compatible symptoms and absent sensation on 10 g monofilament and/or tune fork; PVD by the presence of claudication and absent foot pulses; stroke by presence of sequels and history; and nephropathy by the urinary albumin excretion rate (&gt;20 microg/min). Hypertension was defined by blood pressure (&gt;140/90 mmHg) and/or use of antihypertensive drugs. Body mass index (BMI, kg/m2) and waist-to-hip ratio (WHR) were calculated. CHD was present in 36% and PVD in 33% of the patients. Among the microvascular, 37% had nephropathy (12% with macroalbuminuria); 48% retinopathy (15% proliferative retinopathy). DSN was present in 36%. Seventy three percent of the patients presented arterial hypertension. Cholesterol levels were &gt;200 mg/dl in 64% and BMI &gt; 30 kg/m2 in 36%. Twenty two percent of patients were smokers and 21% ex-smokers. Diabetic complications are frequent among out patients referring to general hospitals. Almost all patients presented at least one risk factor for cardiovascular disease, justifying the efforts for identification and adequate control." }, { "id": "wiki20220301en002_174485", "title": "Metabolic syndrome", "score": 0.008695652173913044, "content": "American Heart Association There is confusion as to whether, in 2004, the American Heart Association and National Heart, Lung, and Blood Institute intended to create another set of guidelines or simply update the National Cholesterol Education Program definition. Central obesity: waist circumference ≥ 102 cm or 40 inches (male), ≥ 88 cm or 35 inches(female) Dyslipidemia: TG ≥ 1.7 mmol/L (150 mg/dL) Dyslipidemia: HDL-C < 40 mg/dL (male), < 50 mg/dL (female) Blood pressure ≥ 130/85 mmHg (or treated for hypertension) Fasting plasma glucose ≥ 5.6 mmol/L (100 mg/dL), or use of medication for hyperglycemia" }, { "id": "pubmed23n0886_24038", "title": "High Systolic and Diastolic Blood Pressure Variability Is Correlated with the Occurrence of Peripheral Arterial Disease in the First Decade following a Diagnosis of Type 2 Diabetes Mellitus: A New Biomarker from Old Measurement.", "score": 0.008695652173913044, "content": "<iBackground</i. To assess whether the visit-to-visit variability in blood pressure (BP) is a risk factor of peripheral arterial disease (PAD) in patients with type 2 diabetes mellitus (T2DM) 10 years after diagnosis. <iMethods</i. The electronic medical records of 825 patients, who were diagnosed with type 2 diabetes mellitus (T2DM) during 2000-2002 and regularly followed for 10 years, were retrospectively reviewed. A total of 53,284 clinic visit records, including analysis of BP, BMI, serum glycohemoglobin, and lipid profile, were analyzed. <iResults</i. Patients were categorized into two groups according to their visit-to-visit variability in systolic and diastolic BP (SBP and DBP, resp.). The high-risk group included patients with high SBP and DBP visit-to-visit variability; this group had a 1.679-fold (95% CI: 1.141-2.472, <iP</i = 0.009) increased risk of PAD compared with patients in the low-risk group. Cox regression analysis also demonstrated that the age at which the patients were diagnosed with T2DM, smoking status, and mean creatinine level was significantly associated with increased risk of PAD with a hazard ration of 1.064 (95% CI: 1.043-1.084, <iP</i &lt; 0.001), 1.803 (95% CI: 1.160-2.804, <iP</i = 0.009), and 1.208 (95% CI: 1.042-1.401, <iP</i = 0.012), respectively. <iConclusions</i. High SBP and DBP visit-to-visit variability is correlated with PAD in the first decade following a diagnosis of T2DM." }, { "id": "wiki20220301en013_91208", "title": "Multiple myeloma", "score": 0.008620689655172414, "content": "Signs and symptoms Because many organs can be affected by myeloma, the symptoms and signs vary greatly. Fatigue and bone pain are the most common symptoms at presentation. The CRAB criteria encompass the most common signs of multiple myeloma: Calcium: serum calcium >0.25 mmol/l (>1 mg/dl) higher than the upper limit of normal or >2.75 mmol/l (>11 mg/dl) Renal insufficiency: creatinine clearance <40 ml per minute or serum creatinine >1.77 mol/l (>2 mg/dl) Anemia: hemoglobin value of >2g/dl below the lowest limit of normal, or a hemoglobin value <10g/dl Bone lesions: osteolytic lesions on skeletal radiography, CT, or PET/CT Bone pain" }, { "id": "pubmed23n0790_18567", "title": "High efficient and cost-effective screening method for diabetic cardiovascular risk.", "score": 0.008620689655172414, "content": "The vascular complications of outpatients with diabetes at ordinary hospitals vary. Ischemic heart disease is barely predictable after treatment using previously reported therapeutic indices. We developed a simple and noninvasive screening method to evaluate the possibility of ischemic heart disease in patients with diabetes. Five years of clinical data from 337 outpatients (196 males and 141 females) with diabetes were analyzed. Twenty-three males and 14 females had ischemic heart disease. We examined the possibility of predicting ischemic heart disease after analyzing this population. The analyzed laboratory data included the following: minimum value of right or left ankle-brachial indices (ABI), maximum value of right or left pulse wave velocities (PWV), aortic calcification diagnosed on plain chest radiographs, plaque score (PS), maximum value of intima media thickness at the cervical artery (IMT), electrocardiographic (ECG) ischemic changes (including ST-T changes or abnormal Q waves, which were re-examined by a cardiologist), HbA1c, low-density lipoprotein cholesterol (LDL-C), uric acid (UA), urine albumin, age, sex, disease duration, and body mass index. All data were subjected to multivariate logistic regression analyses. The presence of ECG ischemic changes, aortic calcification, minimum ABI, maximum IMT, LDL-C, and UA were evaluated in multivariate logistic regression analysis with the onset of ischemic heart disease. The receiver operating characteristic curve indicated an area under the curve of 0.879 (0.820 - 0.938; P = 0.00). Ischemic heart disease could be predicted in patients with diabetes using a combination of results from conventional physical and laboratory tests." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 29, 177 ] ], "word_ranges": [ [ 4, 24 ] ], "text": "In splenectomized patients, the risk of acquiring serious infections by encapsulated germs is increased, again Pneumococcus being the most frequent." }, "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": "Streptococcus pneumoniae.", "2": "Pseudomonas aeruginosa.", "3": "Salmonella no typhi.", "4": "Pneumocystis jirovecii.", "5": "Streptococcus viridans." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en042_60103", "title": "List of clinically important bacteria", "score": 0.012647898816809465, "content": "S Salmonella Salmonella enteritidis Salmonella typhi Salmonella typhimurium Serratia marcescens Shigella dysenteriae Spirillum volutans Staphylococcus Staphylococcus aureus Staphylococcus epidermidis Stenotrophomonas maltophilia Streptococcus Streptococcus agalactiae Streptococcus avium Streptococcus bovis Streptococcus cricetus Streptococcus faceium Streptococcus faecalis Streptococcus ferus Streptococcus gallinarum Streptococcus lactis Streptococcus mitior Streptococcus mitis Streptococcus mutans Streptococcus oralis Streptococcus pneumoniae Streptococcus pyogenes Streptococcus rattus Streptococcus salivarius Streptococcus sanguis Streptococcus sobrinus T Treponema U Ureaplasma urealyticum V VibrioVibrio choleraeVibrio commaVibrio parahaemolyticusVibrio vulnificusWWolbachia Y YersiniaYersinia enterocoliticaYersinia pestisYersinia pseudotuberculosis'' See also List of bacterial orders List of bacteria genera List of human diseases associated with infectious pathogens" }, { "id": "wiki20220301en031_48014", "title": "Overwhelming post-splenectomy infection", "score": 0.012567656765676567, "content": "Patients without a spleen often need immunizations against pathogens that normally require opsonization and phagocytosis by macrophages in the spleen. These include common human pathogens with bacterial capsules (Streptococcus pneumoniae, Salmonella typhi, Neisseria meningitidis, E. coli, Hemophilus influenzae, Streptococcus agalactiae, Klebsiella pneumoniae, Pseudomonas aeruginosa ). Capsules made of polysaccharides (sugars) permit bacteria to evade phagocytosis by macrophages alone, since only proteins are directly recognized by macrophages in phagocytosis. So humoral immunity in forms of IgG and complement proteins is the human immune system's response against bacterial capsules. Prevention Measures to prevent OPSI include vaccination, prophylactic antibiotics and patient education." }, { "id": "InternalMed_Harrison_9732", "title": "InternalMed_Harrison", "score": 0.0125449575600633, "content": "Overwhelming Infection in Asplenic Patients (See also Chap. 325) Patients without splenic function are at risk for overwhelming bacterial sepsis. Asplenic adult patients succumb to sepsis at 58 times the rate of the general population. Most infections are thought to occur within the first 2 years after splenectomy, with a mortality rate of ~50%, but the increased risk persists throughout life. In asplenia, encapsulated bacteria cause the majority of infections. Adults, who are more likely to have antibody to these organisms, are at lower risk than children. Streptococcus pneumoniae is the most common isolate, causing 50–70% of cases, but the risk of infection with Haemophilus influenzae or Neisseria meningitidis is also high. Severe clinical manifestations of infections due to E. coli, S. aureus, group B streptococci, P. aeruginosa, Bordetella holmesii, and Capnocytophaga, Babesia, and Plasmodium species have been described." }, { "id": "InternalMed_Harrison_4616", "title": "InternalMed_Harrison", "score": 0.0124716841864135, "content": "The most serious consequence of splenectomy is increased susceptibility to bacterial infections, particularly those with capsules such as Streptococcus pneumoniae, Haemophilus influenzae, and some gram-negative enteric organisms. Patients under age 20 years are particularly susceptible to overwhelming sepsis with S. pneumoniae, and the overall actuarial risk of sepsis in patients who have had their spleens removed is about 7% in 10 years. The case–fatality rate for pneumococcal sepsis in splenectomized patients is 50–80%. About 25% of patients without spleens will develop a serious infection at some time in their life. The frequency is highest within the first 3 years after splenectomy. About 15% of the infections are polymicrobial, and lung, skin, and blood are the most common sites. No increased risk of viral infection has been noted in patients who have no spleen. The susceptibility to bacterial infections relates to the inability to remove opsonized bacteria from the bloodstream" }, { "id": "wiki20220301en001_64750", "title": "Human pathogen", "score": 0.01154960883871952, "content": "Bacterial Although the vast majority of bacteria are harmless or beneficial to one's body, a few pathogenic bacteria can cause infectious diseases. The most common bacterial disease is tuberculosis, caused by the bacterium Mycobacterium tuberculosis, which affects about 2 million people mostly in sub-Saharan Africa. Pathogenic bacteria contribute to other globally important diseases, such as pneumonia, which can be caused by bacteria such as Streptococcus and Pseudomonas, and foodborne illnesses, which can be caused by bacteria such as Shigella, Campylobacter, and Salmonella. Pathogenic bacteria also cause infections such as tetanus, typhoid fever, diphtheria, syphilis, and Hansen's disease. They typically range between 1 and 5 micrometers in length. Fungal" }, { "id": "article-21991_11", "title": "Functional Asplenism -- Complications -- Overwhelming Post-Splenectomy Infection (OPSI)", "score": 0.011129272631123503, "content": "OPSI is a syndrome that is encountered in post-splenectomy, hyposplenic and functional asplenic patients. Bacteremia caused by encapsulated microorganisms characterize the syndrome. The syndrome might present without a visible primary source of infection, and with a short prodromal phase, Clinical presentations include septic shock, disseminated intravascular coagulopathy, and bilateral adrenal hemorrhage. OPSI is a medical emergency and administration of antibiotics should be administered promptly along with supportive measures. Hyposplenic patients might already be on prophylactic antibiotics, and hence, cultures might be negative; however, antibiotic therapy should continue. Empiric parental antibiotic therapy should include vancomycin and either cefotaxime or ceftriaxone. Although the efficacy of intravenous immunoglobulin  (IVIg) treatment for asplenic sepsis has not been proven, some experts recommend its administration in this situation. The morbidity of OPSI is high, and death may result in 24 to 48 hours, with mortality rates of 50% to 70%. This syndrome has been observed up to 10 to 30 years post-diagnosis with hyposplenism. Some series indicate that the risk of OPSI decreases with the time elapsed since splenectomy, while other studies do not show a significant reduction. The most commonly reported pathogen in OPSI is Streptococcus pneumoniae." }, { "id": "pubmed23n0124_14347", "title": "Meningitis and septicaemia in adults splenectomized for Hodgkin's disease.", "score": 0.010845736702434522, "content": "Splenectomized and asplenic persons are at risk of developing sudden episodes of meningitis and/or septicaemia, frequently due to Streptococcus pneumoniae (overwhelming postsplenectomy infection, or OPSI). The application of staging splenectomy to patients with Hodgkin's disease (HD) generated a new population at risk for OPSI. We reviewed the cases of sudden meningitis and/or septicaemia in a series of 491 consecutive adults with HD. No case was recorded among 149 non-splenectomized patients. 6 episodes of OPSI were observed in 5 of 342 splenectomized patients (crude frequency 1.75%, actuarial frequency at 10 yr 3.87%). The infecting organisms were Streptococcus pneumoniae (5 cases) and Salmonella enteritidis (1 case). 2 episodes (1 fatal) occurred during first complete remission (CR), 15 and 120 months, respectively, after splenectomy, 4 episodes (2 fatal) occurred after first relapse. For splenectomized patients in continuous CR, the cumulative risk of OPSI was 2.30% (95% CL 0-6.10%), and it was 15.25% (95% CL 0-35.37%) for splenectomized patients who had relapsed. These data suggest that, in adults with HD, the risk of OPSI should not limit the indication to staging splenectomy and does not warrant systematic prophylaxis. However, in splenectomized relapsed patients, OPSI can be a troublesome complication and appropriate prophylaxis could be useful." }, { "id": "pubmed23n0716_11286", "title": "[Epidemiology and clinical features in diabetic patients with invasive infections treated at the Clinical Hospital of Infectious Diseases of Iaşi, Romania, between 2008-2010].", "score": 0.010840188014101058, "content": "Infections in the diabetic population can be severe and life threatning at least for two reasons: clinical signs are often torpid, masqued by chronical complications of diabetes leading to late recognition and medical adresability and also because of the inability to control established infection due to complex cell-mediated and humoral immunity deffects. The aim of the study was to evaluate the etiology, clinical features and outcome in diabetic patients with invazive disease. A retrospective study was conducted between January 2008 and December 2010 at The Clinical Hospital of Infectious Diseases Iaşi among 75 diabetic patients with sepsis of microbiologically confirmed etiology (positive cultures from normally sterile sites) and sepsis with clinically suspected etiology (positive cultures from pus). Cases with positive urocultures and coprocultures only, were excluded. From 75 diabetics, 56% were males, 90,7% being over 50 years. Severe cases of sepsis (33/75, 44%) were associated more often with insulin-treated diabetes than non-insulin treated group (40% vs. 4%, p&lt;0,005) probably because of multiple comorbidities associated as suggested by a high Charlson score (6,09 vs. 4,09, p&lt;0,05). There were 64 cases with confirmed etiology and 11 cases with clinically suspected etiology. Staphylococcus aureus and Escherichia coli were the most common agents isolated, being involved in 16 (21,3%) cases each, followed by coagulase negative Staphylococci (14/18,66%), Enterococcus spp.(6/8%), group B Streptococcus (3/4%), Streptococcus pneumoniae, Enterobacter spp., Salmonella spp. (2/2,66% each), Aerococcus viridans, Streptococcus equi, Klebsiella pneumoniae, Neisseria meningitidis, Sphyngomonas paucimobilis, Pseudomonas aeruginosa, Proteus mirabilis (1/1,33%). Multiple septic disseminations occured in 17(22,6%) cases and meningeal involvment was doccumented in 10(15,6%) cases. Meticillin resistance was noted in 53,3% for invasive isolates of S. aureus. Among 16 invazive strains of E. coli, 25% were resistant to 3rd generation cephalosporins, 17% to ciprofloxacin and 6,6% to aminoglycosides and colimycin. There were no E. coli strains resistant to imipenem, piperacillin-tazobactam and aztreonam. The mean mortality rate was 14,66%. The high level of resistance of S. aureus and E. coli to commonly used antibiotics and meningeal involvement imposes a multidisciplinary approach of the diabetic patient. Proper knowledge of the pathogers involved in the potential invazive diseases is an important tool for successful treatment with appropriate empirical broad-spectrum antimicrobial agents." }, { "id": "pubmed23n0313_4914", "title": "Overwhelming postsplenectomy infection with vaccine-type Streptococcus pneumoniae in a 12-year-old girl despite vaccination and antibiotic prophylaxis.", "score": 0.010082047003198442, "content": "This report describes a 12-year-old girl who developed vaccine-type pneumococcal septicemia (type 4, Danish nomenclature) 2 years after splenectomy for recurrent idiopathic thrombocytopenia despite vaccination with the 23-valent vaccine 4 weeks before surgery and antibiotic prophylaxis with penicillin V. The disease presented as high fever with shivering and vomiting followed by disseminated petechiae and a deteriorated general condition. Initial laboratory studies showed severe sepsis with leucocytopenia and thrombocytopenia, a markedly elevated CRP, and disseminated intravascular coagulation. Despite antibiotic treatment, which was initiated with clindamycin, cefotaxime and trimethoprim/sulfamethoxazole and was switched to cefotaxime and penicillin after the result of the blood culture had been obtained, the patient had to be ventilated, and hemofiltration became necessary because of acute renal insufficiency. Furthermore, she required amputation of all her toes because of severe necrosis. No type-specific pneumococcal antibody titers were detected during and after infection. It remains unclear whether the susceptibility to Streptococcus pneumoniae was due to primary failure of antibody production or a decline in antibody levels after vaccination. Patients and/or their relatives should be informed that neither vaccination nor continuous antibiotic prophylaxis can guarantee full protection against infection with S. pneumoniae in patients after splenectomy." }, { "id": "wiki20220301en032_76383", "title": "Splenomegaly", "score": 0.010055365575639148, "content": "Diagnosis Abdominal CT is the most accurate and spleen need to be larger 2-3 times to be palpable below the costal margin in physical examination that can help in diagnosis. Treatment If the splenomegaly underlies hypersplenism, a splenectomy is indicated and will correct the hypersplenism. However, the underlying cause of the hypersplenism will most likely remain; consequently, a thorough diagnostic workup is still indicated, as, leukemia, lymphoma and other serious disorders can cause hypersplenism and splenomegaly. After splenectomy, however, patients have an increased risk for infectious diseases. Patients undergoing splenectomy should be vaccinated against Haemophilus influenzae, Streptococcus pneumoniae, and Meningococcus. They should also receive annual influenza vaccinations. Long-term prophylactic antibiotics may be given in certain cases." }, { "id": "article-27365_3", "title": "Pediatric Pneumonia -- Etiology", "score": 0.00989786073127724, "content": "The etiology of pneumonia in the pediatric population can be classified by age-specific versus pathogen-specific organisms. [3] Neonates are at risk for bacterial pathogens present in the birth canal, and this includes organisms such as group B streptococci, Klebsiella, Escherichia coli, and Listeria monocytogenes . [4] [5] [6] Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus can be identified in late-onset neonatal pneumonia. [4] Viruses are the main cause of pneumonia in older infants and toddlers between 30 days and 2 years old. [7] In children 2 to 5 years old, respiratory viruses are also the most common. [8] [9] The rise of cases related to S. pneumoniae and H. influenzae type B is observed in this age group. [10] [11] Mycoplasma pneumonia frequently occurs in children in the range from 5 to 13 years old [12] [13] ; however, S. pneumoniae is still the most commonly identified organism. [8] Adolescents usually have the same infectious risks as adults. It is important to consider tuberculosis (TB) in immigrants from high prevalence areas, and children with known exposures. Children with chronic diseases are also at risk for specific pathogens. In cystic fibrosis, pneumonia secondary to S. aureus and Pseudomonas aeruginosa is ubiquitous. [14] Patients with sickle cell disease are at risk of infection from encapsulated organisms. [15] Children who are immunocompromised should be evaluated for Pneumocystis jirovecii , cytomegalovirus, and fungal species if no other organism is identified. [16] Unvaccinated children are at risk for vaccine-preventable pathogens." }, { "id": "wiki20220301en032_27078", "title": "Trimethoprim/sulfamethoxazole", "score": 0.00980392156862745, "content": "Proteus vulgaris Providencia rettgeri Providencia stuartii Salmonella typhi (typhoid fever) Non-typhi Salmonella Serratia spp. Shigella spp. Staphylococcus aureus Staphylococcus epidermidis Staphylococcus saprophyticus Stenotrophomonas maltophilia Streptococcus agalactiae Streptococcus pneumoniae Streptococcus pyogenes Streptococcus viridans Toxoplasma gondii (toxoplasmosis) Tropheryma whippelii (Whipple's disease) Vibrio cholerae (cholera) Yersinia enterocolitica Yersinia pestis (bubonic plague) Yersinia pseudotuberculosis" }, { "id": "pubmed23n0243_9925", "title": "[Fulminant pneumococcal septicemia in splenectomized patients].", "score": 0.00980392156862745, "content": "Four cases of fulminant pneumococcal septicemia in splenectomized patients are reported. Three had undergone splenectomy for trauma 42, 28 and 14 years prior to the septicemia. The fourth had been splenectomized for suspected lymphoma 3 years earlier. In 3 out of 4 patients the symptomatology was so rapidly progressive that a physician was consulted within 12 hours. Two patients hospitalized after a second consultation and 20 hours after the first symptoms had evidence of septic shock, disseminated intravascular coagulation and hypoglycemia, and died within a few hours despite early antibiotherapy. Diplococci were seen in peripheral smears of these 2 patients and in the buffy coat of the 3 cases in which this was carried out. These four cases reemphasize the fact that during their entire life splenectomized patients are at risk for development of overwhelming septicemia even when the splenectomy was performed because of trauma. Therefore, such patients should be aware of this risk, should be treated promptly with antibiotics in the event of a febrile episode, and should be vaccinated against pneumococci and possibly other encapsulated bacteria such as Haemophilus influenzae and Neisseria meningitidis." }, { "id": "wiki20220301en343_15149", "title": "Classification of pneumonia", "score": 0.009708737864077669, "content": "Opportunistic pneumonia People with weakened immune defense, such as HIV/AIDS patients, are highly susceptible to opportunistic infections affecting the lungs. Most common pathogens are Pneumocystis jiroveci, Mycobacterium avium-intracellulare complex, Streptococcus pneumoniae, Haemophilus species. Less frequent pathogens are Cryptococcus neoformans, Histoplasma capsulatum, Coccidioides immitis, cytomegalovirus (CMV), and Toxoplasma gondii. Chemotherapy-induced immunodeficiency may lead to severe lung infections. Pathogens commonly associated with lung infectioins are bacteria (like Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and Nocardia species), viruses (eg, respiratory syncytial virus, parainfluenza virus, influenza virus A and influenza B, and cytomegalovirus), and fungi (eg, Aspergillus, Fusarium, and Mucorales species, and Pneumocystis jirovecii)." }, { "id": "pubmed23n0244_4289", "title": "[Changes in infectious endocarditis in 3 decades].", "score": 0.009708737864077669, "content": "The course, clinical picture and outcome were compared in 101 patients with infective endocarditis (1975-79, phase III) with our earlier investigations 1947-57 (phase I) and 1961-74 (phase II). An impressive change in this disease was found: - The average age of the patients is higher. - Acute cases and postoperative courses (after valve replacement) are more common and the outcome in these cases is better. Subacute courses are on the decrease. The clinical picture often is oligosymptomatic: - Fever is absent in a quarter, cardiac murmur in nearly a fifth and splenomegaly in four fifths of the patients. - For the first time 5 patients with right-heart endocarditis were observed in phase III. Three of these patients were intravenous drug abusers. The initial clinical picture was misinterpreted as pneumonia or pulmonary embolism. - The most common infective agents were streptococci, followed by staphylococci. The portion of negative blood cultures was strikingly high (35%). - Despite the higher frequency of acute courses, mortality has decreased. Urgent cardiac valve replacement, which has been performed in a fifth of our patients, can prevent irreversible congestive heart failure." }, { "id": "wiki20220301en056_70172", "title": "Pine oil", "score": 0.009615384615384616, "content": "Properties as a disinfectant Pine oil is a disinfectant that is mildly antiseptic. It is effective against Brevibacterium ammoniagenes, the fungi Candida albicans, Enterobacter aerogenes, Escherichia coli, Gram-negative enteric bacteria, household germs, Gram-negative household germs such as those causing salmonellosis, herpes simplex types 1 and 2, influenza type A, influenza virus type A/Brazil, influenza virus type A2/Japan, intestinal bacteria, Klebsiella pneumoniae, odor-causing bacteria, mold, mildew, Pseudomonas aeruginosa, Salmonella choleraesuis, Salmonella typhi, Salmonella typhosa, Serratia marcescens, Shigella sonnei, Staphylococcus aureus, Streptococcus faecalis, Streptococcus pyogenes, and Trichophyton mentagrophytes." }, { "id": "pubmed23n0523_13419", "title": "[Abscess of the spleen].", "score": 0.009615384615384616, "content": "Splenic abscess is a rare disease but with increasing frequency. The authors present 9 patients with splenic abscess treated at the Institute of Digestive System Diseases, Clinical Centre of Serbia, in a period from January 1, 1986 to May 15, 2004. Splenic abscess was the complication of septic endocarditis in 4, trauma in 2, dental infection in 1, while in 2 cases it was the complication of chemotherapy in myeloproliferative disorders. All 9 patients had fever, 7 - abdominal pain, 4 - left shoulder pain, and 1 patient had nausea and vomiting. Higher white blood count was found in 6 patients, pleural effusion in 4, elevated left hemidiaphragm in 1 and basal pneumonia in 1 patient as well. Ultrasonography and CT were the most reliable diagnostic procedures. CT was superior in diagnosis of multiple small abscesses. Culture of the pus recovered the Enterococcus in 3 cases, Streptococcus a hemolyticus in 1, Staphylococcus epidermidis and Candida albicans in 1, Staphylococcus aureus, E. Coil and Candida albicans in 1, Staphylococcus aureus i Salmonella enteritidis in 1 case. Eight patients underwent splenectomy and 1 was cured by combined antibiotics in high doses. One patient died postoperatively due to septic endocarditis that had been present before surgery. The authors believe that splenectomy and antibiotics administered according to drug susceptibility test as well as management of underlying disease are the method of choice for splenic abscess treatment. Conservative antibiotic treatment is indicated in selected cases only." }, { "id": "article-27349_19", "title": "Pneumocystis jirovecii Prophylaxis -- Differential Diagnosis", "score": 0.009600389863547758, "content": "Due to their poor immune response, patients with HIV and those with immunosuppression for other causes, such as malignancy, autoimmune disease, or iatrogenic due to underlying condition or organ transplant patients, require prophylaxis for numerous pathogens. These pathogens include: Aspergillus species Candida albicans Clostridium difficile Coccidioides immitis Cryptococcus neoformans Cytomegalovirus Histoplasma capsulatum Legionella pneumophila Microsporidium Mycobacterium avium complex Mycobacterium tuberculosis Pseudomonas aeruginosa Salmonella Staphylococcus aureus Streptococcus pneumoniae Streptococcus pyogenes Toxoplasma gondii [2] [3] [5]" }, { "id": "Surgery_Schwartz_10090", "title": "Surgery_Schwartz", "score": 0.009562245491564862, "content": "Clinical manifestations include fever, left upper quadrant pain, leukocytosis, and splenomegaly in about one-third of patients. The diagnosis is confirmed by ultrasound or CT scan, which has a 95% sensitivity and specificity. Common organ-isms are aerobic microbes (streptococci and Escherichia coli), but other microorganisms have also been isolated (Mycobac-terium tuberculosis and Salmonella typhi). Upon discovery of a splenic abscess, broad-spectrum antibiotics should be initi-ated, with adjustment to more specific therapy based on culture results and continuation of treatment for a minimum of 14 days. Splenectomy is the operation of choice, but percutaneous and open drainage are options for patients who either cannot toler-ate splenectomy or where the clinical scenario warrants splenic preservation, particularly in children.90 Percutaneous drainage is often successful for patients with unilocular disease and may result in avoidance of splenectomy. Patients with multilocular disease" }, { "id": "wiki20220301en238_27556", "title": "Pus", "score": 0.009523809523809525, "content": "Some disease processes caused by pyogenic infections are impetigo, osteomyelitis, septic arthritis and necrotizing fasciitis. Pyogenic bacteria A great many species of bacteria may be involved in the production of pus. The most commonly found include: Staphylococcus aureus Staphylococcus epidermidis Streptococcus pyogenes Escherichia coli (Bacillus coli communis) Streptococcus pneumoniae (Fraenkel's pneumococcus) Klebsiella pneumoniae (Friedländer's bacillus) Salmonella typhi (Bacillus typhosus) Pseudomonas aeruginosa Neisseria gonorrhoeae Actinomyces Burkholderia mallei (Glanders bacillus) Mycobacterium tuberculosis (tubercle bacillus) Staphylococcus aureus bacteria is the most common cause of boils. Historical terminology" }, { "id": "wiki20220301en416_13095", "title": "Silane quats", "score": 0.009433962264150943, "content": "Anabaena cylindricia Chlorella Chlorophyta (green) Chrysophyta (brown) Oscillatoria borneti Pleurococcus Protococcus Scenedesmus quadricauda Selenastrum gracile Acinetobacter calcoaceticus Aeromonas hydrophilia Bacillus cereus Bacillus subtilis Bacillus typhimurium Citrobacter diversus Clostridium perfringens Corynebacterium bovis Corynebacterium diphtheriae Cutibacterium acnes Enterobacter aerogenes Enterobacter agglomerans Enterobacter cloacae Enterococcus Enterococcus faecalis Escherichia coli Klebsiella pneumoniae Klebsiella terrigena MHV-A59 MS2 Virus Mycobacterium tuberculosis Phi6 Proteus mirabilis Proteus vulgaris Pseudomonas aeruginosa Pseudomonas cepacia Salmonella enterica Salmonella typhi Salmonella typhimurium SARS-CoV-2 Serratia liquefaciens Serratia marcescens Stachybotrys chartarum Staphylococcus aureus Staphylococcus epidermidis Streptococcus faecaliis Streptococcus pyrogenes Vancomycin-resistant enterococci Alternaria alternata Aspergillus flavus" }, { "id": "pubmed23n0754_5640", "title": "[Management of infection risk in asplenic patients].", "score": 0.009433962264150943, "content": "Each year in France 6000 to 9000 patients are splenectomised or spleen embolized. As spleen has immunological functions, it contributes to protect against infections. Thus, hypo or asplenia increase the risk of infection, especially the risk of Overwhelming Post-Splenectomy Infection (OPSI). OPSI is a medical emergency, characterized by aspecific symptoms, which may rapidly progress to fulminant infection and death in 50% of cases within 48 h. Encapsulated bacteria as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis are most of the time responsible of these infections in asplenic patients. To prevent OPSI, several measures are essential and must begin before a scheduled surgery or just after an urgent splenectomy. Patients must carry a card. The first proposed prevention measure is to enhance partial surgery when it's possible. Then, the two other measures, antibiotic prophylaxis and vaccination, shall be implemented whatever is the indication of surgery. Postoperative antibiotic prophylaxis by phenoxymethyl-penicillin is prescribed for two years minimum and lifelong prophylaxis should be offered to high risk of pneumococcal infection patients. Pneumococcal, H. influenzae type b and meningococcal vaccination should be administered 2 to 6 weeks before scheduled splenectomy and 2 weeks after urgent surgery. Yearly, patients must receive Influenza vaccination. As an interindividual variation exists in vaccinal response, measurement of serotype-specific antibodies can be used, if available, to individualized risk patients and to organize revaccination. Finally, to prevent OPSI, patient and next-of-kin must be educated about prevention measures and infectious risk to optimize patient's compliance." }, { "id": "pubmed23n0293_23088", "title": "Lung abscess in patients with AIDS.", "score": 0.009345794392523364, "content": "We identified 31 patients with human immunodeficiency virus (HIV) infection and lung abscess. All patients had advanced HIV disease, and the mean CD4 cell count was 17/mm3 (range, 2-50/mm3). Twenty-two patients (71%) had previous opportunistic infections, and 24 (77%) had previous pulmonary infections. Symptoms at the time of presentation included fever (90% of patients), cough (87%), dyspnea (35%), pleuritic chest pain (26%), and hemoptysis (10%). The microbiological etiology was established for 28 patients, and the pathogens recovered were bacteria (65%), Pneumocystis carinii (6%), fungi (3%), and mixed microorganisms (16%). The pathogens included Pseudomonas aeruginosa (11), Streptococcus pneumoniae (6), P. carinii (5), Klebsiella pneumoniae (5), Staphylococcus aureus (4), Aspergillus species (3), viridans streptococcus (2), Haemophilus influenzae (1), Streptococcus milleri (1), Proteus mirabilis (1), and Cryptococcus neoformans (1). Mycobacterium tuberculosis was not isolated; two patients for whom a microbiological etiology was not established responded to antituberculous therapy. Patients were treated for 2-12 weeks; 25% of the patients received &gt; 4 weeks of therapy. The outcome was poor: 36% of the patients had recurrences, and 19% died. In patients with AIDS, lung abscess is associated with advanced HIV infection, is due to a broad spectrum of pathogens, responds poorly to antibiotics, and has a poor prognosis." }, { "id": "pubmed23n0266_12883", "title": "[High incidence and mortality of systemic pneumococcal disease among persons without spleen].", "score": 0.009345794392523364, "content": "We surveyed 472 cases of culture-confirmed systemic pneumococcal disease that were reported to the Norwegian Notification System for Infectious Diseases during a 12-month period in 1992-93. The clinicians in charge of the patients filled in a questionnaire providing information on underlying disease and outcome for 461 (98%) of the patients. Eight of these patients were splenectomized; all of them more than ten years before. Four died, two survived but had serious sequelae, and two survived without obvious sequelae upon discharge from hospital. Using a rough estimate of the prevalence of unvaccinated splenectomized persons in Norway, we estimate that this group, compared to the normal population, has a relative risk of 25 of developing systemic pneumococcal disease and a relative risk of 75 of dying from pneumococcal disease. The serotype of the pneumococcal strain that caused the disease was determined for seven of the eight patients. All serotypes were represented in the 23-valent pneumococcal polysaccharide vaccine. We strongly recommend that doctors trace and vaccinate splenectomized individuals." }, { "id": "wiki20220301en267_8283", "title": "Austrian syndrome", "score": 0.009279623413203689, "content": "The oldest recorded patient with Austrian syndrome had a history of health concerns such as hypertension, and diabetes mellitus which increased her risk of Austrian syndrome. Mechanism/pathophysiology Osler's triad, also known as Austrian syndrome, was first introduced in the 19th century. Streptococcus pneumoniae is the cause of Osler's triad of meningitis, pneumonia, and endocarditis. The portal of entry for this triad is said to be the lungs, followed by meningitis and endocarditis. Significant risk factors are heavy alcohol consumption, old age, splenectomy, immunosuppression, etc. Endocarditis typically involves the aortic valve. The native aortic valve is the most frequent vegetation site for Streptococcus pneumoniae and is considered the most common cardiac lesion." }, { "id": "wiki20220301en546_19535", "title": "Innate immune defect", "score": 0.009259259259259259, "content": "Interleukin-1 receptor-associated kinase deficiency is an inherited disorder of the immune system. This immunodeficiency leads to recurrent infections caused by the pyogenic bacteria, for example Streptococcus pneumoniae, Staphylococcus aureus and Pseudomonas aeruginosa, but not by other infectious agents. Most patients with IRAK-4 deficiency suffer from invasive bacterial infections, which can cause sepsis, meningitis or they affect the joints that can lead to inflammation and arthritis. These invasive infections can also cause areas of tissue breakdown and pus production (abscesses) on internal organs. In addition, patients are characterized by infections of the upper respiratory tract, eyes or skin. Although fever is a common reaction to bacterial infections, many people with IRAK-4 deficiency do not at first develop a high fever in response to these infections, even if the infection is severe. Most patients have their first bacterial infection before age 2, and the infections can" }, { "id": "pubmed23n0705_21606", "title": "Clinical features of patients with recurrent invasive Streptococcus pneumoniae disease.", "score": 0.009259259259259259, "content": "Invasive Streptococcus pneumoniae (pneumococcal) disease (IPD) carries a high risk of death, approximately 15% to 20% in pneumonia, 40% in meningitis and 10% to 15% in septicemia. The occurrence of 2 or more IPD (recurrent) in the same individual is uncommon. The authors investigated the clinical features of patients with recurrent IPD to assess whether they possessed risk factors that increased their likelihood of recurrent IPD. Between 1983 and 2010, the authors identified 27 patients with recurrent IPD during inpatient surveillance of 889 patients with IPD in Huntington, WV, by recovery of pneumococci from otherwise sterile sites. Serotype/serogroup (ST/SG) was determined by capsular swelling and the penicillin MIC by E-strip. Clinical data were abstracted from hospital charts. Sixteen (59%) of 27 patients were 65 years and older at first IPD, males predominated (67%), two-thirds had pneumonia and 21 (78%) had the same clinical diagnosis at both IPD. Four (80%) of 5 patients with the same ST experienced their second IPD 1 to 6 months apart, unlike most patients with discordant ST/SGs (P = 0.047). Eighty-four percent of ST/SGs were included in the 23-valent pneumococcal vaccine and occurred as often during the first and second IPD. Twenty (77%) of 26 adults suffered from comorbid diseases placing them at high risk of IPD, including multiple myeloma, HIV/AIDS, neoplasia of hematological origin and sickle cell disease. Recurrent IPD occurred uncommonly. Comorbid conditions including multiple myeloma and immunosuppressive/immunodeficient conditions, chronic alcoholism and splenectomy represented unique risk factors for recurrent IPD but did not predict recurrences." }, { "id": "wiki20220301en261_22381", "title": "Acute infectious thyroiditis", "score": 0.009218984564455907, "content": "Causes Despite the thyroid gland being extremely resistant to infection, it is still susceptible to infection by various bacteria. The cause can be almost any bacterium. Staphylococcus aureus, Streptococcus pyogenes, Staphylococcus epidermidis, and Streptococcus pneumoniae in descending order are the organisms most commonly isolated from acute thyroiditis cases in children. Other aerobic organisms are Klebsiella sp, Haemophilus influenza, Streptococcus viridans, Eikenella corrodens, Enterobacteriaceae, and salmonella sp." }, { "id": "Surgery_Schwartz_10160", "title": "Surgery_Schwartz", "score": 0.009174311926605505, "content": "In fact, encapsulated bacteria, such as S pneumoniae, N meningitidis, and H influenzae, were rarely encountered in those series in whom vaccination was routinely adopted.193-196Sepsis by uncommon bacteria as well by protozoa infec-tions such as malaria and babesiosis are also known to affect asplenic patients.196-200Clinical Features. OPSI is uniformly fatal without treat-ment, and thus sepsis in a splenectomized patient is a medical emergency.21,187,192 Therefore, any clinical suggestion of infec-tion, including seemingly isolated fevers, must be viewed with a high index of suspicion and treated empirically as thorough investigation proceeds. OPSI may begin with a relatively mild-appearing prodrome of symptoms. In addition to fever, nonspe-cific symptoms such as malaise, myalgias, headache, vomiting, diarrhea, abdominal pain, and others should be viewed with alarm in the asplenic patient. This process can progress rapidly to fulminant bacteremic septic shock, with hypotension," }, { "id": "wiki20220301en489_1271", "title": "Neonatal infection", "score": 0.00909090909090909, "content": "Clostridium tetani can cause a generalised form of tetanus in the neonate. This usually occurs when the mother has not been vaccinated against tetanus and the baby has not acquired passive immunity. The umbilical cord region is the most susceptible. Other bacterial pathogens include Streptococcus agalactiae, Streptococcus pyogenes, Viridans streptococci, Streptococcus pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa. Viruses" }, { "id": "pubmed23n0501_4572", "title": "[Purulent pericarditis with pericardial tamponade caused by Streptococcus agalactiae and Salmonella enterica no typhi].", "score": 0.00909090909090909, "content": "Purulent pericarditis (PP) is an uncommon condition with high mortality. In the preantibiotic period, Staphyloccocus aureus and Streptococcus pneumoniae were the most common etiologic agents. We describe the case of a 75-year old man with septic shock, PP and cardiac tamponade caused by Streptococcus agalactiae and Salmonella enterica no-typhi. To our knowledge this association of pathogenic organisms has not been previously reported in the literature. The pathogenesis is here reviewed, and in our patient presumably, purulent pericarditis occurred via hematogeneus spread undergoing upper gastrointestinal endoscopy. The patient's course was complicated and he died on 34th hospital day. After this case report it is considered that differential etiologic diagnosis of PP should include these agents, especially in immunodepressed patients with predisposing factors." }, { "id": "pubmed23n0727_198", "title": "Sacroiliitis due to Salmonella Typhi: A case report.", "score": 0.009009009009009009, "content": "Pyogenic infections of the sacroiliac joint are observed quite rarely. The most frequent causative microorganisms are Staphylococcus aureus, Streptococcus species, and Pseudomonas aeruginosa that are commonly found in patients under intravenous medication. In this paper, a rare sacroiliitis case that developed due to Salmonella Typhi is discussed. A woman at the age of twenty applied to our clinic with complaints of fever, headache and diarrhea with which she had been suffering for five days. On physical examination, she had a slight fever, with a body temperature of 38.6°C. She was hospitalized, and Salmonella Typhi was isolated from her blood culture. Later on, the patient described pain during left hip movement. Diffusion-weighted magnetic resonance imaging and scintigraphic examinations revealed left sacroiliitis. Although sacroiliitis arising from Salmonella Typhi infection is a rare entity, it should not be ignored in patients who have a clinical history for sacroiliitis." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 412, 608 ] ], "word_ranges": [ [ 72, 104 ] ], "text": "the TP53 mutation, although it establishes prognosis, is not indicated at diagnosis, but when treatment is going to be initiated (first line and prior to successive lines in case they are needed)." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 63, 310 ] ], "word_ranges": [ [ 12, 54 ] ], "text": "We are told of a leukocytosis at the expense of lymphocytes with a B-CLL phenotype. It seems that there are no other alarming data. No clinical data are given (so we assume that the patient is asymptomatic). No cytopenias... Conclusion: FOLLOW UP." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Study of TP53 mutations to establish prognosis.", "2": "Bone aspirate/biopsy to confirm the diagnosis.", "3": "PET/CT to establish the therapeutic attitude.", "4": "New clinical and analytical control in 6 months.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0771_21251", "title": "[Chronic lymphocytic leukemia].", "score": 0.018447998646018447, "content": "Chronic lymphocytic leukemia (CLL) is a lymphoproliferative disorder that accounts for approximately 30 % of adult leukemias and 25 % of Non-Hodgkin lymphomas (NHL). It is the most common form of leukemia in the western world (incidence 3-5/100 000). Elderly people are mainly affected, median age at diagnosis is around 70 years and there is a slight predominance in men. The etiology of the disease is unknown. The initial symptoms are nonspecific. Cervical lymphadenopathy and splenomegaly followed by general fatigue are seen most commonly. Other possible symptoms include night sweats, fever, loss of weight (so-called B symptoms) and frequent infections. Several patients develop autoimmune complications as autoimmune hemolytic anemia (AIHA) or immune thrombocytopenia (ITP). To confirm the diagnosis more than 5000 B-lymphocytes/µl need to be present. The expression of the typical surface markers CD5, CD19, and CD23 has to be confirmed by flow cytometry. Imaging studies as X-ray of the chest, ultrasound of the abdomen, or CT scan are used to assess the degree of lymphadenopathy or organomegaly. A bone marrow biopsy is not mandatory for the diagnosis. According to the European Binet staging system, CLL is divided into 3 stages (A, B and C). Patients in Binet stage A have 0 to 2 areas of node or organ enlargement with normal levels of hemoglobin and platelets. Binet stage B patients have 3 to 5 areas of node or organ enlargement and normal or slightly decreased levels of hemoglobin and platelets. Binet stage C patients have anemia (hemoglobin &lt; 10 g/dl) and/or thrombocytopenia (platelet counts &lt; 100 000/µl), with or without lymphadenopathy or organomegaly. As there is no survival benefit associated with early intervention, asymptomatic patients with early stage CLL (Binet stage A and B) are usually not treated but are followed on a \"watch and wait\" principle. Treatment indications include stage Binet C or signs of an active disease as rapidly progressive lymphadenopathy or organomegaly together with physical limitation, B symptoms that cannot be tolerated, rapidly deteriorating blood values, or rapidly increasing leukocyte counts. The patient's physical condition has major impact on the treatment decision. Currently immunochemotherapy with fludarabine, cyclophosphamide and the CD20-antibody rituximab (FCR) is the standard of care in previously untreated and physically fit CLL-patients. An alternative regimen is the combination of bendamustine and rituximab (BR). Physically compromised patients can be treated with the oral drug chlorambucil or with bendamustine with or without rituximab. Due to high morbidity and mortality, allogeneic stem cell transplantation is limited to a small group of patients and should be discussed in a high-risk situation, such as 17p deletion, lack of response to standard therapy or early relapse." }, { "id": "pubmed23n0491_6249", "title": "[Chronic lymphocytic leukemia--the old and the new].", "score": 0.01710319164162015, "content": "Chronic Lymphocytic Leukemia (CLL) is the most frequent lymphoproliferative disease and leukaemia in western countries. CLL occurs more frequently in men than women, the median age at diagnosis is 65 years. CLL is defined as a persisting chronic lymphocytosis &gt; 5 G/l with classical morphological features (small lymphocytic cells with round nuclei, dense chromatin and small cytoplasmic rim) and a classical immunophenotype (CD5+, CD19+, CD20+, CD23+); however, deviations from classical morphology are frequent. In cases with classical diagnostic features in the peripheral blood, a bone marrow biopsy is not necessary for diagnosis. Prognostic features comprise the stage of the disease according to the Rai or Binet systems, laboratory markers such as LDH, beta-2-microglobulin, lymphocyte doubling time and CD38 expression by flow cytometry (and ZAP-70 expression if available) as well as the status on IgV(H) hypermutations and cytogenetic analysis. Up to 2/3 of patients do not need treatment at the time of diagnosis and can initially be followed using a watch and wait strategy. If therapy becomes necessary, initial standard treatment still is chlorambucil. Later, purine analogues and Alemtuzumab are treatment options for refractory or relapsing disease. Therapies with antibodies such as Alemtuzumab and Rituximab in combination with purine analogues are currently under clinical investigation. With recurrent or atypical infections, hypogammaglobulinemia should be searched for and immunoglobulins should be substituted if necessary. However, their prophylactic use is not recommended." }, { "id": "pubmed23n0825_9939", "title": "[Chronic lymphatic leukemia].", "score": 0.015914786967418545, "content": "Chronic lymphocytic leukemia (CLL) is the most common form of leukemia in the Western world. Median age at diagnosis is around 70 years. To confirm the diagnosis more than 5000 B-lymphocytes/µl need to be present. The expression of the typical surface markers CD5, CD19, CD20 and CD23 has to be confirmed by flow cytometry. A bone marrow biopsy is not mandatory for the diagnosis. Before start of treatment the assessment of 17 p deletion and/or TP53-mutational status is recommended. Treatment indications include stage Binet C or signs of an active disease as rapidly progressive lymphadenopathy or organomegaly together with physical limitation, B symptoms that cannot be tolerated, rapidly deteriorating blood values, or rapidly increasing leukocyte counts (Lymphocyte doubling time less than 6 months). The patient's physical condition has major impact on the treatment decision. Currently immunochemotherapy with fludarabine, cyclophosphamide and the CD20-antibody rituximab (FCR) is the standard of care in previously untreated and physically fit patients. An alternative regimen is the combination of bendamustine and rituximab (BR) or ofatumumab. Physically compromised patients can be treated with the oral drug chlorambucil in combination with an anti-CD20 antibody. Due to high morbidity and mortality, allogeneic stem cell transplantation is limited to a small group of patients and should be discussed in a high-risk situation, such as 17 p deletion and/or TP53-mutation, lack of response to standard therapy or early relapse. Recently several new chemo-free treatment options have been introduced within clinical trials. Among them are monoclonal antibodies, most of them targeting the CD20 molecule: besides the licensed drugs rituximab and ofatumumab, obinutuzumab, in combination with chemotherapy, has recently shown high clinical efficacy in front-line treatment of elderly patients with CLL. Novel agents have been designed to block aberrant signaling from the B-cell receptor. Ibrutinib acts by inhibiting the Bruton's tyrosine kinase (BTK) while idelalisib represents a first-in-class specific inhibitor of the phosphoinositol-3 kinase (PI3K) delta isoform. Another class of drugs with potential impact for chemo-free treatment strategies in CLL is the BH3-mimetic inhibitor of the Bcl-2 family of pro-survival proteins, ABT-199. Given all these novel agents and targets, chemo-free or at least chemo-reduced concepts may become reality in the near future for our patients suffering from CLL. " }, { "id": "pubmed23n0363_6664", "title": "[CD43 in B-cell chronic lymphocytic leukemia].", "score": 0.01584022038567493, "content": "CD43 (other names: sialophorin, leukosialin, sialoglycoprotein of white blood cells) is an integral cell membrane mucin. In population of peripheral B cells CD43 occurs only on activated B cells and CD5 positive B cells. These last cells create neoplasm population in patients with B-cell chronic lymphocytic leukemia (B-CLL). Anti-CD43 monoclonal antibodies are used routinely in investigations of tissue fragments in cases of non-Hodgkin's lymphoma, whereas we did not find publication on theme of CD43 expression on peripheral blood B cells in patients with B-cell chronic lymphocytic leukemia. Wherefore advisable appeared estimation CD43 expression on B-CLL cells and comparison it with expression of typical B-CLL markers--such as CD5 and CD6. Immunological phenotype of peripheral blood and bone marrow lymphocytes has been evaluated using flow cytometry (Cytoron Absolute Ortho-Diagnostic Systems) and two-color staining. Twenty six untreated patients with B-CLL were studied. Because on well-known correlations between CD43 expression and metastasis potential of tumor, patients were divided on two groups differing score of total tumor mass (score TTM). Score TTM was evaluated according to criterion of Jaksic and Vitale. Twelve patients whose TTM score was equal or lower than 9 and median lymphocytosis was 24.6 x 10(9) in microliter were included in group I. 14 patients whose TTM score was higher than 9 were included in group II. Median lymphocytosis in these patients was 152.6 x 10(9) in microliter. The median percentage of CD43+/CD19+ cells in peripheral blood was 62.6% in the group I, and 75% in the group II (p &lt; 0.05). Median fluorescence intensity (MFI) of CD43 antigen was 87.7 in the I group comparing to 77.4 in the group II. So one observed tendency to lowering MFI during tumor growing but the difference was not significant (p = 0.25). In peripheral blood during progression of disease more clearly than CD43+ cells increased percentage of CD5+ and CD6+ cells. The median percentage of CD19+/CD5+ cells was 62.7% in the group I, 82.4% in the group II and the difference was significant (p &lt; 0.002). The difference in the median percentages CD6+/CD19+ cell 71.8% in group I and 84.3% in the II one were also significant (p &lt; 0.03). MFI of CD5 and also CD6 antigens did not change in course of disease. Moreover, examination of CD43 and CD5 expression in marrow additionally to blood study were performed in 12 cases (6 from group I, 2 from group II and 4 new not included). The median percentage of CD43+/CD19+ cell was 35.1% in blood and 43.7% In marrow, in contrast to these results was the median percentage of CD19+/CD5+ cell, which was higher in peripheral blood (70.4%) than in bone marrow (60.9%). The results of this study indicate that CD43 is present on peripheral blood B-CLL cells. Moreover, percentage of these cell increases during progression of disease however more weakly than percentage of CD5 and CD6 positive cells. Expression of CD43 is independent from expression CD5 and CD6 and diminishes during tumor mass increasing, what can depended from releases exocellular domains of CD43. CD43+ cell from B-CLL patients have a tendency to accumulation in tissues what is illustrated by higher percentage of CD43+ cell in bone marrow than in peripheral blood." }, { "id": "pubmed23n1076_182", "title": "An unknown chromosomal aberration in a patient with chronic lymphocytic leukemia: Extra isochromosome 4q.", "score": 0.014973262032085561, "content": "The genetic characterization of chronic lymphocytic leukemia (CLL) has made significant progress over the past few years. Chromosomal abnormalities are detected in up to 80% of patients. Determination of new chromosomal disorders is important in the pathogenesis and treatment facilities. A patient was diagnosed with CLL Stage 2 on 2012 and followed since then by hematology clinic. She was 63 years old. Mature, small lymphocytes, and smudge cell was found in the patient's peripheral blood smear. Bone marrow (BM) biopsy made and hypercellularity showing infiltration of atypical cells with CD5+, CD20+, and CD23+ were determined. Hypoplasia is detected in myeloid/erythroid series, and Stage 2 reticular fibers proliferation were detected. The patient was followed up without medication. While follow-up of patient's white blood cell: 57300, hemoglobin: 5.36, and PLT: 99700 are determined in May 2014. According to the patient's flow results, CD5+, CD23+, and FMC7+ were detected. Mature, small lymphocytes and smudge cell was found in the patient's peripheral blood smear. In ultrasonography imaging, multiple laps were found in the abdomen and multiple neck lymph nodes were detected. The patient BM aspiration was performed in 2014, and hypercellularity was found to contain 54% of atypical lymphocytes in the BM. Fluorescence in situ hybridization (FISH) analysis made two times in 2014. At first, FISH analysis patient's rate of 18% in RB1/13q14.2/13qter revealed a deletion of the gene regions. Patient's FISH result was reported as normal (for RB1/13q14.2/13qter) after 5 months at second analysis. Cytogenetic analysis is made from the patient's BM at the same time. According to the results of karyotyping and FISH, 47, XX, isochromosome 4q (+i4q) is determined. According to literature, extra isochromosome 4q is reported by our case for the first time in CLL. She was diagnosed with Stage 4 CLL and FISH treatment was initiated. Our patient showed disease progression compared to previous results. Hence, we offer that this evidence can be considered regarding triggering the disease's progression or as a result of disease progression i4q was occurred." }, { "id": "pubmed23n0256_10414", "title": "CD5 negative lymphocytosis mimicking typical B-chronic lymphocytic leukaemia. Description of 26 cases.", "score": 0.013311428451072076, "content": "We report 26 elderly patients (median age 68.3 years) who met diagnostic criteria for B-cell chronic lymphocytic leukaemia (B-CLL) but whose lymphocytes lacked CD5 expression. Haematological and clinical features of this CD5- series were compared with those of 333 CD5+ B-CLL patients from the same institute. No significant differences were observed regarding peripheral blood (PB) and bone marrow (BM) lymphocytosis, Hb level, platelet count, incidence of adenomegaly, hepatomegaly or splenomegaly or diffuse BM pattern. Due to an absence of nodal enlargements or to general clinical condition, lymph node biopsy was performed in only three patients, while spleen histology was examined in two cases following splenectomy. All histological results confirmed the clinical diagnosis of CLL. The distribution of the CD5- subjects according to the different staging categories proposed by Rai, Binet and Mandelli was similar to that of CD5+ subjects. Ten patients received standard chemotherapy with Chlorambucil (CHL) and Prednisone (PDN). All achieved partial remission, although one of these patients later died of disease progression; 80 months after diagnosis. We conclude that rare cases of CD5- lymphocytosis fulfilling all criteria for B-CLL may occur. Haematological and clinical features at presentation and the response to conventional treatment with Chlorambucil support our hypothesis of considering this disease as a less frequent subgroup of B-CLL." }, { "id": "wiki20220301en254_2214", "title": "Oncology", "score": 0.013217509793902231, "content": "Diagnosis and staging Diagnostic and staging investigations depend on the size and type of malignancy. Blood cancer Blood investigations including hemoglobin, total leukocyte count, platelet count, peripheral smear, red cell indices. Bone marrow studies including aspiration, flow cytometry, cytogenetics, fluorescent in situ hybridisation and molecular studies. Lymphoma Excision biopsy of lymph node for histopathological examination, immunohistochemistry, and molecular studies. Blood investigations include lactate dehydrogenase (LDH), serum uric acid, and kidney function tests. Imaging tests such as computerised tomography (CT scan), positron emission tomography (PET CT). Bone marrow biopsy. Solid tumors Biopsy for histopathology and immunohistochemistry. Imaging tests like X-ray, ultrasonography, computerised tomography (CT), magnetic resonance imaging (MRI) and PET CT." }, { "id": "pubmed23n0526_10108", "title": "Blastic transformation after splenectomy in a patient with nonvillous splenic marginal zone lymphoma with p53 overexpression: a case report.", "score": 0.01211484593837535, "content": "A 61-year-old man with no subjective symptom was admitted to our hospital for further examination of the causes of anemia (hemoglobin, 9.5 g/dL) and thrombocytopenia (platelets, 9.2 x 10(4)/microL), which had been pointed out in a medical checkup half a year previously. A bone marrow examination showed 73% lymphoid cells. Immunophenotyping of these cells were CD19+CD20+CD3-CD5-CD10-CD23-, and light chain restriction (kappa) was positive by fluorescence-activated cell sorting analysis. A computed tomography scan showed mild splenomegaly. To confirm the diagnosis histologically, we performed a splenectomy. Finally, we diagnosed the patient's disease as nonvillous splenic marginal zone lymphoma (SMZL). A month after the splenectomy, the white blood cell count was remarkably increased to 7 x 10(4)/microL with the blastic transformation of lymphoid cells. We first treated the patient with fludarabine and then with the CHOP regimen (cyclophosphamide, hydroxydaunomycin, vincristine [Oncovin], and prednisone), but the disease was so refractory that the patient died of the disease 13 months after the splenectomy. Immunohistochemical staining and a molecular examination for p53 were carried out with specimens from the splenectomy. We found overexpression of the p53 protein in lymphoid cells and a point missense mutation in codon 280 at exon 8 that changed AGA (Arg) to AGT (Ser). This case may indicate the existence of a more aggressive subset of SMZL, suggesting a reconsideration of the roles of splenectomy and p53 overexpression in the diagnostic and therapeutic approaches to patients with SMZL." }, { "id": "pubmed23n0863_3840", "title": "[Monoclonal B-cell lymphocytosis: from literature to laboratory practice].", "score": 0.012019914651493598, "content": "Monoclonal B-cell lymphocytosis (MBL) is defined as an asymptomatic condition characterized by the presence of less than 5,000 monoclonal B-cells per microliter and the absence of clinical signs or symptoms of a B-cell lymphoproliferative disorder. Most MBL cases involve B cells presenting an identical phenotype to CLL (CLL-like MBL) with a Catovsky-Matutes score of 3 to 5 and share the same chromosomal abnormalities than CLL. Depending on the absolute B cell count, one may distinguish low-count CLL-like MBL (&lt;500 B cells/μL) which have no evidence of progression, no reduction in overall survival, no increase in infection risk and do not require any specific follow-up. Patients with clinical CLL-like MBL (&gt;500 B cells/μL) have a 1% to 2% per year risk of progression to CLL requiring therapy, a higher risk of infectious complications and mortality implicating an annual follow-up by hematologist. MBL may also express other less common phenotypes and are named atypical MBL in case of CD5 antigen expression (Catovsky-Matutes score: 1-2) and non-CLL-like MBL for CD5 negative cases (Catovsky-Matutes score: 0-2). Their poorer prognosis implicates imaging studies, bone marrow biopsy and cytogenetic analysis in addition to physical examination in order to rule out non-hodgkinien lymphoma, and require a more frequent follow-up. This review focuses on key concepts in the classification, diagnosis, monitoring and biology of MBL in laboratory practice. " }, { "id": "pubmed23n1110_4796", "title": "Chronic lymphocytic leukemia presenting as gingival swelling and tooth mobility.", "score": 0.009900990099009901, "content": "Chronic-lymphocytic-leukemia (CLL) is the most prevalent leukemia in developed countries, caused by monoclonal proliferation of CD5+ B-cells and accumulation of mature-appearing-neoplastic lymphocytes in blood, bone marrow, and secondary lymphoid organs. Oral manifestations of CLL are infrequent and rarely reported in literature. We report a new case of a 67-year old man who presented with the complaints of tooth mobility and gingival swelling. Extra-oral examination was remarkable for cutaneous pallor and bilateral cervical lymphadenopathy involving the submandibular, and deep cervical lymph nodes on both sides of the neck. Complete blood count revealed normal red blood cell count (4.25 × 106/μl), normal platelet count (136 × 103/μl) and increased white blood cell count (25.3 × 103/μl). Differential white blood cell count showed marked lymphocytosis (88%), and blood film revealed the presence of leukocytosis, with small mature-looking lymphocytes, and mild thrombocytopenia. A flow cytometry immune-phenotyping revealed that 55% of peripheral blood cells were monoclonal B-lymphocytes expressing CD19, CD20, CD23, CD200, CD22, CD5, CD38, CD11c, sIgD and Kappa light chain confirming the diagnosis of CLL. Oral healthcare professionals should consider systemic causes, such as CLL, in the differential diagnosis of generalized tooth mobility and gingival swelling, particularly in patients with associated symptoms such as lymphadenopathy, fever, weight loss, and general fatigue." }, { "id": "article-24574_30", "title": "Lymphocytosis -- Evaluation", "score": 0.009900990099009901, "content": "Additional testing: Flow Cytometry: Peripheral blood flow cytometry is essential to determine the proliferation of monoclonal cells. It is a costly test and should not be ordered routinely on all patients with lymphocytosis. Certain features on peripheral blood smear or on review of CBC which prompt a physician to order flow cytometry include: The presence of lymphoblasts on the peripheral blood smear, suggesting ALL- This should also prompt a referral to a tertiary care center to obtain further workup. The presence of other abnormal lymphocyte morphology on PBS as detailed above ALC more than 30000 cells/microL Persistent unexplained lymphocytosis for more than one month Abnormalities in other cell lines including anemia and thrombocytopenia Presence of lymphadenopathy and/or hepatosplenomegaly in the right clinical context where reactive causes have been ruled out Flow cytometry patterns are beneficial in delineating clonality and differentiating clonal disorders as follows: CLL: lymphocytes are CD5+, CD23+, CD20 (dim), CD10-, cyclin D1-, weak sIg (surface immunoglobulin), FMC -, CD200 + MCL: lymphocytes are CD5+, CD23-, CD10-, CD20+, sIg +, cyclin D1 +, FMC +, CD200- FL: lymphocytes are CD5-, CD10+, CD20+, sIg+ and often BCL2+, BCL6+ MZL: lymphocytes are CD5-, CD10-, CD20+, sIg+, cyclin D1- HCL: lymphocytes are CD5-, CD10-, CD20+, sIg+, CD11c+, CD25+, CD103+ T-LGL: lymphocytes are CD3+, CD8+, CD16+, CD56+ Fluorescence in situ hybridization (FISH), karyotype, and mutation analysis: FISH, karyotype, and certain mutation analysis help diagnose and risk stratification of hematologic malignancies, especially CLL and lymphomas. The FISH can not only help to ascertain the clonal nature of lymphocytosis but also helps to confirm the diagnosis of certain lymphomas. Examples include: FL: characterized by t(14,18) MCL: characterized by t(11,14) HCL: characterized by the presence of BRAF mutation CLL: different karyotypic abnormalities including del 17p, del 11q, trisomy 12, and del 13q14." }, { "id": "pubmed23n0874_13088", "title": "Concomitant Presence of Two Distinct Clones of Chronic Lymphocytic Leukemia and Plasma Cell Myeloma in a Patient.", "score": 0.00980392156862745, "content": "A 74 years old male patient, presented with history of generalized weakness, fatigue, loss of appetite and breathlessness on exertion for past one and a half months. On examination, he was found to have significant pallor and generalized lymphadenopathy (cervical, axillary and inguinal). The skeletal survey showed punched out lytic lesions in skull and pelvic bones. The peripheral smear examination showed lymphocytosis with absolute lymphocyte count of 25,000/μL. The bone marrow aspirates revealed a hypercellular marrow with 74 % lymphocytes &amp; 14 % plasma cells, suggestive of chronic lymphoplasmacytic disorder. The bone marrow biopsy had two morphologically distinct populations of lymphocytes &amp; plasma cells. The immunohistochemical markers on bone marrow biopsy showed hat plasma cells were positive for CD138 with kappa light chain restriction. Flow cytometry showed B cell population with CD19/CD5 co expression, CD5/CD23 coexpression, were positive for CD22, CD20 and negative for FMC-7 and lambda light chain. In addition, plasma cells were also identified as CD45 negative cells and showed CD38/CD138 co-expression with variable CD19 and CD56 positivity. Serum protein electrophoresis revealed M band, serum immunofixation electrophoresis corresponded to IgA -Kappa. The final diagnosis of chronic lymphocytic leukemia with concomittant presence of plasma cell myeloma was concluded. This case imparts an important message to look for presence of coexisting entities in a single specimen and highlights the benefits of testing both plasma cell and B-cell compartments when the clinical features are not entirely consistent Flow cytometry together with protein electrophoresis can help to clinch difficult and rare dual diagnosis. These cases are rare and pose therapeutic challenge. " }, { "id": "pubmed23n0375_22046", "title": "[Monitoring minimal residual disease in patients with hairy cell leukemia in complete remission after treatment with 2-chlorodioxyadenosine].", "score": 0.009708737864077669, "content": "Treatment of hairy cell leukemia with 2-chlorodeoxyadenosine (2-CdA) induces in 85% patients complete remission. Complete remission is defined as the condition when signs of activity of the disease are absent, splenomegaly and lymphadenopathy are absent, the hemoglobin concentration is &gt; or = 120 g/l, the absolute number of granulocytes is &gt; or = 1.5 x 10(9)/l and the number of thrombocytes is &gt; or = 100 x 10(9)/l. In complete remission in the peripheral blood, bone marrow aspirate and bioptic samples obtained by trephin bone marrow core biopsy, using standard staining (hematoxylin-eosin and May-Grünwald-Giemsa's method), no leukemic cells are present. When more sensitive methods are used (immunophenotyping, immunohistochemistry or molecular genetic methods), a persisting leukemic population can be detected which is described as minimal residual disease (MRD). For detection of MRD the authors used immunohistochemical examination of bone marrow with DBA.44 antibodies. As leukemic cells they described those which produced intense cytoplasmic and membrane positivity with antibody DBA.44 and corresponded morphologically to hairy cells. For evaluation computer analysis of the picture LUCIA-M was used. The infiltration grade was examined on three areas of standard size (3 x 65,265 micron 2) and expressed in percent. A total of 45 trepanobioptic specimens from 21 patients were examined who achieved after treatment with 2-CdA complete remission. In all samples suitable for evaluation the presence of leukemic cells (MRD) was detected with a median of 3% and a range of 1% to 18%. With induction of complete remission correlates also the low serum level of the soluble receptor for IL-2 (sIL-2R). In a female patient after 24 months of treatment with 2-CdA the grade of leukemic infiltration rose from 1% to 12% and during the 36th month to 50% DBA.44+ leukemic cells. The incipient relapse in this patient was not associated, despite marked infiltration of bone marrow, with failure of hematopoiesis and a marked rise of sIL-2R." }, { "id": "pubmed23n1058_1052", "title": "High-Grade Epstein-Barr Virus-Negative Biphenotypic Lymphoma with Expression of B- and T-Cell Markers and Leukemia Presentation: Case Report and Literature Review.", "score": 0.009615384615384616, "content": "Lymphomas are presently categorized according to their origin from B or T lymphocytes. The co-expression of CD3 in B-cell lymphomas or CD20 in T-cell lymphomas has been rarely reported. Immature and less often mature lymphomas may incorporate the rearrangements of both B- and T-cell antigen receptor genes (dual genotype or bigenotype). Lymphoma cells with a sole genotype hardly concurrently express both B- and T-cell markers (biphenotypic lymphomas). We describe a 63-year-old female who was presented with obstructive jaundice and epigastric pain of 10 days. Initial CBC revealed 43×10&lt;sup&gt;3&lt;/sup&gt;/μL white blood cells, 11.2 g/dL hemoglobin, and 88x10&lt;sup&gt;3&lt;/sup&gt;/μL platelets. CT abdomen revealed hepatomegaly and suspected pancreatic mass with large retroperitoneal lymph nodal mass. Peripheral smear showed 56% lymphoid cells with blast morphology. The bone marrow (BM) aspirate smear was infiltrated by 83% immature-looking cells. BM biopsy showed interstitial to diffuse extensive infiltration by primitive-looking cells, positive for pan-B-cell antigens CD20, CD79, and PAX5 as well as the T-cell antigen CD4, CD5, CD3, while negative for all immaturity markers (CD34, TdT, and CD1a). In situ hybridization for Epstein-Barr virus (EBV)-encoded small RNA (EBER) was negative. Flow cytometry on BM aspirate showed an abnormal population (50%) expressing the B-cell antigens (CD19, CD20, CD79, CD22) and CD10, and showed lambda light chain restriction as well as the T-cell antigens cCD3 and CD4 with partial CD5. The analysis showed, also, another abnormal population of lambda restricted monotypic B cells (8%) with dimmer CD45 (blast gate) and showed the same immunophenotype (expressing the B-cell antigens), but negative for CD10, cCD3, CD5, and CD4. Conventional cytogenetic revealed complex karyotype. Molecular studies revealed rearrangements of the immunoglobulin heavy chain region consistent with a clonal B-cell population. TCR gene rearrangement analysis was equivocal concerning clonality but was not conclusive for clonal T-cell disease. Our final diagnosis was peripheral blood and BM involvement by EBV-negative high-grade lymphoid neoplasm (in leukemic phase with blast morphology) and an ambiguous immunophenotype with a differential diagnosis that may include the rare entity of bigenotypic lymphoma or an unusual case of high-grade B-cell lymphoma with aberrant expression of T-cell markers (biphenotypic lymphomas)." }, { "id": "pubmed23n0834_3336", "title": "Antigen Expression on Blast Cells and Hematological Parameters at Presentation in Acute Lymphoblastic Leukemia Patients.", "score": 0.009615384615384616, "content": "To analyze the expression of various antigens on the leukemic blasts and to determine the hematological parameters, in Acute Lymphoblastic Leukemia (ALL) patients at presentation. Observational study. King Edward Medical University, Lahore and Hameed Latif Hospital, Lahore, from February 2013 to March 2014. A total of 50 newly diagnosed and untreated patients of ALL were selected from Mayo Hospital and Hameed Latif Hospital. These patients included both genders and all age groups. Hemoglobin, total leukocyte count and platelet count were determined on hematology analyser-Sysmex-Kx-2I. Blast cell percentage was estimated on Giemsa stained blood smears. Immunophenotyping was done on bone marrow samples by 5 colour flowcytometery on Beckman Coulter Navious Flowcytometer. An acute leukemia panel of 23 antibodies was used. The data was entered and analyzed in SPSS version 22. Of the 50 ALL patients, 36 (72%) were B-ALL and 14 (28%) T-ALL. There were 18 (36%) children and 32 (64%) adults. T-ALL included 22% of the childhood and 31% of the adult cases. Immunophenotypic analysis showed that CD19, CD79a and CD20 were B-lineage specific markers whereas cCD3, CD3 and CD5 were T-lineage specific. CD10 was the most sensitive marker for B-ALL and CD7 was the most sensitive marker of T-ALL. TdT was expressed in 92% B-ALL and 71% T-ALL cases, CD34 in 58% and 43% cases and CD45 in 83% and 100% respectively. High leukocyte count (&gt; 50 x 109/L) was present in 58% cases. Hemoglobin was &lt; 10 g/dl in 74% patients and platelet count was below 20 x 109/Lin 12% patients. Leukocyte count, hemoglobin, platelet count and blast cell % did not show a significant difference in the two ALL immunotypes. The frequency of T-ALL is higher in childhood as well as adult ALL in our population compared to the Western literature. Antigenic expression of the blast cells also shows some interesting differences. A large number of our patients present with high leukocyte count which is a known factor associated with poor prognosis." }, { "id": "pubmed23n0735_5890", "title": "A 61-year-old man presented with myopathy, neuropathy, and inflammatory dermatitis responsive to chronic lymphocytic leukemia treatment.", "score": 0.009523809523809525, "content": "The prevalence of paraneoplastic neurologic syndrome in cancer is 0.01%. Neurological syndromes can be seen in chronic lymphocytic leukemia (CLL) and mostly present as either leukemic infiltration of the central nervous system (CNS) or progressive multifocal leukoencephalopathy. To our knowledge, this is the first reported case of combined sensory-motor neuropathy, myopathy, and dermatitis in a patient with CLL. A 61-year-old African American man presented with acute dysphagia, rapidly progressive proximal limb-girdle weakness, and dermatitis. He had a white blood cell (WBC) count of 14,600/mm(3), hemoglobin of 11.4 mg/dL, and a platelet count of 165,000/mm(3). Lymphocytes comprised 15% of the total WBC with an absolute lymphocyte count of 2100/mm(3). Metabolic profile was unremarkable except for a serum creatine phosphokinase (CPK) level of 1056 mg/dL. Serum protein electrophoresis, serologic studies for autoimmune, genetic diseases, and paraneoplastic syndromes were all negative. Electrodiagnostic studies revealed sensorimotor neuropathy with mixed axonal and demyelinating features. Muscle biopsy revealed discrete areas of interstitial fibrosis juxtaposed to areas of intact muscle without any inflammation. At that point, a bone marrow biopsy was done because of anemia and slightly elevated mean corpuscular volume of 103. Bone marrow biopsy revealed minimal involvement with CD5/CD19-positive CLL. Flow cytometry demonstrated monoclonal CD5/CD19/CD20/CD23-positive cells, with dim kappa expression, and negative FMC-7 and CD3. This case doesn't meet the criteria for CLL/small lymphocytic lymphoma. However, considering the possibility of paraneoplastic phenomenon for his symptoms, it was decided to start the patient on CLL-directed therapy with Rituximab and Cyclophosphamide. After only two cycles, the patient experienced a dramatic improvement in his muscle strength with disappearance of the rash. This case highlights a unique clinical picture of inflammatory dermatitis with electromyography and biopsy findings suggestive of myopathy and combined sensorimotor neuropathy with response to CLL-directed therapy. Also the symptoms started before peripheral lymphocytosis which masked the diagnosis for over a year." }, { "id": "pubmed23n0346_332", "title": "[Mantle cell lymphoma as a diagnostic and therapeutic problem].", "score": 0.009523809523809525, "content": "The authors present the characteristics of a group of 23 patients with mantle cell lymphoma. In the group only a slight predominance of men over women was found (1.1:1), the median age was 63 years. Twenty-one (91%) of the patients were diagnosed in stage IV (Ann Arbor). In all these patients the bone marrow was affected. In 19 of them immunoflowcytometric analysis revealed the typical clone of B lymphocytes (CD5 positive)/CD 23 negative). The majority of patients had at the time of diagnosis a large tumourous mass with massive splenomegaly (61%), hepatomegaly (57%) and bulky disease (52%). The node was excised in 17 patients, but in four patients (24%) during the first session the diagnosis was not assessed correctly. In the laboratory findings an inclination to anaemia, thrombocytopenia, lymphocytosis and in particular to high levels of serological indicators of activity of the disease dominated--lactate dehydrogenase, beta-2-microglobulin and serum thymidine kinase. All patients were treated by chemotherapy. Complete remission was achieved by the date of evaluation in one patient (4%), partial remission in seven patients (30%) but 48% patients did not respond to first line treatment. Nine patients of the group died, their median of survival was 14 months (0-24), the median of the follow up of the remaining patients was 133 months (2-31). Two female patients had large-dose treatment with subsequent administration of autologous stem cells. The first one is after 370 days of treatment in complete remission, the second one developed a relapse 100 days after the procedure. From the results and analysis of the literature ensues that mantle cell lymphoma is one of the aggressive malignant B-lymphoproliferations with a very adverse prognosis and it deserves therefore special diagnostic and intense therapeutic attention." }, { "id": "pubmed23n0657_12622", "title": "A rare occurrence of hairy cell leukemia in the Thai population: a case report.", "score": 0.009433962264150943, "content": "Hairy cell leukemia (HCL) has been mainly reported from the Western countries. Herein we describe a case of HCL diagnosed in a Thai patient. A 36-year-old man presented with abdominal discomfort, frequent gum bleeding and significant weight loss for 2 months. Physical examination revealed moderate anemia, petechial hemorrhage on the extremities and an enlarged spleen down to the umbilicus. No hepatomegaly or lymphadenopathy was detected. Complete blood counts revealed a hemoglobin (Hb) of 6.6 g/dL, a white blood cell (WBC) count of 1.6 x 10(9)/L (neutrophil 16%, lymphocyte 71%, monocyte 11%, atypical lymphocyte 1%), and a platelet (PLT) count of 17 x 10(9)/L. Abnormal large mononuclear cells with villous projections were seen in the blood smear. Although bone marrow (BM) aspiration resulted in a dry tap, abnormal lymphocytes with villous projections could again be identified in the touch preparation. Flow cytometric analysis showed a distinct population above the normal lymphocyte region on CD45/SSC gates with a strong expression of CD19, CD20, CD22, CD25, CD11c, and kappa. CD5, CD23, CD10, CD4, and CD8 were all negative. BM biopsy was consistent with HCL. The patient was treated with splenectomy followed by 8 cycles of fludarabine and cyclophosphamide chemotherapy. At 21 months after diagnosis, the patient was doing well with a Hb of 16.9 g/dl, a WBC count of 6.8 x 10(9)/L, neutrophil 49.9%, lymphocyte 39.6%, monocyte 8.6%, and a PLT count of 329 x 10(9)/L). No abnormal lymphoid cells were detected in the blood smear. This present report represents the first Thai HCL case that was immunophenotypically confirmed by flow cytometry and successfully treated at Siriraj Hospital." }, { "id": "pubmed23n0347_22507", "title": "[Detection of PNH clones using flow cytometry in aplastic anemia and paroxysmal nocturnal hemoglobinuria].", "score": 0.009433962264150943, "content": "To detect and quantify by flow cytometry (FC) PNH clones in paroxysmal nocturnal haemoglobinuria (PNH) and aplastic anaemia (AA) patients. We have performed a flow cytometric analysis to determine the granulocyte expression of CD55 and CD59 from 29 patients with AA and 11 patients with PNH. In the 11 PNH patients the study showed 58 +/- 34% and 56 +/- 32% (mean +/- SD) CD55(-) y CD59(-) granulocytes. A good correlation was found between the results of FC and haemolysis. The follow-up study showed PNH clone progression in one case and stability in 5 cases. Among 11 AA patients studied at diagnosis, two presented a population of CD55(-) granulocytes (14% and 48%) with CD59 normal, this defect disappeared in both patients after immunosuppressive therapy. The FC study revealed PNH clones in 7 cases among the 26 analyzed after treatment (23 with ATG and/or CyA), in 3 cases with negative Ham's test (in two this became positive 6 and 12 months later). The mean values obtained in these 7 patients with PNH-AA syndrome were 26 +/- 15% y 36 +/- 30% (mean +/- SD) CD55(-) and CD59(-) granulocytes. The median time from diagnosis to detection of PNH phenomenon was 83 months. In the follow-up study, 4 cases had stability, one case had a decrease and one a progression of the abnormal clone. In a retrospective analysis, among the 7 patients with PNH-AA syndrome, 5 had a partial response after the initial treatment. The FC on granulocytes is a useful method to diagnose and characterize PNH. This test is good for early detection of PNH clones in AA patients at initial diagnosis and in long term survivors. In both diseases it permits measuring the extent of the abnormal clone and its follow up. The extent of the defect is more related to haemolysis than the haematopoietic deficiency. PNH development seems to be more frequent in AA patients with incomplete response after immunosuppressive therapy and in some cases the defect could be latent at the time of diagnosis." }, { "id": "pubmed23n0932_6385", "title": "The sorafenib anti-relapse effect after alloHSCT is associated with heightened alloreactivity and accumulation of CD8+PD-1+ (CD279+) lymphocytes in marrow.", "score": 0.009345794392523364, "content": "We studied three FLT3 ITD acute myeloid leukemia (AML) patients who relapsed after allogeneic haematopoietic stem cell transplantation (alloHSCT) and received multikinase inhibitor (MKI) sorafenib as part of salvage therapy. MKI was given to block the effect of FLT3 ITD mutation which powers proliferation of blast cells. However, the known facts that sorafenib is more effective in patents post alloHSCT suggested that this MKI can augment the immune system surveillance on leukaemia. In the present study, we investigated in depth the effect of sorafenib on the alloreactivity seen post-transplant including that on leukaemia. The patients (i) responded to the treatment with cessation of blasts which lasted 1, 17 and 42+ months, (ii) developed skin lesions with CD3+ cell invasion of the epidermis, (iii) had marrow infiltrated with CD8+ lymphocytes which co-expressed PD-1 (programmed cell death protein 1 receptor, CD279) in higher proportions than those in the blood (163±32 x103 cells/μl vs 38±8 x103 cells/μl, p&lt;0.001). The Lymphoprep fraction of marrow cells investigated for the expression of genes involved in lymphocyte activation showed in the patients with long lasting complete remission (CR) a similar pattern characterized by (i) a low expression of nitric oxide synthase 2 (NOS2) and colony stimulating factor 2 (CSF2) as well as that of angiopoietin-like 4 (ANGPTL4) (supporting the immune response and anti-angiogenic) genes, and (ii) higher expression of fibroblast growth factor 1 (FGF1) and collagen type IV alpha 3 chain (COL4A3) as well as toll like receptor 9 (TLR9) and interleukin-12 (IL-12) (pro-inflammatory expression profile) genes as compared with the normal individual. The positive effect in one patient hardly justified the presence of unwanted effects (progressive chronic graft-versus-host disease (cGvHD) and avascular necrosis of the femur), which were in contrast negligible in the other patient. The anti-leukemic and unwanted effects of sorafenib do not rely on each other." }, { "id": "pubmed23n0259_17791", "title": "Atypical chronic lymphocytic leukaemia with t(11;14)(q13;q32): karyotype evolution and prolymphocytic transformation.", "score": 0.009345794392523364, "content": "In order to define better the cytological and clinical features of atypical B-cell chronic lymphocytic leukaemia (B-CLL) with t(11:14)(q13;q32), sequential morphologic immunological and cytogenetic studies were performed in seven patients belonging to a series of 72 consecutive cases presenting with a diagnosis of CLL or atypical CLL according to the FAB criteria. Cytologic diagnosis in these seven patients with t(11;14) was typical CLL in two cases presenting with &lt; 10% large lymphocytes (LL) and prolymphocytes (PL) and atypical CLL in five cases in which LL and PL comprised between 10% and 55%. The diagnosis was supported by histologic findings on bone marrow biopsy (five cases) or splenectomy specimens (two cases). A progressive increase of peripheral LL and PL was observed, resulting in a switch of FAB diagnosis over a 6-60-month period from typical CLL into atypical CLL in two cases and from atypical CLL into prolymphocytic leukaemia in five cases. Immunophenotyping showed a mature B-cell phenotype with CD19, CD22, CD24 positivity and CD10 negativity in all patients. A bright-staining pattern for surface immunoglobulins (SIg) was detected in 6/7 cases, CD5 positivity in 6/7 cases, and CD23 positivity in 1/7 cases. The FMC-7 monoclonal antibody was positive in &gt; 40% cells in 5/6 cases. Chromosome changes in addition to t(11;14) were seen in five cases; in two cases unbalanced translocations involving the 3q21 chromosome region, resulting in partial trisomy for the long arm of chromosome 3, were detected early in the course of the disease. Karyotype evolution that was associated with disease progression occurred in 3/6 assessable patients. Comparison of these findings with similar data from 65 B-CLL patients without t(11:14) showed that atypical morphology, switch of FAB diagnosis during the course of the disease, and karyotype evolution were more frequently seen in cases with t(11;14) (5/7 v 15/65 cases, P = 0.015, 7/7 v 7/65 cases, P &lt; 0.0001, and 3/6 v 5/45 assessable cases, P = 0.04, respectively). The frequency of positivity for CD23 and bright SIg staining differed significantly in the two groups. It is concluded that t(11;14) identifies a cytologically atypical subset of B-CLL, characterized by frequent cytologic and cytogenetic evolution and by a distinct immunological profile, sharing some biological features with mantle cell lymphoma." }, { "id": "wiki20220301en566_561", "title": "Epstein–Barr virus-associated lymphoproliferative diseases", "score": 0.009259259259259259, "content": "receptor, and, in EBV+ HLH cases, circulating EBV. In the latter cases, histological examination of lymphatic, bone marrow, liver, neuronal, and other involved tissues show infiltrations of small EBV+ T cells, scattered small bystander EBV+ B cells, reactive histiocytes, reactive macrophages, and, in ~70% of cases, hemophagocytosis, i.e. ingestion of erythrocytes, leukocytes, platelets, and/or their precursor cells by histiocytes and macrophages. (Evidence of hemophagocytosis is not critical for the diagnosis of HLH.) The EBV in infected lymphocytes is in its lytic cycle rather than any latent phase. Criteria consistent with the diagnosis of HLH, as developed by the Histiocytic Society (2004), include finding five of the eight following signs or symptoms: fever ≥38.5 °C; splenomegaly; low blood levels of any two of the following, hemoglobin (<10 mg/L), platelets (<100,000/μL), or neutrophils <1,000/μl; either one or both of the following, blood fasting triglyceride levels >265 mg/dL" }, { "id": "pubmed23n0079_1903", "title": "[DBMP-85 was effective at diagnosis and LVP was effective at relapse in a case of acute mixed leukemia].", "score": 0.009259259259259259, "content": "A 16 year-old boy was admitted to our hospital in April 1985, because of bilateral submandibular swellings. Hematological examination revealed Hb was 7.3 g/dl, WBC was 89,000/microliters (76% blast), and platelet was 154,000/microliters. His bone marrow was hypercellular and consisted with 91% blasts. Myeloperoxidase staining was positive for 38% of blasts. Auer rods were seen in some of blasts. Thus, the diagnosis was M1 according to FAB classification. Cytogenetic studies of 20 marrow cells were performed and all cells had 46, XY, -1, -7, 3q-, 7q-, 17q+, +2mar. Eighty five percent of blasts expressed HLA-DR and 43% of blasts expressed CD2 and CD13 simultaneously. Thus, this leukemia was considered as the hybrid type of acute mixed leukemia by surface marker analysis. DBMP-85 regimen, the chemotherapy for AML, was started after admission and complete remission (CR) was attained in June 1985. After 4 courses of post remission chemotherapy, he discharged in December 1985 and was followed at our outpatient clinic without chemotherapy. His disease was relapsed in June 1986, and the combination chemotherapy with mitoxantrone, etoposide and Ara-C was applied to him but failed to attain CR. Then, LVP protocol, the chemotherapy for ALL, was started and CR was achieved. The blasts at relapse had morphologically myeloid features, and expressed HLA-DR, CD2 and CD13 as well as at diagnosis. Cytogenetic studies at relapse showed some karyotype except gaining 12p- anomaly. Therefore, same blasts were considered to emerge at relapse. Our case suggests that LVP therapy may be effective for AML expressing myeloid and lymphoid surface markers." }, { "id": "wiki20220301en018_98872", "title": "Chronic lymphocytic leukemia", "score": 0.009178625454842798, "content": "Diagnosis The diagnosis of CLL is based on the demonstration of an abnormal population of B lymphocytes in the blood, bone marrow, or tissues that display an unusual but characteristic pattern of molecules on the cell surface. CLL is usually first suspected by a diagnosis of lymphocytosis, an increase in a type of white blood cell, on a complete blood count test. This frequently is an incidental finding on a routine physician visit. Most often the lymphocyte count is greater than 5000 cells per microliter (µl) of blood but can be much higher. The presence of lymphocytosis in an person who is elderly should raise strong suspicion for CLL, and a confirmatory diagnostic test, in particular flow cytometry, should be performed unless clinically unnecessary." }, { "id": "pubmed23n0792_7780", "title": "[Identification of splenic marginal zone lymphoma from B lymphoproliferative disorders by flow cytometry].", "score": 0.009174311926605505, "content": "The splenic marginal zone lymphoma (SMZL) is a relatively rare chronic B lymphoproliferative disease, which primarily manifest increase of peripheral blood lymphocyte count and/or scale, and splenomegaly, while the peripheral superficial lymph nodes are often not swollen. Therefore, the splenectomy are usually needed to confirm the diagnosis, but the majority of patients could not accept such management, resulting in early difficult diagnosis. This study was purposed to explore the more prior way for diagnosis based flow cytometry (FCM). Six patients with suspected diagnosis of SMZL were used as research objects, 10 healthy bone marrow donors and 10 cases of chronic lymphocytic leukemia (CLL), 3 cases of hairy cell leukemia (HCL), 3 cases of lymphatic plasma cell lymphoma/Waldenströ's macroglobulinemia (LPL/WM) were selected as control. The immunophenotype of bone marrow cells were analyzed and compared by FCM using a panel of antibodies including CD45, CD5, CD10, CD19, CD20, CD22, CD23, CD25, CD103, CD11c, CD123, κ,λ, Cyclin D1, and combined with bone marrow cell morphology. The results indicated that 6 cases of suspected SMZL showed a large increase of lymphocytes and splenomegaly. Because absence of peripheral lymphadenopathy, 6 patients did not suffer from lymph node biopsy, only 1 patient underwent diagnostic splenectomy. The immunophenotypes of bone marrow in patients and controls were analyzed by FCM, as a result, except for the healthy donors, varying degrees of abnormal mature B cell clones were found in bone marrow of all patients, and the further differentiation from other B-cell tumors was performed through CD5, CD10 expression and combination with other B-cell phenotype. All 6 cases of SMZL patients expressed CD19(+) and CD20(+), but CD10 expression was negative, 4 patients expressed CD5(-), 2 patients expressed CD5(+). The expressions of CD23, CD38, ZAP-70, CD11c, CD103, CD123, Cyclin D1 were negative. The morphological examination of bone marrow cells showed velutinous abnormal lymphocytes. Combined with clinical characteristics, 6 patients were diagnosed as SMZL, 1 patient suffered from splenectomy because of concurrent hypersplenism, and this postoperative pathologic examination confirmed the patient with SMZL. Ten cases of CLL mainly expressed CD5, CD23; 3 cases of HCL had more typical morphology of \"hair like\" in addition to CD11c, CD103 and CD123 positive; 3 cases of LPL/WM had significantly increased light chain restriction expression, IgM, plasmacytoid lymphocytes. It is concluded that the FCM immunophenotype analysis can be used as a powerful tools for clinical diagnosis of SMZL." }, { "id": "pubmed23n0694_17017", "title": "[The limited possibility of using a simplified approach to detect minimal residual disease by the flow cytometry technique in children with precursor B-lineage acute lymphoblastic leukemia].", "score": 0.009174311926605505, "content": "Minimal residue disease (MRD) is a state in which the tumor cells remain in the patient in the amounts unrecognizable with the standard cytological techniques. Flow cytometry is one of the basic methods for evaluation of MRD in precursor B-lineage acute lymphoblastic leukemia (PBLALL). The so-called simplified three-color analysis using the combination of CD19/CD10/CD34 antibodies has been proposed to detect MRD in the midcourse of induction therapy. Four-to-nine-color is presently used to identify MRD. One hundred and thirty-four bone marrow samples taken at different stages of therapy in 55 children with PBLALL were examined to estimate the possibility of using the flow cytometry technique using the 3-color simplified approach to determining MRD. The results of the simplified and standard approaches were compared in the samples stained with 6-8 monoclonal antibodies in the combinations that always included CD19, Cd10 and CD34. The comparison revealed that MRD had been incorrectly identified by the simplified method in 8.0, 17.6, and 75.8% of the patients on therapy days 15, 36, and 85, respectively. In addition, the content of residual tumor cells with respect to the threshold values more frequently proposed to stratify patients was found to be incorrectly calculated in some true positive samples. Thus, when the simplified approach was applied using the results of MRD detection to stratify the patients into risk groups, 16.0, 27.4, and 81.8% of the samples would yield incorrect information on therapy days 15, 36, and 85, respectively. Thus, the simplified approach to identifying MRD is most applicable on day 15 of therapy; however, there may be mistakes in this point of observation. This method used on day 36 more frequently yields incorrect results and is inapplicable on day 85." }, { "id": "wiki20220301en254_37373", "title": "Monoclonal B-cell lymphocytosis", "score": 0.00909090909090909, "content": "MLB falls into three phenotypes that are distinguished based on the cell surface marker proteins which they express viz., the CLL/SLL, atypical CLL/SLL, and non-CLL/SLL phenotypes. These markers are: CD5, CD19, CD20, CD23, and immunoglobulins (Ig) (either Ig light chains or complete Ig, i.e. light chains bound to Ig heavy chains. Distinguishing between these phenotypes is important because they progress to different lymphocyte malignancies. The following table gives the markers for the three MBL phenotypes with (+) indicating the expression (either dim, moderate, or bright depending or the intensity of their expression), (−) indicating the absence of expression, and na indicating not applicable as determined using fluorescent probes that bind the marker proteins. Detection of fluorescent probe binding by the cells requires the use of flow cytometry preferably employing 6 to 8 different fluorescent probes that bind to different markers on 5 million cells from the patient's blood. The" }, { "id": "wiki20220301en179_39478", "title": "B-cell prolymphocytic leukemia", "score": 0.009009009009009009, "content": "Immunophenotype This technique is used to study proteins expressed in cells using immunologic markers. In B-PLL patients there is strong expression of surface immunoglobulin – a membrane-bound form of an antibody, b-lymphocyte surface antigens CD19, CD20, CD22, CD79a and FMC7, and weak expression of CD5 and CD23. Due to the similarities among lymphoproliferative disorders, it is often difficult to diagnose patients. Immunophenotyping helps distinguish B-PLL from similar diseases, one of its key identifiers is the absence in expression of the surface antigens CD10, CD11c, CD25, CD103 and cyclin D1 – an important regulator of cell-cycle progression. A case has been described as CD20+, CD22+, and CD5-. It can also be CD5+. Another case was described as CD45+, CD19+, CD20+, CD5+, HLA-DR+, CD10-, CD23+/-, CD38+ and FMC7-." }, { "id": "pubmed23n0673_21307", "title": "[Minimal residual disease monitoring by flow cytometry in children with acute lymphoblastic leukemia].", "score": 0.009009009009009009, "content": "The cells that have avoided the action of antitumor drugs may be retained after remission achievement during induction therapy and consolidation. A combination of these cells is given the name minimal residual disease (MRD). Multicolor flow cytometry has recently attracted considerable interest as the most promising method for measuring the content of residual tumor blasts. This technique is based on the detection of the so-called leukemia-associated immunophenotype (LAIP), i.e., a tumor-specific combination of the expression of membrane and cytoplasmic markers. Flow cytometry may be successfully used to monitor MRD in 90-95% cases of acute lymphoblastic leukemia (ALL) and in 80-85% of patients with acute myelocytic leukemia. The sensitivity of flow cytometry, which is real for routine flow techniques, is a possibility of identifying one cell among 10(4)-10(5) cells. Multicolor flow cytometry (that involves the simultaneous analysis of the expression of a few markers) is the most reasonable tool for MRD monitoring. The monoclonal antibody panels recommended by different groups of investigators for MRD monitoring in B-lineage ALL include antibodies to the pan-B-cell antigen CD19, markers of different stages of differentiation of B-lineage precursors of CD10, CD34, and CD20 and leukemia-associated markers different for each panel, such as CD22, CD38, CD58, CD45, TdT, CD13, CD33. The hyperexpression of CD10, CD34, CD19, TdT, the decreased expression of CD38, CD45, CD22, CD19, the simultaneous expression of markers of different stages of differentiation of B lymphocytes, such as CD10 and CD20, and the lymphoblast coexpression of myeloid markers of CD13, CD33, CDS15 are the most frequently described immunophenotype aberrations in B-lineage ALL. The selection of combinations of markers for MRD monitoring in children with T-ALL is based on the simultaneous expression of combinations of the antigens characteristic for early stages of differentiation of normal T lymphocytes, namely TdT and cytoplasmic CD3. Some authors consider the use of CD99 versus TdT to be most appropriate. There is recent evidence that MRD-positive patients have a higher cumulative risk for recurrences as compared with those without residual blasts. Moreover, the longer the tumor cells are retained during therapy, the worse the prognosis is. Thus, for choice of the adequate intensity of antitumor therapy, it is necessary to qualitatively and quantitatively assess MRD by multicolor flow cytometry at different stages of therapy." }, { "id": "pubmed23n0749_1875", "title": "A case of chronic lymphocytic leukemia with massive ascites.", "score": 0.008928571428571428, "content": "An 81-year old woman with a history of chronic lymphocytic leukemia (CLL) was admitted with night sweats and abdominal distension. A complete blood count showed hemoglobin 5 g/dL, white blood cell (WBC) count 28.5×10(9)/L and platelets 38.4×10(9)/L. Peripheral blood smear examination showed a large number of smudge cells and lymphocytosis composed of mature-looking lymphocytes with clumped nuclear chromatin. Computed tomography scan demonstrated enlarged cervical, axillary, paraaortic, retroperitoneal and mesenteric lymph nodes with concomitant omental thickening and ascites. Also, the liver and the spleen were enlarged in the presence of multiple ill-defined hypoechoic areas in the latter. Histopathological analysis of the cervical lymph node biopsy was consistent with CLL. Bone marrow examination showed diffuse infiltration of the marrow with small lymphocytes. Analysis of the ascitic fluid revealed an exudate with WBC 1220 cells/mL. Cytocentrifuge preparation of the ascitic fluid showed small mature lymphoid cells containing hyperchromatic nuclei with coarsely granular chromatin. On flow cytometric analysis of the ascitic fluid, expression of CD5, CD19, CD20, CD22, CD23, CD45 and HLA-DR was compatible with a diagnosis of CLL, in accordance with the results of the peripheral blood analysis. The patient was treated with chemotherapy consisting of cyclophosphamide, vincristine and prednisolone but died within one month after development of non-chylous ascites." }, { "id": "pubmed23n0816_12179", "title": "[Analysis and significance of hematopoietic progenitor B cells in patients with acute leukemia].", "score": 0.008928571428571428, "content": "Normal hematopoietic B progenitor cells are similar with acute B lymphoblastic leukemia (ALL) cells in terms of morphology and immunophenotypes which easily result in misdiagnosis of diseases. This study was purposed to explore the importance of B progenitor cell (BPC) level in differential diagnosis of hematologic diseases. A total of 664 specimens including 87 specimens from patients with non-malignant hematologic diseases as control and 577 specimens from AL patients in different progressive stage were analyzed. Out of 577 specimens 26 were collected from ALL patients, 261 were collected from B-ALL, 290 were collected from AML. The relation of different clinical status (new diagnosis, remission, relapse), age and degree of leukemia cell involvement with hematopoietic BPC level were analyzed through identification of CD34/CD10/CD19/CD45 antibody combination and quantification of hematopoietic BPC. The results indicated that (1) CD45 distributed from positive to weak positive, and with very low side scatter. The early hematopoietic BPC expressed CD34⁺, along with increasing of cell maturation, the CD34 expression gradually disappeared, while CD19 and CD10 showed positive in whole stage of hemaropoietic BPC, and early CD10 highly was expressed. (2) the mean percentage of hematopoietic BPC was 1.36% in control group, 0.60% in T-ALL, 1.39% in B-ALL and 0.80% in AML; the detected rate of hematopoietic BPC in control, T-ALL, B-ALL and AML were 87.4%, 61.5%, 83.5%, 75.9%, respectively; the mean percentage of hematopoietic BPC was 0.37% at new diagnosis, 1.66% in remission and 0.55% in relapse. (3) along with increase of age, the hematopoietic BPC level generally disclined. (4) specimens &gt;5% hematopoietic BPC were mainly found in remission stage of leukemia patients. It is concluded that the hematopoietic BPC are present in malignant and non-malignant hematologic diseases. The changes of hematopoietic BPC level correlate with disease state, age and leukemia cell involvement. The increased hematopoietic BPC level are observed most often in the patients with remission after themotherapy. It should be carefully to diagnose and discriminate between malignant and benign cells with double positive CD19 and CD10. Use of multiparametric flow cytometry and optimal antibody combination are important for discriminating hematopoietic BPC from minor residual disease and accuratly diagnosing diseases and evaluating curative effectiveness." }, { "id": "pubmed23n0746_7661", "title": "Case report: rare case of infiltration of small lymphocytic B-cell lymphoma in the thyroid gland of female patient with B-cell chronic lymphocytic leukemia (CLL-B/SLL-B).", "score": 0.008849557522123894, "content": "The article presents a case of 57-year-old woman with the infiltration of rare small lymphocytic B cell lymphoma in the thyroid gland. Initially, the patient was followed-up due to chronic lymphocytic B-cell leukemia diagnosed on the basis of histopathological examination of cervical lymph node. Eight months later, general symptoms occurred along with lymphocytosis and exacerbation of lesions in lymph nodes, and therefore, chemotherapy was started according to COP regimen. After four chemotherapy cycles, further progression of the disease was observed during chemotherapy. Computed tomography (CT) performed at that time showed generalized lymphadenopathy and the presence of an irregular area in left thyroid lobe. On palpation, the thyroid was asymmetrical, with enlarged left lobe and palpable lymph node packages on the left side of the neck. The levels of thyroid hormones and anti-thyroid antibodies were normal. Ultrasound examination of the thyroid gland showed non-homogeneous hypoechogenic structure of the left lobe and complete focal remodeling. Cytological examination of left-lobe lesion obtained during fine needle aspiration biopsy showed multiple small lymphoid cells, suggestive of small lymphocytic lymphoma. To confirm this diagnosis, flow cytometry of the biopsy material sampled from the left lobe was performed showing B cellimmunophenotype: CD19+/CD20+/CD22 dim/FMC-7, CD23+/CD5+, sCD79b-+, CD38-, CD10-, kappa and lambda-/weak reaction. The results of flow cytometry of the thyroid bioptate and blood were nearly identical, confirming leukemic nature of the infiltration in left thyroid lobe. Cytogenetic findings included the presence of 17p deletion (TP53 gene). The patient received immunochemotherapy with alemtuzumab. The progression of the disease occurred in the sixth week of therapy. The treatment was discontinued after 8 weeks due to worsening of patient's general status. The patient died 15 months after the diagnosis." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 189, 253 ] ], "word_ranges": [ [ 28, 37 ] ], "text": "When associated with palpable mass, 60% correspond to carcinoma." }, "2": { "exist": true, "char_ranges": [ [ 25, 146 ] ], "word_ranges": [ [ 5, 22 ] ], "text": "In the presence of unilateral and uniorificial hematic telorrhea, the most frequent cause is intraductal papilloma (50%)," }, "3": { "exist": true, "char_ranges": [ [ 254, 296 ] ], "word_ranges": [ [ 37, 44 ] ], "text": "Paget's disease is of the eczematous type." }, "4": { "exist": true, "char_ranges": [ [ 297, 362 ] ], "word_ranges": [ [ 44, 51 ] ], "text": "In hyperprolactinemia, telorrhea is bilateral and pluriorificial." }, "5": { "exist": true, "char_ranges": [ [ 363, 454 ] ], "word_ranges": [ [ 51, 63 ] ], "text": "Mammography often does not show papillomas, being more useful ultrasound and galactography." } }

{ "1": "Given the hematic nature of the discharge, the most likely diagnosis is infiltrating ductal carcinoma.", "2": "Intraductal papilloma.", "3": "Paget's disease of the nipple.", "4": "Tumor hyperprolactinemia.", "5": "Mammography will indicate the diagnosis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1063_25069", "title": "A rare case of intraductal papilloma with atypical ductal hyperplasia in a male breast: A pathological diagnosis.", "score": 0.01793400286944046, "content": "Male breast cancer is itself a very rare condition and represents 0.5%-1% of all breast cancers diagnosed. Atypical ductal hyperplasia (ADH), intraductal papilloma (IP), and ductal carcinoma <iin situ</i are also very rare in a male breast. Only a few cases of ADH with gynecomastia have been reported in English literature until now. Here, we report a rare case of an IP with ADH associated with gynecomastia in an elderly male, who complained of right nipple pain, discharge, and tiny retroareolar mass. Mammography showed a subareolar nodule graded as the Breast Imaging-Reporting and Data System 4B. It is difficult to differentiate, both clinically and radiologically, between benign and malignant papillary lesions and invasive carcinoma, because of the similarity of findings. Hence, any male with palpable unilateral hard fixed lesions in the retroareolar region with complaints of nipple discharge, skin changes, or axillary lymphadenopathy should have a histopathological evaluation." }, { "id": "pubmed23n0799_4654", "title": "The role of breast ductoscopy in evaluation of nipple discharge: a chinese experience of 419 patients.", "score": 0.01778827233372688, "content": "The aim of this study is to report our experience with ductoscopic evaluation for screening patients with nipple discharge and evaluate any potential indications and benefits of ductoscopy. From January 2010 to December 2012, 419 female patients with nipple discharge were enrolled in this study. All patients involved in this study showed no mass in ultrasound and mammography. Data concerning age, clinical characteristics of nipple discharge, nipple discharge cytology, ductoscopic and postsurgical diagnosis, and complications were statistically analyzed. Ductoscopy examinations were completed in 405 patients (96.66%). For these 405 patients, there were 519 ductoscopic investigations. 112 (27.65%) patients were found to have intraductal papillary lesions of which 62 were operated in our hospital. Postsurgical diagnosis showed 8 (12.9%) malignancy including 6 DCIS and 2 invasive ductal carcinomas. All of the 8 patients meet at least two criteria of pathologic nipple discharge (single duct, spontaneous, bloody nipple discharge). The other patients with nonpapillary lesions are still under surveillance. By univariate analysis, patients with unilateral, single duct, spontaneous and bloody nipple discharge were more likely to have intraductal papillary lesions. By multivariate analysis, unilateral, spontaneous, and bloody nipple discharge showed statistically significant correlations with intraductal papillary lesions revealed by ductoscopy. Ductoscopy is a safe and efficient investigation in preoperative screening of the patients with nipple discharge. Clinical characteristics have predictive value in selection of patients for ductoscopical investigation. Patients with clinical characteristics of unilateral, spontaneous, and bloody nipple discharge were more likely to have intraductal papillary lesions revealed by ductoscopy. " }, { "id": "pubmed23n0272_5414", "title": "Management of nipple discharge.", "score": 0.017615384615384616, "content": "In a series of 9,312 women who consulted one of the authors with a complaint of disease of the breast between 1959 and 1991, nipple discharge was the presenting symptom in 448 (4.8 percent). Nipple discharge was spontaneous in 243 (2.6 percent) and provoked in 205 (2.2 percent) of the patients. The ages of the patients ranged from 13 to 75 years (mean of 42.5 years) in the spontaneous and 16 to 70 years (mean of 37.8 years) in the provoked discharge group. When a palpable mass was found, biopsy was undertaken, while in instances of nipple discharge only, subareolar exploration was performed. Of the 115 patients in the spontaneous and 25 patients in the provoked groups who underwent biopsy, the most frequent cause of nipple discharge was intraductal papilloma (47.8 percent). Nipple discharge was the result of carcinoma in 35 patients (14.4 percent) in the spontaneous and six patients (2.9 percent) in the provoked group, respectively. In patients with a palpable mass, the incidence of carcinoma was 61.5 percent compared with 6.1 percent in patients with nipple discharge only. Patients presenting with nipple discharge should undergo biopsy or subareolar exploration based on the presence or absence of a palpable tumor. The patients in whom no clinical findings could be detected should have follow-up evaluation at regular intervals." }, { "id": "pubmed23n1131_14533", "title": "Nipple Adenoma: Case Report of a Rare Entity.", "score": 0.016547008547008548, "content": "A nipple adenoma is a rare benign breast tumor. The commonest presentation of this rare entity is nipple erosion, serosanguinous discharge, induration, or tumor formation at the nipple. It often mimics malignant breast lesions or nipple eczema and is mistaken for Paget's disease of the nipple or dermatological pathology. It may be misdiagnosed pathologically as ductal carcinoma of the breast. This may cause a diagnostic delay or a faulty diagnosis. Treatment is the excision of the tumor with or without nipple excision. Here, we report a case of nipple adenoma that projected out of the nipple along with nipple erosion, serosanguinous discharge, and occasional bleeding from the adenoma. A 37- year-old woman presented with a tumor on her right nipple for eight months, with the erosion of the nipple and serosanguinous discharge. The patient gave a history of a small amount of bleeding occasionally. Axilla was normal. The patient was advised to have a mammosonography. It showed an oval-shaped, well-demarcated, hypoechoic, uniformly solid nodule in the right nipple. There was no microcalcification seen on mammography. A punch biopsy was done to establish the diagnosis. It showed ductal hyperplasia and papillary proliferation of glandular structures suggestive of nipple adenoma. Complete resection of the tumor with partial excision of the nipple was done with a satisfactory cosmetic result. Though very uncommon, the possibility of nipple adenoma should be thought of when a patient presents with nipple erosion and discharge with or without a clinically obvious tumor. Timely diagnosis with histopathological correlation is important since it allows for less invasive surgical methods. In our case, we could attain a cosmetically satisfactory outcome without a remnant tumor. Paget's disease of the nipple also has a similar clinical presentation, and it is a premalignant condition. The objective of presenting this case is to highlight the possibility of this rare benign condition, which may be easily missed clinically and also demands careful histopathological examination for its correct diagnosis." }, { "id": "pubmed23n0659_9928", "title": "Breast discharge: ultrasound and Doppler evaluation.", "score": 0.01582751744765703, "content": "Nipple discharge causes discomfort and anxiety to many women. Nipple discharge is most commonly associated with endocrine alterations and/or medications. These often result in duct ectasia and/or fibrocystic changes that may lead to discharge from one or several ducts. The most common cause of clinically significant discharge is intraductal growth of the ductal epithelium, due to hyperplasia, micropapillary proliferation, solitary papillomas and/or ductal carcinoma (both in situ and invasive). The aim of the study was to evaluate the role of the gray-scale ultrasound and colour Doppler in the diagnosis of intraductal pathology in patients with nipple discharge. One hundred &amp; seven patients were included in the study, (age range 23-65years). Standard mammographic views were taken. Ultrasound evaluation was performed for all cases; ductography for 20 cases and ductoscopy for 3 cases. US guided fine needle biopsy was done in 7 cases; microducectomy of affected duct was done in 20 cases and major duct excision in 5cases. Fibro-optic Ductoscopy is performed for 3 cases. Revision of biopsy specimens of 17 cases with intraluminal masses detected by US revealed: Six cases with intraductal carcinoma, intraductal papilloma in 7 cases, 1 case of ductal papillomatosis. Three cases showed atypical cells: Intraductal papilloma with atypia in 2 cases, proliferative hyperplasia with atypia in one case. Eighty eight cases had simple duct ectasia (51 bilateral multiple and 37 focal duct ectasia). No dilated ducts were detected in 2 cases. Fibro-optic Ductoscopy confirmed the presence of intraductal papilloma in one case, carcinoma in one case, no intraductal masses in the third case. A 6 months follow-up was requested for all cases with no detected intra luminal pathology. Ultrasound examination is highly sensitive (100%) but less specific (82.4%) in diagnosis of intraductal pathology. Colour &amp; power Doppler are sensitive (94%) in detecting flow in intraductal echogenic masses to differentiate them from insipissated secretions. Colour and power Doppler raises specificity and diagnostic accuracy to 100%. Ductography is an underused procedure that is sensitive (100%) but less specific (60%) in characterization of intraductal filling defects. Ultrasonography is a mandatory complement to mammography in these cases, US guided fine needle biopsy is minimally invasive technique in confirming the diagnosis of suspicious mass. Ultrasound may also be a guide to fibro-optic ductoscope. Ductography - Nipple discharge - Intraductal carcinoma - Intraductal papilloma - In situ ductal carcinoma - Invasive ductal carcinoma - Duct ectasia - Breast ductoscopy." }, { "id": "pubmed23n0943_5486", "title": "[Diagnosis of a Non-Invasive Ductal Carcinoma, Assisted by Long-Term Follow-Up of Spontaneous Nipple Discharge - A Case Report].", "score": 0.015791945520723258, "content": "We report a case of a non-invasive ductal carcinoma revealed on long-term follow-up of spontaneous nipple discharge. The patient, a 36-year-old woman, had noticed spontaneous nipple discharge from both breasts over a 3-year period. Mammography and ultrasonography did not reveal any lesions in the breasts. The nipple discharge from her left breast stopped 36 months after initial clinical assessment. However, the nipple discharges from her right breast transformed into a bloody discharge from a single duct. Ultrasonography showed a tumor, 6mm in diameter, in the upper-outer quadrant of her right breast. A core needle biopsy for breast tumor led to a pathological diagnosis of non-invasive ductal carcinoma. We conducted a whole-body clinical examination but no metastatic lesions were detected. Subsequently, we performed breastconserving surgery and sentinel lymph node biopsy. The pathological diagnosis was non-invasive ductal carcinoma in situ. The tumor was positive for estrogen and progesterone receptors, but negative for HER2/neu. The Ki-67 labeling index was 5%. The surgical margin was negative. We diagnosed the tumor as TisN0M0=Stage 0. Endocrine therapy comprising tamoxifen (20mg/day)was initiated. Four years after surgery, she was well without any metastases." }, { "id": "pubmed23n0099_14966", "title": "Intraductal papillomas: diagnostic and surgical procedures.", "score": 0.01552868658131816, "content": "A series of 98 patients with spontaneous nipple discharge, is reported. Diagnosis was based on: clinical examination, cytology of breast secretion, mammography and galactography. Surgical resection was recommended in the following cases: galactographic evidence of intraductal papilloma or papillomatosis, dubious or positive cytology, persisting hemorrhagic or sero-hemorrhagic secretion. The injection of vital staining before the operation allowed the precise location of the lesion. In the group of patients studied ten cases of ductal carcinomas (5 in situ and 5 smaller than 1 cm), 4 cases of atypical intraductal hyperplasia, 13 cases of solitary papilloma and 22 cases of multiple papillomatosis were diagnosed." }, { "id": "pubmed23n0287_13595", "title": "[The role of ductal galactography in the differential diagnosis of breast carcinoma].", "score": 0.015085081950099175, "content": "The authors report on a series of 1009 consecutive patients submitted to clinical examination, mammography, cytology and galactography for the presence of nipple discharge. Galactography was performed mainly in the presence of hematic nipple discharge. Surgical biopsy was performed in 392 cases, and 52 cancers (31 invasive and 21 intraductal lesions) were diagnosed, which were suspected at palpation, mammography, cytology and galactography in 17, 17, 18 and 31 cases, respectively. Forty of 52 cancers were suspected on the basis of combined exam findings, while 8 cancers (7 intraductal and 1 invasive lesions) were submitted to biopsy on the basis of a galactographic diagnosis of multiple benign papilloma, an (invasive) lesion with a diagnosis of single papilloma, and 3 (invasive) lesions because of persistent hematic discharge. Cancer was suspected with only one exam in 14 cases: 3 at cytology, 2 at mammography, 1 at clinical examination and 8 at galactography. Hematic discharge alone is not a sufficient reason to indicate surgery, because its positive predictive value for cancer is low (&lt; or = 10%), while cytology is of limited help because of its poor sensitivity (34.6%). In contrast, galactography (59.6% sensitivity) gives a greater contribution to differential diagnosis and is always indicated in the presence of hematic discharge. Galactographic evidence suspicious for cancer (67.3% positive predictive value) or for multiple papilloma (9.7% positive predictive value) is sufficient to advise open biopsy. The surgical removal of single papillomas is of questionable benefit, since single papillomas are benign lesions, with no clear evidence of progression to cancer. In our series, only one cancer was misdiagnosed as a single papilloma at galactography (0.5% positive predictive value)." }, { "id": "pubmed23n0072_10076", "title": "[Differential diagnosis of nipple discharge].", "score": 0.014973262032085561, "content": "An analysis of results of contrast mammography in 42 women having spontaneous, persistent and unilateral discharge from the nipple of the breast of serous, serous-hemorrhagic and hemorrhagic character was made. The cause of the discharge was found to be intraductal papillomas and cystadenopapillomas in 55% of the cases, breast cancer--in 2% which were not diagnosed by noncontrast mammography." }, { "id": "pubmed23n0515_13511", "title": "[Evaluation of bloody nipple discharge].", "score": 0.014732475268588448, "content": "A 64-year old woman was referred for radiological evaluation of right sided bloody nipple discharge lasting for five months. Finally galactography supposed the diagnosis of an intraductal papilloma which was confirmed by surgery. Histopathologically an eight millimeter measuring intraductal papilloma with atypical ductal hyperplasia with signs of a carcinoma in situ was seen." }, { "id": "wiki20220301en326_7517", "title": "Nipple adenoma", "score": 0.014509285029885476, "content": "A nipple adenoma is a rare benign tumour of the breast. The condition may also be known as : Florid papillomatosis of the nipple Florid adenomatosis Subareolar duct papillomatosis Erosive adenomatosis Signs and symptoms Nipple adenomas may be felt as a lump under the nipple or areola. They may come to attention because of nipple pain, ulceration, swelling or discharge. Diagnosis Definition A nipple adenoma is a type of intraductal papilloma that arises within the lactiferous ducts that are located within the nipple. Differential diagnosis The microscopic appearance of a nipple adenoma can be mistaken for carcinoma. Other conditions that have similar symptoms and signs as nipple adenoma include Paget's disease of the breast, other intraductal papillomas, ductal carcinoma in situ (DCIS), syringomatous adenoma of the nipple and subareolar sclerosing duct hyperplasia." }, { "id": "pubmed23n1165_4914", "title": "Ductal carcinoma in situ of the breast arising in a solitary intraductal papilloma.", "score": 0.014473999520728493, "content": "Ductal disease is a broad group encompassing both benign and malignant entities which may overlap clinically and radiologically. Ductal carcinoma in situ (DCIS) is a noninvasive breast malignancy accounting for 20% of newly diagnosed breast cancer cases. It involves malignant epithelial cells confined to the duct(s). Although they are commonly diagnosed incidentally on screening mammography, DCIS may present with nipple discharge or a palpable lump. Benign diseases of the duct include intraductal papilloma and may present similarly with bloody or serous nipple discharge. Imaging evaluation will help in differentiating between the 2 entities and pathological examination will provide the final diagnosis. We present a case of a 72-year-old female who was presented with serous and bloody discharge and histology revealed intermediate grade ductal carcinoma in situ involving an intraductal papilloma." }, { "id": "wiki20220301en034_74814", "title": "Nipple discharge", "score": 0.01446975354742345, "content": "A blocked or enlarged milk duct can result in nipple discharge. Intraductal papillomas are non-cancerous lesions and commonest in women age 30 to 50. Divided into central and peripheral papillomas, nipple discharge is more frequently observed when they are central. Up to half of women with intraductal papillomas may present with bloody nipple discharge, but it can also be straw-coloured. They are usually too small to feel and have a rare association with breast cancer. 15-20% of people with nipple discharge are found to have duct ectasia. This is usually in perimenopausal and menopausal women, who may have associated pain and retraction of the nipple. A lump may also be present. Ductal carcinoma in situ (DCIS) usually presents with abnormal findings on mammography, but can less frequently present with a lump or nipple discharge in women, whereas in men with DCIS, nipple discharge is the common presentation." }, { "id": "pubmed23n0558_9614", "title": "Solitary intraductal papilloma of the breast--a diagnostic dilemma and the role of conferencing between surgeons and cytologist.", "score": 0.014437302316090195, "content": "A 40 year female, presented with the complaints of spontaneous, sticky, blood stained discharge from the nipple of the left breast since 6 months. On examination there was no lump palpable in either breast. Cytology of the nipple discharge (ND) showed scanty cellularity consisting of tight papillary clusters of ductal cells in a hemorrhagic and inflammatory background. The nuclei were bland and showed degenerative atypia. Mammography showed no significant lesion. Our patient underwent microdochechtomy. Histopathology showed intraductal papilloma. Limitations of cytology must be kept in mind by both, the pathologist and the surgeon. The cytological diagnosis of a papillary tumor is provisional and the definitive diagnosis must await histological examination. In view of rarity of this lesion, combined with the overlapping of cytologic features in benign and malignant papillary lesions, conferencing and communication with the surgeon should be an integral part of patient evaluation and management. In our case this approach resulted in less radical excision of breast tissue." }, { "id": "pubmed23n0672_9530", "title": "Predicting occult malignancy in nipple discharge.", "score": 0.014321357285429142, "content": "This study was a retrospective analysis of patients who underwent minor or major duct surgery for pathological nipple discharge. The results of clinical examination, mammography, ultrasonography and cytodiagnosis of the nipple discharge were studied in order to predict those patients at risk of underlying or occult malignancy. Between January 2004 and December 2006, 55 female patients aged between 24 and 82 years old underwent major or minor duct excision, 49 of which were for pathological nipple discharge. Results of several preoperative investigations were compared with the surgical pathology to determine how their sensitivity and specificity faired in predicting malignant ductal pathology. Of the 49 patients undergoing surgery for nipple discharge, 21 were diagnosed with intraductal papilloma, 19 with duct ectasia, 6 with carcinoma, 2 with benign breast disease and 1 with lobular carcinoma in situ. In all of the patients determined to have malignancy, none demonstrated malignant changes on mammography or ultrasonography. Only 2 of the 6 patients with malignancy were found to have atypical cells on cytological analysis. The sensitivity of blood detected in nipple discharge at predicting malignancy was 0.83, specificity of 0.53, positive predictive value of 0.20 and negative predictive value 0.96. Despite the various tests used in the assessment of pathological nipple discharge, this study highlights their limited help at predicting the cause. This, together with several other studies, demonstrates that ductal surgery remains the only reliable way of providing a diagnosis, in addition to being the major therapeutic measure." }, { "id": "pubmed23n0647_16940", "title": "Nipple discharge screening.", "score": 0.014188861985472156, "content": "Nipple discharge is a common complaint among women. It is classified as normal or abnormal depending on features such as laterality, cycle variation, quantity, color or presentation (i.e., induced vs spontaneous). It can be related to benign conditions, such as intraductal papilloma, duct ectasia, plasma cell mastitis or galactorrhea; or to malignant conditions such as ductal, lobular or papillary carcinoma. Techniques used in nipple discharge evaluation include mammography, ultrasound, cytology (which could be assisted by a mammary pump), duct endoscopy, ductography, immunochemical methods and at least surgical excision of the pathological ducts for diagnosis and treatment in the same procedure." }, { "id": "wiki20220301en273_18984", "title": "Intraductal papilloma", "score": 0.013905654000289702, "content": "Intraductal papillomas of the breast are benign lesions with an incidence of approximately 2-3% in humans. They result from abnormal proliferation of the epithelial cells lining the breast ducts. Two types of intraductal papillomas are generally distinguished. The central type develops near the nipple. They are usually solitary and often arise in the years nearing menopause. On the other hand, the peripheral type are often multiple papillomas arising at the peripheral ducts, and are usually found in younger women. The peripheral type are associated with a higher risk of malignancy. They are the most common cause of bloody nipple discharge in women age 20-40 and generally do not show up on mammography due to their small size. They may be detectable on ultrasound. A galactogram is the most definitive test but is somewhat invasive. The masses are often too small to be palpated or felt. A galactogram is therefore necessary to diagnose the type of lesion." }, { "id": "pubmed23n0905_1196", "title": "Diagnostic value of endoscopic appearance during ductoscopy in patients with pathological nipple discharge.", "score": 0.01387699932417211, "content": "To explore the features of ductoscopic appearance that may be diagnostic in patients with pathologic nipple discharge (PND) and to discuss the diagnostic criteria for intraductal tumors. We reviewed 247 patients with PND but without a palpable mass who were evaluated using either surgical biopsy or excision. Data concerning patient age, duration of discharge, discharge color, and the details of endoscopic appearance were analyzed according to the pathological results. The postoperative diagnosis in 61 patients (24.70%) was a nonmass lesion, and 186 patients (76.52%) had an intraductal tumor. Among those with intraductal lesions, 10 patients (4.05%) had a malignant tumor, including 4 (1.62%) with ductal carcinoma in situ and 6 (2.43%) with invasive ductal carcinoma. On univariate analysis, patients of older age with spontaneous and bloody discharge were more likely to suffer from intraductal lesions. On logistic regression analysis, bloody nipple discharge, morphology, and a broad lesion base revealed by ductoscopy showed a statistically significant correlation with malignancy (p = 0.001, p &lt; 0.001, p = 0.022, respectively). Both clinical features and endoscopic appearance are significant for the precise diagnosis of an intraductal lesion seen on ductoscopy. The endoscopic features of bloody discharge, morphology, and a broad lesion base are independent risk factors for malignancy and represent new criteria for the diagnosis of patients with PND." }, { "id": "pubmed23n1060_20872", "title": "Unilateral nipple discharge in a man without a palpable mass diagnosed as breast cancer.", "score": 0.013761467889908258, "content": "A 69-year-old man without a family history of breast cancer presented to his primary care physician with a 1-year history of clear, unilateral nipple discharge (ND) without an associated palpable breast mass. His laboratory findings were significant for hyperprolactinaemia at 28 ng/mL. Diagnostic work up including mammography, ultrasound and core needle biopsy ultimately revealed a ductal carcinoma in situ and a rare papillary variant of invasive ductal carcinoma. The patient was referred to a multidisciplinary oncology team and underwent a right total mastectomy followed by adjuvant hormonal therapy. The patient made a good postoperative recovery and remains without evidence of recurrence 6 months from surgery. Male breast cancer is rare, but its incidence is increasing. Male breast cancer presenting as ND without a palpable mass is uncommon. Early recognition of breast symptoms in men can lead to earlier diagnoses and improved outcomes." }, { "id": "pubmed23n0932_9574", "title": "Breast imaging in patients with nipple discharge.", "score": 0.01367386669138778, "content": "Nipple discharge is a common symptom in clinical practice, representing the third leading breast complaint, after pain and lumps. It is usually limited and has a benign etiology. The risk of malignancy is higher when the discharge is uniductal, unilateral, spontaneous, persistent, bloody, or serous, as well as when it is accompanied by a breast mass. The most common causes of pathologic nipple discharge are papilloma and ductal ectasia. However, there is a 5% risk of malignancy, mainly ductal carcinoma in situ. The clinical examination is an essential part of the patient evaluation, allowing benign nipple discharge to be distinguished from suspicious nipple discharge, which calls for imaging. Mammography and ultrasound should be used together as first-line imaging methods. However, mammography has low sensitivity in cases of nipple discharge, because, typically, the lesions are small, are retroareolar, and contain no calcifications. Because the reported sensitivity and specificity of ultrasound, it is important to use the correct technique to search for intraductal lesions in the retroareolar region. Recent studies recommend the use of magnetic resonance imaging in cases of suspicious nipple discharge in which the mammography and ultrasound findings are normal. The most common magnetic resonance imaging finding is non-mass enhancement. Surgery is no longer the only solution for patients with suspicious nipple discharge, because short-time follow-up can be safely proposed." }, { "id": "wiki20220301en455_28433", "title": "Galactography", "score": 0.012869618507737091, "content": "Causes for nipple discharge include duct ectasia, intraductal papilloma, and occasionally ductal carcinoma in situ or invasive ductal carcinoma. The standard treatment of galactographically suspicious breast lesions is to perform a surgical intervention on the concerned duct or ducts: if the discharge clearly stems from a single duct, then the excision of the duct (microdochectomy) is indicated; if the discharge comes from several ducts or if no specific duct could be determined, then a subareolar resection of the ducts (Hadfield's procedure) is performed instead. To avoid infection, galactography should not be performed when the nipple discharge contains pus. See also Galaxy References Projectional radiography Breast imaging Cancer screening" }, { "id": "pubmed23n0134_16495", "title": "Management of nipple discharge by clinical findings.", "score": 0.01267689854494718, "content": "In a review of 249 office patients who complained of nipple discharge, breast nodularity and duct ectasia was the cause in three quarters. The clinical diagnosis was made by observing that more than one duct was involved and by the color of the discharge. On average, the patients were 10 years younger than those with cysts and 20 years younger than those with carcinoma. In half, the discharge could persist or recur for months or years. Nipple discharge was not commonly associated with carcinoma, and when it was, the carcinoma was almost always palpable. Nipple discharge, including bloody discharge, should be regarded as a sign of a benign breast disorder, not of breast cancer. Duct papillomas can be recognized by exploring the single profusely discharging duct, regardless of the color of the discharge. Other than patients with an obvious lump, the only patients who require surgical exploration are those with a single profusely discharging duct, not because cancer is a significant possibility but merely to rid the patient of the nuisance of the continuing discharge from a duct papilloma. Of 249 patients with nipple discharge, breast nodularity and duct ectasia was the cause in 75 percent. The median age of these patients was the mid 30s. The discharge was chronic or recurring in half. Only 4 percent of all the patients with nipple discharge had an associated breast cancer. When cancer was present, an obvious lump was usually palpable. Bloody discharge was much more likely to be associated with benign breast disorders than cancer. A single profusely discharging duct should be explored regardless of the discharge color because of the likelihood of finding a duct papilloma." }, { "id": "pubmed23n0849_16429", "title": "[Intraductal metachronic papilloma: Clinical case].", "score": 0.012650674304809643, "content": "The association of gynecomastia and bloody nipple discharge (thelorragia) leads us to the diagnosis of intraductal papilloma. This is a very rare benign tumor in children. A 2 year old male child was referred due to gynecomastia and bloody nipple discharge of the left breast. A mastectomy was performed. At the age of 4 he returned with identical symptoms but in the right breast. A right mastectomy was also required. An excellent clinical outcome was present in the follow up. The pathology reported intraductal papilloma with no evidence of malignancy or atypia. The intraductal papilloma rarely affects children, there are 15 reported cases. Ultrasound is the most useful diagnostic method. In male patients, mastectomy is recommended to ensure definitive diagnosis and treatment." }, { "id": "pubmed23n0860_24338", "title": "Intraductal Papilloma with Benign Pathology on Breast Core Biopsy: To Excise or Not?", "score": 0.012057648401826482, "content": "The management of intraductal papillomas on core biopsy continues to be controversial. Papillomas with atypia are typically excised. However, it is unclear whether surgical excision is warranted for benign lesions. A retrospective review of our institution's pathology and radiology databases from January 2009 through May 2014 identified 119 patients with a diagnosis of benign papilloma without atypia on core biopsy. We determined the rate of carcinoma identification on surgical excision. The average patient age was 52.8 years (range 24-84 years). Indication for core biopsy included: abnormal imaging (n = 106), nipple discharge (n = 21), or palpable mass (n = 24). Seventy-five patients underwent surgical excision after core biopsy. Sixteen patients (21.3 %) had atypia in the excision specimen (combination atypical ductal hyperplasia, n = 11; atypical lobular hyperplasia, n = 8; lobular carcinoma-in situ, n = 3), 15 (93.8 %) of which were in the surrounding breast tissue. Two patients (2.7 %) had malignancy (ductal carcinoma-in situ and micropapillary carcinoma-in situ). As a result of surgical findings, 12 % of patients had a change in management. In comparing those with benign findings on surgical pathology and those whose disease was upstaged, there was no statistically significant difference in family history of breast cancer, indication for core biopsy, mammographic findings, or location of papilloma. Benign papillomas diagnosed on core biopsy are rarely upstaged to malignancy on surgical excision. However, at least 21 % of patients may have atypical findings in the surrounding tissue, which could change clinical management. Surgical excision should be considered in patients with benign papillomas." }, { "id": "pubmed23n0538_16706", "title": "Twenty-year outcome following central duct resection for bloody nipple discharge.", "score": 0.011347875425545328, "content": "Patients found with pathologic nipple discharge present a diagnostic dilemma to surgeons. No one diagnostic test, including cytology or radiologic imaging, has proved superior to any other in the differentiation of benign versus malignant sources of pathologic nipple discharge. Ductoscopy has been introduced as a way to assist with identification of potential sources of pathologic nipple discharge. Ductoscopy is also useful in the resection of deep or peripheral masses that may be missed with standard blind resection. This report evaluates the risk of missed malignancy following central duct resection (CDR). Records of 56 patients who underwent CDR for pathologic nipple discharge greater than 15 years previous were reviewed. Data including type of nipple discharge, future biopsy, and pathology reports were all examined. Of the 56 patients, 36 had bloody, 18 serous, and 2 green initial discharges. Fifty-seven percent were found to have intraductal papilloma as the source of discharge, with fibrocystic disease and ductal ectasia providing the next most common causes. One woman was found to have ductal cancer and one lobular carcinoma in situ at time of CDR. Patients were followed for a mean period of 22 years. Fourteen women required future biopsy. Of these, 10 had benign disease and 4 had cancer, 3 on the ipsilateral side. The 3 women with breast cancer were 9, 13, and 17 years from initial resection. CDR for pathologic nipple discharge is an effective way to diagnose and treat pathologic nipple discharge without missing underlying cancers." }, { "id": "pubmed23n0209_4301", "title": "Nipple discharge from the breast.", "score": 0.011264432554210082, "content": "Abnormal nipple discharge is rare, constituting only 3-5% of mammary consultation. In the present paper 267 patients with primary nipple discharge operated on at Institut Gustave-Roussay (IGR) in Villejuif, France, between January 1, 1960 and December, 1974 were evaluated. In all cases, the nipple discharge was symptomatic, spontaneous, and represented the primary reason for the patient's consultation. During the same period 1,145 cases of nipple discharge were treated at IGR. Of the 1,145 cases with symptomatic nipple discharge, 267 patients (23%) required surgical intervention. Among these, fibrocystic disease and duct ectasia were the leading causes of nipple discharge occurring in 42% of surgical specimens. Twenty one per cent of the patients had carcinoma and 35% were found to have intraductal papilloma. The overall incidence of malignancy, however, was 4.8% among the 1,145 women with nipple discharge. On the average, patients with nipple discharge due to malignancy were ten years older than those with benign lesions (Table 2). Approximately 25% of patients with malignant discharge and 5% with benign discharge have associated tumor. Over 60% of the patients with both discharge and a mass had malignancy." }, { "id": "article-18591_18", "title": "Breast Nipple Discharge -- Differential Diagnosis", "score": 0.011152725759467333, "content": "Intraductal papilloma Duct ectasia Fibrocystic changes and mastitis Intraductal carcinoma Paget disease of the nipple" }, { "id": "pubmed23n0977_8410", "title": "[A Case of Neuroendocrine Carcinoma with Long-Term Abnormal Nipple Discharge].", "score": 0.010937126464260101, "content": "We diagnosed invasive breast ductal cancer in a 42-year-old woman. About 10 years previously, she noticed an abnormal nipple discharge, and core needle biopsy indicated intraductal papilloma of the breast. However, the secretion continued, and we performed core needle biopsy again, which suggested invasive breast ductal cancer. Ultrasonography showed a hypoechoic tumor and an irregular low echo area. Breast MRI showed cystography tuberculum in the whole left breast. Pathological findings indicated solid papillary carcinoma with neuroendocrine differentiation, T2N0M0, stage ⅡA, ER(+), PgR(+), HER2 0. In this case, although needle biopsy was performed, the patient's long-term course provided key insights into the diagnosis. Moreover, the long-term bloody discharge from the nipple was a pathognomonic finding of intraneural secretory breast cancer, and it seemed important to take this morbus into consideration and follow-up on it." }, { "id": "pubmed23n0572_17100", "title": "Breast sonography in localizing the cause of nipple discharge: comparison with galactography in 52 patients.", "score": 0.01086829836829837, "content": "The purpose of this study was to evaluate breast sonography in localizing abnormalities in the discharging duct in patients with spontaneous nipple discharge. Fifty-two patients with unilateral bloody or serous nipple discharge and normal findings on palpation and mammography underwent breast sonography before surgical duct excision. The results of sonography were compared with the findings of galactography and histologic examination of the surgical specimen. The final diagnosis was benign in 47 cases (90%) and malignant in 5 cases (10%). Sonography visualized an echogenic intraductal tumor in 36 (69%) of 52 cases, dilated duct(s) without an intraductal tumor in 6 cases (12%), and no abnormality in 10 cases (19%). Eighty percent of papillomatous lesions, 58% of other benign lesions, and 20% of malignant lesions were sonographically positive. The abnormal duct was surgically removed after methylene blue staining in 38 cases, after sonographically guided wire localization in 11 cases, after both wire localization and methylene blue staining in 1 case, and with review of the diagnostic galactographic images in 2 cases. Sonography was found to be a valuable method for localizing intraductal abnormalities, especially papillomatous lesions, in patients with nipple discharge with no other clinical or radiologic findings. Preoperative sonographically guided wire localization can be used successfully instead of conventional methylene blue staining in cases with problems in cannulation of the discharging duct. Galactography remains the primary diagnostic method, especially in depicting malignant causes of nipple discharge, which may be seen only as duct dilatation on sonography." }, { "id": "wiki20220301en063_44817", "title": "International Classification of Diseases for Oncology", "score": 0.010357624831309042, "content": "M8501/2 Comedocarcinoma, noninfiltrating (C50._) Ductal carcinoma in situ, comedo type DCIS, comedo type M8501/3 Comedocarcinoma, NOS (C50._) M8502/3 Secretory carcinoma of breast (C50._) Juvenile carcinoma of breast M8503/0 Intraductal papilloma Duct adenoma, NOS Ductal papilloma M8503/2 Noninfiltrating intraductal papillary adenocarcinoma (C50._) Noninfiltrating intraductal papillary carcinoma Intraductal papillary adenocarcinoma, NOS Intraductal papillary carcinoma, NOS Ductal carcinoma in situ, papillary DCIS, papillary M8503/3 Intraductal papillary adenocarcinoma with invasion (C50._) Infiltrating papillary adenocarcinoma Infiltrating and papillary adenocarcinoma M8504/0 Intracystic papillary adenoma Intracystic papilloma M8504/2 Noninfiltrating intracystic carcinoma M8504/3 Intracystic carcinoma, NOS Intracystic papillary adenocarcinoma M8505/0 Intraductal papillomatosis, NOS Diffuse intraductal papillomatosis" }, { "id": "article-23703_2", "title": "Intraductal Papilloma -- Introduction", "score": 0.0102867666403578, "content": "Intraductal papilloma is a benign tumor found within breast ducts. The abnormal proliferation of ductal epithelial cells causes growth. A solitary intraductal papilloma is usually found centrally posterior to the nipple affecting the central duct. Multiple intraductal papillomas are located peripherally, found in any breast quadrant affecting the peripheral ducts. [1] Women of all ages can develop intraductal papillomas. Breast tumor risk factors include contraceptive use, hormone replacement therapy, lifetime estrogen exposure, and family history. [2] Patients with symptoms often present with spontaneous bloody or clear nipple discharge. An intraductal papilloma may be occasionally palpable. However, most patients with intraductal papillomas are asymptomatic. Small intraductal papillomas often will show no signs or symptoms. [1] Working up an intraductal papilloma is imperative due to the possibility of harboring occult carcinoma. [3] It is classified as a high-risk precursor lesion due to its association with atypia, ductal carcinoma in situ (DCIS), and carcinoma. [1] Surgical excision with complete tumor removal is the recommended treatment. [4]" }, { "id": "pubmed23n0509_15150", "title": "The role of nipple discharge cytology in the diagnosis of breast disease: a study of 1948 nipple discharge smears from 1530 patients.", "score": 0.009900990099009901, "content": "In this study a review of 1948 nipple discharge (ND) samples from 1530 patients in the age range of 18-83 years was undertaken to determine whether cytological findings from ND smears could provide useful diagnostic information regarding various breast lesions. The study included 1494 females and 36 males and was carried out during a period of 20 years 8 months. The clinical information in all patients was obtained from clinicians (coauthors), medical records and a review of biopsies in 205 patients who had undergone surgery following the cytodiagnosis. Of the ND samples examined, 1480 were unilateral while 468 were from 234 bilateral ND. The cytodiagnoses were: benign 624, inadequate (despite two to three repeat samples) 492, inflammatory 96, papillary lesion not otherwise specified (NOS) 229, suspicious 22 (21 females, one male) and malignant 67 (63 females, four males). A breast biopsy in the 22 suspicious cases revealed breast carcinoma in 18 cases (females n = 17, male n = 1), atypical ductal hyperplasia (female n = 1), fibroadenoma (female n = 1) and a papilloma in two females. In the 67 cases with a diagnosis of malignancy 65 revealed a breast carcinoma in the biopsy (female n = 62, male n = 3) while one female was diagnosed as fibroadenoma and one male as florid gynaecomastia. In 63 cases (females n = 61; males n = 2) with clinical lumpy areas consistent with the diagnosis of fibrocystic condition in ND, the biopsy confirmed a fibrocystic process. In 53 of 229 cases with ND findings suggestive of a papillary lesion (NOS) the biopsy revealed a papilloma in 41 cases while in 12 cases no lesion was found. In the remaining cases of all the groups only a clinical follow-up and appropriate investigations were performed with no untoward outcome. Based on our study it is felt that cytological examination of ND smears seems to be a reasonably specific method in the diagnosis of malignant and suspicious cases but may be somewhat less specific for other diagnoses." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 200, 349 ] ], "word_ranges": [ [ 39, 65 ] ], "text": "an acute toxoplasmosis can behave like this and also give a macular exanthema, although the one of this girl is related to the intake of amoxicillin." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

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

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0559_10414", "title": "Screening tests for diagnosis of cervical lymphadenopathy presenting as prolonged fever.", "score": 0.01818181818181818, "content": "During a two years period, 16 cases having cervical lymphadenopathy presenting as prolonged fever were studied in Abbassia fever hospital, Cairo, Egypt. Patients were subjected to careful history, thorough clinical examination, complete blood picture, tuberculin test, chest x-ray, Monospot test, indirect fluorescent antibody test for toxoplasmosis, detection of cytomegalovirus antibodies and lymph node biopsy with histopathological examination. Ten within normal subjects were taken as controls. The patients were grouped on histopathological basis into 5 groups: (1) One (6%) of the cases was non-specific lymphadenitis diagnosed by clinical examination of the scalp and leucocytosis with polymorphonuclear predominance. (2) Reactive lymphadenitis included 6 (38%) of the cases. Infectious mononucleosis cases were diagnosed by clinical triad of fever, pharyngitis and cervical lymphadenopathy, relative lymphocytosis, monocytosis and positive monospot test. Cytomegalovirus case was diagnosed by lymphocytosis, monocytosis and negative monospot test. Toxoplasmosis cases were diagnosed by monocytosis, negative tuberculin test and positive indirect fluorescent antibody test. (3) Granulomatous lymphadenitis comprised 6 (3%) of the cases. Tuberculous cases were diagnosed by high ESR and highly positive tuberculin test. Sarcoidosis cases were diagnosed by negative tuberculin test and presence of hilar lymphadenopathy. (4) Non-Hodgkin lymphoma case (6%) was diagnosed by clinical deterioration and total lymph node biopsy. 15) Systemic infections were diagnosed by clinical examination, blood culture for salmonellae and brucellae, Widal and Brucella agglutination tests. It is concluded from this study that screening tests are important aids in the diagnosis of cases of cervical lymphadenopathy presenting by prolonged fever especially if lymph node biopsy and histopathological examination are not available or contraindicated. Tub" }, { "id": "pubmed23n0717_2208", "title": "Infectious mononucleosis-like syndrome probably attributable to Coxsackie A virus infection.", "score": 0.016426969257157937, "content": "Infectious mononucleosis (IM) is a clinical syndrome most often attributable to Epstein-Barr virus (EBV). Characteristic clinical features of EBV IM include bilateral upper lid edema, exudative or nonexudative pharyngitis, bilateral posterior cervical adenopathy, and splenomegaly ± maculopapular rash. Laboratory features of EBV IM include atypical lymphocytes and elevated levels of serum transaminases. Leukopenia and thrombocytopenia are not uncommon. The syndrome of IM may also be attributable to other infectious diseases, eg, cytomegalovirus (CMV), human herpes virus-6 (HHV-6), or Toxoplasma gondii. Less commonly, viral hepatitis, leptospirosis, brucellosis, or parvovirus B(19) may present as an IM-like infection. To the best of our knowledge, only 2 cases of IM-like infections attributable to Coxsackie B viruses (B(3) and B(4)) have been reported. We present the first reported case of an IM-like syndrome with sore throat, fatigue, atypical lymphocytes, and elevated levels of serum transaminases likely due to Coxsackie A in an immunocompetent adult." }, { "id": "pubmed23n0498_10724", "title": "Infectious disease capsules: a pox on your house.", "score": 0.016124871001031993, "content": "A 31-year-old, previously healthy white man presented to the emergency department with complaints of malaise, fevers, shortness of breath, a non-productive cough, and a \"rash.\" His physical exam revealed a temperature of 100.2F, a pulse of 129 bpm, respiratory rate of 14 BPM, and blood pressure of 140/74 mm Hg. He was alert, oriented, and in no distress. His oropharynx was dry, his neck was supple, and cervical lymphadenopathy was absent. He had tachycardia, bilateral wheezes, and rhonchi with prolonged expirations. There was a diffuse vesicular eruption enveloping his entire body with involvement sparing his palms and soles (Figures 1 and 2). Laboratory values showed a hemoglobin of 16.0 g/dL and a white blood cell count of 7100 cells/pL, with 39%neutrophils, 23% bands, and 35% lymphocytes. His platelet count was mildly decreased to 86,000 x 103/pL. Chest radiograph revealed bilateral diffuse interstitial infiltrates. A diagnosis of acute varicella-zoster virus pneumonia (varicella pneumonia) was made, and the patient was started on IV acyclovir (10 mg/kg every 8 hours). Upon further questioning, the patient stated that his daughter had been diagnosed with \"chickenpox\" 7 days ago. The patient had numerous exposures to chickenpox in the past but had never developed clinical expressions of varicella. He was not at risk for HIV infection, not having multiple sexual partners, IV drug abuse, or blood transfusions. During the 1 day of in-hospitalization, his fever abated and the pulmonary signs diminished. Following discharge, IV acyclovir was replaced by valacyclovir to complete a 7-day course of therapy." }, { "id": "pubmed23n0083_1756", "title": "[Acute infection associated with HIV: clinical and laboratory picture].", "score": 0.016112170223233503, "content": "Very few case reports evaluate clinical and laboratory parameters of acute HIV infection. This paper describes seven such cases, four being mononucleosis like disease and one lymphocytic meningitis. Clinical manifestations were fever (7/7), lymphadenopathy (7/7), enlarged liver size (7/7) pharyngitis (6/7), malaise (4/7) and anorexia (4/7). Inversion of the normal T4/T8 ratio was present in 3/5 patients, all with normal absolute values for T4 cells. Moderate transaminase increases were found in 5/6; 5/7 had atypical lymphocytes in blood smear and 5/5 had abnormal mucoprotein levels. All patients had a total remission of clinical symptoms within two weeks. However, the abnormal lymph nodes and the enlarged liver persisted. Follow-up for ten months showed 4/7 patients with all abnormalities resolved and 3/7 still with persistent enlarged lymph nodes." }, { "id": "pubmed23n0476_2513", "title": "Acute human immunodeficiency virus syndrome in an adolescent.", "score": 0.015489084684886918, "content": "Acute human immunodeficiency virus (HIV) seroconversion illness is a difficult diagnosis to make because of its nonspecific and protean manifestations. We present such a case in an adolescent. A 15-year-old boy presented with a 5-day history of fever, sore throat, vomiting, and diarrhea. The patient also reported a nonproductive cough, coryza, and fatigue. The patient's only risk factor for HIV infection was a history of unprotected intercourse with 5 girls. Physical examination was significant for fever, exudative tonsillopharyngitis, shotty cervical lymphadenopathy, and palpable purpura on both feet. Laboratory studies demonstrated lymphopenia and mild thrombocytopenia. Hemoglobin, serum creatinine, and urinalysis were normal. The following day, the patient remained febrile. Physical examination revealed oral ulcerations, conjunctivitis, and erythematous papules on the thorax; the purpura was unchanged. Serologies for hepatitis B, syphilis, HIV, and Epstein-Barr virus were negative. Bacterial cultures of blood and stool and viral cultures of throat and conjunctiva showed no pathogens. Coagulation profile and liver enzymes were normal. Within 1 week, all symptoms had resolved. The platelet count normalized. Repeat HIV serology was positive, as was HIV DNA polymerase chain reaction. Subsequent HIV viral load was 350 000, and the CD4 lymphocyte count was 351/mm3. HIV is the seventh leading cause of death among people aged 15 to 24 in the United States, and up to half of all new infections occur in adolescents. Our patient presented with many of the typical signs and symptoms of acute HIV infection: fever, fatigue, rash, pharyngitis, lymphadenopathy, oral ulcers, emesis, and diarrhea. Other symptoms commonly reported include headache, myalgias, arthralgias, aseptic meningitis, peripheral neuropathy, thrush, weight loss, night sweats, and genital ulcers. Common seroconversion laboratory findings include leukopenia, thrombocytopenia, and elevated transaminases. The suspicion of acute HIV illness should prompt virologic and serologic analysis. Initial serology is usually negative. Diagnosis therefore depends on direct detection of the virus, by assay of viral load (HIV RNA), DNA polymerase chain reaction, or p24 antigen. Both false-positive and false-negative results for these tests have been reported, further complicating early diagnosis. Pediatricians should play an active role in identifying HIV-infected patients. Our case, the first report of acute HIV illness in an adolescent, emphasizes that clinicians should consider acute HIV seroconversion in the appropriate setting. Recognition of acute HIV syndrome is especially important for improving prognosis and limiting transmission. It is imperative that we maintain a high index of suspicion as primary care physicians for adolescents who present with a viral syndrome and appropriate risk factors." }, { "id": "pubmed23n0379_13456", "title": "Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr virus.", "score": 0.014932386571294313, "content": "Knowledge regarding the clinical characteristics and natural history of acute infectious mononucleosis is based largely on older, often retrospective, studies without systematic follow-up. Differences in diagnosis, methodology, or treatment between historical and current practice might affect an understanding of this illness. Using a prospective case series design, we enrolled 150 persons with an acute illness serologically confirmed as Epstein-Barr virus infection. The goal of the study was to assess symptoms, physical examination findings, laboratory tests, and functional status measures during the acute presentation and 1, 2, and 6 months later. Acutely, infectious mononucleosis was characterized by the symptoms of sore throat and fatigue and substantial functional impairment. Objective physical and laboratory examination findings included pharyngitis and cervical lymphadenopathy, a moderate absolute and atypical lymphocytosis, and mildly elevated transaminase levels. The traditional signs of fever and splenomegaly were relatively uncommon. By 1 month, most symptoms and signs and all laboratory tests had returned to normal. Fatigue, cervical lymphadenopathy, pharyngitis, and functional health status improved more slowly. In contemporary practice most of the classical illness features of infectious mononucleosis are observed. Symptoms, signs, and poor functioning might be protracted in some patients." }, { "id": "pubmed23n0357_20887", "title": "[A case with infectious mononucleosis-like syndrome caused by human herpes virus-6 infection].", "score": 0.014303959131545339, "content": "A 26-year-old female was admitted because of multiple fractures in lower extremities. While in the hospital, she developed a high fever and generalized skin eruption. Physical examination revealed bilateral cervical lymphadenopathy and mild hepatosplenomegaly. The white cell count was 11,200 with 11% atypical lymphocytes. Serum GOT, GPT, LDH were markedly elevated. Infectious mononucleosis was suspected, but the serological test for EB virus did not show evidence of acute EB virus infection. Anti-HSV, CMV, hepatitis A virus antibody titers also did not show significant change during the coarse. The serological test for HHV-6 only showed increased titer of IgM and IgG antibodies. Rapidly elevated IgG antibody titer was indicative of reactivation of HHV-6. So, she was diagnosed as mononucleosis-like syndrome caused by HHV-6, probably reactivated infection. Her symptoms gradually disappeared during a month." }, { "id": "pubmed23n0985_25692", "title": "[THE FEATURES OF THE COURSE OF INFECTIOUS MONONUKLEOSIS OF DIFFERENT ETIOLOGY IN CHILDREN].", "score": 0.013996965692751922, "content": "Aim - to study the effect of different pathogens (EBV, CMV, HHV-6, and MIXT) on the severity of clinical-paraclinical manifestations of infectious mononucleosis in children. The clinical and laboratory study performed for 410 children aged from 10 months up to 12 years with infectious mononucleosis. The association of herpes viruses, mainly EBV, CMV and HHV type 6, takes part in the formation of the clinical picture of IM in (52,9%) of cases. The sole participation of EBV in the development of IM was observed only in (34,1%), CMV (9,02%) and HHV-6 in (3,17%) patients. The etiology of infectious mononucleosis in children affects the acuity, severity, and intensity of the clinical and paraclinical signs of the disease. Infectious mononucleosis VEB etiology is manifested by acute onset (79,5%), intoxication (70,5%), subfebrile and febrile fever up to 7 days (61,03%), lacunar tonsillitis (85,8%), hepatomegaly ( 88,2%), splenomegaly (63,8%), mostly moderate (81,7%) with lymphocytosis (62,9%) and monocytosis (20,5%). For CMV mononucleosis - acute onset (89,9%), severe course (29,8%), febrile and high fever for up to 7 (56,7%) or more days, neutrophilic leukocytosis (73,55) with atypical mononuclear cells (64,7%) and anemia (29,7%). Severe (33,3%), with prolonged high fever (50%), exanthema syndrome (33,3%), pharyngitis without tonsillitis (66,7%), leukocytosis (66,7%) with accelerated ESR (66,7%) and monocytosis (33,3%) are characteristic of HHV-6 infection. For MIXT - acute onset (78,3%), intoxication (79,7%), lacunar tonsillitis (92,9%), hepatomegaly (84,1%) and splenomegaly (67%), low-grade and febrile fever from 3- x (27,1%) up to 7 days (35,05%), lymphocytosis (55,3%) with neutropenia (57,4%), atypical mononuclear cells (48,2%) and hypochromic anemia (17,29 %)." }, { "id": "wiki20220301en005_4079", "title": "Infectious mononucleosis", "score": 0.013723544973544973, "content": "Acute HIV infection can mimic signs similar to those of infectious mononucleosis, and tests should be performed for pregnant women for the same reason as toxoplasmosis. People with infectious mononucleosis are sometimes misdiagnosed with a streptococcal pharyngitis (because of the symptoms of fever, pharyngitis and adenopathy) and are given antibiotics such as ampicillin or amoxicillin as treatment. Other conditions from which to distinguish infectious mononucleosis include leukemia, tonsillitis, diphtheria, common cold and influenza (flu)." }, { "id": "wiki20220301en032_60070", "title": "Lymphadenopathy", "score": 0.01321250691754289, "content": "Lymph node enlargement is recognized as a common sign of infectious, autoimmune, or malignant disease. Examples may include: Reactive: acute infection (e.g., bacterial, or viral), or chronic infections (tuberculous lymphadenitis, cat-scratch disease). The most distinctive sign of bubonic plague is extreme swelling of one or more lymph nodes that bulge out of the skin as \"buboes.\" The buboes often become necrotic and may even rupture. Infectious mononucleosis is an acute viral infection usually caused by Epstein-Barr virus and may be characterized by a marked enlargement of the cervical lymph nodes. It is also a sign of cutaneous anthrax and Human African trypanosomiasis Toxoplasmosis, a parasitic disease, gives a generalized lymphadenopathy (Piringer-Kuchinka lymphadenopathy). Plasma cell variant of Castleman's disease - associated with HHV-8 infection and HIV infection" }, { "id": "wiki20220301en005_4078", "title": "Infectious mononucleosis", "score": 0.012877180575200377, "content": "Differential diagnosis About 10% of people who present a clinical picture of infectious mononucleosis do not have an acute Epstein–Barr-virus infection. A differential diagnosis of acute infectious mononucleosis needs to take into consideration acute cytomegalovirus infection and Toxoplasma gondii infections. Because their management is much the same, it is not always helpful, or possible, to distinguish between Epstein–Barr-virus mononucleosis and cytomegalovirus infection. However, in pregnant women, differentiation of mononucleosis from toxoplasmosis is important, since it is associated with significant consequences for the fetus. Acute HIV infection can mimic signs similar to those of infectious mononucleosis, and tests should be performed for pregnant women for the same reason as toxoplasmosis." }, { "id": "pubmed23n0269_15945", "title": "A case of cytomegalovirus mononucleosis associated with pleural effusion.", "score": 0.01273741332529394, "content": "A 5 year old boy had a spiky fever accompanied by a mild pharyngitis, cervical lymphadenopathy and hepatosplenomegaly. Laboratory findings revealed leukocytosis with 26% atypical lymphocytes, and liver dysfunction. A chest X-ray showed pneumonia and a considerable amount of pleural effusion. Serum antibody titers for cytomegalovirus (CMV) were elevated significantly and CMV-DNA (polymerase chain reaction) was detected in the pleural effusion. Only 13 cases of pleural effusion associated with infectious mononucleosis have been reported previously in the literature, but there was no documentation that proved CMV infection. The case reported here suggests that the pleural effusion was caused by the infiltration of mononuclear cells to the pleura as a result of systemic inflammation, and the possible alternative of host immune response against CMV was related to recent Varicella zoster virus infection." }, { "id": "article-24574_4", "title": "Lymphocytosis -- Etiology", "score": 0.012681159420289856, "content": "Infectious: Viral infections: Epstein-Barr Virus (EBV): Infectious Mononucleosis (IM) is a classic example of viral infections associated with lymphocytosis. Acute IM is a disease characterized by fever, lymphadenopathy, pharyngitis, splenomegaly, and various hematologic manifestations, among which lymphocytosis is the most common and presents in up to two-thirds of cases. [1] Cytomegalovirus (CMV): CMV can cause a disease indistinguishable from EBV IM. Human Immunodeficiency Virus (HIV): Although chronic HIV infection resulted in lymphopenia and decreased CD4+ lymphocytes count, primary HIV infection can lead to an acute febrile mononucleosis-like illness with associated lymphocytosis. A negative heterophile test can help distinguish the two. [2] Other Viruses: Influenza, hepatitis, mumps, measles, rubella, and human T Lymphocytic virus type 1 (HTLV-1), adenovirus, to name a few. Bacterial Infections: Most of the acute bacterial infections will cause neutrophilia; however, notable exceptions include: Bartonella henselae : Bartonella henselae leads to cat scratch disease, a disease transmitted by scratch or bite from an infected cat, that leads mostly to self-limited lymphadenopathy, but can be associated with ocular or neurologic manifestations. Lymphocytes are large and atypical. Bordetella Pertussis : Pertussis is characterized by increased lymphocytes that are small with a deeply cleaved nucleus, clinical correlation is needed to differentiate from some lymphoid malignancies that might share the morphologic appearance. Other: Brucellosis, syphilis, malaria Parasitic Infections: Toxoplasma Gondii: symptomatic toxoplasmosis occurs most commonly in immunocompromised hosts. Lymphocytosis with atypical lymphocytes is a hematologic hallmark of the disease, that can present as a mononucleosis-like illness. [3] Other: Babesiosis Mycobacterial Tuberculosis" }, { "id": "Pediatrics_Nelson_2203", "title": "Pediatrics_Nelson", "score": 0.012678383656301638, "content": "Initial laboratory tests of regional lymphadenopathy include a complete blood count and inflammatory markers. Infectious mononucleosis is characterized by lymphocytosis with atypical lymphocytes; thrombocytopenia and elevated hepatic enzymes are common. Cultures of infected skin lesions and tonsillar exudates should be obtained. Isolation of group A streptococci from the oropharynx suggests, but does not confirm, streptococcal cervical lymphadenitis. A blood culture should be obtained from children with systemic signs and symptoms of bacteremia. Serologic testing for EBV and for B. henselae should be obtained if there are appropriate findings. The most reliable test for diagnosis of acute EBV infection is the IgM antiviral capsid antigen (Fig. 99-1). Heterophil antibody is also diagnostic but is not reliably positive in children younger than 4 years with infectious mononucleosis." }, { "id": "pubmed23n0565_20506", "title": "[Retrospective evaluation of patients who were diagnosed as infectious mononucleosis between 1984-2005].", "score": 0.012604709973131026, "content": "In this study, the clinical and laboratory features of 26 infectious mononucleosis (IMN) cases who have been diagnosed between the years of 1984-2005 were evaluated retrospectively. The mean age of the patients was 26+/-11 years, the rate of being hospitalized was 65%, and mean hospitalization period was 9.2+/-6 days. Fever (81%), weakness (50%), sore throat (50%), headache (50%) and swollen neck (35%) were the most common symptoms, while in the physical examination cervical lymphadenopathy (81%), splenomegaly (69%), hyperemic pharynx (65%), hepatomegaly (54%) and tonsillitis (50%) were observed. Laboratory results yielded leukocytosis in 21%, leucopenia in 12%, anemia in 44%, thrombocytopenia in 5% and elevated transaminase levels in 84% of the patients. Of the patients 15 (57.7%) had the history of using antibiotics before the diagnosis. Serological diagnosis was performed by Paul-Bunnel test and/or IgM positivity against Epstein-Barr virus (EBV) viral capsid antigen (VCA). Tonsillo-pharyngitis secondary to edema and respiratory distress due to lymphadenopathy pressure were detected in four patients, whereas pancytopenia was established only in one patient, as complications. This study emphasized that, although IMN is a self-limited infection, the diagnostic difficulties may arise when the clinical course is atypical, and rarely seen life-threatening complications may also develop during IMN course." }, { "id": "pubmed23n1078_5134", "title": "Case of haemophagocytic lymphohistiocytosis following Epstein-Barr virus infection.", "score": 0.012594367015098723, "content": "Haemophagocytic lymphohistiocytosis (HLH) is a rare diagnosis that carries a high degree of mortality. We present this case of a previously healthy 22-year-old woman, who was admitted acutely ill to the hospital. One week prior, she had been seen by her primary care physician for fatigue and malaise. At that time, she was noted to have anterior and posterior cervical lymphadenopathy. She was referred to the emergency room and was diagnosed with acute Epstein-Barr virus (EBV) mononucleosis based on her clinical symptoms and positive heterophile antibody test. She was discharged after an uneventful 48-hour stay on the wards. She represented 7 days after discharge with cough, fatigue, nausea, vomiting, epigastric abdominal pain, diarrhoea, weight loss and subjective fevers. She had also reported haematemesis, epistaxis and melaena. Vital signs included temperature 36.9°C, blood pressure 90/50 mm Hg, heart rate 130 beats per minute and respiratory rate 32 breaths per minute. Physical examination was notable for an acutely ill appearing woman with scleral icterus, hepatosplenomegaly and palpable cervical and axillary lymphadenopathy. Complete blood count showed pancytopaenia with haemoglobin 59 g/L (normal 120-160 g/L), white blood cell count 2.7×10<sup9</sup/L (normal 4-10.5×10<sup9</sup/L) and platelet count 50×10<sup9</sup/L (normal 150-450×10<sup9</sup/L). The white blood cell count differential included 58% neutrophils (normal 38%-77%) with immature neutrophils in band form elevated at 45% (normal &lt;14%), 16% lymphocytes (normal 20%-48%), 7% monocytes (normal &lt;12%) and no eosinophils (normal &lt;6%). Blood smear revealed anisocytosis, poikilocytosis and hypochromia. Coagulation panel showed elevated levels of d-dimer level at 1.39 µg/mL (normal &lt;0.45 µg/mL), prolonged prothrombin time at 34.4 s (normal 11-15 s), prolonged activated partial thromboplastin time of 55.6 s (normal 25-34 s), prolonged international normalised ratio at 3.31 (normal &lt;1.1) and low fibrinogen 60 mg/dL (normal &gt;200 mg/dL). Lipid panel showed cholesterol at 114 mg/dL (normal 125-200 mg/dL), triglycerides 207 mg/dL (normal 30-150 mg/dL), high-density lipoprotein cholesterol 10 mg/dL (normal 40-60 mg/dL) and low-density lipoprotein cholesterol 63 mg/dL (normal &lt;100 mg/dL). Other lab abnormalities included elevated ferritin of 6513 ng/mL (normal 10-150 ng/mL) and elevated lactate dehydrogenase of 1071 unit/L (normal 95-240 unit/L). Soluble interleukin-2 receptor alpha level was elevated at 60 727 units/mL (normal 223-710 units/mL). Fluorodeoxyglucose-positron emission tomography (FDG-PET) scan showed abnormal tracer localisation within the paratracheal, hilar, pelvic, abdominal and subcarinal lymph nodes, along with FDG-PET positive hepatosplenomegaly. A bone marrow biopsy showed hypercellular marrow (95% cellularity) with trilineage haematopoiesis, haemophagocytic cells, polytypic plasmacytosis and T-cell lymphocytosis, along with positive latent membrane protein-1 immunohistochemical staining for EBV. EBV quantitative DNA PCR showed &gt;1 million copies. These findings were consistent with a diagnosis of HLH secondary to EBV infection. Despite intense therapy with the HLH-94 protocol, the patient expired from her illness after a prolonged hospital course." }, { "id": "pubmed23n1129_1788", "title": "An Unusual Presentation of Glandular Fever.", "score": 0.012196908651380851, "content": "Epstein-Barr virus (EBV) is an ubiquitous DNA herpesvirus with &gt;90% of adults &gt;40 years of age showing a serological response. While in their youth, primary EBV infection may pass unnoticed, young adults have a high incidence of infectious mononucleosis (IM). This is characterized by a triad of pharyngitis, cervical lymphadenopathy, and fever because of a self-limiting lymphoproliferative disease. Common complications include but are not limited to hepatitis, splenomegaly, encephalitis, and haemophagocytic lymphohistiocytosis (HLH) with evidence that Caucasian males and smokers are more likely to suffer severe disease. Here we present a 21-year-old male who presented with a 2-week history of fever, dry cough, and a 4-week history of pharyngitis. He had no exposure to unwell contacts and denied any new sexual partners. Examination revealed general pallor with tender bilateral cervical lymphadenopathy and pharyngeal erythema. Admission bloods revealed pancytopenia (WCC 1.5 × 10<sup9</sup/L, Plt 84 × 10<sup9</sup/L, and Hb 82 g/L) with normal reticulocyte count and raised mean corpuscular volume (114 fL). Serum vitamin B12 and folate were low with serum ferritin raised (1027 <iµ</ig/L) suggesting a proinflammatory state. Admission liver function tests, coeliac serology, autoimmune panel (ANA, ANCA, and anti-dsDNA), hepatitic (hepatitis A, B, and E), human immunodeficiency virus (HIV), toxoplasmosis, parvovirus, and CMV serology were normal. The monospot test on day 1 of the presentation was negative. Ultrasound (US) of the abdomen on day 3 of the presentation revealed isolated splenomegaly (16.8 cm). Day 4 EBV serology (VCA IgM, VCA IgG, and EBNA IgG) was negative as such haematological investigations including JAK2, serum free light chains, and BCR-ABL were undertaken alongside cervical lymph node core biopsy. Repeat Monospot testing on day 7 came back positive. Repeat EBV serology now showed equivocal EBV VCA IgG (0.77 OD) and positive VCA IgM (9.04 OD) with concurrent new hepatitis. Histopathology of the core biopsy revealed Sternberg-reed cells and a mixed immunoblastic reaction in keeping with resolving IM. This case highlights the need for physicians to have a strong clinical suspicion of IM and understand the multiple ways in which IM may be present as well as the time lag to positivity in serological testing." }, { "id": "wiki20220301en012_5140", "title": "Lymphocytosis", "score": 0.012021057201780094, "content": "Causes of absolute lymphocytosis include: acute viral infections, such as infectious mononucleosis (glandular fever), hepatitis and Cytomegalovirus infection other acute infections such as pertussis some protozoal infections, such as toxoplasmosis and American trypanosomiasis (Chagas disease) chronic intracellular bacterial infections such as tuberculosis or brucellosis chronic lymphocytic leukemia acute lymphoblastic leukemia lymphoma post-splenectomy state CARD11-related congenital B cell lymphocytosis (rare, also known as BENTA disease) Causes of relative lymphocytosis include: age less than 2 years; acute viral infections; connective tissue diseases, thyrotoxicosis, Addison's disease, splenomegaly with splenic sequestration of granulocytes." }, { "id": "wiki20220301en257_9056", "title": "Herpes labialis", "score": 0.011806914546640575, "content": "Signs and symptoms Herpes infections usually show no symptoms; when symptoms do appear they typically resolve within two weeks. The main symptom of oral infection is inflammation of the mucosa of the cheek and gums—known as acute herpetic gingivostomatitis—which occurs within 5–10 days of infection. Other symptoms may also develop, including headache, nausea, dizziness and painful ulcers—sometimes confused with canker sores—fever, and sore throat. Primary HSV infection in adolescents frequently manifests as severe pharyngitis with lesions developing on the cheek and gums. Some individuals develop difficulty in swallowing (dysphagia) and swollen lymph nodes (lymphadenopathy). Primary HSV infections in adults often results in pharyngitis similar to that observed in glandular fever (infectious mononucleosis), but gingivostomatitis is less likely." }, { "id": "wiki20220301en005_4077", "title": "Infectious mononucleosis", "score": 0.01162681669010783, "content": "Other tests Epstein–Barr nuclear antigen detection. While it is not normally recognizable until several weeks into the disease and is useful for distinguishing between a recent-onset of infectious mononucleosis and symptoms caused by a previous infection. Elevated hepatic transaminase levels are highly suggestive of infectious mononucleosis, occurring in up to 50% of people. By blood film, one diagnostic criterion for infectious mononucleosis is the presence of 50% lymphocytes with at least 10% atypical lymphocytes (large, irregular nuclei), while the person also has fever, pharyngitis, and swollen lymph nodes. The atypical lymphocytes resembled monocytes when they were first discovered, thus the term \"mononucleosis\" was coined. A fibrin ring granuloma may be present." }, { "id": "pubmed23n0324_10987", "title": "[Agranulocytosis as a complication of acute infectious mononucleosis].", "score": 0.010732290421495764, "content": "Acute infections mononucleosis is the most common clinical manifestation of primary Epstein-Barr virus (EBV) infection occurring during adolescence. It is a benign lymphoproliferative, usually self-limiting disease. Complications are relatively rare, but they may occur, especially hematological. Most common are autoimmune hematolytic anemia and thrombocytopenia, and they respond to corticoid therapy. Deuteration of white blood cells is rather rare, whereas mild neutropenia is a normal finding during the course of acute disease. On the other hand, agranulocytosis is extremely rate, and almost every case has been reported in the literature. Filgrastim--the recombinant human granulocyte colony-stimulating factor (G-CSF) stimulates the activation, proliferation and maturation of progenitor granulocyte cells. This drug is usually applied in treatment of iatrogenic neutropenia, during chemotherapy of malignancies and in some idiopathic and cyclic neutopenias. A female patient, 18 years of age, has been hospitalized at the Clinic of Infectious Diseases in Novi Sad on two occasions. First because of severe acute infectious mononucleosis with acute hepatitis and jaundice 10 days after onset of symptoms. Physical examination revealed severe intoxication, dehydration, icteric skin, mucosis and massive hepatosplenomegaly. The diagnosis was confirmed by ELISA IgM, EBV VCA positive and ELISA IgG EBV VCA and IgG EBVNA negative results. The patient was discharged from hospital after 24 days without complaints and with normal physical and laboratory findings. For several days she felt well, but gradually severe fatigue and malaise occurred and she became febrile again. That was the reason why she was hospitalized again, two weeks later. This time she was febrile, extremely intoxicated with general lymphadenopathy, catarrhal gingivostomatitis and massive splenomegaly. The first laboratory findings showed severe neutropenia (absolute count of granulocytes was 0.156 x 10/l, with only 12% segmented neutrophils). Mild anemia--3.05 x 10/l was also registered, while the platelet count was normal. Other biochemical analyses were normal, the Coombs' test negative, while the serological response was also normal. Bone marrow puncture was performed and normocellular bone marrow was registered, somewhere hypercellular due to hyperplasia of granulocyte progenitor cells from promyelocytes to normal maturated cells. Anemia showed megaloblastoid proliferation, while megakaryocytes were normal. High doses of corticosteroids were applied (dexamethasone 160 mg daily) and filgrastim 5 micrograms every other day. From the very beginning of therapy the patient felt better, whereas granulocytes responded with elevation as soon as 48 hours after initiation of therapy. On the sixth day the treatment was stopped because the level of granulocytes was normal and the patient has completely recovered. She was discharged from hospital 4 weeks later with mild meteorism, but normal physical and laboratory findings and mild splenomegaly registered only by ultrasonography. During the last 10 years only several cases of severe leukopenia with acute infectious mononucleosis had been reported in literature. In all cases it was associated with some other hematological complications and it occurred in young adults without previously registered immunodeficiency. We have no knowledge about application of filgrastim in treatment of EBV-induced agranulocytosis, but the International Association for Studying Agranulocytosis and Aplastic Anemia reported that in 4% of patients Epstein-Barr virus can cause agranulocytosis even a year after the occurrence of acute disease." }, { "id": "wiki20220301en503_18576", "title": "Eosinophilic myocarditis", "score": 0.010585585585585585, "content": "The DRESS syndrome is a severe immunological drug reaction. It differs from other drug reactions in that it: a) is caused by a particular set of drugs; b) typically occurs after a delay of 2 to 8 weeks following intake of an offending drug; c) presents with a specific set of signs and symptoms (i.e. modest or extreme elevations in blood eosinophil and atypical lymphocyte counts; acute onset of a skin rash; lymphadenopathy; fever; neuralgia; and involvement of at least one internal organ such as the liver, lung, or heart; d) develops in individuals with particular genetic predispositions; and e) involves reactivation of latent viruses, most commonly human herpesvirus 6 or more rarely human herpes virus 5 (i.e. human cytomegalovirus), human herpesvirus 7, and human herpesvirus 4 (i.e. Epstein–Barr virus). These viruses usually become dormant after infecting humans but under special circumstances, such as drug intake, are reactivated and may contribute to serious diseases such as the" }, { "id": "wiki20220301en218_4165", "title": "List of skin conditions", "score": 0.010521799153032479, "content": "Giant condyloma acuminatum (Buschke–Löwenstein tumor, giant condyloma of Buschke–Löwenstein tumor) Hand-foot-and-mouth disease Heck's disease (focal epithelial hyperplasia) Hemorrhagic fever with renal syndrome Hepatitis B Hepatitis C Herpangina Herpes gladiatorum (scrum pox) Herpes simplex Herpes zoster oticus (Ramsay–Hunt syndrome) Herpetic keratoconjunctivitis Herpetic sycosis Herpetic whitlow HIV-associated pruritus Human monkeypox Human T-lymphotropic virus 1 infection Human tanapox Immune reconstitution inflammatory syndrome (immune recovery syndrome) Infectious mononucleosis (glandular fever) Inflammatory skin lesions following zoster infection (isotopic response) Intrauterine herpes simplex Kaposi sarcoma Lassa fever Lipschütz ulcer (ulcus vulvae acutum) Measles (rubeola, morbilli) Milker's nodule Modified varicella-like syndrome Molluscum contagiosum Myrmecia Neonatal herpes simplex Ophthalmic zoster" }, { "id": "InternalMed_Harrison_14506", "title": "InternalMed_Harrison", "score": 0.01047794117647059, "content": "Person with AIDS <100 CD4+ T cells/μL; CMV seropositivity Retinitis; gastrointestinal Ganciclovir, valganciclovir, Oral valganciclovir disease; neurologic disease foscarnet, or cidofovir 1192 often involves sexually active young adults. With incubation periods of 20–60 days, the illness generally lasts for 2–6 weeks. Prolonged high fevers, sometimes with chills, profound fatigue, and malaise, characterize this disorder. Myalgias, headache, and splenomegaly are common, but in CMV (as opposed to Epstein-Barr virus) mononucleosis, exudative pharyngitis and cervical lymphadenopathy are rare. Occasional patients develop rubelliform rashes, often after exposure to ampicillin or certain other antibiotics. Less common are interstitial or segmental pneumonia, myocarditis, pleuritis, arthritis, and encephalitis. In rare cases, Guillain-Barré syndrome complicates CMV mononucleosis. The characteristic laboratory abnormality is relative lymphocytosis in peripheral blood, with >10% atypical" }, { "id": "article-27104_8", "title": "Pharyngitis -- History and Physical", "score": 0.009936444697400872, "content": "If viral in etiology, associated symptoms often include coughing, rhinorrhea, conjunctivitis, headache, and a rash. Group A beta-hemolytic streptococcal pharyngitis typically has an acute onset, lacks signs of a viral upper respiratory infection such as a cough or rhinorrhea, and is associated with fever, tonsillar exudates, and cervical adenopathy. Pharyngitis due to the Epstein-Barr virus, otherwise known as infectious mononucleosis,  can cause headaches, fever, tonsillar hypertrophy, lymphocytosis, and atypical lymphocytes. Myalgia and fatigue are commonly reported symptoms. Infectious mononucleosis can have both anterior and posterior cervical lymphadenopathy. Patients can have persistent lymphadenopathy and fatigue for up to 3 weeks. It is important to assess for hepatomegaly or splenomegaly. If a morbilliform rash develops after amoxicillin for presumed Group A beta-hemolytic streptococci, infectious mononucleosis should be suspected." }, { "id": "wiki20220301en302_4979", "title": "Cervical lymphadenopathy", "score": 0.00980392156862745, "content": "Classification Cervical lymphadenopathy can be thought of as local where only the cervical lymph nodes are affected, or general where all the lymph nodes of the body are affected. Causes Infection Pericoronitis Staphylococcal lymphadenitis Mycobacterial lymphadenitis Rubella Cat scratch fever Infectious mononucleosis Streptococcal pharyngitis Viral respiratory infection Toxoplasmosis Tuberculosis Brucellosis Primary herpes simplex infection (primary herpetic gingivostomatitis) Syphilis (secondary) Cytomegalovirus Human immunodeficiency virus Histoplasmosis Chicken pox" }, { "id": "pubmed23n0377_8012", "title": "Diagnosis of atypical cases of infectious mononucleosis.", "score": 0.00980392156862745, "content": "The variable manifestations of infectious mononucleosis rarely cause clinicians to suspect primary Epstein-Barr virus or cytomegalovirus infection; consequently, costly diagnostic tests and unnecessary treatments are undertaken. Seventeen cases of clinically atypical and 11 cases of clinically typical infectious mononucleosis were diagnosed through screening for atypical and apoptotic lymphocytes in the peripheral blood samples by means of an automated hematologic analyzer. Atypical and typical cases did not differ significantly with respect to peripheral white blood cell counts; percentages of lymphocytes, atypical lymphocytes, CD4(+) lymphocytes, human leukocyte antigen--DR positivity in CD3 lymphocytes, or apoptotic cells in blood smear after incubation; or levels of aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase. Only the percentage of CD8(+) lymphocytes was significantly higher in patients with typical infectious mononucleosis than it was in patients with atypical infectious mononucleosis. Because certain atypical cases of infectious mononucleosis display laboratory abnormalities that are characteristic of typical infectious mononucleosis, enhanced awareness can help in the diagnosis." }, { "id": "wiki20220301en100_5895", "title": "List of MeSH codes (C02)", "score": 0.00973885094415428, "content": "– african swine fever – circoviridae infections – hepadnaviridae infections – hepatitis b – hepatitis b, chronic – herpesviridae infections – bell palsy – chickenpox – cytomegalovirus infections – cytomegalovirus retinitis – encephalitis, herpes simplex – encephalitis, varicella zoster – epstein-barr virus infections – burkitt lymphoma – infectious mononucleosis – leukoplakia, hairy – herpes simplex – herpes genitalis – herpes labialis – kaposi varicelliform eruption – keratitis, herpetic – keratitis, dendritic – stomatitis, herpetic – herpes zoster – herpes zoster ophthalmicus – herpes zoster oticus – zoster sine herpete – infectious bovine rhinotracheitis – malignant catarrh – marek disease – pseudorabies – roseolovirus infections – exanthema subitum – sarcoma, kaposi – papillomavirus infections – warts – condylomata acuminata – epidermodysplasia verruciformis – papovaviridae infections" }, { "id": "pubmed23n1083_4142", "title": "Primary Epstein-Barr virus infection shortly after primary Cytomegalovirus infection: a case report.", "score": 0.009708737864077669, "content": "Infectious mononucleosis (IM) and mononucleosis-like illnesses are common viral infectious diseases which are often accompanied by a high fever, pharyngitis and lymphadenopathy in adults, although such infection in childhood is generally subclinical. Most cases of IM are caused by the Epstein-Barr virus (EBV) or Cytomegalovirus (CMV). However, it is difficult to diagnose IM only with subjective symptoms, and thus EBV and CMV are nearly indistinguishable in clinical practice. A 20-year-old healthy Japanese woman had a 2-day history of high fever and consulted us. She had sex for the first time 6 months earlier. Her virus antibodies showed that she was infected with primary CMV. About 5 months later, she again experienced high fever and lymph node enlargement at the posterior cervical region. Her virus antibodies showed that she was infected with primary EBV at that time. Herein, we report a healthy adult Japanese woman with primary EBV infection relatively soon after primary CMV infection. It is very interesting to compare the symptoms and/or clinical data after EBV and CMV infection in the same patient within a short period of time. Our patient was diagnosed based only on subjective symptoms, physical examination and laboratory data, without tests of such virus-related antibodies. Therefore, clinicians should bear in mind that primary EBV infection and/or primary CMV infection is possible when patients have symptoms such as high fever, pharyngitis and lymphadenopathy, even in healthy adults." }, { "id": "pubmed23n0279_19449", "title": "Atypical exanthema in a patient with infectious mononucleosis.", "score": 0.009615384615384616, "content": "A 19-year-old male with a sore throat developed numerous, indistinct, erythematous, maculopapular lesions on the trunk. The eruptions, which mimicked secondary syphilis, continued for seven weeks and faded away without pigmentation or scarring. The laboratory examinations revealed lymphocytosis with atypical lymphocytes, seroconversion of Epstein-Barr virus titers, and elevation of transaminase in liver function." }, { "id": "Pediatrics_Nelson_2200", "title": "Pediatrics_Nelson", "score": 0.00958963820910393, "content": "The characteristic triad of EBV infectious mononucleosis is fever, pharyngitis, and lymphadenopathy. The pharynx shows enlarged tonsils and exudate and, sometimes, anenanthem with pharyngeal petechiae. Lymphadenopathy ismost prominent in the anterior and posterior cervical andsubmandibular lymph nodes and less commonly involvesaxillary and inguinal lymph nodes. Other findings includesplenomegaly in 50% of cases, hepatomegaly in 10% to 20%, and maculopapular or urticarial rash in 5% to 15%. A diffuse,erythematous rash develops in approximately 80% of mononucleosis patients treated with amoxicillin. Compared with EBV infection, infectious mononucleosis-like illness caused by CMV has minimal pharyngitis and often more prominentsplenomegaly; it often presents with fever only. The mostcommon manifestation of toxoplasmosis is asymptomaticcervical lymphadenopathy, but approximately 10% of casesof acquired toxoplasmosis develop chronic posterior cervical lymphadenopathy and fatigue, usually" }, { "id": "wiki20220301en566_552", "title": "Epstein–Barr virus-associated lymphoproliferative diseases", "score": 0.0094441790093964, "content": "During the infection's acute phase, individuals generally have high levels of infective EBV in their oral/nasal secretions plus high blood levels of EBV, atypical lymphocytes, CD8 T cells, and memory B cells (up to 50% of the latter cells are EBV+). The tonsils and cervical lymph nodes in these cases are hyperplasic and contain mixtures of normal-appearing lymphocytes, activated lymphocytes, plasma cells, and Reed–Sternberg-like cells. Many of these normal-appearing and activated B cells and a small percentage of the tissue's T and NK cells are EBV+ with the virus being mostly in its lytic cycle rather than latent phases. The diagnosis of mild IM cases is often overlooked or made based on clinical and routine laboratory findings. These cases as well as asymptomatic and more severe cases of EBV infection are diagnosed definitively as EBV-associated by finding during the initial infection period the Epstein–Barr virus, IgM antibody to EBV viral-capsid antigen (VCA-IgM), IgG antibody to" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 254, 435 ] ], "word_ranges": [ [ 43, 76 ] ], "text": "As an analytical data, it says that there is a lengthening of the aPTT. So, they want you to know, she has positive lupus ac and link it directly to antiphospholipid syndrome (APS)." }, "2": { "exist": true, "char_ranges": [ [ 436, 502 ] ], "word_ranges": [ [ 76, 89 ] ], "text": "A Leiden's does not alter coagulation, so it is ruled out as well." }, "3": { "exist": true, "char_ranges": [ [ 0, 253 ] ], "word_ranges": [ [ 0, 43 ] ], "text": "In this question what they assume is that this is a 45-year-old woman who is diagnosed with pulmonary thromboembolism (PTE). With this diagnosis, options 3 and 4 are directly excluded (also, she is female, so we would not have to think about hemophilia)" }, "4": { "exist": true, "char_ranges": [ [ 0, 253 ] ], "word_ranges": [ [ 0, 43 ] ], "text": "In this question what they assume is that this is a 45-year-old woman who is diagnosed with pulmonary thromboembolism (PTE). With this diagnosis, options 3 and 4 are directly excluded (also, she is female, so we would not have to think about hemophilia)" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

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

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1102_22675", "title": "Case 294: Catastrophic Antiphospholipid Syndrome.", "score": 0.01624468557649597, "content": "History A 50-year-old woman presented to the emergency department of our hospital with a 2-day history of lower limb pain associated with unusual asthenia and diffuse arthralgia over the past 3 weeks. She was a native of Guinea and had lived in France for most of her life, working as a personal care assistant. Her only medical history of note was an occurrence of fetal death at 12 weeks gestation when she was 35 years old. She had bilateral lower limb swelling, without changes in skin temperature or color. All proximal and distal arterial pulses were felt. General physical examination findings were otherwise unremarkable. Her laboratory tests showed a decreased hemoglobin concentration of 8.9 g/dL (normal range, 12-16 g/dL), a decreased platelet count of 45 × 10<sup9</sup/L (normal range, [150-400] × 10<sup9</sup/L), a C-reactive protein level of 158 mg/L (normal range, &lt;5 mg/L), and a d-dimer level of 2000 mg/L (normal range, &lt;500 mg/L]). Compression US of the lower limbs revealed bilateral calf vein thrombosis involving the fibular and posterior tibial veins. Curative anticoagulation using low-molecular-weight heparin (enoxaparin, subcutaneous injection of 100 units per kilogram of body weight twice a day) was started. The day after the start of anticoagulation therapy, the patient reported dyspnea and acute chest and abdominal pain. Her vital signs were assessed, and she had elevated blood pressure and increased heart rate and respiratory rate, but she remained afebrile. Her cardiac auscultation was unremarkable, besides tachycardia. Skin examination revealed small areas of necrosis on the fingertips of her right hand. Laboratory studies were repeated and showed an increase in serum creatinine level from a baseline value of 0.49 mg/dL to a new value of 1.01 mg/dL (normal range, 0.6-1.1 mg/dL), an apparition of low-grade proteinuria of 0.43 g per day (normal range, &lt;0.3 g/ day), and a high serum troponin level of 1066 ng/L (normal range, &lt;14 ng/L), whereas electrocardiography showed no ST segment modification and echocardiography revealed a moderately altered left ventricular ejection fraction (45%). There was no coronary occlusion seen at emergency coronarography. Contrast-enhanced CT of the chest, abdomen, and pelvis was performed (Figs 1, 2) together with cardiac MRI (Figs 3, 4)." }, { "id": "pubmed23n0479_1411", "title": "[Catastrophic antiphospholipid syndrome and acute heart failure. Report of a case].", "score": 0.015685328185328185, "content": "A 33 years old woman was admitted to the hospital after four days with cough, dyspnea, orthopnea and hemoptysis. Blood pressure was 170/90 mmHg, pulse was 112 and temperature was normal. She had cyanosis and a left ventricular gallop, without heart murmurs. A chest radiograph revealed pulmonary edema and echocardiogram showed a global left ventricular systolic disfunction. Oxygen and furosemide were started, but cardiopulmonary collapse ensued. The patient was supported with mechanical ventilation and treated with inotropic drugs. A right sided cardiac catheterization showed pulmonary wedge pressure of 18 mmHg and a cardiac index of 3 l/min/m2. The levels of creatinine and urea nitrogen were elevated and a urine protein was 97 mg/dl. Coagulation tests were normal except by a positive lupic anticoagulant. Markers of connective tissue diseases or vasculitis were negatives. The clinical evolution suggested that a catastrophic antiphospholipid syndrome was ongoing. Intravenous corticoids, gammaglobulin and cyclophosphamide were administered with transient improvement. On her fourth day of treatment, the patient presented sudden pulmonary bleeding and embolism. A plasmapheresis was performed with improvement of renal, cardiac and pulmonary function. After this episode, the patient has been treated with prednisone and oral anticoagulants treatment for the last two years, without further clinical events." }, { "id": "pubmed23n0962_14441", "title": "[Pulmonary embolism in a girl with nephrotic syndrome and factor V Leiden - case report].", "score": 0.014062775524598836, "content": "Thromboembolic complications are found in 2-3% of children with nephrotic syndrome (NS); this increased risk is caused by hypovolemia, hemoconcentration, increased number and activity of platelets, hyperfibrinogenemia and loss of coagulation inhibitors. Risk is even higher in case of additional factors e.g. congenital thrombophilia. Girl with NS aged 17 11/12 years was admitted to hospital due to respiratory tract infection with cough and back pain. NS started 9 months earlier and she had two bouts of disease, and was treated only with prednisone (current dose - 60 mg/48h). On admission she was without any abnormalities on auscultation, with BP 111/65 mmHg, HR 80 bpm, satO2 99%. Lab results showed the increase of WBC 18.3×103/μL, D-dimers 23038 μg/L and proteinuria 900 mg/dL. Other values of examined parameters were in normal limits. Chest X-ray and ECG were also normal. Presumptive diagnosis of pulmonary embolism was made and the patient was given 1000IU of antithrombin III and nadroparine (2x90IU/kg/24h s.c.). In ECHO the occlusion of left pulmonary artery and preserved blood flow in right were revealed. In angioCT clot nearly filling lumen of left pulmonary artery, clot in intermediate part of right pulmonary artery, and focus of pulmonary infarction in 10th segment of left lung were found. Doppler USG of lower limb veins did not reveal thrombi or perforator vein incompetence. Treatment with nadroparine was continued, and rapid improvement of clinical condition and disappearance of pain and cough were observed. Mycophenolate mofetil was added, which resulted in subsidence of proteinuria. Rivaroxaban was used in prophylaxis of recurrences of thromboembolism. Tests for thrombophilia revealed factor V Leiden in patient." }, { "id": "pubmed23n0771_8195", "title": "Pulmonary hypertension secondary to hyperviscosity in a patient with rheumatoid arthritis and acquired von Willebrand disease: a case report.", "score": 0.013997113997113998, "content": "Acquired von Willebrand disease is initiated by autoantibodies and hyperviscosity syndrome caused by a massive polyclonal hypergammaglobulinemia. Acquired von Willebrand disease associated with autoimmune disease in addition to pulmonary hypertension during emergency room presentation is a rare condition. To the best of our knowledge, this is the second case reported in the literature treated with success; the first one was reported in 1987. A 28-year-old mestizo man with a 3-year history of inflammatory arthritis was admitted to our hospital. An overlap of rheumatoid arthritis with systemic lupus erythematosus was suspected; therefore methotrexate was initiated, and later changed to leflunomide because of liver toxicity. Prothrombin time, international normalized ratio and activated partial thromboplastin times were normal (11/10.4 seconds; 1.2; 31.1/26.9 seconds, respectively), von Willebrand factor activity was observed with low ristocetin cofactor at 33.6UI/dL, high von Willebrand factor antigen &gt;200UI/dL, and a low von Willebrand factor: ristocetin cofactor to von Willebrand factor antigen ratio. He was admitted to the emergency room with a 24-hour evolution of progressive dyspnea, cough, thoracic pain, and palpitations, 104 beats/min, 60/40 mmHg, temperature of 38°C, pulse oximetric saturation 88% and 30 breaths/minute. Cold, pale and mottled skin was also observed. He was then transferred to the intensive care unit. The placement of a pulmonary artery catheter was made. The initial patterns showed a precapillary pulmonary hypertension; acute pulmonary embolism was the first choice for diagnosis. Pulmonary angiography was conducted, and when no clot was discovered, pulmonary artery hypertension associated with connective tissue disease was considered. Serum protein electrophoresis confirmed the presence of a massive polyclonal hypergammaglobulinemia, and no paraproteinemia or monoclonal cell population was found from the electrophoretic pattern of the patient's plasma. Hypergammaglobulinemia was the cause of hyperviscosity syndrome associated with autoantibodies. Three sessions of plasma exchange therapy were made, and clinical improvement was observed. He was then discharged from the intensive care unit and hospital, respectively. He is now attended by an external consult and has no respiratory symptomatology. Hyperviscosity syndrome with pulmonary arterial hypertension presentation in a patient with acquired von Willebrand disease in an autoimmune context is a rare condition that can be treated successfully with plasmapheresis and critical care support." }, { "id": "wiki20220301en114_9174", "title": "Brodifacoum", "score": 0.012942564909520064, "content": "In another case reported in 2013, a 48-year-old female patient reported 4 days of mild dyspnea, dry cough, bilateral popliteal fossae pain, and diffuse upper abdominal pain. She had no history of liver disease or alcohol or illicit substance abuse. Initial physical examination was remarkable only for mildly pale conjunctivae and mild abdominal tenderness and pain in the left popliteal fossa. A complete blood count and complete metabolic panel were normal. Prothrombin time (PT) was above 100 s, partial thromboplastin time (PTT) was above 200 s and international normalized ratio (INR) was reported as above 12.0. Urinalysis revealed hematuria (blood in the urine). Venous Doppler ultrasound of lower extremities demonstrated left popliteal vein thrombosis. Computed tomography scan of the abdomen demonstrated transmural hematoma, and a fecal occult blood test was positive. A full anticoagulant work-up showed critical reduction of vitamin K-dependent factors II, VII, IX, and X. PT and PTT" }, { "id": "pubmed23n0903_20488", "title": "A 2-year-old boy with circulatory failure owing to streptococcal toxic shock syndrome: case report.", "score": 0.012487812195304883, "content": "A 2-year-old boy presented with severe hypotension and acute kidney injury after a prodrome of non-bloody diarrhoea and fever in the preceding 3 days. He had a mild Ebstein cardiac anomaly but otherwise a normal past history and growth. On examination, he looked ill, his temperature was 37.5 °C, circulation was poor, and there were several purpuric lesions on the face, hands and scrotum. Haemoglobin was 7.8 g/dL (11-14), total white cell count 27 × 10<sup9</sup/L, platelets 62 × 10<sup9</sup/L, blood urea nitrogen 20.7 mmol/L (4.2-17.1), serum creatinine 95.4 μmol/L (21.2-36.2), CRP 154 mg/L (&lt;5), AST 296 U/L (11-50), ALT 909 U/L (7-40) and C<sub3</sub component of complement 0.8 g/L (0.9-1.8). Activated partial thromboplastin time (APTT) and prothrombin time (PT) were prolonged and fibrinogen level was 1.0 g/L (2-4). He received immediate fluid resuscitation (IV 0.9% saline solution, 2 × 10 ml/kg boluses, followed by glucose 5/0.45% sodium chloride solution, 2 × 10 ml/kg) and antibiotics (ciprofloxacin and amikacin) but circulation continued to deteriorate with development of decreased consciousness. He was placed on mechanical ventilation and vasopressor agents were added. Despite improved circulation over the next 2 days, he developed oliguria, progressive fluid overload, generalised oedema and a right-sided pleural effusion. Dialysis was commenced on day 3 of admission. Differential diagnosis included sepsis, atypical haemolytic uraemic syndrome and lupus nephritis. Blood and urine cultures remained negative but an anti-streptolysin O titre of 1318 (&lt;200) IU/mL led to the diagnosis of streptococcal toxic shock syndrome which is rare in early childhood and associated with high mortality. Haemodialysis was commenced and continued for 10 days with successful treatment of fluid overload and subsequent extubation. Renal function was completely restored over the following 6 weeks and he was discharged in good clinical condition about 2 months after intial admission. The clinical course and outcome are discussed, and the importance of timely initiation of dialysis when there is fluid overload is emphasised." }, { "id": "pubmed23n0681_21394", "title": "[Metastatic prostate cancer complicated with chronic disseminated intravascular coagulopathy causing acute renal failure, mimicking thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: pathomechanism, differential diagnosis and therapy related to a case].", "score": 0.011251844564682735, "content": "Disseminated intravascular coagulopathy (DIC) is characterized as activation of the clotting system resulting in fibrin thrombi, gradually diminishing levels of clotting factors with increased risk of bleeding. Basically two types of DIC are distinguished: (1) chronic (compensated) - with alteration of laboratory values and (2) acute (non-compensated) - with severe clinical manifestations: bleeding, shock, acute renal failure (ARF), transient focal neurologic deficit, delirium or coma. Chronic DIC related to metastatic neoplasia is caused by pancreatic, gastric or prostatic carcinoma in most of the cases. Incidence rate of DIC is 13-30% in prostate cancer, among those only 0.4-1.65% of patients had clinical signs and symptoms of DIC. In other words, chronic DIC is developed in one of eight patients with prostate cancer. DIC is considered as a poor prognostic factor in prostatic carcinoma. The similar clinical and laboratory findings of TTP-HUS (thrombotic thrombocytopenic purpura - hemolytic uremic syndrome) and DIC makes it difficult to differentiate between them. A 71 years old male patient with known chronic obstructive pulmonary disease, benign prostatic hyperplasia, significant carotid artery stenosis, gastric ulcer and alcoholic liver disease was admitted to another hospital with melena. Gastroscopy revealed intact gastric mucosa and actually non-bleeding duodenal ulcer covered by clots. Laboratory results showed hyperkalemia, elevated kidney function tests, indirect hyperbilirubinemia, increased liver function tests, leukocytosis, anemia, thrombocytopenia and elevated international normalized ratio (INR). He was treated with saline infusions, four units of red blood cells and one unit of fresh frozen plasma transfusions. Four days later he was transported to our Institution with ARF. Physical examination revealed dyspnoe, petechiae, hemoptoe, oliguria, chest-wall pain and aggressive behavior. Thrombocytopenia, signs of MAHA (fragmentocytes and helmet cells in the peripheral blood), normal INR, elevated lactate dehydrogenase (LDH) and ARF suggested TTP-HUS. Hemodialysis and six plasmaferesis (PF) were carried out. After the fifth PF, skin manifestations of thrombotic microangiopathy occurred on the feet. Clotting analysis revealed elevated D-dimer (&gt;5 μg/mL), normal fibrinogen (3.2 g/L), a slightly raised INR (1.36) and activated partial prothrombin time (APTT) (45.8 sec), normal reticulocyte (57 G/L) and a slightly low platelet count (123 G/L), which proved to be chronic DIC. Therapeutic dose of low-molecular-weight heparin (LMWH) was started. Elevated prostate-specific antigen (PSA) (109.6 ng/mL) suggested prostatic carcinoma. Prostate biopsy revealed adenocarcinoma (Gleason: 4+4 for left lobe and 3+3 for right lobe). Elevated alkaline phosphatase suggested metastases in the bone, which were confirmed by bone scintigraphy. Combined androgen blockade (CAB) was started. After three months follow-up our patient's status is satisfactory. PSA is in the normal range (4.6 ng/mL). Thrombocytopenia of uncertain origin with normal or raised INR, APTT, elevated D-dimer, normal fibrinogen and reticulocyte count prove the diagnosis of chronic DIC. This process warrants searching for metastatic neoplasia. Due to the relatively low serum levels of circulating procoagulant factors (e.g. tissue factor), therapeutic dose of LMWH can be used with good efficiency in chronic DIC with low risk of bleeding. Severe DIC as a complication of metastatic prostate cancer can be treated by androgen deprivation therapy (ADT) or CAB in combination with ketokonazole and concomitant use of supportive treatment. Deme D, Ragán M, Kovács L, Kalmár K, Varga E, Varga T, Rakonczai E. Metastatic prostate cancer complicated with chronic disseminated intravascular coagulopathy causing acute renal failure mimicking thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: pathomechanism, differential diagnosis and therapy related to a case." }, { "id": "wiki20220301en041_54510", "title": "Thrombophilia", "score": 0.009928766588602655, "content": "Diagnosis Tests for thrombophilia include complete blood count (with examination of the blood film), prothrombin time, partial thromboplastin time, thrombodynamics test, thrombin time and reptilase time, lupus anticoagulant, anti-cardiolipin antibody, anti-β2 glycoprotein 1 antibody, activated protein C resistance, fibrinogen tests, factor V Leiden and prothrombin mutation, and basal homocysteine levels. Testing may be more or less extensive depending on clinical judgement and abnormalities detected on initial evaluation. For hereditary cases, the patient must have at least two abnormal tests plus family history." }, { "id": "wiki20220301en014_34439", "title": "Von Willebrand disease", "score": 0.009900990099009901, "content": "Diagnosis Basic tests performed in any patient with bleeding problems are a complete blood count-CBC (especially platelet counts), activated partial thromboplastin time-APTT, prothrombin time with International Normalized Ratio-PTINR, thrombin time-TT, and fibrinogen level. Patients with abnormal tests typically undergo further testing for hemophilias. Other coagulation factor assays may be performed depending on the results of a coagulation screen. Patients with von Willebrand disease typically display a normal prothrombin time and a variable prolongation of partial thromboplastin time." }, { "id": "pubmed23n0540_7041", "title": "An unusual cause of acute abdominal pain - a case presentation.", "score": 0.009900990099009901, "content": "In 1983, Graham Hughes described a condition of Antiphospholipid Syndrome in which there was a danger of thrombosis. The condition is readily detectable by blood tests and, once diagnosed; the risk of further thrombosis can be significantly reduced by anticoagulation treatments. Affected groups of patients can be distinguished by a specific blood test - the detection of antiphospholipid antibody (Ref-1). Patients with Hughes syndrome have hypercoaguable state with a markedly increased risk of both arterial and venous thrombosis and there is temporal persistence of antibody positivity. A 44-year-old woman was admitted under the acute surgical \"take\" with left sided abdominal pain radiating to her back. She had a history of borderline thyrotoxicosis in the early 1990s. She was on etonogestrel-releasing implants for contraception and there was no history of previous deep venous thrombosis. She was very tender, locally, over the left side of the abdomen. Investigations showed haemoglobin of 13.2 g/dl, white cell count of 19.9 10*9/L, and platelets 214 10*9/L with neutrophilia. Amylase and renal function tests were found to be normal. Liver function tests were deranged with Gamma GT 244 u/l (twice normal). An abdominal Ultrasound Scan suggested a possible splenic infarction, which was confirmed by a CT scan of her abdomen. Tests were carried out to investigate the possibility of a post thrombotic state. Coagulation risk factors for thrombosis were within the normal limits; Protein S 67 %(60-140), Protein C 103 % (72-146), Antithrombin 3 110 %(80-120) and Activated P C Resistance was 1.9(2.0-4.3). The Hams test was negative but the Anticardiolipin antibody test was positive. IgM level was 52 (normal is up to 10) and IgG was 18.8 (normal is up to 10). She also had border line APC Sensitivity 1.9 (2 to 4.3). Kaolin time 49 sec (70-120) Ktmix 64 sec (70-120), thyroid function test revealed TSH 0.32 micro/L, fT4 20.2 pmol/L (10-25). Subsequent determination of Anticardiolipin antibody was negative. Her symptoms were settled with the use of simple analgesia and she was discharged home with long-term anticoagulation medication. The INR target for long-term anticoagulation was aimed at &gt;3. This case presented to us as an acute abdominal pain. Subsequent investigations revealed the presence of splenic infarction. Coagulation risk factors for thrombosis proved negative. Haematological investigations revealed the presence of anticardiolipin antibodies at the first instance but subsequent determinations were negative. Hence, it mimicked Hughes syndrome initially but the criteria for temporal persistence of anticardiolipin antibody was not fulfilled. Unusual surgical presentation of a thrombotic abnormality as abdominal pain due to splenic infarction." }, { "id": "wiki20220301en011_19168", "title": "Coagulation", "score": 0.00980392156862745, "content": "Assessment Numerous tests are used to assess the function of the coagulation system: Common: aPTT, PT (also used to determine INR), fibrinogen testing (often by the Clauss method), platelet count, platelet function testing (often by PFA-100), thrombodynamics test. Other: TCT, bleeding time, mixing test (whether an abnormality corrects if the patient's plasma is mixed with normal plasma), coagulation factor assays, antiphospholipid antibodies, D-dimer, genetic tests (e.g. factor V Leiden, prothrombin mutation G20210A), dilute Russell's viper venom time (dRVVT), miscellaneous platelet function tests, thromboelastography (TEG or Sonoclot), euglobulin lysis time (ELT). The contact activation (intrinsic) pathway is initiated by activation of the \"contact factors\" of plasma, and can be measured by the activated partial thromboplastin time (aPTT) test." }, { "id": "pubmed23n1085_24991", "title": "Case 294.", "score": 0.00980392156862745, "content": "History A 50-year-old woman presented to the emergency department of our hospital with a 2-day history of lower limb pain associated with unusual asthenia and diffuse arthralgia over the past 3 weeks. She was a native of Guinea and had lived in France for most of her life, working as a personal care assistant. Her only medical history of note was an occurrence of fetal death at 12 weeks gestation when she was 35 years old. She had bilateral lower limb swelling, without changes in skin temperature or color. All proximal and distal arterial pulses were felt. General physical examination findings were otherwise unremarkable. Her laboratory tests showed a decreased hemoglobin concentration of 8.9 g/dL (normal range, 12-16 g/dL), a decreased platelet count of 45 × 10<sup9</sup/L (normal range, 150-400 × 10<sup9</sup/L), a C-reactive protein level of 158 mg/L (normal range, &lt;5 mg/L) and a d-dimer level of 2000 mg/L (normal range, &lt;500 mg/L). Compression US of the lower limbs revealed bilateral calf vein thrombosis involving the fibular and posterior tibial veins. Curative anticoagulation using low-molecular-weight heparin (enoxaparin, subcutaneous injection of 100 units per kilogram of body weight twice a day) was started. The day after the start of anticoagulation therapy, the patient reported dyspnea and acute chest and abdominal pain. Her vital signs were assessed, and she had elevated blood pressure and increased heart rate and respiratory rate, but she remained afebrile. Her cardiac auscultation was unremarkable, besides tachycardia. Skin examination revealed small areas of necrosis on the fingertips of her right hand. Laboratory studies were repeated and showed an increase in serum creatinine level from a baseline value of 0.49 mg/dL to a new value of 1.01 mg/dL (normal range, 0.6-1.1 mg/dL), an apparition of low-grade proteinuria of 0.43 g per day (normal range, &lt;0.3 g/day), and a high serum troponin level of 1066 ng/L (normal range, &lt;14 ng/L), whereas electrocardiography showed no ST segment modification and echocardiography revealed a moderately altered left ventricular ejection fraction (45%). There was no coronary occlusion seen at emergency coronarography. Contrast-enhanced CT of the chest, abdomen, and pelvis was performed (Figs 1, 2) together with cardiac MRI (Figs 3, 4)." }, { "id": "pubmed23n0308_14555", "title": "Activated protein C resistance phenotype in patients with antiphospholipid antibodies.", "score": 0.009708737864077669, "content": "The effect of antiphospholipid antibodies (aPL) on the action of activated protein C (APC) was examined in 32 patients: 19 with lupus anticoagulant (LA), 6 with anticardiolipin antibodies (aCL), and 7 with LA and aCL. Eighteen patients had a ratio of activated partial thromboplastin time (APTT) with APC to APTT without APC (APTT ratio) &lt;2.06 (cut-off level) and no factor V Leiden mutation; these patients showed APC-resistance (APC-R) phenotype. The mean prolongation of APTT after addition of APC in a control group was 45.3 seconds, with a lower limit of 31.4 seconds. Only 3 of the 18 patients with low APTT ratio had a prolongation of &lt;31.4 seconds; they were classified as true APC-R phenotype, whereas the other 15 patients were classified as spurious APC-R. Of the 3 patients with true APC-R, 2 had deep venous thrombosis, 1 with pulmonary embolism, and the third had recurrent abortion. Of the other 15 patients, 2 had had ischemic stroke, 1 had recurrent abortion, and 12 were asymptomatic. Circulating APC level was measured in 14 of the 18 aPL patients with a low APTT ratio; it was lower than the normal lower limit in 4 patients and within the lower limit in 2. Three of the 4 patients with reduced APC levels had a history of thrombosis. We conclude that patients with aPL who show APC-R phenotype due to a low APTT ratio without the factor V Leiden mutation can be classified into two groups: true and spurious APC-R phenotype. Since those with true APC-R phenotype could have greater thrombotic risk, adequate classification of these patients is important. Moreover, aPL can sometimes interfere with the activation of protein C, thus reducing the circulating levels of APC, and this could constitute another thrombotic risk factor." }, { "id": "wiki20220301en022_80570", "title": "Prothrombin time", "score": 0.009615384615384616, "content": "The prothrombin time (PT) – along with its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) – is an assay for evaluating the extrinsic pathway and common pathway of coagulation. This blood test is also called protime INR and PT/INR. They are used to determine the clotting tendency of blood, in such things as the measure of warfarin dosage, liver damage, and vitamin K status. PT measures the following coagulation factors: I (fibrinogen), II (prothrombin), V (proaccelerin), VII (proconvertin), and X (Stuart–Prower factor). PT is often used in conjunction with the activated partial thromboplastin time (aPTT) which measures the intrinsic pathway and common pathway of coagulation. Laboratory measurement" }, { "id": "pubmed23n0055_296", "title": "Treatment of massive pulmonary thromboembolism with low intrapulmonary dosages of urokinase. Short-term angiographic and hemodynamic evolution.", "score": 0.009615384615384616, "content": "Sixteen patients who had massive pulmonary thromboembolism and shock had no history of cardiopulmonary disease. We present an evaluation of the short-term effects of fibrinolytic treatment consisting of intrapulmonary administration of a bolus of 500,000 IU of urokinase followed by infusion of 1 x 10(6) IU into the right auricle over 12 h and subsequent intravenous infusion of heparin. For each patient, the effectiveness of treatment was evaluated by comparing pretreatment angiographic and hemodynamic parameters with those measured 48 h after the start of treatment. The Miller index fell from 22.9 +/- 5.9 to 9.8 +/- 3.3 (p less than 0.001), with a mean improvement of 57.2 percent. All the hemodynamic parameters studied (cardiac output and index, total pulmonary vascular resistance, and systolic, diastolic, and mean pulmonary vascular pressure) also exhibited statistically significant differences between pretreatment and posttreatment values (p less than 0.001 for each parameter), with a mean improvement of over 30 percent in each case. All the patients survived, and in no case did treatment fail; only one patient (6.2 percent) suffered severe hemorrhage. We conclude that this form of administration of urokinase is useful for patients with critical massive pulmonary thromboembolism." }, { "id": "wiki20220301en589_2750", "title": "Acquired haemophilia", "score": 0.009523809523809525, "content": "Diagnosis Any acute or recent onset of bleeding symptoms in a patient with no previous history of bleeding, especially in elderly or post-partum patients, and an unexplained isolated prolonged activated partial thromboplastin time (aPTT) suggest the diagnosis of AHA, and need further investigation. The differential diagnosis in prolonged aPPT with a normal prothrombin time (PT) includes factor deficiencies, lupus anticoagulant or heparin therapy. The first step to distinguish between factor deficiency and the presence of an inhibitory substance is to perform a mixing test, in which patient plasma and normal plasma are mixed and aPTT measured; correction of prolonged aPTT suggests a factor deficiency while persistent prolongation indicates the presence of an inhibitor. Prolongation of the aPTT in a mixture of patient and normal plasma after a 1-2 h incubation compared to an immediate mix is typical of FVIII autoantibodies, as FVIII inhibitors are time and temperature-dependent." }, { "id": "pubmed23n0405_10934", "title": "[Relative value of different antiphospholipid antibodies detected in a department of internal medicine: retrospective study of 124 patients].", "score": 0.009523809523809525, "content": "The value of antiphospholipid antibodies (aPL) detected in the sera of the patients of an Internal Medicine department is not univocal and is still much debated. To test the contribution of such new markers, we reviewed the records of patients having antiphospholipid antibodies detected between 1996 and 1997. One hundred and twenty four patients, having at least one of these two aPL: lupus anticoagulant (LA), anticardiolipin antibodies (aCL), or one of these two anti-proteins: anti-beta 2glycoprotéin I antibodies (anti-beta 2GPI) or anti-prothrombin antibodies (aPT), were studied. LA was detected by a PTT-LA technique and aCL, anti-beta 2GPI and aPT by ELISA-sandwich techniques. For each patient we recorded sex, age, personal and familial history of thrombosis, fetal losses and systemic disease, the reason of aPL detection, the final diagnosis, activated partial thromboplastin time (aPTT), platelets count and type of aPL. The population was composed of 77 women (62%) and 47 men (38%) with a mean age of 54 years [12-92 years]. A thrombocytopenia was strongly correlated to aCL presence (OR = 6.15 et p = 0.03). The reason of aPL detection was venous thrombosis, recurrent fetal losses, systemic disease, infectious disease or fortuitous discovery of a prolonged aPTT. The final diagnosis was a systemic disease in 57% of cases, an infectious disease in 14.5%, a thrombosis in 4.5% and a neoplasia in 3%. LA was detected in 54% of patients, aCL in 39.5%, anti-beta 2GPI in 23% and aPT in 31%. No relationship between the aPTT value and the type of aPL could be established. Our study shows that familial histories of venous thrombosis or systemic disease are useful to enhance antiphospholipid antibodies detection; that LA is mostly associated to systemic and infectious diseases; that aCL and anti-beta 2GPI are predominant in case of venous thrombosis and that thrombocytopenia has to enhance aCL detection and the discussion about a possible APS." }, { "id": "pubmed23n1076_13320", "title": "Diagnostic analysis of lupus anticoagulant using clot waveform analysis in activated partial thromboplastin time prolonged cases: A retrospective analysis.", "score": 0.009433962264150943, "content": "Hemophilia was diagnosed in precedence research of clot waveform analysis (CWA) using the activated partial thromboplastin time (APTT). In patients with antiphospholipid syndrome (APS), lupus anticoagulant (LA) causes an increase in APTT, suggesting that the waveform would probably be distorted. Therefore, we evaluated using clinical samples. CWA may be useful low cost for clinical detection of LA. We assessed the clinical value of CWA for detection of LA and coagulation using clinical blood samples collected from patients with a prolonged APTT. We used patient samples inspected between April 2011 and March 2013 in Yamagata University Hospital. CWA was performed using the ACL TOP coagulation analyzer, and the associated software program was used to calculate APTT clotting endpoints. An atypical peak was defined as a derivative plot that did not conform to the normal S-shaped clot reaction curve. In total, 162 patients, including 66 men and 96 women, with an average age of 46 years (range: 24-89 years) were included. We also collected control samples from unmatched healthy donors. All 162 patients were divided according to medication history or condition into the following five groups: heparin (n = 20), warfarin (n = 23), hepatic dysfunction (n = 13), normal (n = 20), and LA-positive antiphospholipid syndrome (APS; n = 86). Twenty healthy individuals were included as controls.Eighty patients had an atypical peak. Among all, 78 patients (90.6%) were LA-positive, and 2 patients (2.5%) were treated with warfarin. The remaining two patients had prothrombin time international normalized ratios (PT-INR) &gt;4.0 while taking warfarin. Those who were APS LA positive with thrombosis and without thrombosis had split the reaction of clotting time, deceleration/acceleration time (D/A) ratio of 2.36 (1.99,3.24) vs 2.34 (2.04,2.86), respectively. The significant atypical peak and D/A ratio extension may be explained by the clotting waveforms observed specifically in patients with LA-positive APS." }, { "id": "pubmed23n0014_4347", "title": "[Long-term anticoagulant therapy in subjects over 75 years of age. 100 cases].", "score": 0.009433962264150943, "content": "100 patients (median age 79 years) were given anticoagulant therapy (ACT) for a period of time averaging 5 years 3 months (522 follow-up years).--Out of 3 522 Quick tests, converted into prothrombin times and all carried out in the same laboratory, the prothrombin time was at or less than 32% in 60.5%, and 34% in 69.6% of the tests.--The mean therapeutic doses were less than 27% of those for adults, and were decreased by 3 mg of phenindione per year over the age of 75, only the actively treated cases being retained.--The risks are the same as those for the middle-aged adult. They depend more on the quality of the investigations than upon age. In the group which has been studied, slight or frank haemorrhagic complications (0.05/year/patient) were the result of a demonstrable overdosage in only one case in four. They were not responsable for any deaths in this series.--because of the referral patterns, the patients studied consisted of 79 with ischaemic heart disease, 27 with peripheral vascular disease, 9 cerebrovascular accidents, and 6 with thrombo-emoblic problems, not counting the 23 complications during the course of the study. In those patients with ischaemic heart disease, well-regulated anticoagulant treatment was associated with a favourable clinical course, and the correlation was significant.--there is not argument against the administering of a full and prolonged course of ACT to a patient of more than 75 years of age." }, { "id": "pubmed23n0983_5225", "title": "Preserve encephalus in surgery of trauma: online survey. (P.E.S.T.O).", "score": 0.009345794392523364, "content": "Traumatic brain injury (TBI) is a global health problem. Extracranial hemorrhagic lesions needing emergency surgery adversely affect the outcome of TBI. We conducted an international survey regarding the acute phase management practices in TBI polytrauma patients. A questionnaire was available on the World Society of Emergency Surgery website between December 2017 and February 2018. The main endpoints were the evaluation of (1) intracranial pressure (ICP) monitoring during extracranial emergency surgery (EES), (2) hemodynamic management without ICP monitoring during EES, (3) coagulation management, and (4) utilization of simultaneous multisystem surgery (SMS). The respondents were 122 representing 105 trauma centers worldwide. ICP monitoring was utilized in 10-30% of patients at risk of intracranial hypertension (IH) undergoing EES from about a third of the respondents [<in</i = 35 (29%)]. The respondents reported that the safest values of systolic blood pressure during EES in patients at risk of IH were 90-100 mmHg [<in</i = 35 (29%)] and 100-110 mmHg [<in</i = 35 (29%)]. The safest values of mean arterial pressure during EES in patients at risk of IH were &gt; 70 mmHg [<in</i = 44 (36%)] and &gt; 80 mmHg [<in</i = 32 (26%)]. Regarding ICP placement, a large percentage of respondents considered a platelet (PLT) count &gt; 50,000/mm<sup3</sup [<in</i = 57 (47%)] and a prothrombin time (PT)/activated partial thromboplastin time (aPTT) &lt; 1.5 times the normal control [<in</i = 73 (60%)] to be the safest parameters. For craniotomy, the majority of respondents considered PLT count &gt; 100,000/mm<sup3</sup [<in</i = 67 (55%)] and a PT/aPTT &lt; 1.5 times the normal control [<in</i = 76 (62%)] to be the safest parameters. Almost half of the respondents [<in</i = 53 (43%)], reported that they transfused red blood cells (RBCs)/plasma (P)/PLTs at a ratio of 1/1/1 in TBI polytrauma patients. SMS was performed in 5-19% of patients, requiring both an emergency neurosurgical operation and EES, by almost half of the respondents [<in</i = 49 (40%)]. A great variability in practices during the acute phase management of polytrauma patients with severe TBI was identified. These findings may be helpful for future investigations and educational purposes." }, { "id": "pubmed23n0287_7260", "title": "[Splenic infarction caused by paradoxical emboli in severe pulmonary hypertension].", "score": 0.009259259259259259, "content": "A 55-year-old woman developed increasing shortness of breath and breath-independent pain in the left lower chest. 20 years previously she had had an episode of pulmonary embolism and 10 years previously a central venous thrombosis in the left eye. No cause of the increased thrombogenesis had been found. On admission she had resting dyspnoea but a stable circulation. On auscultation the breath sounds were diminished over the left base and there was a diastolic murmur over the pulmonary area with an accentuated second sound. There was also marked tenderness below the left costal margin. Recurrent pulmonary embolism or left-sided pleuropneumonia was suspected. Arterial blood gases (without additional oxygen) showed severe hypoxaemia (pO2 42.3 mm Hg, pCO2 27.8 mm Hg, pH 7.455, oxygen saturation 80.5%). Transthoracic and transoesophageal echocardiography showed normal left ventricular dimensions, right atrial and ventricular dilatation, and an atrial septal aneurysm with a right to left interatrial shunt. Right heart catheterisation demonstrated severe pulmonary hypertension. Sonography, computed tomography and scintigraphy revealed multiple splenic infarcts. Heparinisation was instituted (partial thromboplastin time 70-90 s) and overlapping oral anticoagulation to a Quick value of 20%. Subsequently the calcium antagonist felodipine (15 mg daily) was given. The mean pulmonary artery pressure was 61 mm Hg before and 57 mm Hg after treatment. Splenic infarction resulting from paradoxical embolisation is rare, but should be routinely considered in the presence of thromboembolic phenomena." }, { "id": "pubmed23n1068_13411", "title": "Case 290.", "score": 0.009259259259259259, "content": "History A 26-year-old man presented with a 1-month history of chest pain, a palpable and painful right inguinal mass, and edema in the right lower extremity. One month earlier, he started to experience left chest pain with no cough. Pulmonary CT angiography (CTA) revealed a left lower lobe segmental pulmonary embolus. The local hospital made a diagnosis of pulmonary embolism (PE). He received anticoagulants, and his chest pain was gradually relieved. At the time of current presentation, the patient was experiencing right lower extremity swelling and pain. Physical examination revealed a 4 × 3 cm palpable right inguinal mass with no redness. His medical history and family history were negative. The results of laboratory work-up were normal, with a D-dimer level of 0.16 mg/L fibrinogen equivalent units (reference range, &lt;0.46 mg/L) and an international normalized ratio of 2.45 (therapeutic range, 2.0-3.0 for a patient taking warfarin), except the prothrombin time was 28.2 seconds (reference range, 9.6-12.8 seconds) and the activated partial thromboplastin time was 52.2 seconds (reference range, 24.8-33.8 seconds). Echocardiography, chest radiography, chest CT, and contrast-enhanced CT revealed no abnormalities. The patient underwent right lower extremity vascular conventional US (Philips IU22; Philips) with an L9-3 probe (3-9 MHz, venous condition) and contrast-enhanced US (1.5-2.0 mL, SonoVue; Bracco) with an intravenous bolus injection at the initial evaluation. Two days later, noncontrast and contrast-enhanced CT images of the lower abdomen (1.5 mL per kilogram of body weight, 300 mg/mL iomeprol, Iomeron; Bracco) were acquired for further evaluation (Figs 1-3)." }, { "id": "wiki20220301en198_22391", "title": "PCO2", "score": 0.009174311926605505, "content": "Medicine In medicine, the partial pressure of carbon dioxide in arterial blood is called or PaCO2. Measurement of in the systemic circulation indicates the effectiveness of ventilation at the lungs' alveoli, given the diffusing capacity of the gas. It is a good indicator of respiratory function and the closely related factor of acid–base homeostasis, reflecting the amount of acid in the blood (without lactic acid). Normal values for humans are in the range 35–45 mmHg. Values less than this may indicate hyperventilation and (if blood pH is greater than 7.45) respiratory alkalosis. Values greater than 45 mmHg may indicate hypoventilation, and (if blood pH is less than 7.35) respiratory acidosis. Aquatic Sciences" }, { "id": "pubmed23n0406_14754", "title": "The clinical spectrum of acute renal infarction.", "score": 0.009174311926605505, "content": "Acute renal infarction is an oft-missed diagnosis. As a result, its true incidence, although presumed to be low, is actually unknown. Surprisingly, the medical literature on the subject, other than anecdotal case reports, is scarce. To increase physician awareness of the diagnosis and to identify predictive clinical and laboratory features of the entity. Between 1 November 1997 and 31 October 2000, 11 cases of acute renal infarction in 10 patients were diagnosed in our center by contrast-enhanced computerized tomography. The medical charts of these patients were reviewed regarding risk factors, clinical presentation, possible predictive laboratory examinations, and outcome. During the 36 month observation period, the incidence of acute renal infarction was 0.007%. The mean age of the patients (5 men and 5 women) was 67.4 +/- 21.1 (range 30-87 years). In four cases the right and in five the left kidney was involved; in the other two cases bilateral involvement was seen. In 7/10 patients, an increased risk for thromboembolic events was found. Six had chronic atrial fibrillation and one had a combined activated protein C resistance and protein S deficiency. Three patients had suffered a previous thromboembolic event. Two cases were receiving anticoagulant therapy with an INR of 1.6 and 1.8, respectively. On admission, flank pain was recorded in 10/11, fever in 5 and nausea/vomiting in 4 cases. Hematuria was detected in urine reagent strips in all cases. Serum lactate dehydrogenase and white blood cell count were elevated in all cases (1,570 +/- 703 IU/L and 12,988 +/- 3,841/microliter, respectively). In no case was the diagnosis of acute renal infarction initially entertained. The working diagnoses were renal colic in 2, pyelonephritis in 3, renal carcinoma, digitalis intoxication, and suspected endocarditis in one patient each, and an acute abdomen in 3. Time from admission to definitive CT diagnosis ranged from 24 hours to 6 days. Three patients were treated with intravenous heparin and another with a combination of i.v. heparin and renal intra-arterial urokinase infusion with, in the latter case, no recovery of function of the affected kidney. With the exception of this one patient (with a contralateral contracted kidney) who required maintenance dialysis, in all other cases serum creatinine levels remained unchanged or reverted to the baseline mean of 1.1 mg/dl (0.9-1.2). Acute renal infarction is not as rare as previously assumed. The entity is often misdiagnosed. Unilateral flank pain in a patient with an increased risk for thromboembolism should raise the suspicion of renal infarction. In such a setting, hematuria, leucocytosis and an elevated LDH level are strongly supportive of the diagnosis." }, { "id": "pubmed23n0975_25910", "title": "Acquired hemophilia A presenting as progressive intra-abdominal hemorrhage, muscle hemorrhage and hemothorax postpartum: A case report and literature review.", "score": 0.00909090909090909, "content": "Acquired hemophilia A (AHA) is a rare antibody-mediated condition in which autoantibodies form against a coagulation factor, most commonly factor VIII (FVIII), causing severe coagulopathy. Here the present report presents a case of AHA in a 35-year-old postpartum woman with continuous polyserous bloody effusions who was admitted to the First Affiliated Hospital of Zhejiang Chinese Medical University (Hangzhou, China) in October 2017 without a history of trauma, anticoagulation treatment or coagulopathy. At presentation, the patient's hemoglobin level was low (70 g/l; normal range: 115-150 g/l) g/l, blood pressure was 89/58 mmHg (normal range, 90-140/60-90 mmHg), and activated partial thromboplastin time was 68.4 sec (normal range: 25.0-36.0 sec), with a normal international normalized ratio (0.94; normal range, 0.8-1.2). The reaction time in thrombography was prolonged (35.8 min; normal range: 5-10 min), coagulation FVIII had markedly decreased activity (12.6%; normal range, 60-150%), and FVIII inhibitor had a high titer [7.4 Bethesda units (BU)/ml; normal range, 0-0.6 BU/ml]. Notably, the patient's autoantibody level was markedly higher than normal (1:320; normal range: &lt;1:100). The patient was successfully treated with bleeding control, eradication of FVIII inhibitor, and treatment of the underlying disease. To the best of our knowledge, this is the first case of AHA with polyserous bloody effusions in a patient with an autoimmune disorder during the postpartum period. Reports of such rare cases will aid the characterization of disease pathogenesis, which may in turn lead to the recognition and timely treatment of this rare disorder." }, { "id": "pubmed23n1162_136", "title": "A 52-Year-Old Man With Chest Pain and Dyspnea.", "score": 0.00909090909090909, "content": "A 52-year-old man came to the cardiac surgery clinic for pulmonary thromboendarterectomy (PTE) evaluation. He had initially appeared at an outside hospital 1 year earlier, with chest pain and shortness of breath. He had no known chronic conditions. A CT pulmonary angiogram (CTPA) at that time showed a filling defect at the bifurcation of the main pulmonary artery. A transthoracic echocardiogram revealed mild mitral valve regurgitation, but otherwise the results were normal. As he was hemodynamically stable and not hypoxemic, he was treated solely by anticoagulation. Despite adhering to prescribed apixaban, he developed progressive dyspnea and reduced exercise tolerance over the subsequent year. A repeat CTPA performed 12 months after the initial presentation showed a persistent filling defect at the level of the pulmonary artery bifurcation, with a new extension now completely occluding the right main pulmonary artery. A pulmonary angiogram confirmed this complete occlusion, and right heart catheterization revealed precapillary pulmonary hypertension, with a mean pulmonary artery pressure of 50 mm Hg. His anticoagulation was transitioned to enoxaparin for presumed apixaban treatment failure, and an investigation for hypercoagulable conditions was initiated. His lupus anticoagulant test result was positive, but he did not meet the criteria for antiphospholipid syndrome because he was negative for anticardiolipin and β<sub2</sub-glycoprotein antibodies. Assays for antithrombin III, protein C, prothrombin gene, and factor V Leiden mutations produced normal results." }, { "id": "pubmed23n1108_4052", "title": "Acquired hemophilia: clinical case of hemorrhage caused by inhibitors against factor VIII.", "score": 0.009009009009009009, "content": "Acquired hemophilia is caused by antibodies against coagulation factors, especially against factor VIII. As it is a low prevalence disease, our objective is to present an idiopathic case of acquired hemophilia to facilitate decision-making in clinical practice for others, exposing the therapeutic modality used. 65 years old woman, started with non-trauma hematomas, with asthenia, adynamia and dyspnea. Laboratory studies showed anemia (hemoglobin 7.1 g/dl, hematocrit 21%, mean corpuscular volume 91 fl, mean corpuscular hemoglobin 29.6 pg) and long clotting times (activated partial thromboplastin time 100 seconds) and with prothrombin time and International Normalized Index (17 seconds and 1.2 seconds respectively). So, plasma dilution tests were performed with plasma, without aPTT correction (1:2, 76.6 seconds; 1: 4, 60 seconds; 1: 8, 45 seconds) evidencing the presence of the inhibitor. The diagnosis was confirmed by the decrease in factor VIII (1%) and the presence of the factor VIII inhibitor (256 UB). The treatment started with prednisone and cyclophosphamide. Due to the presence of severe bleeding, treatment with activated prothrombin complex concentrate (CCpa) was required. Subsequently, Rituximab was prescribed, with clinical improvement and increased levels of hgb and reduced aPTT from the first week of treatment. The approach of acquired hemophilia should include control of the bleeding, the search for the etiology ruling out of the main causes of malignant neoplasms according to age and gender, and the immediate initiation of immunosuppression to decrease inhibitor levels." }, { "id": "pubmed23n0346_278", "title": "[Pulmonary thromboembolism angiographically confirmed: clinical and prognostic aspects].", "score": 0.009009009009009009, "content": "The aim of this study was to evaluate the clinical profile and prognosis of patients with an angiographically proven thromboembolism. Data from 22 consecutive patients (13 males, 9 females; mean age 57.3 +/- 16.8 years) with pulmonary embolism confirmed by pulmonary angiography were reviewed. All our patients were previously submitted to non-invasive diagnostic procedures (blood examinations, EKG, chest x-ray, echocardiography). A V/Q scan was also performed in 5 patients. Fourteen patients were traditionally treated with heparin alone and the rest received thrombolytic therapy and heparin. Two patients had a thromboembolectomy. At discharge, all our patients were submitted to an oral anticoagulant therapy. The mean duration of the follow-up period was 26 +/- 12 months. The majority of the patients were in the 6th decade of life and it was possible to identify a hypercoagulable state in 82%. The most common symptom at the time of presentation was sudden chest pain (64%). The most specific sign in non-invasive procedures were right side cardiac dilatation seen echocardiographically (73%) and the mismatch in the V/Q scan (80%). The most common haemodynamic parameter (91%) observed in the right heart catheterization of these patients was the finding of a gradient between diastolic pulmonary artery and pulmonary capillary wedge pressures. Uneventful angiography was performed in all patients who showed massive pulmonary embolism (86%). Three patients (13.6%) died during the acute phase. At the end of the follow-up period, 10 patients were asymptomatic and 5 had heart failure. Four died, which corresponds to an overall mortality of 31.8% in 2.2 years of follow-up. None of the clinical or haemodynamic parameters analyzed (age, gender, arterial blood gases at presentation, hypercoagulable states, thrombolysis, pulmonary hypertension and extension of the embolism) were related to mortality. Angiographically confirmed pulmonary thromboembolism is still a poor outcome situation, even when a lot of diagnostic and therapeutic procedures are available." }, { "id": "pubmed23n0235_2666", "title": "Longterm follow-up of patients with pulmonary thromboembolism. Late prognosis and evolution of hemodynamic and respiratory data.", "score": 0.008928571428571428, "content": "Seventy-six patients with various forms of pulmonary thromboembolic disease were followed-up for 1 to 15 years. All were free of other cardiopulmonary disease at the time of the first examination which was performed at least two months after the last pulmonary embolism. Catheterization was repeated in all survivors on average 4.8 years later. Severe chronic pulmonary hypertension (mean pulmonary artery pressure (PPA greater than 30 mm Hg) did not occur after a single episode of acute embolism, was infrequent after single subacute or recurrent emboli (8 of 9 patients), and was common after occult emboli (12 of 13 patients). Mortality in all clinical groups correlated with PPA and with the presence of right heart failure. In survivors, no correlation was found between the longterm changes of PPA and age, duration of disease, interval between catheterizations, PaO2, or cardiac output. Pulmonary hypertension progressed further in patients with initial PPA greater than 30 mm Hg. In contrast, none of the patients with normal or borderline PPA at the initial examination developed severe pulmonary hypertension during the follow-up. Since the future course of patients could be predicted from the first examination, repeated hemodynamic investigation proved to be of minor prognostic value." }, { "id": "wiki20220301en464_20969", "title": "Hypertensive disease of pregnancy", "score": 0.008849557522123894, "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": "pubmed23n0564_22244", "title": "[Chance finding of a bilateral central pulmonary embolism while using cardiac computed tomography for the clarification of a coronary anomaly].", "score": 0.008849557522123894, "content": "A 42 year-old man reported transient breathlessness and chest pain on the first day after a four-hour flight. During the following five months the symptoms recurred four times. After another episode he went to an outpatient department for further assessment. Blood tests demonstrated slightly elevated LDH (343 U/l) and also a minor increase of the D-dimers (710 microg/l). Hypercholesterolemia was also found (LDL-cholesterol 180 mg/dl). The rest of the blood tests, including the cardiac enzymes, were within normal limits. The electrocardiogram (ECG) showed sinus rhythm, heart rate 85 bpm and pre-terminal T-negativity in the precordial leads V1 to V3. Resting echocardiography and chest X-ray showed no significant abnormalities. The exercise ECG demonstrated no further ECG changes. However, because of the symptoms and a cardiovascular risk profile (family history, hypercholesterolemia and smoking) a coronary angiography was performed, which excluded coronary artery disease but revealed a so-called \"right-sided single coronary artery\", the left and right coronary arteries originating with a common stem from the right sinus of valsalva. To define the exact course of the left main coronary artery (whether in front of the pulmonary artery, between the two great arteries, retroaortic or septal) a contrast-enhanced cardiac computed tomography (CT) was performed, which demonstrated an anomalous position of the left main coronary artery in front of the pulmonary artery. Bilateral pulmonary embolism was an additional and unexpected finding. Oral anticoagulation was initiated after a coagulopathy had been excluded. The ultrasonography of the leg did not demonstrate any thrombosis. There was no evidence of malignant disease. Mild symptoms and absence of right heart congestion do not exclude pulmonary embolism. Depending on the symptoms and history, pulmonary thrombembolism has to be considered, especially if cardiac or extra-cardiac causes have been eliminated. The diagnostic method of choice for the detection or exclusion of pulmonary embolism is contrast-enhanced multi-slice spiral CT." }, { "id": "wiki20220301en034_65309", "title": "Partial thromboplastin time", "score": 0.008771929824561403, "content": "The partial thromboplastin time (PTT) or activated partial thromboplastin time (aPTT or APTT) is a blood test that characterizes coagulation of the blood. A historical name for this measure is the kaolin-cephalin clotting time (KCCT), reflecting kaolin and cephalin as materials historically used in the test. Apart from detecting abnormalities in blood clotting, partial thromboplastin time is also used to monitor the treatment effect of heparin, a widely prescribed drug that reduces blood's tendency to clot. Partial thromboplastin time (PTT) measures the overall speed at which blood clots form by means of two consecutive series of biochemical reactions known as the intrinsic pathway and common pathway of coagulation. PTT measures the following coagulation factors: I (fibrinogen), II (prothrombin), V (proaccelerin), VIII (anti-hemophilic factor), X (Stuart–Prower factor), XI (plasma thromboplastin antecedent), and XII (Hageman factor)." } ] } } }

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{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "InternalMed_Harrison_29376", "title": "InternalMed_Harrison", "score": 0.012276287011123915, "content": "Level of consciousness is the patient’s relative state of awareness of the self and the environment, and ranges from fully awake to comatose. When the patient is not fully awake, the examiner should describe the responses to the minimum stimulus necessary to elicit a reaction, ranging from verbal commands to a brief, painful stimulus such as a squeeze of the trapezius muscle. Responses that are directed toward the stimulus and signify some degree of intact cerebral function (e.g., opening the eyes and looking at the examiner or reaching to push away a painful stimulus) must be distinguished from reflex responses of a spinal origin (e.g., triple flexion response—flexion at the ankle, knee, and hip in response to a painful stimulus to the foot). Orientation is tested by asking the person to state his or her name, location, and time (day of the week and date); time is usually the first to be affected in a variety of conditions." }, { "id": "Surgery_Schwartz_12108", "title": "Surgery_Schwartz", "score": 0.011327607966263429, "content": "scoring for motor assessment tests. Characteristic motor reactions to pain in patients with depressed mental status include withdrawal from stimulus, localization to stimulus, flexor (decorticate) posturing, extensor (decerebrate) posturing, or no reaction (in order of wors-ening pathology). Figure 42-1 diagrams the clinical patterns of posturing. This forms the basis of determining the Glasgow Coma Scale (GCS) motor score, as detailed in Table 42-2. Light touch, proprioception, temperature, and pain testing may be useful in awake patients but is often impossible without good cooperation. It is critical to document sensory patterns in spinal cord injury (SCI) patients. Muscle stretch reflexes should be examined. Often com-paring left to right or upper extremity to lower extremity reflexes for symmetry is the most useful for localizing a lesion. Check for ankle-jerk clonus or up-going toes (Babinski’s test). Presence of either is pathologic and signifies upper motor neuron" }, { "id": "Surgery_Schwartz_12147", "title": "Surgery_Schwartz", "score": 0.010604166666666666, "content": "Observe whether the patient is visually attentive. Clearly command: “Tell me your name.” Then ask the patient to lift up two fingers on each side sequen-tially, and wiggle the toes. A visually or verbally unresponsive patient should be assessed for response to peripheral stimuli such as nail-bed pressure, or deep central painful stimulation, such as a firm, twisting pinch of the sensitive supraclavicular skin. Watch for eye opening and movement of the extremities, whether purposeful or reflexive. Assess the verbal response. The motor, verbal, and eye-opening scores may be correctly assigned using this rapid examination. An initial assessment of the probability of significant head injury can be made, assuming that pharmacologic and toxic elements have not obscured the examination. The surveyor must also take note of any external signs of head injury, including bleeding from the scalp, nose, or ear, or deformation of the skull or face.Classification TBI can be classified as mild," }, { "id": "article-19180_19", "title": "Cerebral Contusion -- History and Physical", "score": 0.010537190082644629, "content": "A detailed neurologic examination is performed. If sedation was given, it should be stopped for an adequate neurological assessment. The patient is evaluated for response to stimuli with a response in eye, motor, and verbal forms. The Glasgow coma scale (GCS) was established in 1974 by Teasdale and Jennett. [29] It helps obtain the best response in a patient and presents the status to the healthcare team. It also helps in comparing future evaluations. The pupillary response is critical in the initial assessment. Glasgow coma scale: [29] Eye opening (Score 1-4) Spontaneous – 4 To speech – 3 To pain – 2 No response – 1 Verbal function (Score 1-5) Alert and oriented – 5 Confused/disoriented – 4 Inappropriate words – 3 Incomprehensible sounds – 2 No response – 1 Motor function (Score 1-6) Obeys commands – 6 Localizes pain – 5 Withdraws from pain – 4 Decorticate flexion – 3 Decerebrate extension – 2 No response – 1" }, { "id": "article-30545_9", "title": "Brain Trauma -- History and Physical -- Exam", "score": 0.009935344098033242, "content": "Assuming that the patient's airway, breathing, and circulation are intact, the patient should then be evaluated using the Glasgow Coma Scale (GCS), assessing for eye-opening, verbal responses, and motor responses. The minimum score is 3, and the maximum score is 15. Glasgow Coma Scale [10] : Eye-opening response Spontaneous (4) To verbal stimuli (3) To pain (2) No response (1) Verbal response Oriented (5) Confused (4) Inappropriate words (3) Incomprehensible speech (2) No response (1) Motor response Obeys commands for movement (6) Purpose movement to painful stimuli (5) Withdraws to painful stimuli (4) Flexion response to painful stimuli (decorticate posturing) (3) Extension response to painful stimuli (decerebrate posturing) (2) No response (1)" }, { "id": "article-25803_7", "title": "Neurologic Exam -- Clinical Significance -- Glasgow Coma Scale", "score": 0.009919689024166636, "content": "The Glasgow coma scale (GCS) is a standard to determine the level of awareness in trauma or critically ill patients who present with impaired consciousness. It is a 15 point scale that gives a general idea of the extent of brain injury. [12] The GCS is divided and scored according to eye-opening, verbal response, and motor response. The eye-opening response is scored as spontaneous – 4, opens to verbal command – 3, opens to pain – 2, and no response – 1. The verbal response is scored as oriented – 5, confused – 4, inappropriate responses – 3, incomprehensible sounds – 2, and no response – 1. The motor response is scored as obeys commands – 6, spontaneous movement or localizes to painful stimuli – 5, withdrawal from pain – 4, abnormal flexion (decorticate) – 3, abnormal extension (decerebrate) – 2, and no response – 1. The scores are added and classified as follows: Minor brain injury – 13 to 15 points, moderate brain injury- 9 to 12 points, and severe brain injury- 3 to 8 points. [8]" }, { "id": "pubmed23n0712_25048", "title": "An evidence-based approach to emergency ultrasound.", "score": 0.009900990099009901, "content": "Paramedics bring into the ED an elderly man who is complaining of right-sided chest and abdominal pain. Earlier this morning, a friend had arrived at the patient's home and found him on the floor at the bottom of the stairs. The patient is in pain, somewhat altered, and unable to provide further details about what happened. After numerous attempts, the paramedics were only able to place a 22-gauge peripheral line. On examination, his blood pressure is 98/55 mm Hg, heart rate is 118 beats per minute, respiratory rate is 32 breaths per minute, oxygen saturation is 94% on a nonrebreather, and temperature is 36.0 degrees C (96.8 degrees F). His Glasgow Coma Scale score is 12 (eyes 3, verbal 4, motor 5). Given the unclear events surrounding his presentation and the concern for trauma, the patient is boarded and collared. His chest is stable but tender, and because of noise in the resuscitation room, you have difficulty auscultating breath sounds. The abdominal examination is notable for marked tenderness over the right upper quadrant and right flank, with some guarding. There is also mild asymmetric swelling of his right lower extremity. The patient is critically ill, his history is limited, and at this point the differential is quite broad. You consider the possibility of a syncopal episode followed by a fall, with a closed head injury, blunt thoracic trauma, and blunt abdominal trauma. His hypotension could be secondary to hypovolemia (dehydration or blood loss due to a ruptured aortic aneurysm), heart failure (left- or right-sided dysfunction), cardiac tamponade, tension pneumothorax, or sepsis. Your ED recently purchased an ultrasound machine, you wonder whether bedside ultrasound can help narrow the differential and guide your resuscitation. You call over one of your new faculty members who just finished resident training; a fortunate decision for both you and the patient." }, { "id": "pubmed23n1081_21454", "title": "Management of hypotony-related maculopathy after combined phacoemulsification and trabeculectomy: January consultation #1.", "score": 0.00980392156862745, "content": "A 59-year-old man with mild to moderate pigmentary glaucoma was referred for management of hypotony-related maculopathy 3 years after combined phacoemulsification and trabeculectomy in his right eye. His ocular history is significant for retinal detachment in the right eye that was surgically treated with a pars plana vitrectomy and scleral buckle 5 years prior to the current presentation and 1 year prior to his combined phacoemulsification-trabeculectomy procedure. After trabeculectomy, he reportedly had a wound leak with hypotony and choroidal effusion. The patient was referred to a second surgeon who performed a bleb revision with a pericardial patch graft, but the patient had a severe intraocular pressure (IOP) spike in the immediate postoperative period requiring suture removal. This resulted in recurrent hypotony with maculopathy. A second bleb revision with pericardial patch graft was performed but was not successful in raising the IOP out of the single digits or in resolving the maculopathy. Accordingly, the patient was referred for further assessment. At presentation, the patient's corrected distance visual acuity was 20/100 in the right eye and 20/20 in the left eye. Applanation tonometry IOP was 4 mm Hg and 16 mm Hg for the right and left eyes, respectively. Central corneal thickness was 609 μm in the right eye and 574 μm in the left eye. The right pupil was noted to be slightly irregular with a relative afferent pupillary defect. Slitlamp examination of the right eye was notable for a moderately elevated, Seidel test-negative bleb, and deep anterior chamber. The left eye had a Krukenberg spindle and mild nuclear sclerotic cataract but was otherwise unremarkable. Fundus examination of the right eye was notable for significant macular folds with edematous nerve fiber layer (NFL) and optic nerve. The left optic nerve and fundus examination were unremarkable. Gonioscopy revealed open angles with dense trabecular meshwork pigment in both eyes. There was a nicely patent superior sclerostomy in the right eye. There was no cyclodialysis cleft. Optical coherence tomography (OCT) of the macula showed chorioretinal folds and NFL edema in the right eye and was normal in the left eye (Figure 1JOURNAL/jcrs/04.03/02158034-202101000-00022/figure1/v/2021-01-04T143903Z/r/image-tiff). The OCT of the optic nerve in the right eye was distorted secondary to the chorioretinal folds, whereas the left eye was notable for mild superior thinning of the NFL (Figure 2JOURNAL/jcrs/04.03/02158034-202101000-00022/figure2/v/2021-01-04T143903Z/r/image-tiff). Humphrey visual field revealed a superior nasal step in the right eye (Figure 3JOURNAL/jcrs/04.03/02158034-202101000-00022/figure3/v/2021-01-04T143903Z/r/image-tiff). Axial lengths were 25.33 mm and 26.53 mm in the right and left eye, respectively; it is notable that the right eye had a shorter axial length despite the scleral buckle, which demonstrates the degree of axial shortening from hypotony (Figure 4JOURNAL/jcrs/04.03/02158034-202101000-00022/figure4/v/2021-01-04T143903Z/r/image-tiff). What would be your approach for managing this patient's hypotony? Does the fact that the referring surgeon had performed 2 failed bleb revision procedures prior to referral influence your approach? Given that a previous attempt at revision resulted in an extreme IOP spike would you also recommend a glaucoma procedure? If so, what procedure would you perform? Would you do it coincident with the revision or in a staged procedure later on an as-needed basis?" }, { "id": "wiki20220301en481_17390", "title": "Maddox wing", "score": 0.00980392156862745, "content": "Example instructions and examiner questions: \"Hold the device up to your eyes and look into the eye piece as if you're reading a book\" \"What number is the white arrow pointing to?\" It is important for the examiner to ask \"Is it actually pointing to the number (e.g. number 4) or in between two numbers (e.g. between the numbers 3 and 5)?\" This avoids possible confusion as only the odd numbers show on one side of the scale and the even figures on the other, if misinterpreted, diagnosis may be incorrect. \"What number is the red arrow pointing to?\" \" I want you to lift the red torsion lever and hold it parallel to the red arrow\" Recording Example: MW: cc exo 10∆ R/L 7∆ excyclo 4° OR MW: cc -10∆ R/L 7∆ excyclo 4° MW cc eso 5∆ ө Key:" }, { "id": "wiki20220301en027_70278", "title": "Paediatric Glasgow Coma Scale", "score": 0.009708737864077669, "content": "The Paediatric Glasgow Coma Scale (British English) or the Pediatric Glasgow Coma Score (American English) or simply PGCS is the equivalent of the Glasgow Coma Scale (GCS) used to assess the level of consciousness of child patients. As many of the assessments for an adult patient would not be appropriate for infants, the Glasgow Coma Scale was modified slightly to form the PGCS. As with the GCS, the PGCS comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible PGCS (the sum) is 3 (deep coma or death) whilst the highest is 15 (fully awake and aware person). The pediatric GCS is commonly used in emergency medical services. Coma scale Best eye response: (E) 4. Eyes opening spontaneously 3. Eye opening to speech 2. Eye opening to pain 1. No eye opening or response Best verbal response: (V)" }, { "id": "InternalMed_Harrison_29372", "title": "InternalMed_Harrison", "score": 0.009708737864077669, "content": "Several additional points about the examination are worth noting. First, in recording observations, it is important to describe what is found rather than to apply a poorly defined medical term (e.g., “patient groans to sternal rub” rather than “obtunded”). Second, subtle CNS abnormalities are best detected by carefully comparing a patient’s performance on tasks that require simultaneous activation of both cerebral hemispheres (e.g., eliciting a pronator drift of an outstretched arm with the eyes closed; extinction on one side of bilaterally applied light touch, also with eyes closed; or decreased arm swing or a slight asymmetry when walking). Third, if the patient’s complaint is brought on by some activity, reproduce the activity in the office. If the complaint is of dizziness when the head is turned in one direction, have the patient do this and also look for associated signs on examination (e.g., nystagmus or dysmetria). If pain occurs after walking two blocks, have the patient" }, { "id": "pubmed23n0062_6676", "title": "[Diffuse axonal injury (DAI) in an autopsy case of head trauma with long survival].", "score": 0.009615384615384616, "content": "The authors reported a clinico-pathological case survived 11 months after a traffic accident. A 41-year-old man had been hit by a motor car and was found in a state of semicoma. On admission, his consciousness level was III-100 to 200 (Japan Coma Scale). Pupils were isocoric; light reflex was present. Linear fracture of occipital bone was disclosed by Skull X-ray and subarachnoid hemorrhage was revealed on CT scan. This comatose state, lasting 24 hours, slowly improved and eventually he presented the so-called Korsakoff's syndrome until his death. He could not recognized his relatives, only uttered some meaningless words. He was unable to obey simple verbal orders. The patient was incontinent and right pyramidal sign was positive. On repeated CT scans, cerebral ventricles gradually increased in size; especially the enlargement of the fourth ventricle was remarkable. He expired of septic shock caused by bed sores. At autopsy brain weighed 1190 g. Old gloss contusional scars were observed on the bilateral frontal lobes including the orbital area and on the left temporal pole. Gliding contusions were revealed in the subcortical white matter beneath the left superior frontal convolution. Fibrillary gliosis was noted in this region, the deep white matter underlying the left temporal pole and the tissue surrounding the anterior horn of the left lateral ventricle. Nerve fibers were fragmented and lacerated at corpus callosum, anterior commissure and posterior limb of the left internal capsule. Bilateral pyramidal tracts showed mild myelin pallor at the brainstem. Loss of Purkinje cells were observed. This case would correspond to mile type of diffuse axonal injury proposed by Adams and Gennarelli. (ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "InternalMed_Harrison_2096", "title": "InternalMed_Harrison", "score": 0.009615384615384616, "content": "When asked to copy a simple line drawing, the patient fails to copy detail on the left, and when the patient is asked to write, there is a tendency to leave an unusually wide margin on the left. Two bedside tests that are useful in assessing neglect are simultaneous bilateral stimulation and visual target cancellation. In the former, the examiner provides either unilateral or simultaneous bilateral stimulation in the visual, auditory, and tactile modalities. After right hemisphere injury, patients who have no difficulty detecting unilateral stimuli on either side experience the bilaterally presented stimulus as coming only from the right. This phenomenon is known as extinction and is a manifestation of the sensory-representational aspect of hemispatial neglect. In the target detection task, targets (e.g., A’s) are interspersed with foils (e.g., other letters of the alphabet) on a 21.5to 28.0-cm (8.5 to 11 in.) sheet of paper, and the patient is asked to circle all the targets. A" }, { "id": "pubmed23n0601_58", "title": "Purple-red papules on foot.", "score": 0.009523809523809525, "content": "An 88-year-old Caucasian man of Italian ancestry came into our clinic with multiple, painful purple-red \"growths\" on his left foot that he'd had for several years. The patient had no systemic complaints (no fever, chills, weight loss, night sweats). He had a history of hypertension, a cardiac valve replacement, and chronic back pain (secondary to a motor vehicle accident). He was taking warfarin and nadolol. The patient had multiple, 0.1- to 0.5-cm purple-red papules and nodules on the dorsal and plantar surfaces of the left foot, with associated moderate lower extremity edema and mottled dyspigmentation. We did a punch biopsy, which showed a nodular neoplasm composed of moderately plump, spindle-shaped cells in short interweaving fascicles and numerous extravasated erythrocytes in the spaces (\"vascular slits\") between the spindle-shaped cells. What is your diagnosis, and how would you manage this condition?" }, { "id": "wiki20220301en138_49202", "title": "Present arms (command)", "score": 0.009523809523809525, "content": "When carrying an assault rifle, such as an AK-74M (the standard service rifle of the Russian Ground Forces) personnel will put the left hand flat over the neck of the weapon, while the right hand, which should have by default been on the barrel of the gun, stays the same. When performing an unarmed present arms, the right hand is brought to the right temple, while not quite, touching; the head has to be covered. The same format is also used by countries in the Russian led Commonwealth of Independent States (CIS), which includes countries such as Belarus, Armenia, and Tajikistan. Ukraine has conducted the command differently since the fall of the Soviet Union, executing it similarly to the Polish version." }, { "id": "pubmed23n0925_14683", "title": "Diffuse skin rash, altered mental status · Dx?", "score": 0.009433962264150943, "content": "A 74-YEAR-OLD CAUCASIAN MAN presented to the hospital with intractable back and chest pain, a diffuse skin rash, and altered mental status. He said that 2 days ago, he'd gone to a different local hospital for treatment of back pain and a headache that had begun 3 days earlier. He was treated with intravenous hydromorphone and sent home with a prescription for meperidine. He said that several hours after being treated with the hydromorphone, the rash developed on his head and then spread to his trunk and upper extremities. WHAT IS YOUR DIAGNOSIS? HOW WOULD YOU TREAT THIS PATIENT?" }, { "id": "wiki20220301en561_21028", "title": "Vadim Ershov", "score": 0.009433962264150943, "content": "Initially, Ershov refused to give evidence, called himself with a false name and claimed to be a tramp. Later, while confessing to law enforcement officials, he pointed to his real residence where irrefutable evidence was found - the tools of the crime (two knives that he called \"feathers\"), as well as the belongings of the victims (old jacket and a worn coat) and their passports. An important clue against Ershov was his diary of seven columns, in which he wrote down all his attacks in detail: the first column - the number of the victim, the second - the time of year, the third - the instrument of the crime (capital \"P\" - committed with a knife; capital \"N\" - committed with a table knife; \"p\" - crime committed by hands or with a stick), the fourth - the nature of the injury (\"p\" - wound, \"t\" - corpse), the fifth - sex of the victim, the sixth - the crime scene and year of the crime. According to Ershov, the outcome of all his attacks was surely checked through the media (read" }, { "id": "pubmed23n0763_14041", "title": "History of head trauma in a 6-year-old boy: maybe more than meets the eye (and head).", "score": 0.009345794392523364, "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": "wiki20220301en026_42065", "title": "Right Ho, Jeeves", "score": 0.009345794392523364, "content": "I was reading in the paper the other day about those birds who are trying to split the atom, the nub being that they haven't the foggiest as to what will happen if they do. It may be all right. On the other hand, it may not be all right. And pretty silly a chap would feel, no doubt, if having split the atom he suddenly found the house going up in smoke and himself being torn limb from limb. When stirred, Bertie Wooster sometimes unintentionally employs spoonerisms, as he does in chapter 12: \"Tup, Tushy!—I mean, Tush, Tuppy!\". Bertie occasionally uses a transferred epithet, using an adjective to modify a noun rather than using the corresponding adverb to modify the verb of the sentence, as in the following quote in chapter 17: \"It was the hottest day of the summer, and though somebody had opened a tentative window or two, the atmosphere remained distinctive and individual\"." }, { "id": "wiki20220301en027_70279", "title": "Paediatric Glasgow Coma Scale", "score": 0.009259259259259259, "content": "Coma scale Best eye response: (E) 4. Eyes opening spontaneously 3. Eye opening to speech 2. Eye opening to pain 1. No eye opening or response Best verbal response: (V) 5. Smiles, oriented to sounds, follows objects, interacts. 4. Cries but consolable, inappropriate interactions. 3. Inconsistently inconsolable, moaning. 2. Inconsolable, agitated. 1. No verbal response. Source: Best motor responses: (M) 6. Infant moves spontaneously or purposefully 5. Infant withdraws from touch 4. Infant withdraws from pain 3. Abnormal flexion to pain for an infant (decorticate response) 2. Extension to pain (decerebrate response) 1. No motor response Any combined score of less than eight represents a significant risk of mortality. See also Apgar score References Diagnostic intensive care medicine Pediatrics Medical scales Coma Medical assessment and evaluation instruments" }, { "id": "wiki20220301en003_41376", "title": "W. H. R. Rivers", "score": 0.009259259259259259, "content": "This was the first stage of the recovery process and Head and Rivers dubbed it the \"protopathic\", taking its origins from the Middle Greek word protopathes, meaning \"first affected\". This protopathic stage seemed to be marked by an \"all-or-nothing\" aspect since there was either an inordinate response to sensation when compared with normal reaction or no reaction whatever if the stimulation was below the threshold. Finally, when Head was able to distinguish between different temperatures and sensations below the threshold, and when he could recognise when two compass points were applied simultaneously to the skin, Head's arm began to enter the second stage of recovery. They named this stage the \"epicritic\", from the Greek epikritikos, meaning \"determinative\"." }, { "id": "pubmed23n0648_15276", "title": "Who rules the roost?", "score": 0.009174311926605505, "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": "pubmed23n0306_14018", "title": "[Automatic movements of extremities induced in primary massive brain lesion with apneic coma].", "score": 0.009174311926605505, "content": "In three cases of primary massive brain lesion with apneic coma, various automatic movements of the extremities were elicited by physical or sensory stimulation. In each case, these movements appeared after a period of cessation of spontaneous respiration followed by flaccid tetraplegia. Brainstem reflexes were absent throughout in all cases. The movements were induced mainly by ventroflexion of the neck, and each case showed movements as described below: in the first case, the patient flexed her elbows and raised both arms slowly, a typical Lazarus sign; in the second case, the patient raised both arms and showed myoclonic movements; and the third case showed abduction of both legs and extension in the upper extremities. Pathology in the first case showed ischemic changes in the entire brain and brainstem. Although ischemic change was also found in the anterior horn cells and white matter of the spinal cord of C1-C4 and of T4 and below, the spinal cord of C5-T3 was relatively well-preserved. These movements appear to have essentially originated in spinal neurons; however, it is assumed that they must have recovered from spinal shock which occurred due to upper level transection. These movements were induced by ventroflexion of the neck, so mechanical extension of the spinal roots, mechanical compression of the spinal cord, and various modalities of the sensation afferent might have some relation to these movements. As tonic neck reflex might also be a cause of these, movements, association with the lower medulla could not be ruled out completely. These movements appeared nearing or after brain death. Although in each case of brain death the spinal cord may have been affected by specific conditions, such as impaired circulation of whole central nervous sysytem, it might have been transversed at upper level, which then causes spinal automatism. These movements might appear even in the state of brainstem death. In each case, the distribution and severity of hypoxic changes in the spinal cord may have resulted in variations in the type and characteristics of these movements." }, { "id": "pubmed23n0412_17981", "title": "[Importance of early rehabilitation of a child with severe multiple injuries: case report].", "score": 0.00909090909090909, "content": "This is a case presentation of an eight-year-old boy, a traffic accident victim with severe polytrauma. The boy was admitted to hospital with lacerations and contusion injuries of the left basal frontal and left temporal brain region, moderate brain tissue edema and fracture of the left clavicle which were diagnosed by CT (computer tomography). The boy was in coma (Glasgow Coma Scale--5). Oral feeding and catheter removal were established after one month. Three months later his state of consciousness improved, he could carry out simple orders, started vocalization and visited ambulance by wheel chair. Speech and independent walking were achieved 4 months after the accident. Physical therapy included: neural-stimulation by Vojta and sclerodermal message from seventh day. Later on, speech and work therapy were applied. Drug therapy included: muscle relaxants and tranquilizers while orthopedic treatment meant plastic immobilization. Control CT revealed chronic subdural hemathoma in the right frontal-parietal region. The boy could walk, talk, have normal diet, and controlled sphincters four months after severe trauma. Now, he is functional and on the level of moderate mental retardation. Early rehabilitation was extremely important in his recovery." }, { "id": "wiki20220301en028_45160", "title": "List of Blame! characters", "score": 0.00909090909090909, "content": "Blon - One of Davine Lu Linvega's henchmen. Blon is capable of creating worm-like creatures, possibly the same way the Safeguard use to 'download' common safeguards to any location. He can also release leech-like creatures, about a foot and a half long, which attach to a target's spine and render the target unconscious. Another of Blon's abilities is that he can use what is possibly alchemy to create radically different forms apart from his humanoid form. The first is a massive, metallic centipede-like creature which ravages Killy with multiple blades before Blon reveals his true form. As he finishes transforming into his humanoid form, Killy fires the Gravitational Beam Emitter at \"Level 4\" disintegrating all but Blon's head and the remains of his arms and legs. Several people believe that he dies here, but he actually appears later. His first defeat allows Pcell to detect the 70-kilometer long holes left by Killy's GBE. When Dhomochevsky, Cibo and Iko set out to find Killy and" }, { "id": "pubmed23n1060_22549", "title": "Presbyopic patient with hyperopia and moderately steep corneas: December consultation #1.", "score": 0.009009009009009009, "content": "A 47-year-old woman was referred for refractive surgery evaluation. She has no ocular or medical history. Spectacle dependence is her chief concern. She cannot tolerate contact lens. The corrected near and distance visual acuity (CDVA) are 20/20, easily, in both eyes. The manifest refraction is +3.50 in the right eye and +2.75 in the left eye (dominant eye). The intraocular pressure and the results from a slitlamp examination and a fundus retinoscopy are normal. She has no dry eye and no complaints of halos or glare. She works in an office using a computer most of the day.The Scheimpflug device revealed the thinnest point of corneal thickness to be 497 μm in the right eye and 501 μm in the left eye ( and ). Keratometry (K) values were K1 43.20 diopters (D), K2 45.00 D, and Kmax 45.50 D in the right eye and K1 43.40 D, K2 45.00 D, and Kmax 46.00 D in the left eye. Optical coherence tomography revealed thinnest epithelial thickness of 48 μm in the right eye and 49 μm in the left eye. A Zernike analysis showed low values for coma and spherical aberrations.(Figure is included in full-text article.)(Figure is included in full-text article.)The topographic maps, despite the relative scale, revealed a pattern that seems to truncate in the center, in both eyes, but especially in the right eye. Pachymetric progression indices were within normal limits ().(Figure is included in full-text article.)What kind of surgery (if any) would you recommend to this patient? Would you consider laser in situ keratomileusis (LASIK) with a thin, predictable LASIK flap? And in this case, what are your limits for final, postoperative steep K? How much concern would you have if this patient needed an excimer laser enhancement?Would you offer clear lens extraction (CLE)? And in this case any specific intraocular lens (IOL) model?What data helped you most in making your decision? If you recommend proceeding with surgery, would age have played any significant role in the decision process?" }, { "id": "wiki20220301en332_10598", "title": "The Hand That Rocks the Wheelchair", "score": 0.009009009009009009, "content": "as the butt of all the jokes, she's almost never funny or interesting.\" He concluded his review by stating, \"I'm not sure I liked it, but I did engage with it, which is an improvement over the last few weeks of the show,\" and ultimately gave the episode a C+ rating, placing it third out of four, being beaten by The Simpsons episode \"The Scorpion's Tale\" and the Bob's Burgers episode \"Sheesh! Cab, Bob?\", and beating The Cleveland Show episode \"The Blue, The Gray and The Brown\". In a slightly more positive review of the episode, Jason Hughes of TV Squad praised the episode for its Meg-centric storyline, writing, \"Meg is great as the incredibly needy, creepy, crazy, stalker type.\" Hughes also praised actress Mila Kunis for her portrayal of Meg, noting, \"almost expected her to turn into Annie Wilkes from Misery and strap Joe to a bed.\" Hughes also stated his concern about the developments in the Stewie storyline writing, \"I wonder if this was an acknowledgement that Stewie has changed" }, { "id": "pubmed23n0921_12662", "title": "Image: Extensive Pneumocephalus.", "score": 0.008928571428571428, "content": "A 53-year-old man was admitted to our hospital following a traffic accident. He had been riding a bicycle and was knocked down by a motorcycle, injuring the right side of his forehead. Upon arrival at our department, he was conscious and we found no cerebrospinal fluid rhinorrhea or otorrhea. His Glasgow Coma Scale score was 15. Neurologic examination was normal, except for reduced vision in his right eye. Head computed tomography showed extensive pneumocephalus involving the cisterna ambiens, prepontine and suprasellar cisterns, and temporal, frontal, parietal, and occipital lobes. A right frontal skull fracture was evident. The patient was treated conservatively, with bed rest with the head of the bed elevated at 30 degrees. The patient was instructed to avoid any movements that might increase intracranial pressure, and he was placed on conventional concentration oxygen therapy of about 40%. Repeat computed tomography 9 hours later showed partial absorption of the pneumocephalus, which was almost completely absorbed 4 days later. He recovered well and was discharged after 7 days. At the 1-month follow-up, the patient was well, although the reduced vision in his right eye persisted." }, { "id": "wiki20220301en010_18702", "title": "Eddie Rickenbacker", "score": 0.008928571428571428, "content": "In a dramatic retelling of the incident, Rickenbacker's autobiography relates his astonishing experiences. While he was still conscious but in terrible pain, Rickenbacker was left behind while some ambulances carried away bodies of the dead. When Rickenbacker arrived at a hospital, his injuries appeared so grotesque that the emergency surgeons and physicians left him for dead for some time. They instructed their assistants to \"take care of the live ones.\" Rickenbacker's injuries included a fractured skull, other head injuries, a shattered left elbow with a crushed nerve, a paralyzed left hand, several broken ribs, a crushed hip socket, a pelvis broken in two places, a severed nerve in his left hip, and a broken left knee. Rickenbacker's left eyeball was also blown out of its socket." }, { "id": "pubmed23n0819_22605", "title": "Apraxia, autism, attention-deficit hyperactivity disorder: do we have a new spectrum?", "score": 0.008849557522123894, "content": "Gio is a bilingual 6-year 10-month-old boy new to your practice who presents for an unscheduled visit with concerns for speech and language delay. He was born in Portugal, and his native language is Portuguese. When he was 21 months old, his family moved to Italy and then moved to the United States 3 years later. He had very little contact with other children while living in Italy, but his parents report that he has made friends quickly in the United States. His family speaks Portuguese at home, although his father is fluent in English. He started school 3 months after moving to the United States and is currently repeating kindergarten. He is in a sheltered English classroom with several other students who speak Portuguese. He is able to understand and follow directions in English. A recent school evaluation revealed solidly average nonverbal reasoning skills and relative weaknesses in verbal reasoning and working memory. His speech is described as unintelligible in conversation, both in English and Portuguese. Results of a special education evaluation qualified him for services with a bilingual therapist. His teachers are very concerned that he may have autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD). They describe him as having limited interest in other children, poor eye contact, and hypersensitivities. He wanders at recess. He is very skilled at art and seems to prefer to draw rather than interact with others. He needs constant support and redirection throughout the school day. He has difficulty putting on his coat, using playground equipment, and following daily classroom routines. On the Vanderbilt Rating Scale, his teacher endorses 17 of 18 ADHD symptoms as present often or very often and significant impairment in his performance. Gio presents to your clinic as a relatable young boy with childhood apraxia of speech. Only his productions of single words and short routine phrases are intelligible. He attempts to engage in conversation but averts his gaze and becomes frustrated when asked to repeat things. Scores on the Parent Conners Rating Scale and Social Responsiveness Scale are not elevated. When you bring up school's concerns, his father describes feeling somewhat badgered by his teachers about possibility of ASD. School is considering placement in an inclusion classroom for children with ASD. What do you recommend? How would you advise his parents?" }, { "id": "wiki20220301en012_138204", "title": "Alien hand syndrome", "score": 0.008849557522123894, "content": "When there is a major disconnection between the two hemispheres resulting from callosal injury, the language-linked dominant hemisphere agent which maintains its primary control over the dominant limb loses, to some degree, its direct and linked control over the separate \"agent\" based in the nondominant hemisphere, and the nondominant limb, which had been previously responsive and \"obedient\" to the dominant conscious agent. The possibility of purposeful action occurring outside of the realm of influence of the conscious dominant agent can occur and the basic assumption that both hands are controlled through and subject to the dominant agent is proven incorrect. The sense of agency that would normally arise from movement of the nondominant limb now no longer develops, or, at least, is no longer accessible to consciousness. A new explanatory narrative for understanding the situation in which the now inaccessible nondominant hemisphere based agent is capable of activating the" }, { "id": "pubmed23n0895_1210", "title": "Apraxia, Autism, Attention-Deficit Hyperactivity Disorder: Do We Have a New Spectrum?", "score": 0.008771929824561403, "content": "Gio is a bilingual 6-year 10-month-old boy new to your practice who presents for an unscheduled visit with concerns for speech and language delay. He was born in Portugal, and his native language is Portuguese. When he was 21 months old, his family moved to Italy and then moved to the United States 3 years later. He had very little contact with other children while living in Italy, but his parents report that he has made friends quickly in the United States. His family speaks Portuguese at home, although his father is fluent in English.He started school 3 months after moving to the United States and is currently repeating kindergarten. He is in a sheltered English classroom with several other students who speak Portuguese. He is able to understand and follow directions in English. A recent school evaluation revealed solidly average nonverbal reasoning skills and relative weaknesses in verbal reasoning and working memory. His speech is described as unintelligible in conversation, both in English and Portuguese.Results of a special education evaluation qualified him for services with a bilingual therapist. His teachers are very concerned that he may have autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD). They describe him as having limited interest in other children, poor eye contact, and hypersensitivities. He wanders at recess. He is very skilled at art and seems to prefer to draw rather than interact with others. He needs constant support and redirection throughout the school day. He has difficulty putting on his coat, using playground equipment, and following daily classroom routines. On the Vanderbilt Rating Scale, his teacher endorses 17 of 18 ADHD symptoms as present often or very often and significant impairment in his performance.Gio presents to your clinic as a relatable young boy with childhood apraxia of speech. Only his productions of single words and short routine phrases are intelligible. He attempts to engage in conversation but averts his gaze and becomes frustrated when asked to repeat things. Scores on the Parent Conners Rating Scale and Social Responsiveness Scale are not elevated. When you bring up school's concerns, his father describes feeling somewhat badgered by his teachers about possibility of ASD.School is considering placement in an inclusion classroom for children with ASD. What do you recommend? How would you advise his parents?" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 139, 260 ] ], "word_ranges": [ [ 23, 37 ] ], "text": "Permanent post-surgical hypoparathyroidism after parathyroidectomy of an adenoma with minimally invasive surgery is rare." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 390, 590 ] ], "word_ranges": [ [ 62, 89 ] ], "text": "\"The pathophysiology of the hungry bone syndrome (HBS) is related to an imbalance between bone formation and bone resorption, which is associated with hypocalcemia, hypophosphatemia and hypomagnesemia" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Permanent surgical hypoparathyroidism.", "2": "Transfusion of citrated blood.", "3": "Vitamin D insufficiency.", "4": "Hungry bone syndrome.", "5": "Osteomalacia." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0629_20980", "title": "[Primary hyperparathyroidism. Postoperative normocalcemic hyperparathyrinemia after curative parathyroidectomy].", "score": 0.018424611223799865, "content": "Normocalcemic hyperparathyrinemia, i.e. elevated parathyroid hormone (PTH) levels after parathyroidectomy in patients with primary hyperparathyroidism (pHPT) may occur in the course of postoperative recovery without the development of persistence or relapse. Intraoperative and long-term (7 year) postoperative PTH and calcium levels after curative parathyroidectomy are demonstrated on the basis of a case report of a 62-year-old female patient with severe pHPT and pronounced osseous and renal manifestations. The intraoperative PTH gradient displayed a decrease from 1072 pg/ml to 13 pg/ml (normal range 11-67 pg/ml) followed by an increase of up to 287 pg/ml. The hyperparathyoid values decline to subnormal levels on administration of calcium and vitamin D and increase again after tapering these medications. The inverse calcium/PTH correlation in the course of the 7-year observation period suggests an intact feed-back mechanism. Preoperative PTH screening was performed in 316 consecutive normocalcemic thyroid patients to evaluate the rate of incidental hyperparathyroidism in patients with normal serum calcium levels. Of these patients 31 (9.8%) with normocalcemia (average 2.28 mmol/l, normal range 2.1-2.7 mmol/l) exhibited increased PTH levels averaging 84.2 pg/ml. A parathyroid adenoma was found intraoperatively as the cause for normocalcemic pHPT in only 1 of these 31 patients. A review of the literature revealed that late postoperative elevated parathyroid hormone levels after successful pHPT surgery occur in 21.5%. Multiple causes are discussed, e.g. reactive hyperparathyroidism in cases of relative hypocalcemia, hungry bone syndrome, vitamin D deficiency, renal dysfunction and ethnic or lifestyle differences. In mild cases of postoperative hyperparathyrinemia observation of the patient may be sufficient. In cases of reactive hyperparathyroidism due to hypocalcemia, administration of calcium is indicated, in symptomatic patients, additional administration of vitamin D or calcitriol is necessary. Vitamin D deficiency per se needs adequate substitution. In cases of ongoing hyperparathyrinemia an interdisciplinary diagnostic and therapeutic approach is required." }, { "id": "pubmed23n0573_22645", "title": "[The hungry bone syndrome--an update].", "score": 0.016677089847821555, "content": "The Hungry Bone Syndrome (HBS) represents an important cause of prolonged hypocalcemia after parathyreoidectomy (PTX) due to primary, secondary or tertiary hyperparathyreoidism. The sudden postoperative withdrawal of parathyroid hormone (PTH) induces a stop in osteoclastic bone resorption without affecting the osteoblastic activity. Consequently, an increased bone uptake of calcium, phosphate and magnesium is observed. Risk factors for the development of HBS include: Large parathyroid adenomas, age &gt; 60 years, high preoperative levels of serum PTH, calcium and alkaline phosphatase. In these patients a careful monitoring of clinical symptoms of hypocalcemia as well as the laboratory parameters are warranted during the immediate postoperative period. Treatment with oral calcium, and especially in patients with renal failure, additionally active vitamin D should be started as soon as possible after PTX. In severe cases of HBS, the administration of intravenous calcium is necessary. The duration of therapy is governed by symptoms and severity of the HBS and may last for up to 12 or more months. While prevention of HBS in high risk patients includes preoperative Vitamin D, the role of bisphosphonates has yet to be established." }, { "id": "pubmed23n1123_1241", "title": "[Primary hyperparathyreoidism - diagnostic procedures and management].", "score": 0.015306395504415307, "content": "Hypercalcemia as a laboratory result is often diagnosed during evaluation for osteoporosis. Any form of hypercalcemia should be evaluated further. Owing to fluctuating calcium levels, the measurement should be repeated and corrected for elevated albumin levels by calculation or by measuring ionized calcium. In the diagnosis of primary hyperparathyroidism, measurement of parathyroid hormone, creatinine/glomerular filtration rate, phosphate, 25-OH vitamin D3 and 24-hour urine values are essential for differential diagnosis. Kidney ultrasound is used to detect nephrocalcinosis or kidney stones, and dual-energy X-ray absorptiometry (DXA) to determine bone mineral density (BMD) at the lumbar spine, femoral neck, total femur, and distal forearm. Complete cure is only possible through surgical resection of the adenoma(s). The indication for surgery is dependent on the age of the patient, existing complications, and the patient's preference. Diagnostic imaging should only be performed if surgery is planned. Typically, neck ultrasound and 99mTc MIBI scintigraphy are sufficient to localize the parathyroid adenoma. Presurgical diagnostic evaluation of the thyroid is reasonable for surgical planning. Vitamin-D deficiency should be normalized before surgery. Postsurgical calcium and vitamin-D administration will prevent postsurgical hypocalcemia and hungry-bone disease, and may optimize the outcome of BMD. Treatment of osteoporosis without fractures might not be necessary, owing to normalization of BMD several years after parathyroid surgery. The continuation of specific anti-osteoporotic treatment with bisphosphonates post-surgery did not have any advantage and hence cannot be recommended." }, { "id": "pubmed23n0582_8471", "title": "Short-term outcomes of parathyroidectomy in patients with or without 25-hydroxy vitamin D insufficiency.", "score": 0.013310318373609513, "content": "25-OH Vitamin D (VitD) plays a role in serum calcium (Ca) and parathyroid hormone (PTH) homeostasis. VitD insufficiency in patients with primary hyperparathyroidism (HPT) may be associated with greater disease severity and a higher incidence of multi-gland disease and postoperative normocalcemic PTH elevation. One hundred ten patients with HPT undergoing parathyroidectomy had preoperative VitD levels as follows: levels were insufficient (&lt; or =20 ng/mL) in 55 patients (group 1) and sufficient (&gt;20 ng/mL) in 55 patients (group 2). All patients had preoperative localizing sestamibi scans and/or ultrasounds and postoperative serum Ca and PTH levels. A focused approach was performed when possible, and intraoperative PTH monitoring (IPM) was used in all patients. Patients with VitD insufficiency had significantly higher preoperative Ca (11.3 +/- 1.2 versus 10.8 +/- 0.9 mg/dL, P = 0.012) and PTH levels (204 +/- 138 versus 156 +/- 179 pg/mL; P = 0.006) as well as higher bone specific alkaline phosphatase (P = 0.006). Localization studies were similar. IPM levels were significantly higher in group 1 at all time intervals. Both groups were similar in operative time, conversions to bilateral explorations, number of glands removed, and number of frozen sections. The glands in group 1 were larger (1757 versus 524 g; P = 0.005). Postoperative Ca levels, PTH levels, rates of eucalcemia, and rates of eucalcemic PTH elevation were all similar. Patients with HPT and VitD insufficiency may have significantly more severe disease based on preoperative serum Ca and PTH levels, bone markers, and gland size. IPM levels in these patients are higher but can be used to predict postoperative eucalcemia, an outcome which appears be independent of VitD status." }, { "id": "wiki20220301en025_72250", "title": "Hyperparathyroidism", "score": 0.012646124425526664, "content": "Primary hyperparathyroidism may only be cured by removing the adenoma or overactive parathyroid glands. In those without symptoms, mildly increased blood calcium levels, normal kidneys, and normal bone density monitoring may be all that is required. The medication cinacalcet may also be used to decrease PTH levels in those unable to have surgery although it is not a cure. In those with very high blood calcium levels, treatment may include large amounts of intravenous normal saline. Low vitamin D should be corrected in those with secondary hyperparathyroidism but low Vitamin D pre-surgery is controversial for those with primary hyperparathyroidism. Low vitamin D levels should be corrected post-parathyroidectomy." }, { "id": "wiki20220301en025_70085", "title": "Hypoparathyroidism", "score": 0.01221500352823807, "content": "Hypoparathyroidism is decreased function of the parathyroid glands with underproduction of parathyroid hormone (PTH). This can lead to low levels of calcium in the blood, often causing cramping and twitching of muscles or tetany (involuntary muscle contraction), and several other symptoms. It is a very rare disease. The condition can be inherited, but it is also encountered after thyroid or parathyroid gland surgery, and it can be caused by immune system-related damage as well as a number of rarer causes. The diagnosis is made with blood tests, and other investigations such as genetic testing depending on the results. The primary treatment of hypoparathyroidism is calcium and vitamin D supplementation. Calcium replacement or vitamin D can ameliorate the symptoms but can increase the risk of kidney stones and chronic kidney disease. However teriparatide, brand name Forteo, a biosimilar peptide to parathyroid hormone, may be given by injection." }, { "id": "wiki20220301en025_72253", "title": "Hyperparathyroidism", "score": 0.011861534737351732, "content": "Common manifestations of hypercalcemia include weakness and fatigue, depression, bone pain, muscle soreness (myalgias), decreased appetite, feelings of nausea and vomiting, constipation, pancreatitis, polyuria, polydipsia, cognitive impairment, kidney stones (), vertigo and osteopenia or osteoporosis. A history of acquired racquet nails (brachyonychia) may be indicative of bone resorption. Radiographically, hyperparathyroidism has a pathognomic finding of rugger jersey spine. Parathyroid adenomas are very rarely detectable on clinical examination. Surgical removal of a parathyroid tumor eliminates the symptoms in most patients. In secondary hyperparathyroidism due to lack of Vitamin D absorption, the parathyroid gland is behaving normally; clinical problems are due to bone resorption and manifest as bone syndromes such as rickets, osteomalacia, and renal osteodystrophy." }, { "id": "pubmed23n0740_8397", "title": "[Primary hyperparathyroidism: diagnosis and management].", "score": 0.01152977139819245, "content": "The prevalence of primary hyperparathyroidism (HPT) varies between 1 and 4/1.000 in the general population. HPT is nowadays most often asymptomatic. The classical bone disease has been replaced by osteopenia or osteoporosis with a preferential bone loss in cortical sites. The incidence of nephrolithiasis has been considerably lowered, but renal lithiasis is still the most frequent complication of HPT. The diagnosis is most often made by chance or during the workup of an abnormal bone mass. Hypercalcemia and an elevated PTH concentration, or at least a PTH level in the upper part of the normal range, generally point to a diagnosis of HPT. Additional tests include an evaluation of renal function, vitamin D measurement, determination of 24-hour urinary calcium and bone densitometry. Besides symptomatic HPT, classical recommendations for surgery include age less than 50, serum Ca at least 1 mg/dl above the upper limit of normal, creatinine clearance &lt; 60 ml/min and osteoporosis. Surgical referral will, however, take into account patient age and comorbidities, as well as patient preferences. In the hands of an experienced surgeon, the success rate of parathyroidectomy is 95-98% and the rate of permanent complications is 1-3%. Parathyroid scintigraphy is the best preoperative localization technique of the adenoma. When surgery is contraindicated or refused by the patient, bisphosphonates or cinacalcet can be indicated in cases of osteoporosis or clinically significant hypercalcemia, respectively." }, { "id": "pubmed23n1089_20848", "title": "[Normocalcemic with elevated post-operative parathormone in primary hyperpara-thyroidism: 9 case reports and literature review].", "score": 0.010829805005904549, "content": "To summarize and analyze the clinical characteristics of primary hyperpara-thyroidism (PHPT) with normocalcemic parathormone elevation (NPE) after surgical treatment, so as to improve the therapeutic ability and standardized post-operative follow-up of PHPT patients. Nine patients who were diagnosed with PHPT in the Department of Endocrinology of China-Japan Friendship Hospital from August 2017 to November 2019 were selected as the subjects. They all developed NPE within 6 months after surgical treatment. The clinical features and outcomes were collected and analyzed retrospectively, in addition, the related literature was reviewed. Clinical features: among the 9 patients, 6 were middle-aged and elderly females and 3 were male. The main clinical manifestations were bone pain, kidney stones, nausea and fatigue except for one case of asymptomatic PHPT. Pre-operative examination showed high serum calcium [(3.33±0.48) mmol/L], low serum phosphorus [0.76 (0.74, 0.78) mmol/L], high 24-hour urinary calcium [8.1(7.8, 12.0) mmol/24 h], obviously elevated intact PTH [(546.1±257.7) ng/L], vitamin D deficiency [25-hydroxyvitamin D<sub3</sub (21.0±5.7) nmol/L]. Serum levels of bone alkaline phosphatase [7 patients 41.3(38.6, 68.4) μg/L, 2 patients &gt;90 μg/L] and N-terminal midcourse osteocalcin (&gt;71.4 μg/L) were significantly elevated. The estimated glomerular filtration rate decreased in 2 patients. Imaging examination: 7 patients had osteoporosis. Renal calculi were found in 3 patients by renal ultrasound. Imaging examination of parathyroid glands found definite lesions in all the patients, including 2 cases of multiple lesions and 7 cases of single lesions. two patients underwent parathyroidectomy, while other patients were treated with microwave thermal ablation. PTH increased 1 month after therapy [(255.0±101.4) ng/L], and no recurrent lesions were found by parathyroid ultrasound. After combined treatment with cal-cium and vitamin D for six months, PTH decreased significantly and the level of serum calcium remained normal at anytime during the follow-up period. The occurrence of postoperative NPE may be related to the higher pre-operative PTH, vitamin D deficiency and lower creatinine clearance. However, NPE may not predict recurrent hyperthyroidism or incomplete parathyroidectomy. Adequate calcium and vitamin D supplementation after surgery seems to be beneficial for patients with NPE. Post-operative follow-up of PHPT patients should be standardized to prevent and treat post-operative NPE." }, { "id": "wiki20220301en033_83966", "title": "Parathyroidectomy", "score": 0.01041093377361952, "content": "Complications While mild hypocalcemia is common after partial parathyroidectomy, some people experience persistently prolonged low calcium levels. This is called hungry bone syndrome. Despite the reactivation of unresected parathyroid glands producing normal to elevated levels of PTH, serum calcium continues to be low. The balance between calcium influx and efflux within the bone continues to be disrupted, favoring the former. The bone is said to be \"hungry\" as it consumes minerals without regard to PTH; calcium, magnesium, and phosphate continue to be deposited into the bones, resulting into hypocalcemia, hypomagnesemia, and hypophosphatemia. Prolonged calcium supplementation may be required. Hungry bone syndrome is particularly common in people who are on long-term regular dialysis. See also List of surgeries by type References External links Surgical removal procedures Endocrine surgery" }, { "id": "wiki20220301en086_41148", "title": "Tertiary hyperparathyroidism", "score": 0.010041205812188245, "content": "Early pharmaceutical treatment for tertiary hyperparathyroidism may include supplementing vitamin D and the use of cinacalcet. Cinacalcet acts to increase the sensitivity of the calcium sensing receptors to calcium leading to a reduction in parathyroid hormone release, however, its use has limited impact in those with tertiary hyperparathyroidism. These treatments are more likely only transient therapies before parathyroidectomy is performed. Indications for surgery in tertiary hyperparathyroidism commonly involve the development of chronic, severe conditions including osteopenia, persistent severe hypercalcemia, bone pain and pathologic fracture. Other indications include development of conditions such calciphylaxis. Surgical options for tertiary hyperparathyroidism include subtotal parathyroidectomy (three and one half of total tissue) and total parathyroidectomy with autotransplatation of resected tissue. Outcomes from surgery are generally favourable and a return to normalised" }, { "id": "InternalMed_Harrison_28523", "title": "InternalMed_Harrison", "score": 0.009949230265312806, "content": "A decline in serum calcium occurs within 24 h after successful surgery; usually blood calcium falls to low-normal values for 3–5 days until the remaining parathyroid tissue resumes full hormone secretion. Acute postoperative hypocalcemia is likely only if severe bone mineral deficits are present or if injury to all the normal parathyroid glands occurs during surgery. In general, there are few problems encountered in patients with uncomplicated disease such as a single adenoma (the clear majority), who do not have symptomatic bone disease or a large deficit in bone mineral, who are vitamin D and magnesium sufficient, and who have good renal and gastrointestinal function. The extent of postoperative hypocalcemia varies with the surgical approach. If all glands are biopsied, hypocalcemia may be transiently symptomatic and more prolonged. Hypocalcemia is more likely to be symptomatic after second parathyroid explorations, particularly when normal parathyroid tissue was removed at the" }, { "id": "pubmed23n0498_18613", "title": "Secondary hyperparathyroidism after removal of a parathyroid adenoma.", "score": 0.009900990099009901, "content": "To report a case of secondary hyperparathyroidism after successful extirpation of a single parathyroid adenoma. We present the clinical, pathologic, and laboratory findings in a 29-year-old woman with primary hyperparathyroidism. Serum calcium, phosphorus, and parathyroid hormone (PTH) concentrations, bone turnover, and results of densitometry studies before and after parathyroidectomy were evaluated. A young woman had noted fatigue, nervousness, weight loss, back pain, and polyuria for 3 months. She had hypercalcemia, hypophosphatemia, high PTH concentrations, and increased markers of bone turnover. Subperiosteal bone resorption of the distal phalanges, femoral and spine osteopenia, and osteoporosis in the radius were found. A nodule was palpated in the right side of the neck and localized by ultrasonography, nuclear medicine imaging studies, and computed tomography. A single parathyroid adenoma was removed; no other parathyroid lesions were found. Postoperatively, hypoparathyroidism developed. Supplementation with intravenously and orally administered calcium and vitamin D relieved her symptoms and normalized the serum calcium and phosphate concentrations. Subsequently, however, PTH levels were high and remained above the upper normal range for 27 weeks of follow-up, while calcium concentrations remained normal. These findings were consistent with physiologic secondary hyperparathyroidism due to \"hungry bone syndrome,\" in the setting of normal renal function. Postoperatively, markers of bone resorption declined faster than those of bone formation, and sequential densitometry studies showed increments in bone mineral density. This patient with primary hyperparathyroidism fulfilled the criteria for surgical extirpation of the neck mass. The prolonged postoperative increase in PTH level was indicative of physiologic secondary hyperparathyroidism that resolved gradually, along with the normalization of the increased bone turnover and bone mineral density during the 40-week observation period." }, { "id": "wiki20220301en081_57288", "title": "Secondary hyperparathyroidism", "score": 0.009743856005538249, "content": "Extended Release Calcifediol was recently approved by the FDA as a treatment for secondary hyperparathyroidism (SHPT) in adults with stage 3 or 4 chronic kidney disease (CKD) and low vitamin D blood levels (25-hydroxyvitamin D less than 30 ng/mL). It can help treat SHPT by increasing Vitamin D levels and lowering parathyroid hormone or PTH. It is not indicated for people with stage 5 CKD or on dialysis. In the treatment of secondary hyperparathyroidism due to chronic kidney disease on dialysis calcimimetics do not appear to affect the risk of early death. It does decrease the need for a parathyroidectomy but caused more issues with low blood calcium levels and vomiting. Most people with hyperparathyroidism secondary to chronic kidney disease will improve after renal transplantation, but many will continue to have a degree of residual hyperparathyroidism (tertiary hyperparathyroidism) post-transplant with associated risk of bone loss, etc." }, { "id": "pubmed23n0674_1326", "title": "[Primary hyperparathyroidism: postoperative long-term evolution].", "score": 0.009708737864077669, "content": "The long-term postoperative outcome of 87 patients with primary hyperparathyrodism is here presented. Of the total 78 were females and 9 males, ratio: 8.7:1. Mean age 55.3 ± 10.2 years. Before surgery, 44% had kidney stones, 70% had osteopenia or osteoporosis and 71.2% had hypercalciuria. Decrease renal glomerular filtration was found in 12.6%. Of the total, 72 patients had a single adenoma, two double adenoma, two hyperplasia, four had normal histology and seven could not dispose of the result. Serum calcium, ionized calcium, phosphorus and intact parathyroid hormone were normalized in all post surgery patients. Bone mineral density increased by 6.9% in lumbar spine and 3% in femoral neck. Markers of bone remodeling were normalized and persisted normal 23 months of follow-up, coinciding with the normal intact parathyroid hormone. Same thing happened with the values of 25 OH D. When patients whith initial hypercalciuria were compared with those with normocalciuria, no differences were found in the basal values and postsurgery in both groups. In 11 patients with previous renal glomerular filtration &lt; 60 ml ÷ min, we found a higher intact parathyroid hormone and lower bone mineral density than the rest. The glomerular filtration rate did not change significantly after surgery. In conclusion, the surgical primary hyperparathyroidism, operated by specialized surgeons has an excellent long-term outcome, with normalization of all parameters of phosphocalcic metabolism and bone remodeling and significant improvement in bone mineral density. Adverse effects were scarce and had spontaneous resolution." }, { "id": "pubmed23n0851_3209", "title": "Atypical Parathyroid Adenoma Complicated with Protracted Hungry Bone Syndrome after Surgery: A Case Report and Literature Review.", "score": 0.009615384615384616, "content": "Hungry Bone Syndrome refers to the severe and prolonged hypocalcemia and hypophosphatemia, following parathyroidectomy in patients with hyperparathyroidism. We present the case of an eighteen-year-old woman with a four-year history of hyporexia, polydipsia, weight loss, growth retardation, and poor academic performance. The diagnostic work-up demonstrated primary hyperparathyroidism with hypercalcemia of 13.36 mg/dL, a PTH level of 2551 pg/mL, bone brown tumors, and microcalcifications within pancreas and kidneys. Neck ultrasonography revealed a parathyroid adenoma of 33 × 14 × 14 mm, also identified on (99)Tc-sestamibi scan. Bone densitometry showed decreased Z-Score values (total lumbar Z-Score of -4.2). A right hemithyroidectomy and right lower parathyroidectomy were performed. Pathological examination showed an atypical parathyroid adenoma, of 3.8 g of weight and 2.8 cm in diameter. After surgery she developed hypocalcemia with tetany and QTc interval prolongation. The patient required 3 months of oral and intravenous calcium supplementation due to Hungry Bone Syndrome (HBS). After 42 months, she is still under oral calcium. Usually HBS lasts less than 12 months. Therefore we propose the term \"Protracted HBS\" in patients with particularly long recovery of 1 year. We present a literature review of the diagnosis, pathophysiology, and treatment of HBS. " }, { "id": "pubmed23n0409_20089", "title": "Utility of rapid intraoperative parathyroid hormone assay to predict severe postoperative hypocalcemia after reoperation for hyperparathyroidism.", "score": 0.009615384615384616, "content": "Patients undergoing reoperative parathyroidectomy may develop severe transient or permanent hypoparathyroidism. This study's purpose was to determine the utility of intraoperative parathyroid hormone (IO-PTH) values in predicting the development of severe hypocalcemia for patients undergoing reoperation for primary hyperparathyroidism. Between March 1999 and October 2001, 68 patients with persistent or recurrent hyperparathyroidism underwent reoperation using IO-PTH measurements. The maximum percent decrease and lowest actual PTH value obtained at surgery were compared to determine any correlation with the development of postoperative hypocalcemia requiring supplementation. Of 68 patients, 25 required calcium and calcitriol postoperatively and 43 did not. There was a significant difference between the 2 groups with respect to lowest IO-PTH value (18.4 +/- 2.6 vs 28.0 +/- 3.9 pg/mL; P =.02), percent decrease in IO-PTH (89% +/- 1% vs 80% +/- 3%; P =.03), and lowest postoperative ionized calcium (1.06 +/- 0.01 vs 1.19 +/- 0.01 mmol/L; P &lt;.001). A percent decrease in IO-PTH of 84% or greater was found to be predictive of patients experiencing hypocalcemia requiring supplementation with a positive predictive value of 46% and a negative predictive value of 82%. Although a maximum percent decrease in IO-PTH of 84% or greater was associated with an increased incidence of postoperative hypocalcemia requiring supplementation in the 68-patient cohort, on further analysis the association was significant only for patients with multiglandular disease and not those with single adenomas. This value may be useful for identifying patients who will need closer postoperative monitoring or prophylactic supplementation." }, { "id": "wiki20220301en001_33029", "title": "Osteoporosis", "score": 0.009523809523809525, "content": "uterus and breast gland. The α-form of the estrogen receptor appears to be the most important in regulating bone turnover. In addition to estrogen, calcium metabolism plays a significant role in bone turnover, and deficiency of calcium and vitamin D leads to impaired bone deposition; in addition, the parathyroid glands react to low calcium levels by secreting parathyroid hormone (parathormone, PTH), which increases bone resorption to ensure sufficient calcium in the blood. The role of calcitonin, a hormone generated by the thyroid that increases bone deposition, is less clear and probably not as significant as that of PTH." }, { "id": "pubmed23n0352_121", "title": "Daily follow-up of serum parathyroid hormone and calcium after surgery for primary hyperparathyroidism.", "score": 0.009523809523809525, "content": "To describe the course of parathyroid hormone (PTH) and serum calcium after surgery for primary hyperparathyroidism and to evaluate the usefulness of daily measurement of these parameters. Prospective clinical study. University hospital K. U. Leuven. Daily monitoring of PTH and serum calcium (preoperatively, the first to the 5th postoperative day, and around the 10th day) in 30 patients where a parathyroid adenoma was removed and in 1 patient with a negative neck exploration. In the adenoma cases, PTH and serum calcium showed a sharp drop of PTH to a very low level already on the first postoperative day, whereafter a rapid recovery of the PTH was seen. Serum calcium decreased more slowly: on average, the lowest calcium level was measured on the third day, when a majority of the patients were temporarily hypocalcemic; after 2 weeks, only four patients remained slightly hypocalcemic and no one showed recurrence of the hypercalcemia. In contrast, after unsuccessful surgery (biopsy of four normal glands), the PTH decrease on the first day was far less pronounced and the hypercalcemia disappeared only for a short time. After removal of a parathyroid adenoma, an abrupt fall of PTH precedes the decrease of serum calcium. The first day's PTH level is a reliable indicator of the success of the intervention, and it should be a major point in the postoperative biochemical follow-up. Repeated measurements of serum calcium are useful, but the daily dosage of PTH might be omitted for economic reasons." }, { "id": "pubmed23n0545_12194", "title": "Severe hypocalcemia following bisphosphonate treatment in a patient with Paget's disease of bone.", "score": 0.009433962264150943, "content": "Bisphosphonate therapy is a common and effective treatment for Paget's disease of bone, osteoporosis, hypercalcemia of malignancy and cancer metastatic to bone. Clinically significant hypocalcemia has not been reported in patients with Paget's disease of bone and normal parathyroid function treated with an aminobisphosphonate. We treated a 52-year-old woman with polyostotic Paget's disease of bone (serum alkaline phosphatase level-1971 IU/L [normal 31-110 IU/L]), who had not previously received bisphosphonates, with daily oral 30 mg risedronate, oral 1000 mg elemental calcium and oral 400 IU cholecalciferol. After 10 days of treatment, she developed severe hypocalcemia (5.4 mg/dL [normal 8.7-10.2 mg/dL]), requiring hospitalization and support with 5 days of intravenous calcium gluconate. On the day risedronate treatment began, her PTH was low normal at 14 pg/mL (normal 12-72 pg/mL), consistent with a relatively suppressed PTH axis due to high bone turnover. Her vitamin D level was within normal limits (serum 25(OH)D 19 ng/mL [normal 8-38 ng/mL]), although possibly not optimally repleted. We hypothesize that this case represents an example of hungry bone syndrome in a patient with extensive Paget's disease of bone who received risedronate, causing acute suppression of bone resorption while elevated bone formation rates continued. In the year following her recovery, the patient was successfully treated with slowly titrated anti-resorptive therapy (subcutaneous calcitonin followed by titrated doses of risedronate), and is now clinically well. Physicians should be aware of the potential for hypocalcemia when patients with polyostotic Paget's disease and markedly elevated indicators of bone remodeling are initiated on powerful anti-resorptive therapy." }, { "id": "pubmed23n0315_9375", "title": "Improvements in parathyroid surgery in the intact 1-84 PTH assay era.", "score": 0.009433962264150943, "content": "Measurement of intact 1-84 parathormone (PTH) level by immunometric assays has been an important tool in the medical management of hypercalcaemia. The aim of the present study was to evaluate its practical contribution in the diagnosis and surgical treatment of primary hyperparathyroidism. The results of surgery were compared (number of failed and inadequate cervicotomies, number of overlooked cervical glands) in two groups of primary hyperparathyroid patients operated on without (group I, n = 624) and with (group II, n = 360) intact PTH evaluation. The postoperative intact PTH level was measured 1-50 months after surgery in 109 unselected normocalcaemic patients. The benefit of intact PTH assay was studied in borderline patients. We tried to settle a correlation between parathyroid resected weight and intact PTH pre-operative level in different subsets of the disease. The sensitivity for the diagnosis of primary hyperparathyroidism was 86.6% for intact PTH level alone, and 95.9% when plotted with synchronous serum total calcium. Hyperfunctional adenoma was incidentally discovered in 14 asymptomatic normocalcemic normo-PTH patients. The predictive positive value of intact PTH assay for the diagnosis of primary hyperparathyroidism was 99.3%. Intact PTH assay often affirmed the diagnosis of primary hyperparathyroidism in borderline cases. The postoperative intact PTH measurement was not a good indicator for evaluating the late outcome in seemingly cured patients. Sharp but statistically significant correlation was found between the resected weight and the intact PTH level. The discovery of a small adenoma in a patient with high intact PTH level, bone disease and low vitamin D level should raise suspicion of a second hyperfunctioning gland. Intact PTH assay was a main contributor to the surgical management of primary hyperparathyroidism, reducing the number of unnecessary cervicotomies and enabling the cure of all cases of primary hyperparathyroidism except those due to mediastinal glands. It raised unanswered problems in the late postoperative course." }, { "id": "wiki20220301en033_83965", "title": "Parathyroidectomy", "score": 0.009372349448685327, "content": "Recovery after the operation tends to be swift. The PTH level is back to normal within 10–15 minutes, and can be confirmed by intraoperative rapid assessment during the operation. However, the remaining parathyroid glands may take hours to several weeks to return to their normal functioning levels (as they may have become dormant). Calcium supplements are therefore often required to prevent symptoms of hypocalcemia and to restore lost bone mass. The patient is placed in a semi-Fowler position and the neck is extended. An abbreviated Kocher incision is made and the platysma muscle is dissected horizontally. The strap muscles are released off of the thyroid gland. Then the thyroid gland is mobilized and the parathyroid arterial blood supply is suture ligated. The entire parathyroid adenoma is identified and dissected out. Intraoperative PTH monitoring can begin at this time and will show falling PTH levels if the entire adenoma has been resected. Complications" }, { "id": "wiki20220301en025_72263", "title": "Hyperparathyroidism", "score": 0.00937098386405826, "content": "Surgery can rarely result in hypoparathyroidism. Secondary In people with secondary hyperparathyroidism, the high PTH levels are an appropriate response to low calcium and treatment must be directed at the underlying cause of this (usually vitamin D deficiency or chronic kidney failure). If this is successful, PTH levels return to normal levels, unless PTH secretion has become autonomous (tertiary hyperparathyroidism). Calcimimetics A calcimimetic (such as cinacalcet) is a potential therapy for some people with severe hypercalcemia and primary hyperparathyroidism who are unable to undergo parathyroidectomy, and for secondary hyperparathyroidism on dialysis. Treatment of secondary hyperparathyroidism with a calcimimetic in those on dialysis for CKD does not alter the risk of early death; however, it does decrease the likelihood of needing a parathyroidectomy. Treatment carries the risk of low blood calcium levels and vomiting." }, { "id": "pubmed23n0494_23410", "title": "[PTH assay in the first postoperative day after thyroidectomy early predictor postoperative hypocalcemia?].", "score": 0.009345794392523364, "content": "The purpose of our study is to verify if PTH assay on the first postoperative day is a reliable early predictor of the onset of hypocalcemia. Between October 1999 and May 2000, a prospective trial involved 162 patients who underwent total or near total thyroidectomy at our institute. On the basis of PTH assay on first day we divided the patients in three groups: group A 28 patients with PTH &lt; 10 pg/ml; group B 34 patients with PTH between 10 and 16 pg/ml; group C 100 patients with PTH &gt; 16 pg/ml. In group A: 22 of 28 patients (78.5%) developed postoperative hypocalcemia and 20 (71.4%) needed replacement therapy; in group B: 14 of 34 (41.1%) had postoperative hypocalcemia and 10 (29.4%) received treatment; in group C: 23 of 100 (23%) became hypocalcemic after surgery but only 5 (5%) require calcium-vitamin therapy. A statistically significant correlation (p = 0.0017) was identified between post-operative PTH levels and lowest blood calcium values detected after surgery. The correlation between the drop in blood calcium levels after surgery and postoperative PTH (delta Ca) was statistically even more significant (p = 0.0002); the lower the postoperative PTH, the higher the absolute value of the delta Ca. The authors suggest a clinical approach and pharmacological treatment protocol based on the outcome of PTH assay on the first post-operative day; a solution that is only apparently more costly because it in fact aims to ensure a more timely recourse to blood calcium monitoring or replacement therapy and also an earlier discharge of the patient." }, { "id": "pubmed23n0334_19438", "title": "[Anesthesia and postoperative recovery for parathyroid gland surgery].", "score": 0.009259259259259259, "content": "Anesthesia for surgery of primary hyperparathyroidism (HPT) usually concerns asymptomatic elderly women with moderate hypercalcemia. Cardiovascular repercussions of the endocrine disorder are possible, but they are not frequent except for hypertension. Hyperparathyroid crisis is a life-threatening condition with severe hypercalcemia. Intravenous diphosphonates are very effective drugs to control hypercalcemia. The improvement is transient but allows curative parathyroidectomy to be performed with a minimal risk of cardiac arrhythmias. Anesthesia for surgery of secondary HPT concerns patients with chronic renal failure treated by hemodialysis. Cardiovascular disease is frequent and aggravated by the endocrine disorder. In patients with marked aortic stenosis or severe left ventricular dysfunction, parathyroidectomy should be performed by cervicotomy under local anesthesia. Hyperparathyroidism may persist after renal transplantation (tertiary HPT): in this case cardiovascular disease is minimal and the hypercalcemia is moderate. Parathyroidectomy is usually performed by cervicotomy under general anesthesia. Sternotomy is required in the case of an abnormal mediastinal location of a gland. An interaction between myorelaxants and hyperparathyroidism has been observed. Total blood calcium must be systematically assayed postoperatively because postoperative hypocalcemia is constant. Hypocalcemia is moderate in primary and tertiary HPT, due to transient functional hypoparathyroidism, with lowest observed the 2nd or 3rd postoperative day. Hypocalcemia should not be treated when asymptomatic because it resolutes on the 4th or 5th postoperative day. Intravenous calcium infusion may be necessary for 1 or 2 days, if serum calcium is below 1.9 mmol per liter with symptoms of tetany. Persistent hypocalcemia is due to an hungry bone syndrome or organic hypoparathyroidism that should be treated by oral vitamin D and calcium. In secondary HPT, hypocalcemia is early, marked and asymptomatic. Treatment must often be started on the 6th postoperative hour by intravenous calcium infusion, followed by oral vitamin D and calcium. The absence of postoperative hypocalcemia indicate incomplete removal of all abnormal parathyroid tissue. At the third postoperative day, a second cervicotomy may be performed to complete the neck exploration." }, { "id": "pubmed23n0501_21914", "title": "Primary hyperparathyroidism: diagnosis and management in the older individual.", "score": 0.009259259259259259, "content": "As more and more cases of primary hyperparathyroidism are being detected by screening for serum calcium concentration, the majority of patients are older individuals who are asymptomatic or have symptoms which are difficult to ascribe to hyperparathyroidism. Long-term follow-up has provided evidence that most asymptomatic patients who do not undergo parathyroidectomy will not develop symptomatic complications. Some asymptomatic patients, however, have progression of disease over time. These observations and the lack of reliable predictors of the rate of progression in most patients reinforce the need for careful monitoring in elderly individuals who do not undergo surgery. Biannual measurements of serum calcium concentrations and annual measurements of urinary calcium excretion and bone mineral density should be performed in all patients who are managed conservatively. In elderly patients with symptomatic or complicated primary hyperparathyroidism, parathyroidectomy results in biochemical cure and increased bone density, both at the lumbar spine and the femoral neck, and should be considered. Criteria for surgery include significant hypercalcemia (&gt;1 mg/dl above the upper limit of normal), marked hypercalciuria (&gt;400 mg per day), low bone density, unexplained renal insufficiency and an episode of acute primary hyperparathyroidism. Consideration of parathyroidectomy should also be given to elderly patients with primary hyperparathyroidism who are vitamin D deficient. Radionuclide scanning has become the initial non-invasive study of choice when parathyroid gland localization is necessary before parathyroidectomy; this is generally for fragile patients and reoperative cases. In a subset of older individuals, surgery may not be an option because of coexisting medical problems even though surgical indications are present." }, { "id": "wiki20220301en025_72261", "title": "Hyperparathyroidism", "score": 0.009174311926605505, "content": "Secondary Secondary hyperparathyroidism is due to physiological (i.e. appropriate) secretion of parathyroid hormone (PTH) by the parathyroid glands in response to hypocalcemia (low blood calcium levels). The most common causes are vitamin D deficiency (caused by lack of sunlight, diet or malabsorption) and chronic kidney failure. Lack of vitamin D leads to reduced calcium absorption by the intestine leading to hypocalcemia and increased parathyroid hormone secretion. This increases bone resorption. In chronic kidney failure the problem is more specifically failure to convert vitamin D to its active form in the kidney. The bone disease in secondary hyperparathyroidism caused by kidney failure is termed renal osteodystrophy." }, { "id": "pubmed23n0809_24809", "title": "[Unicentre Results in Surgery of Primary Hyperparathyroidism with Postoperative Long-Term Follow-Up and Value of Intraoperative Quick Parathormone Test].", "score": 0.009174311926605505, "content": "The increasing use of focussed parathyroidectomy is attributed to introduction of intraoperative parathyroid hormone measurement (ioPTH) and novel preoperative imaging techniques. This study assesses the early postoperative and long-term outcomes of surgery and the value of standardised ioPTH in patients undergoing surgery for primary hyperparathyroidism (pHPT). From 01/01/1996 to 09/30/2011, all consecutive patients undergoing surgery for pHPT were documented. Data of this observational study were retrospectively evaluated. Patients were subdivided into 2 groups: A.) use of Quick Intraoperative Intact PTH Assay (n = 142; \"ioPTH group\") vs. B.) control group (\"CG\", n = 44). For clinical long-term follow-up, also pre- and postoperative signs, symptoms and findings of the initial 43 patients obtained during the first 4 years of the study were semiquantitatively compared. 186 consecutive operations for pHPT were performed - in particular, 73 sole parathyroidectomies; 113 combined thyroid and parathyroid resections. Mean operation time was 87 (SD ± 48) min for parathyroidectomy and 120 (SD ± 49) min for combined resections. A persisting hypercalcaemia was found in 16 patients (8.6%) while postoperative elevation of serum calcium and parathormone occurred in 7 patients (3.8%). Postoperative hypocalcaemia was present in 35 patients (18.8%). Differences between both groups regarding hypocalcaemia (p = 1.0), hypercalcaemia (p = 0.67), hyperparathyrinaemia (p = 0.12) and rate of reintervention (p = 0.055) were not significant. Thirty nine of the initial 43 patients reported one or more signs of pHPT (90.7%). Most frequent symptoms were nephrolithiasis (41.9%), back pain (51.2%), discomfort in the upper abdomen (41.9%), fatigue (41.9%) and general weakness (61.1%). Follow-up investigations (mean, 4.7 [range, 3.2-6.5] years) revealed that 65 % of patients reported improvement of general condition, 27% had no change and 8% reported deterioration. IoPTH is now standard in parathyroid surgery. Value of ioPTH correlates directly with selected centre-specific intraoperative criteria. The stricter the criteria the more reliable is the exclusion of multiglandular disease. Surgery for pHPT was performed with a very low complication rate. Through the long-term follow-up, nearly two thirds of patients benefited from the operation." }, { "id": "wiki20220301en020_65372", "title": "Disorders of calcium metabolism", "score": 0.00917165623047976, "content": "Hypocalcemia is common and can occur unnoticed with no symptoms or, in severe cases, can have dramatic symptoms and be life-threatening. Hypocalcemia can be parathyroid related or vitamin D related. Parathyroid related hypocalcemia includes post-surgical hypoparathyroidism, inherited hypoparathyroidism, pseudohypoparathyroidism, and pseudo-pseudohypoparathyroidism. Post-surgical hypoparathyroidism is the most common form, and can be temporary (due to suppression of tissue after removal of a malfunctioning gland) or permanent, if all parathyroid tissue has been removed. Inherited hypoparathyroidism is rare and is due to a mutation in the calcium sensing receptor. Pseudohypoparathyroidism is maternally inherited and is categorized by hypocalcemia and hyperphosphatemia. Finally, pseudo-pseudohypoparathyroidism is paternally inherited. Patients display normal parathyroid hormone action in the kidney, but exhibit altered parathyroid hormone action in the bone." }, { "id": "pubmed23n0345_2775", "title": "Hypocalcemia due to spontaneous infarction of parathyroid adenoma and osteomalacia in a patient with primary hyperparathyroidism.", "score": 0.00909090909090909, "content": "A 49 year-old Japanese woman had subjected enlargement of a cervical tumor, and also suffered two bone fractures in 2 years. The cervical tumor had enlarged further in the month prior to admission, becoming warm and tender. Endocrinological examination revealed that the serum intact PTH concentration was remarkably high at 400 pg/mL despite the low serum calcium concentration, and that the serum vitamin Ds concentration was decreased. Bone roentgenograms revealed severe osteolytic changes compatible with osteitis fibrosa cystica and a pathologic fracture of the humerus. Under a diagnosis of primary hyperparathyroidism, parathyroidectomy was performed, followed by fixation surgery for the pathologic fracture. Histologically, the cervical tumor was a parathyroid chief-cell adenoma with massive necrosis, and the bone pathology by iliac bone biopsy revealed the existence of osteomalacia. She was treated with calcium, vitamins D and K2 and calcitonin after the surgery. This case is a rare condition manifesting hypocalcemia with catastrophic osteoporosis under the coexistence of spontaneous infarction of parathyroid adenoma with osteomalacia, suggesting that the clinical features of hyperparathyroidism are modified by both the autoparathyroidiectomy and the existence of osteomalacia due to vitamin D deficiency." }, { "id": "pubmed23n0371_15735", "title": "[Renal osteodystrophy (3); its treatment in dialysis patients].", "score": 0.009009009009009009, "content": "The prevalence and the clinical gravity of the various histopathological varieties of renal osteodystrophy in dialysis patients depends on the severity of both the aluminium intoxication and that of hyperparathyroidism. The prevalence of bone pains, fractures and hypercalcemias are the highest in adynamic bone diseases (ABD) with severe aluminium intoxication, then in osteitis fibrosa and mixed osteopathy, in the ABD with moderate aluminium intoxication and rare in the mild lesion in spite of similar moderate aluminium intoxication. In the absence of aluminium intoxication, hypercalcemia and hyperphosphatemia prevalence is higher only when intact PTH is more that 4 times the upper limit of normal. When PTH is between 1 and 2 folds the ULN this prevalence is null and bone mineral density is the highest. 2. The low turnover aluminic bone diseases (osteomalacic or adynamic) will be cured by long term deferoxamine treatment. The hazards of such treatment justify the performance of a bone biopsy to ensure the diagnosis. Their prevention relies on adequate treatment of tapwater and definitive exclusion of long term administration of aluminum phosphate binders. 3. Non aluminic osteomalacia will be treated according to the same guidelines given for the uremic patients before dialysis. 4. Non aluminic adynamic bone disease will be cured by means aiming at stimulating PTH secretion as discontinuing 1 alpha hydroxylated vitamin D derivatives, and, if there is no hyperphosphatemia by discontinuation of calcium supplement. In case of hyperphosphatemia in dialysis patients CaCO3 doses have to be nevertheless increased after the dialysate calcium concentration (DCa) has been decreased in order to induce a negative perdialytic calcium balance for PTH secretion stimulation. In the near future substitution of CaCO3 by non calcemic non aluminic phosphate binders will suffice. 5. Osteitis fibrosa due to hyperparathyroidism will be treated first by securing an optimal vitamin D repletion (bringing plasma 25OH vitamin D around 30 and 60 ng/ml or 75-150 nmol/l) and by correcting hypocalcemia and hyperphosphatemia by CaCO3 at high doses (3-12 g/day) taken with the meals. In case of hypercalcemia dialysate calcium concentration will be decreased to correct it or, in a near future, CaCO3 will be decreased to 3 g/day and hyperphosphatemia will be controlled by non calcemic, non aluminic phosphate binders. When hyperphosphatemia is controlled whereas plasma calcium is normal or low, 1 alpha hydroxylated vitamin D derivatives can be administered. 6. Instrumental parathyroidectomy should be considered when plasma levels of intact PTH remain above 7 folds the upper limit of normal whereas hyperphosphatemia persists and hypercalcemia occurs in order to prevent thining of the corticals and subsequent fracture risk. In case of previous exposition to aluminum, a deferoxamine test and/or a bone biopsy will be performed to decide a long term DFO treatment before the parathyroidectomy in order to prevent the transformation of a mixed osteopathy into an aluminic adynamic bone disease. 7. The difficulty of hyperparathyroidism control in dialysis patients is due to poor compliance to phosphate binders and to irreversible parathyroid hyperplasia with occured before the dialysis stage. This stress the primary importance if its early prevention without iatrogenia by first CaCO3 and vitamin D repletion, as soon as the creatinine clearance decreases below 60 ml/min/1.73 m2." }, { "id": "pubmed23n0379_312", "title": "Postoperative course of serum parathyroid hormone and calcium after surgery for primary hyperparathyroidism.", "score": 0.009009009009009009, "content": "The aim of this study was to describe the course of parathyroid hormone (PTH) and serum calcium after surgery for primary hyperparathyroidism, and to evaluate the usefulness of daily measurement of these parameters. PTH and serum calcium were daily monitored during the early postoperative period in 45 patients where a parathyroid adenoma was removed. PTH showed a sharp drop to a very low level already on the first postoperative day, whereafter a rapid recovery began. Serum calcium decreased more slowly: on the average, the lowest calcium level was seen on the second day. A majority of the patients were temporarily hypocalcemic, apparently to various degrees. After two weeks 38 patients showed a normal calcemia, while six patients remained slightly hypocalcemic. It is concluded that after removal of a parathyroid adenoma an abrupt fall of PTH precedes the decrease of serum calcium. The first day's PTH level is a reliable indicator of the success of the intervention and it should be a major point in the postoperative biochemical follow-up. Repeated measurements of serum calcium are useful, in contrast with the daily dosage of PTH which can be omitted for economical reasons." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 247, 288 ] ], "word_ranges": [ [ 37, 44 ] ], "text": "adrenaline first, as it is faster acting," }, "4": { "exist": true, "char_ranges": [ [ 119, 243 ] ], "word_ranges": [ [ 18, 36 ] ], "text": "Subsequently, systemic corticosteroids such as methylprednisolone will be given, which will take a few hours to take effect." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Provoke vomiting.", "2": "Adrenaline 1/1000 subcutaneous.", "3": "Intramuscular adrenaline 1/1000.", "4": "Intramuscular methylprednisolone.", "5": "Nebulized salbutamol." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0987_20176", "title": "[Anaphylaxis in a lactating infant who is allergic to cow's milk protein].", "score": 0.01951637471439452, "content": "Allergy to cow's milk protein is a common problem in children. The clinical manifestations of the reactions that are mediated by IgE are varied and the anaphylactic reactions can be life-threatening. A girl at an age of four months and a half that, five minutes after consuming cereal with cow's milk, had rashes in the perioral area and extensive pruritic micropapular lesions associated with vomit and inspiratory stridor. She received adrenaline by intramuscular injection and antihistamines by intravenous injection. She was first evaluated in a service of allergy treatment when she was six months and twenty days old. The results of the allergen-specific immunoglobulin E test were positive. The treatment was initiated with a hydrolyzed rice formula and supplementary feeding. Anaphylaxis can be the first and last manifestation of a food allergy. The right education for parents about strictly avoiding the food that triggered the allergic reaction and the right training in the use of intramuscular adrenalin may result in a better prognosis for patients." }, { "id": "pubmed23n0912_15811", "title": "THE CASE OF A 14-YEAR-OLD BOY WHO EXPERIENCED ANAPHYLAXIS DUE TO JELLYFISH (MASTIGIAS PAPUA) INGESTION.", "score": 0.01899189918991899, "content": "We report a case of jellyfish allergy diagnosed via an oral food challenge. A 14-year-old boy had no history of jellyfish stings and had been eating commercially available jellyfish products twice yearly for the past 5-6 years. Five minutes after eating a commercially available boiled jellyfish product (100g), he experienced nausea, wheezing, and erythema and had visited our hospital. We suspected an anaphylactic reaction and treated him with intramuscular adrenaline injection, corticosteroid and antihistamine infusions, volume resuscitation, and salbutamol sulfate inhalation, which resulted in an improvement of the symptoms. One-month later in our hospital, we administered an oral food challenge of the same boiled jellyfish product bought at the same grocery store to the patient. After ingesting 14g of boiled jellyfish, he experienced erythema, wheezing, nausea, and abdominal pain. Several reports have described anaphylaxis caused by the ingestion of jellyfish, but the allergens in jellyfish have not been analyzed. A skin prick test for poly-gamma-glutamic acid (PGA) which is a component of jellyfish stings was negative. This suggests that he was sensitized to some allergen other than PGA via a route different from that of jellyfish sting. Our skin prick test for several kinds of edible jellyfish suggests that allergenicity may be different for different jellyfish." }, { "id": "pubmed23n0887_2905", "title": "[Anaphylaxis in children: What pediatricians should know].", "score": 0.016693108919086708, "content": "Anaphylaxis is a severe potentially life-threatening allergic emergency that has been increasing over the last two decades, especially in young children. Anaphylaxis deaths remain rare, in particular in children, and their frequency is stable during this period. Food is the main anaphylaxis trigger in children, notably to cow's milk, peanuts, and tree nuts. In infants, the recognition of anaphylaxis may be difficult. Vomiting, urticaria, and laryngeal edema are more frequent at this age. Cardiovascular involvement is rare, most often encountered in adolescence. A history of asthma or atopy, allergy to particular foods such as peanuts and tree nuts, and adolescence are some risk factors for anaphylaxis and more severe reactions. First-line treatment is intramuscular adrenaline for all patients experiencing anaphylaxis. There are no absolute contra-indications. Guidelines for the prescription of the adrenaline auto-injector and for establishing a personalized care project in allergic children at school have recently been updated. Recognition of anaphylaxis and treatment should also be improved." }, { "id": "pubmed23n0834_20087", "title": "[Bupivacaine-induced Anaphylaxis in a Parturient Undergoing Cesarean Section].", "score": 0.015424311926605505, "content": "We describe a case of anaphylaxis that occurred in a 33-year-old gravida 1, para 1 term woman scheduled for cesarean delivery for breech presentation. Her past history was unremarkable except for orciprenaline allergy. Spinal anesthesia was performed at L3-4 using 2.5 ml of 0.5% hyperbaric bupivacaine and 0.1 mg morphine. Seven minutes after spinal anesthesia, she complained of hoarseness and difficulty in breathing and 3 minutes later, blood pressure decreased to 76/51 mmHg, and oxygen saturation to 87% with supplemental oxygen. Skin flushing was noted in the face and trunk of the body and anaphylaxis was diagnosed. She was treated with a rapid intravenous infusion and iv administration of phenylephrine (total dose 0.4 mg), ephedrine (total dose 25 mg), hydrocortisone and famotidine. Cesarean section was started 23 minutes after spinal anesthesia when blood pressure and oxygen saturation recovered. A male infant was delivered (18 minutes after the onset of anaphylactic event) with Apgar scores of 2 and 5 at 1 and 5 min, respectively and resuscitated with mask ventilation. Umbilical artery blood gas analysis revealed pH 6.85, base excess -20.3 mmol x l (-1) and lactate 109 mg x dl (-1). The mother was discharged from the hospital on the 6th postoperative day. The baby's electroencephalogram, however, demonstrated a pattern consistent with mild hypoxic-ischemic encephalopathy. Lymphocyte stimulation test revealed that she was allergic to bupivacaine. If maternal hypotension persists, i.m. or i.v. adrenaline should be administered immediately because maternal hypotension and hypoxemia may cause significant fetal morbidity and mortality and prompt cesarean section should be considered." }, { "id": "pubmed23n0520_9389", "title": "[The safety of nebulization with 3 to 5 ml of adrenaline (1:1000) in children: an evidence based review].", "score": 0.015359477124183007, "content": "To present the evidence regarding the safety of nebulization with 3-5 ml of adrenaline (1:1000) for the treatment of children with acute inflammatory airway obstruction. An electronic search was undertaken, using mainly Medline databases (January of 1949-July of 2004). The study inclusion criteria for this review were: 1) randomized clinical trial; 2) Patients (up to 12 yrs) with diagnosis of bronchiolitis or laryngotracheobronchitis; 3) use of adrenaline (1:1000) by nebulization. The principal data extracted from the trials included adrenaline dosages and their effects on heart rate and blood pressure and any other side-effects. Seven clinical trials with a total of 238 patients were included for this review. Two of the five trials in which larger dosages (&gt; or = 3 ml) of adrenaline were used demonstrated a significant increase in heart rate. The mean increase in heart rate varied from seven to 21 beats per minute, up to 60 minutes after treatment. The highest incidence of pallor was observed in one trial with 21 children treated by nebulization with 3 ml of adrenaline (47.6% in the adrenaline group vs. 14.3% in the salbutamol group, 30 minutes after treatment). Two clinical trials failed to observe a significant effect on blood pressure from nebulization with adrenaline (4 and 5 ml). Evidence shows that nebulization with 3 to 5 ml of adrenaline (1:1000) is a safe therapy, with minor side-effects, for children with acute inflammatory airway obstruction." }, { "id": "pubmed23n0868_3615", "title": "[Morphine-induced Anaphylaxis before Induction of Anesthesia].", "score": 0.014801938474504846, "content": "We describe a case of anaphylaxia that occurred in a 67-year-old man. He was planned to have an operation on mitral valve prolapse (MVP) for mitral regurgitation (MR). Morphine 5 mg was injected intramusculaly 45 min before operation. Since then, he felt itchy sensation around his inguinal region. After he came to the operating room, he felt itchy sensation all over the body. Initially, his vatal signs were stable. We started to give extracellular fluid including ulinastatin 300,000 U, methylprednisolone 2 g, and ranitidine 50 mg. A few minutes later, he had nettle rash all over the body and his blood pressure decreased to 40/20 mmHg, and the heart rate increased to 120 beats x min(-1). Soon after, he had pulseless electric activity (PEA). We started chest compression and tracheal intubation. We injected adrenaline 1 mg. After doing the continuous chest compression for 2 min, he revived. He had continuous medications including dopamine 5 μg x kg(-1) x min(-1), dobutamine 5 μg x kg(-1) x min(-1), noradrenaline 0.05 μg x kg(-1) x min(-1). We cancelled the operation, and he was transfered to the high care unit (HCU), where his blood pressure was 120/65 mmHg, and heart rate 120 beats x min(-1). After 24 hours, we extubated his trachea. In this case, morphine was considered to be the most likely cause for anaphylaxis." }, { "id": "pubmed23n0126_9096", "title": "[Treatment of acute crises of bronchial asthma in children using subcutaneous salbutamol as an alternative to adrenaline: comparative study].", "score": 0.014223843173011168, "content": "A prospective study has been made in order to asses the efficacy of subcutaneous salbutamol as acute treatment for asthmatic crisis, comparing the results with those of adrenaline. The series consisted of 30 cases, divided into two groups according to the administered treatment, with ages ranging between 5 to 18 years. Once the clinical examination and spirometric measurements were made the first group was treated with subcutaneous adrenaline 0.1 cc/kg (max.; 0.5 cc), while the second was treated with subcutaneous salbutamol 20 micrograms/kg (max.: 500 micrograms). A clinical and spirometric examination was performed at 15, 30, 60 and 90 minutes. A similar increase in FEV1 was observed in the two groups at 15 minutes, maintaining this increase for 90 minutes in the group treated with salbutamol and decreasing in the group treated with adrenaline, being the difference statistically significant (p less than 0.001). In view of this results it seems advisable to administer subcutaneous salbutamol as urgent treatment for an acute asthmatic crisis." }, { "id": "pubmed23n0357_8840", "title": "[Medical treatment of respiratory emergencies].", "score": 0.013758968304422851, "content": "Of the four treatments that can be used to treat respiratory insufficiency due to laryngitis, two, nebulized adrenaline and O2 therapy, are undoubtedly effective. The inhalation of water vapour appears to be increasingly useless and may be also harmful. The use of steroids is still under debate. In recent literature, however, the utility of steroids seems to be confirmed, especially if administered per Os, and even at a relatively low single oral dose (1-2 mg/kg of prednisone). According to the official organs (see Red Book) and according to the Evidence Based Medicine (see Cochrane Library) the treatment of bronchiolitis should be limited to an eventual support therapy, i.e. O2 therapy and rehydration. However, the approach adopted by North American Hospitals and European specialists in infectious diseases is in contrast and consists in the use of beta 2 agonists and steroids in 90-100% and 40-80% of patients, respectively. This contrast could be due to a deficiency in the researches of the Evidenced Based Medicine which is obliged to retrieve studies done over 10-15 years in order to obtain a sufficient number of data for a statistically valid investigation. These studies unfortunately are not updated with regard to the dose of individual drugs and the immediate association of drugs. In particular, with regard to nebulized beta 2 agonists, the absence of a positive effect could be due to an excessively low dose in relation to the age of the patient. According to the most recent knowledge, in fact, reduced doses are no longer required for babies in consideration of age and weight. In reality an equal and even higher dose than that used in adults would be best. The other reason for a lack of response could be the absence of the association of a steroid with a beta 2 agonists at the right moment. The lack of timing in associating these two drugs could also account for the absent response to the steroid. On the basis of these considerations it would be a mistake to give up the use of beta 2 agonists and steroids. Considering also the severity and frequency of a disease as bronchiolitis. To follow the \"fashion\" of the Evidence Based Medicine. Recently, magnesium sulphate, ketamine and the association elium-O2 have been suggested as marginal and not revolutionary medical interventions for the treatment of asthma. Among bronchodilators, the subordinate role of anticholinergics (for ex. ipratropium bromide), and of adrenaline has been defined with respect to beta 2 agonists, in particular salbutamol. The optimisation of the administration by nebulizers of the latter has been fundamental as it has a key role in the treatment of acute severe asthma. In detail, traditional nebulizers tend to be substituted by Metered Dose Inhaler + spacer with a ratio in the dose of 5/1. The venous route is used only in very severe cases and is used late and in intensive care although a single initial intravenous administration could determine a more rapid reduction of bronchoconstriction and reduce the number of nebulized bronchodilatators that can become extremely frequent in most severe cases. For steroids, instead, the only safe therapeutic route is by PO, i.v., i.m.: nebulized steroids although used with a definitely higher dose than that used for chronic asthma, can be used only in the milder forms." }, { "id": "pubmed23n0682_20102", "title": "Allergic shock and death associated with protamine administration in a diabetic patient.", "score": 0.013750954927425514, "content": "Insulin is used to treat patients with both type 1 and type 2 diabetes mellitus. Allergic reactions to insulin might be triggered by insulin itself or inactive ingredients in the insulin formulation, including proteins such as protamine in neutral protamine Hagedorn (NPH) insulin. The use of highly purified animal insulin and human recombinant insulin has reduced the incidence of anaphylactic reactions to insulin from ~30% to &lt;1%. We report a case of fatal allergic shock after the administration of protamine in a patient with a history of allergy to fish and a protamine-containing insulin. A 72-year-old Chinese male patient (height, 175 cm; weight, 80 kg) with a history of diabetes and progressive limb weakness was diagnosed with spinal vascular malformations after admission to the Xuan Wu Hospital of Capital Medical University, Beijing, People's Republic of China. He underwent epidural spinal cord arteriovenous fistula embolization with a liquid embolic agent (ethylene vinyl alcohol copolymer) after spinal cord angiography. During the operation, heparin was infused every hour with 6250, 2500, 2500, and 1250 IU, respectively. The last dose of heparin was administered ~10 minutes before the operation was completed. This was followed by the administration of protamine to neutralize the remaining heparin in the patient's body. Blurry vision and dizziness 5 minutes after protamine administration were followed by pruritus and hives over his neck and face. Oxygen was administered and 10 mg of dexamethasone with 2 mg of epinephrine was injected. The patient's heart rate dropped, his blood pressure decreased, and his arterial oxygen saturation (SaO₂) declined progressively. About 10 minutes after the administration of protamine sulfate, the patient developed bradycardic arrest. Cardiopulmonary resuscitation efforts were undertaken and the patient was administered epinephrine 2 mg IV, atropine 0.5 mg IV, and subsequently, intravenous dopamine (50 mg/h). Ten minutes later, the patient's heart rate gradually increased, but blood pressure fluctuated, and SaO₂ ranged from 90% to 100%. Despite the initial response, the patient lost consciousness and heart rate declined progressively within 5 hours. Vasoactive agents including dopamine, norepinephrine, and adrenaline were administered. After all these measures proved ineffectual, the patient died. It was later determined that the patient had a history of allergic reactions to fish as well as to a premixed insulin that contained soluble human insulin 30% and low-protein intensive insulin zinc 70% (NPH). The Naranjo adverse drug reaction probability scale score for the association of protamine with the allergic reaction was 4, suggesting a possible relationship. This case report highlights a preventable fatal allergic reaction possibly associated with protamine administration in a patient with a history of allergy to a protamine-containing insulin." }, { "id": "article-17372_30", "title": "Allergy -- Treatment / Management", "score": 0.013618062682560984, "content": "Anaphylaxis treatment begins with triage and the removal from exposure, which can involve decontamination if topical agents are involved or clothing is contaminated. Removal of the patient's clothing and standard precautions by staff such as masks, gloves, and gown should take place. Hand washing by staff who may have used latex gloves or eaten peanuts may be necessary. ABC’s (airway, breathing, and circulation) of emergency care should have priority.  Patients should have oxygen and intravenous administration of fluids. The patient should receive epinephrine intramuscularly (IM) (1 to 1000 dilution {1 mg/1ml} 0.3cc) 0.3 to 0.5 mg which can be repeated every 5 to 15 minutes as needed. Most patients should respond to 1 to 3 doses if symptoms persist, progress or the patient becomes hypotensive IV epinephrine should be started at 0.1 mcg/kg/minute by infusion device and titrated to maintain perfusion of body organs. Patients on beta-blockers should be given glucagon 1 to 5 mg over 5 minutes. Antiemetics should be given to treat vomiting often associated with glucagon administration. Histamine type 2 receptor blockers such as famotidine 20 mg IV or ranitidine at  50 mg IV should be administered. The glucocorticoid, methylprednisolone 125 mg, should be given. [26]" }, { "id": "pubmed23n0601_3860", "title": "[Auto-injection with epinephrine in the finger of a 5-year-old child].", "score": 0.01323212211713954, "content": "A 5-year-old boy with food allergies complicated by anaphylactic reactions with dyspnoea and angioedema had been prescribed an autoinjector with epinephrine (0.15 mg) so that his parents could treat him at home if necessary. The patient accidentally injected himself in a finger, which likely makes him the youngest patient to receive an epinephrine auto-injection reported to date. Treatment consisted of phentolamine (0.15 mg in 0.5 ml normal saline) injected subcutaneously at the site of accidental injection; the dose and volume were not adapted according to the age and body weight of the patient as only a local effect was intended. Finger circulation was restored within 20 minutes. Headache, nausea and vomiting were observed after 30 minutes and were most likely a systemic side effect of phentolamine. No other complications occurred. The patient recovered fully and was discharged the following morning. Intramuscular epinephrine autoinjection is standard therapy for severe anaphylactic reactions. The epinephrine autoinjector was introduced in 1980. As allergy and anaphylaxis become more common, increasing numbers of autoinjectors are prescribed, and it is likely that the number of accidental digital autoinjections will also increase. These digits are then at risk of ischaemic necrosis. There is no consensus on therapeutic strategies in such cases. Phentolamine administration appears to be an effective intervention. However, several recent studies have shown that epinephrine may be used safely in hand surgery, which suggests that accidental digital epinephrine autoinjection may not always require immediate treatment." }, { "id": "wiki20220301en516_4023", "title": "Epinephrine (medication)", "score": 0.012445435125847497, "content": "Asthma Epinephrine is also used as a bronchodilator for asthma if specific β2 agonists are unavailable or ineffective. When given by the subcutaneous or intramuscular routes for asthma, an appropriate dose is 0.3 to 0.5 mg. Because of the high intrinsic efficacy (receptor binding ability) of epinephrine, high concentrations of the drug cause negative side effects when treating asthma. The value of using nebulized epinephrine in acute asthma is unclear. Croup Racemic epinephrine has historically been used for the treatment of croup. Regular epinephrine however works equally well. Racemic adrenaline is a 1:1 mixture of the two enantiomers of adrenaline. The L-form is the active component. Racemic adrenaline works by stimulation of the alpha adrenergic receptors in the airway, with resultant mucosal vasoconstriction and decreased subglottic edema, and by stimulation of the β adrenergic receptors, with resultant relaxation of the bronchial smooth muscle." }, { "id": "wiki20220301en003_132080", "title": "Anaphylaxis", "score": 0.012212785568503522, "content": "Epinephrine Epinephrine (adrenaline) (1 in 1,000) is the primary treatment for anaphylaxis with no absolute contraindication to its use. It is recommended that an epinephrine solution be given intramuscularly into the mid anterolateral thigh as soon as the diagnosis is suspected. The injection may be repeated every 5 to 15 minutes if there is insufficient response. A second dose is needed in 16–35% of episodes with more than two doses rarely required. The intramuscular route is preferred over subcutaneous administration because the latter may have delayed absorption. It is recommended that after diagnosis and treatment of anaphylaxis, the patient should be kept under observation in an appropriate clinical setting until symptoms have fully resolved. Minor adverse effects from epinephrine include tremors, anxiety, headaches, and palpitations." }, { "id": "pubmed23n0319_10149", "title": "[Dose-effect of adrenaline nebulization in asthma: comparative study with salbutamol].", "score": 0.01202583837273227, "content": "The aim of this randomized cross-over trial was to evaluate the dose effect and systemic absorption of epinephrine nebulized at 2 and 5 mg in comparison with salbutamol (5 mg). Thirteen asthmatic patients (29 +/- 15 years, 4 men and 9 women) were randomly assigned to receive one nebulization of each of the three treatment regimens at 24 h interval. The evaluation concerned forced expiratory volume in 1 second (FEV1), heart rate, respiratory rate and arterial pressure. All measurements were done at baseline, every 15 minutes during the first hour, and hourly thereafter until return to baseline FEV1. Serum potassium was measured at baseline (T0) and sixty minutes after (T60). Plasma levels of epinephrine were measured at T0, T20, T60. Fifteen minutes after the beginning of nebulization FEV1 improved significantly over baseline in the three groups. These changes were similar in the three groups until T45, while FEV1 improvement was significantly greater in A5 and S groups than A2 group (+640 +/- 470 ml, +721 +/- 349 ml, +406 +/- 306 ml in A5, S and A2 groups respectively, p &lt; 0.01). Bronchodilation lasted significantly longer with salbutamol than with epinephrine (p &lt; 0.05). No side effects were recorded in spite of substantial and dose-dependent systemic absorption of epinephrine. Increasing epinephrine doses produces greater bronchodilation without additional side effects. However this bronchodilation lasts shorter than with salbutamol." }, { "id": "pubmed23n0701_1008", "title": "Systemic reactions to subcutaneous allergen immunotherapy and the response to epinephrine.", "score": 0.011236305752364305, "content": "The use of epinephrine for anaphylaxis to subcutaneous allergen immunotherapy (SCIT) is the standard of care, but its use for mild systemic reactions (SRs) is somewhat controversial. The objective of this study is to determine the rate of SR to SCIT, the symptoms reported, and the response to intramuscular (i.m.) epinephrine over a 1 year period. This retrospective study was designed to evaluate SRs to SCIT to any combination of approximately 20 allergens (pollens, animal emanations, molds, and Hymenoptera) in 773 subjects representing 14,707 visits, receiving approximately 28,000 injections over 1 year. Nurses were instructed to administer epinephrine (1:1000 v/v) 0.2 mL i.m. for signs or symptoms of a SR. SRs were graded using the universal grading system proposed by the World Allergy Organization (WAO) Joint Task Force for Grading SR to Immunotherapy. Thirty-one patients (4%) had 32 SRs, 22 (71%) female, average age 40 yr. Nineteen (61%) had a history of asthma; 7 (22.6%) had a history of a previous SR. SRs were reported on average 24 minutes after injection. Symptoms included: generalized pruritus, 34.4%; upper airway pruritus, 28.1%; cough, 25.0%; shortness of breath, 21.9%. Fourteen SRs were classified as Grade 1, thirteen Grade 2, two Grade 3, and three Grade 4. No Grade 5 or late phase reactions were reported. 29 (90.6%) reactions were treated with epinephrine, 27 (84.4%) glucocorticosteroid, and 30 (93.8%) H1 antihistamine. SRs occurred in 4% of patients receiving SCIT and all who received early intervention with epinephrine responded successfully. The WAO Grading system was useful." }, { "id": "wiki20220301en516_4022", "title": "Epinephrine (medication)", "score": 0.011115961006838353, "content": "Anaphylaxis Epinephrine is the drug of choice for treating anaphylaxis. Different strengths, doses and routes of administration of epinephrine are used. The commonly used epinephrine autoinjector delivers a 0.3 mg epinephrine injection (0.3 mL, 1:1000) and is indicated in the emergency treatment of allergic reactions including anaphylaxis to stings, contrast agents, medicines or people with a history of anaphylactic reactions to known triggers. A single dose is recommended for people who weigh 30 kg or more, repeated if necessary. A lower strength product is available for children. Intramuscular injection can be complicated in that the depth of subcutaneous fat varies and may result in subcutaneous injection, or may be injected intravenously in error, or the wrong strength used. Intramuscular injection does give a faster and higher pharmacokinetic profile when compared to subcutaneous injection." }, { "id": "pubmed23n0680_12269", "title": "[Two cases of rush specific oral tolerance induction for wheat allergy].", "score": 0.010050505050505051, "content": "At present, the only treatment for food allergy is to avoid the allergy-causing food until outgrowing the allergy. Recently, some trials of oral tolerance induction (oral immunotherapy) for milk, egg, or peanut allergy have been reported. We report here the experience of rush specific oral tolerance induction (rush SOTI) for 2 cases, an 8 year-old girl and a 6 year-old boy, with severe wheat allergy. In hospital, the positive reaction to wheat was identified by a double-blind placebo-controlled challenge test, and then the threshold dose of wheat was measured, and rush SOTI was started at the dose below the threshold, ingesting wheat (bread) 5 times a day at 30 minutes interval, increasing the dose by 20% every time. The goal of rush SOTI was set as 5.6 g of wheat protein. The girl achieved the goal on the 10th day, and the boy did on the 8th day. During the course, the girl experienced adverse reactions 9 times and the boy did 6 times, and these were treated with oral antihistamine or inhalation of salbutamol. After leaving hospital, they have been instructed to ingest the maintenance dose of wheat at least twice a week, and they are ingesting wheat without any problems for 6 months or for 3 months. We assume that rush SOTI is a safe and effective maneuver to tolerize children with wheat allergy, as well as egg or peanut allergy." }, { "id": "InternalMed_Harrison_24907", "title": "InternalMed_Harrison", "score": 0.009985688264376789, "content": "be initiated to provide a route for administration of 2.5 mL epinephrine, diluted 1:10,000, at 5to 10-min intervals, volume expanders such as normal saline, and vasopressor agents such as dopamine if intractable hypotension occurs. Replacement of intravascular volume due to postcapillary venular leakage may require several liters of saline. Epinephrine provides both αand β-adrenergic effects, resulting in vasoconstriction, bronchial smooth-muscle relaxation, and attenuation of enhanced venular permeability. Oxygen alone via a nasal catheter or with nebulized albuterol may be helpful, but either endotracheal intubation or a tracheostomy is mandatory for oxygen delivery if progressive hypoxia develops. Ancillary agents such as the antihistamine diphenhydramine, 50–100 mg IM or IV, and aminophylline, 0.25–0.5 g IV, are appropriate for urticaria-angioedema and bronchospasm, respectively. Intravenous glucocorticoids, 0.5–1 mg/kg of methylprednisolone, are not effective for the acute event" }, { "id": "pubmed23n0782_22117", "title": "[Serious systemic adverse events associated with allergen-specific immunotherapy in children with asthma].", "score": 0.00980392156862745, "content": "To retrospectively assess serious systemic adverse effects of standardized dust-mite vaccine in children with asthma. Medical records of 704 children (5-17 years in age) with asthma between January, 2005 and December, 2011 were reviewed. Serious systemic adverse events following treatment with a standardized dust-mite vaccine in these children were analyzed. A total of 336 systemic adverse reactions were observed in 17.0% (120/704) of the patients analyzed of these adverse reactions, 18 (5.4%) were serious (level 3), 318 (94.6%) were not serious (below level 3), and no single case of anaphylactic shock (level 4) was recorded. Systemic adverse events occurred most frequently in the 5 to 11-year age group and in the summer season (from June to August). In the 18 severe cases, the peak expiratory flow (PEF) dropped by 20% immediately after the vaccine injection, and other major clinical symptoms included cough, wheezing and urticaria. All children with serious systemic adverse effects were given inhaled hormone and atomized short-acting beta agonists, oral antihistamines, intravenous dexamethasone and/or intramuscular adrenaline. After these treatments, the clinical symptoms were significantly relieved. The rate of serious systemic adverse events following allergen-specific immunotherapy is relatively low in children with allergic asthma. Conventional medications are effective in managing these immunotherapy-associated adverse events." }, { "id": "pubmed23n0784_11714", "title": "Implementing specific oral tolerance induction to milk into routine clinical practice: experience from first 50 patients.", "score": 0.009708737864077669, "content": "Although the natural history of cow's milk allergy is to resolve during childhood or adolescence, a small but significant proportion of children will remain allergic. Specific oral tolerance induction to cow's milk (CM-SOTI) provides a treatment option in these children with continuing allergy with high success rates. However current sentiment limits widespread availability as existing reports advise that it is too soon to translate CM-SOTI into routine clinical practice. In January 2007 we implemented a slow up-dosing CM-SOTI program. Eligible subjects were identified at routine visits to our children's allergy clinic. Persisting cow's milk allergy was confirmed from recent contact symptoms or a positive baked milk challenge. As allergic symptoms are common during CM-SOTI, families were provided with ready dietetic access for advice on dosing and symptom treatment. Subjects were continuously monitored at subsequent clinic visits or telephonically, where no longer followed, for a median of 49 months. The first 50 subjects (35 males) treated ranged in age from 5.1 to 15.8 years (median 10.3 years). Full tolerance (250 mL) was achieved in 23 subjects, 9 without any symptoms, and a further 9 achieved partial tolerance with continued ingestion. Eighteen children failed to achieve any regular milk ingestion; 11 because of persistent or significant symptoms whilst 8 withdrew against medical advice. Allergic symptoms were predominantly mild to moderate in severity, although 2 cases needed treatment with inhaled salbutamol and a further 2 required intramuscular adrenaline. Clinical tolerance, both full and partial, persists beyond 5 years. We have demonstrated that a CM-SOTI program can be successfully and safely implemented as routine clinical practice with acceptable compliance during prolonged home up-dosing, despite frequent allergic symptoms, and for up to 4 years after starting treatment. CM-SOTI can thus be put into practice more widely where there is appropriate support." }, { "id": "pubmed23n0700_16637", "title": "Acute bronchial asthma.", "score": 0.009708737864077669, "content": "Acute asthma is the third commonest cause of pediatric emergency visits at PGIMER. Typically, it presents with acute onset respiratory distress and wheeze in a patient with past or family history of similar episodes. The severity of the acute episode of asthma is judged clinically and categorized as mild, moderate and severe. The initial therapy consists of oxygen, inhaled beta-2 agonists (salbutamol or terbutaline), inhaled budesonide (three doses over 1 h, at 20 min interval) in all and ipratropium bromide and systemic steroids (hydrocortisone or methylprednisolone) in acute severe asthma. Other causes of acute onset wheeze and breathing difficulty such as pneumonia, foreign body, cardiac failure etc. should be ruled out with help of chest radiography and appropriate laboratory investigations in first time wheezers and those not responding to 1 h of inhaled therapy. In case of inadequate response or worsening, intravenous infusion of magnesium sulphate, terbutaline or aminophylline may be used. Magnesium sulphate is the safest and most effective alternative among these. Severe cases may need ICU care and rarely, ventilatory support." }, { "id": "pubmed23n0910_12519", "title": "[It is all about the form - adrenaline in anaphylaxis: intravenous or intramuscular administration?]", "score": 0.009615384615384616, "content": "Medication errors are a frequent problem in the accident and emergency (A&amp;E) department. A 17-year-old boy was referred to our A&amp;E department with an anaphylactic reaction to peanuts. Because of various shortcomings in the care process in A&amp;E, adrenaline was administered intravenously instead of intramuscularly, resulting in a broad complex tachycardia. We analysed these shortcomings using the 'Prevention and recovery information system for monitoring and analysis' (PRISMA) method. Medication errors are usually a result of shortcomings in non-technical skills, such as communication and situational awareness. Training these skills by applying the concept 'Crew resource management' may reduce medication errors and improve patient safety." }, { "id": "article-17514_21", "title": "Anaphylaxis -- Treatment / Management -- Epinephrine", "score": 0.009547995905189385, "content": "Epinephrine is given through intramuscular injection and at a dose of 0.3 to 0.5 mL of 1:1,000 concentration of epinephrine. Pediatric dosing is 0.01 mg/kg or 0.15 mg intramuscularly (IM) (epinephrine injection for pediatric dosage). Intramuscular delivery has proven to provide more rapid delivery and produce better outcomes than subcutaneous or intravascular. Note if intravenous (IV) epinephrine is to be given, the concentration required is 1:10,000; see the next paragraph. The thigh is preferred to the deltoid when possible. Repeat studies have shown that providers often wait too long before giving epinephrine; it is the treatment of choice, and the rapid benefit much outweighs the risks of withholding treatment. While most patients require only a single dose, repeat doses may be given every 5 to 10 minutes as needed until symptoms improve." }, { "id": "pubmed23n0390_12879", "title": "Comparison of nebulized adrenaline versus salbutamol in wheeze associated respiratory tract infection in infants.", "score": 0.009523809523809525, "content": "(i) To assess the efficacy of bronchodilators in wheeze associated respiratory tract infection (WRTI); and (ii) To compare L-adrenaline with salbutamol in wheeze associated respiratory tract infection. Randomized controlled trial. Ninety one children in age group of 2 months to 2 years with their 1st or 2nd episode of wheezing in association with fever and/or coryza were enrolled. Of these, 45 received L-adrenaline (0.1ml/kg/dose in 1 in 10,000 solution) (Group A) and 46 received salbutamol (0.1mg/kg/dose) (Group B). Three doses of each drug were given, nebulized with oxygen at 20 minutes intervals. Respiratory rate, RDAI score, clinical status and pulse oxymetry was recorded before intervention and 10 minutes after each dose. Patients who showed significant relief were discharged after an observation period of three hours while those who did not were admitted. Both L-adrenaline and salbutamol caused significant improvement in mean symptom score and oxygenation. However, the adrenaline group showed a significantly better improvement in the study parameters than the salbutamol group. More children in the adrenaline group could be sent home after the emergency treatment. Adrenergic agonists both specific and non specific are beneficial in WRTI. Adrenaline is more effective than salbutamol and is thus a better, inexpensive and relatively safe alternative." }, { "id": "pubmed23n0366_18714", "title": "Can epinephrine inhalations be substituted for epinephrine injection in children at risk for systemic anaphylaxis?", "score": 0.009523809523809525, "content": "For out-of-hospital treatment of anaphylaxis, inhalation of epinephrine from a pressurized metered-dose inhaler is sometimes recommended as a noninvasive, user-friendly alternative to an epinephrine injection. To determine the feasibility of administering an adequate epinephrine dose from a metered-dose inhaler in children at risk for anaphylaxis by assessing the rate and extent of epinephrine absorption after inhalation. We performed a prospective, randomized, observer-blind, placebo-controlled, parallel-group study in 19 asymptomatic children with a history of anaphylaxis. Based on the child's weight, 10, 15, or 20 carefully supervised epinephrine or placebo inhalations were attempted. Before dosing, and at intervals from 5 to 180 minutes after dosing, we monitored plasma epinephrine concentrations, blood glucose, heart rate, blood pressure, and adverse effects. Eleven children (mean +/- standard error of the mean: 9 +/- 1 years and 33 +/- 3 kg) in the epinephrine group were able to inhale 11 +/- 2 (range: 3-20) puffs, equivalent to 74% +/- 7% of the precalculated dose or 0.078 +/- 0.009 mg/kg. They achieved a mean peak plasma epinephrine concentration of 1822 +/- 413 (range: 230-4518) pg/mL at 32.7 +/- 6.2 minutes. Eight children (10 +/- 1 years of age and 33 +/- 5 kg) in the placebo group were able to inhale 12 +/- 2 (range: 8-20) puffs, 89% +/- 3% of the precalculated dose, and had a peak endogenous plasma epinephrine concentration of 1316 +/- 247 (range: 522-2687) pg/mL at 44.4 +/- 16.7 minutes. In the children receiving epinephrine compared with those receiving placebo, mean plasma epinephrine concentrations were not significantly higher at any time, mean blood glucose concentrations were significantly higher from 10 to 30 minutes, mean heart rate was not significantly different at any time, and mean systolic and diastolic blood pressures were not significantly increased at most times. After the inhalations of epinephrine or placebo, the children complained of bad taste and many experienced cough or dizziness. After inhaling epinephrine, 1 child developed nausea, pallor, and muscle twitching. Despite expert coaching, because of the number of epinephrine inhalations required and the bad taste of the inhalations, most children were unable to inhale sufficient epinephrine to increase their plasma epinephrine concentrations promptly and significantly. Therefore, we urge caution in recommending epinephrine inhalation as a substitute for epinephrine injection for out-of-hospital treatment of anaphylaxis symptoms in children." }, { "id": "pubmed23n0553_1516", "title": "4. Food allergy in childhood.", "score": 0.009433962264150943, "content": "Food allergies in children present with a wide spectrum of clinical manifestations, including anaphylaxis, urticaria, angioedema, atopic dermatitis and gastrointestinal symptoms (such as vomiting, diarrhoea and failure to thrive). Symptoms usually begin in the first 2 years of life, often after the first known exposure to the food. Immediate reactions (occurring between several minutes and 2 hours after ingestion) are likely to be IgE-mediated and can usually be detected by skin prick testing (SPT) or measuring food-specific serum IgE antibody levels. Over 90% of IgE-mediated food allergies in childhood are caused by eight foods: cows milk, hens egg, soy, peanuts, tree nuts (and seeds), wheat, fish and shellfish. Anaphylaxis is a severe and potentially life-threatening form of IgE-mediated food allergy that requires prescription of self-injectable adrenaline. Delayed-onset reactions (occurring within several hours to days after ingestion) are often difficult to diagnose. They are usually SPT negative, and elimination or challenge protocols are required to make a definitive diagnosis. These forms of food allergy are not usually associated with anaphylaxis. The mainstay of diagnosis and management of food allergies is correct identification and avoidance of the offending antigen. Children often develop tolerance to cows milk, egg, soy and wheat by school age, whereas allergies to nuts and shellfish are more likely to be lifelong." }, { "id": "Pediatrics_Nelson_1792", "title": "Pediatrics_Nelson", "score": 0.009431466235039609, "content": "First-line management of asthma exacerbations includes supplemental oxygen, repetitive, or continuous administration of short-acting bronchodilators. Early administration of oral or intravenous corticosteroids (Fig. 78-4) is important in treating the underlying inflammation. Administration of anticholinergic agents (ipratropium) with bronchodilators decreases rates of hospitalization and duration of time in the emergency department. Intravenous magnesium sulfate is given in the emergency department if there is clinical deterioration, despite treatment with β2-agonists, ipratropium, and systemic glucocorticoids. The typical dose is 25 to 75 mg/kg (maximum 2.0 g) intravenously administered over 20 minutes. Epinephrine (intramuscular) or terbutaline (subcutaneous) is rarely used except when severe asthma is associated with anaphylaxis or unresponsive to continuous administration of short-acting bronchodilators." }, { "id": "pubmed23n0763_14041", "title": "History of head trauma in a 6-year-old boy: maybe more than meets the eye (and head).", "score": 0.009345794392523364, "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": "pubmed23n0994_1460", "title": "Acute Severe Anaphylaxis in Nepali Patients with Neurotoxic Snakebite Envenoming Treated with the VINS Polyvalent Antivenom.", "score": 0.009259259259259259, "content": "Diagnosing and treating acute severe and recurrent antivenom-related anaphylaxis (ARA) is challenging and reported experience is limited. Herein, we describe our experience of severe ARA in patients with neurotoxic snakebite envenoming in Nepal. Patients were enrolled in a randomised, double-blind trial of high vs. low dose antivenom, given by intravenous (IV) push, followed by infusion. Training in ARA management emphasised stopping antivenom and giving intramuscular (IM) adrenaline, IV hydrocortisone, and IV chlorphenamine at the first sign/s of ARA. Later, IV adrenaline infusion (IVAI) was introduced for patients with antecedent ARA requiring additional antivenom infusions. Preantivenom subcutaneous adrenaline (SCAd) was introduced in the second study year (2012). Of 155 envenomed patients who received ≥ 1 antivenom dose, 13 (8.4%), three children (aged 5-11 years) and 10 adults (18-52 years), developed clinical features consistent with severe ARA, including six with overlapping signs of severe envenoming. Four and nine patients received low and high dose antivenom, respectively, and six had received SCAd. Principal signs of severe ARA were dyspnoea alone (n=5 patients), dyspnoea with wheezing (n=3), hypotension (n=3), shock (n=3), restlessness (n=3), respiratory/cardiorespiratory arrest (n=7), and early (n=1) and late laryngeal oedema (n=1); rash was associated with severe ARA in 10 patients. Four patients were given IVAI. Of the 8 (5.1%) deaths, three occurred in transit to hospital. Severe ARA was common and recurrent and had overlapping signs with severe neurotoxic envenoming. Optimising the management of ARA at different healthy system levels needs more research. This trial is registered with NCT01284855." }, { "id": "pubmed23n0494_21587", "title": "[A notice for use for patients who benifit from an adrenaline pen. \"Having an emergency kit is a good thing but knowing how to use it is better\"].", "score": 0.009259259259259259, "content": "We realized that it is essential that the patient who has an auto injector also has the direction sheet in its emergency bag. Patients, families but also young medical doctors' remarks and reflexions led us to create an explanatory didactic, precise, illustrated and practical direction sheet. The goals are to gather succinct information about the patient (personal contact information, medical history); remind emergency numbers (15 or 112) and the emergency treatment (antihistamine, broncholitor if necessary, epinephrine shots). It also indicates step by step how to use the auto injector (Anapen) and emphasizes the need for a medical supervision if the shot has been used. We present this direction sheet and the way to use it." }, { "id": "First_Aid_Step2_943", "title": "First_Aid_Step2", "score": 0.009211376858435682, "content": "T AB LE 2.1 3-5. Characteristics of Croup, Epiglottitis, and Tracheitis Age group affected 3 months to 3 years 3–7 years 3 months to 2 years Incidence in children presenting with stridor 88% 8% 2% Pathogen Parainf uenza virus H. infl uenzae Often S. aureus Onset Prodrome (1–7 days) Rapid (4–12 hours) Prodrome (3 days) leading to acute decompensation (10 hours) Fever severity Low grade High grade Intermediate grade Associated symptoms Barking cough, hoarseness Muffed voice, drooling Variable respiratory distress Position preference None Seated, neck extended None Response to racemic epinephrine Stridor improves None None CXR fndings “Steeple sign” on AP flm “Thumbprint sign”’ on lateral f lm Subglottic narrowing Mild cases: Outpatient management with cool mist therapy and fl uids. Moderate cases: May require supplemental O2, oral and IM corticosteroids, and nebulized racemic epinephrine." }, { "id": "pubmed23n0783_5839", "title": "A case of anaphylaxis to peppermint.", "score": 0.00909090909090909, "content": "Anaphylaxis, a form of IgE mediated hypersensitivity, arises when mast cells and possibly basophils are provoked to secrete mediators with potent vasoactive and smooth muscle contractile activities that evoke a systemic response. We report a case of IgE mediated anaphylaxis to peppermint (Mentha piperita) in a male shortly after sucking on a candy. A 69 year old male developed sudden onset of lip and tongue swelling, throat tightness and shortness of breath within five minutes of sucking on a peppermint candy. He denied lightheadedness, weakness, nausea, vomiting, or urticaria. He took 25 mg of diphenhydramine, but his symptoms progressed to onset of cough, wheeze and difficulty with talking and swallowing. He was rushed to the nearest emergency department, where he was treated with intramuscular epinephrine, antihistamines and steroids. On history, he reported recent onset of mouth itchiness and mild tongue and lip swelling after using Colgate peppermint toothpaste. He denied previous history of asthma, allergic rhinitis, food or drug allergies. His past medical history was remarkable for hypercholesterolemia, gastroesophageal reflux and gout. He was on simvastatin, omeprazole, aspirin, and was carrying a self-injectable epinephrine device. He moved to current residence three years ago and cultivated mint plants in his backyard. He admitted to develop nasal congestion, cough and wheeze when gardening. Physical examination was unremarkable apart from slightly swollen pale inferior turbinates. Skin prick test (SPT) was strongly positive to a slurry of peppermint candy and fresh peppermint leaf, with appropriate controls. Same tests performed on five healthy volunteers yielded negative results. Skin testing to common inhalants including molds and main allergenic foods was positive to dust mites. Strict avoidance of mint containing items was advised. Upon reassessment, he had removed mint plants from his garden which led to resolution of symptoms when gardening. IgE mediated anaphylaxis to peppermint is rare. This case demonstrates a systemic reaction to a commonly consumed item, incapable of triggering anaphylaxis in the far majority of the population, yet causing a severe episode for our patient." } ] } } }

{ "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, 215 ] ], "word_ranges": [ [ 0, 36 ] ], "text": "Applying the CURB-65 severity scale (one of the most commonly used in the ED for stratifying the severity of pneumonia, although in this case simply applying common sense, the patient should be admitted to the ICU)," }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Outpatient treatment at home.", "2": "Admission to an emergency observation unit.", "3": "Hospital admission to the ward.", "4": "Admission to the Intensive Care Unit.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en116_5557", "title": "Hospital-acquired pneumonia", "score": 0.015570095722767477, "content": "HAP typically lengthens a hospital stay by 1–2 weeks. Signs and symptoms New or progressive infiltrate on the chest X-ray with one of the following: Fever > 37.8 °C (100 °F) Purulent sputum Leukocytosis > 10,000 cells/μl In an elderly person, the first sign of hospital-acquired pneumonia may be mental changes or confusion. Other symptoms may include: A cough with greenish or pus-like phlegm (sputum) Fever and chills General discomfort, uneasiness, or ill feeling (malaise) Loss of appetite Nausea and vomiting Sharp chest pain that gets worse with deep breathing or coughing Shortness of breath Decreased blood pressure and fast heart rate" }, { "id": "pubmed23n0995_19768", "title": "Lung Ultrasound for Initial Diagnosis and Subsequent Monitoring of Aspiration Pneumonia in Elderly in Home Medical Care Setting.", "score": 0.014338575393154487, "content": "The number of aspiration pneumonia cases has increased in recent times. A definitive diagnosis of aspiration pneumonia is difficult in resource-limited settings where radiological equipment is unavailable. We report the initial diagnosis and subsequent monitoring of aspiration pneumonia in a home medical care setting. An 88-year-old Japanese male presented an acute onset of dyspnea, fever, and productive cough. At home, lung ultrasound displayed pleural effusion along with B-lines and subpleural consolidations. Upon admission, tests revealed increased total leucocyte counts with left-shifted neutrophils, elevated C-reactive protein levels, and positive sputum Gram stain. Chest X-ray imaging and computed tomography (CT) showed bibasilar infiltrates and wall thickening in the left S10 bronchi. The patient was diagnosed with aspiration pneumonia and treated with an antibiotic. After a 10-day hospitalization, lung ultrasound showed some remaining B-lines and disappearance of pleural effusion and subpleural consolidation. Chest X-ray image was normal, and CT revealed pleural abnormality and disappearance of bibasilar infiltrates, consistent with the ultrasound findings. Aspiration pneumonia develops with various clinical signs. However, diagnosis using chest X-ray imaging or CT in resource-limited settings is difficult. Ultrasound might allow physicians to make more accurate judgments, particularly while monitoring aspiration pneumonia following initial diagnosis in resource-limited settings." }, { "id": "pubmed23n1013_21191", "title": "Dyspnoe, cough and fever in 80-year old patient with chronic heart failure.", "score": 0.01425, "content": "The prevalence of heart failure (HF) in developed countries exceeds 10% in adults over 70 year old. At the following report we aim to present a case of HF worsening complicated by gout attack. 80-year old patient was admitted to the hospital, with the suspicion of pneumonia, because of 3-day history of dyspnoe, cough and fever. Patient reported redness, swelling and pain in the area of left elbow. Prior to admission patient was diagnosed with bursitis and treated with antibiotic without symptoms resolution. There was past medical history of atrial fibrillation, hypertension, intermittent claudication, COPD. One month before, patient was hospitalized due to HF worsening. Diuretics' dosage was increased at that time and symptoms resolved. On admission: blood pressure 145/88 mm Hg, HR 96/min irregular, saturation O2 88% without oxygen therapy. On physical examination, bilateral pulmonary crackles, redness, tenderness of left elbow were found. Laboratory tests demonstrated elevated parameters of inflammation - leukocytosis 13.4G/L, neutrophilia 11G/L, CRP 142.5 mg/L, but normal procalcitonin 0.27 ng/ml. Moreover, high NTproBNP 8573 pg/ml and hyperuricemia 13.1 mg/dl were detected. Chest X-ray indicated pulmonary venous congestion. ECG revealed atrial fibrillation with QRS rate of 100/min, left axis deviation. Therefore, gout attack was diagnosed and after colchicine administration symptoms resolved quickly. Clinical signs including fever, elevated parameters of inflammation and dyspnoe justify pneumonia consideration in differential diagnosis. Importantly, non-infectious causes of inflammatory conditions, like gout must be also considered. Patients with HF often develop hyperuricemia due to diuretic treatment, aggravated catabolism and often co-prevalent chronic kidney disease." }, { "id": "wiki20220301en069_40749", "title": "Community-acquired pneumonia", "score": 0.011267006802721087, "content": "Hospitalization Some CAP patients require intensive care, with clinical prediction rules such as the pneumonia severity index and CURB-65 guiding the decision whether or not to hospitalize. Factors increasing the need for hospitalization include: Age greater than 65 Underlying chronic illnesses Respiratory rate greater than 30 per minute Systolic blood pressure less than 90 mmHg Heart rate greater than 125 per minute Temperature below 35 or over 40 °C Confusion Evidence of infection outside the lung Laboratory results indicating hospitalization include: Arterial oxygen tension less than 60 mm Hg Carbon dioxide over 50 mmHg or pH under 7.35 while breathing room air Hematocrit under 30 percent Creatinine over 1.2 mg/dl or blood urea nitrogen over 20 mg/dl White-blood-cell count under 4 × 10^9/L or over 30 × 10^9/L Neutrophil count under 1 x 10^9/L" }, { "id": "wiki20220301en000_255487", "title": "Jim Henson", "score": 0.010736902705814623, "content": "Henson was having trouble breathing when he woke up at around 2:00 a.m. (EST) on May 15, 1990, and began coughing up blood. He suggested to his wife that he might be dying, but he did not want to take time off from his schedule to visit a hospital. Two hours later, Henson agreed to be taken by taxi to the emergency room at New York–Presbyterian Hospital in Manhattan. Shortly after admission, he stopped breathing and was rushed into the intensive care unit. X-ray images of his chest revealed multiple abscesses in both of his lungs as a result of a previous bacterial infection. Henson was placed on a ventilator but quickly deteriorated over the next several hours despite increasingly aggressive treatment with multiple antibiotics. Although the medicine killed off most of the infection, it had already weakened many of Henson's organs, and he died at 1:21 a.m. the following morning. He was 53." }, { "id": "wiki20220301en013_148122", "title": "Acute bronchitis", "score": 0.01002750687671918, "content": "A variety of tests may be performed in people presenting with cough and shortness of breath: A chest X-ray is useful to exclude pneumonia which is more common in those with a fever, fast heart rate, fast respiratory rate, or who are old. A sputum sample showing neutrophil granulocytes (inflammatory white blood cells) and culture showing that has pathogenic microorganisms such as Streptococcus species. A blood test would indicate inflammation (as indicated by a raised white blood cell count and elevated C-reactive protein). Decreased breath sounds, crackles, wheezing, and rhonchi that clears with coughs may be heard in the chest. Dullness to percussion and pleural rub suggest disease extension beyond the bronchi such as seen with pneumonia. Paroxysms of cough followed by inspiratory whoop and vomiting suggests pertussis." }, { "id": "pubmed23n0886_6897", "title": "Miliary tuberculosis in an immunocompetent male with a fatal outcome.", "score": 0.009900990099009901, "content": "A man aged 33 years, born in Nepal, but resident in the UK for 7 years presented to the emergency department with a 4-day history of general malaise, fever (temperature 38.6°C) and a non-productive cough. His medical history was unremarkable and no high-risk behaviour was identified. Clinical examination confirmed decreased air entry bilaterally with bibasal crackles. He was tachycardic, with a heart rate of 120 bpm. Further investigation with a 12-lead ECG confirmed supraventricular tachycardia (SVT) which was terminated with vagal manoeuvres. His chest radiograph demonstrated left basal consolidation. His white cell count was 11×10<sup9</sup/L and his C reactive protein was 43.2 mg/L. His blood cultures revealed no growth. He was diagnosed with community-acquired pneumonia and started treatment with amoxicillin and clarithromycin. 3 days post admission, he was intubated for 24 hours in the Department of Intensive Care Medicine. Further episodes of SVT were observed and an ECHO showed a severely dilated and impaired left ventricle. Further chest radiographs illustrated diffuse consolidation with evidence of pulmonary oedema. HIV serology was negative. He developed transaminitis and thrombocytopenia. An ultrasound scan of his liver showed no obvious liver pathology. He remained tachypnoeic and due to worsening pulmonary oedema and extensive consolidation, he was readmitted to the intensive care unit. A CT abdomen with contrast showed an unusual pattern of lymphadenopathy with disproportionately enlarged coeliac axis nodes (5×7×5 cm) and minor para-aortic adenopathy, suspicious for lymphoma. On inserting his central venous catheter in his right internal jugular vein, pus was inadvertently aspirated from his right neck. Acid alcohol fast bacilli (AAFFB) were isolated from the pus and was subsequently identified as Mycobacterium tuberculosis He started treatment with antitubercular medication rifater: a combination of rifampicin 720 mg od, isoniazid 300 mg po od and pyrazinamide 1750 mg. In addition, he received ethambutol 1000 mg po od and pyridoxine 5 mg. He developed worsening metabolic acidosis, pH 7.19, loss of respiratory compensation and pancytopenia. Right heart strain was evident on his Focused Intensive Care Echo. He developed an increased oxygen requirement and respiratory distress on the ventilator. An erect chest radiograph showed bilateral pneumothoraces and bronchopleural fistulae. A chest drain was inserted. Following discussion with the Cardiothoracic Surgeons, pleurodesis was not deemed possible. He developed inotropic-dependent shock with worsening lung compliance. As a result of his deteriorating ventilation, acidosis and hyperkalaemia, he started treatment with continuous veno-venous haemofiltration. With a diagnosis of miliary tuberculosis and SVT causing cardiogenic pulmonary oedema, this man sadly died with his family at his bedside 10 weeks following initial hospital presentation." }, { "id": "pubmed23n0565_7072", "title": "[Predictive value of history and physical examination for the diagnosis of community-acquired pneumonia in adults].", "score": 0.009900990099009901, "content": "Community-acquired pneumonia in adults is a serious health problem in the ambulatory care setting. To define clinical variables associated with the presence of pneumonia in adult patients presenting with fever or respiratory symptoms to the emergency department. Prospective study carried out in the emergency department from the Catholic University Hospital in Santiago, Chile. Three hundred twenty-five patients (53+/-22 years) presenting fever or acute respiratory symptoms were included. After obtaining a clinical history and physical examination, the physician established a tentative diagnosis. Subsequently, a definitive diagnosis was made with the chest X rays. Thirty-four percent of the patients had pneumonia. The clinical diagnosis of pneumonia before X-ray examination was variable among emergency physicians (positive likelihood ratio: 1.5-4.8) and showed only moderate sensitivity (79%) and specificity (66%). The clinical variables significantly associated with the presence of pneumonia were: advanced age (over 75 years), cardiovascular disease, fever, chills, sputum production, orthopnea, altered mental status, cyanosis, dullness on percussion, bronchial breath sounds, crackles, any abnormal vital sign (heart rate&gt;or=100 beats/min, respiratory rate&gt;or=20 breaths/min or temperature&gt;or=38 degrees C) and oxygen saturation below 90% breathing air. Clinical judgment prior to observation of chest X rays had moderate sensitivity and specificity for the diagnosis of pneumonia. There were no individual clinical findings, or combination of findings, that could confirm or exclude the diagnosis of pneumonia for a patient suspected of having this illness." }, { "id": "pubmed23n1039_9291", "title": "Clinical and Epidemiological Features of SARS-CoV-2 Patients in SARI Ward of a Tertiary Care Centre in New Delhi.", "score": 0.00980392156862745, "content": "Rapid spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Wuhan, China, prompted heightened surveillance in India. Since the first laboratory confirmed case of SARS-CoV-2 was reported from Kerala on January 30, 2020 novel coronavirus infected pneumonia (NCIP) has been presenting to the hospital emergencies as severe acute respiratory illness (SARI). We aim to find out the rate of SARS-CoV-2 positivity in SARI cases and further clarify the epidemiological and clinical characteristics of NCIP in New Delhi, India. To find out the rate of SARS-CoV-2 positivity in SARI cases presenting to the hospital emergency and describe the epidemiological and clinical characteristics of NCIP. Retrospective, single-center case series of the 82 consecutive hospitalized patients with SARI and subsequent confirmed NCIP cases at Dr Ram Manohar Lohia Hospital, New Delhi between 10th April 2020 and 30th April 2020. Epidemiological, demographic, clinical, laboratory, radiological, and treatment data were collected and analyzed. The primary composite end-point was admission to an intensive care unit (ICU), the use of mechanical ventilation or death. Patients were categorized as severe pneumonia and non-severe pneumonia at time of admission and outcome data was compared. Of the 82 SARI cases, 32(39%) patients were confirmed to be SARS-CoV-2 positive. The median age of NCIP cases was 54.5 years (IQR, 46.25 - 60) and 19(59.3%) of them were males. 24(75%) cases were categorized as severe pneumonia on admission. 22(68.8%) patients had 1 or more co-morbidities. Diabetes mellitus 16(50%), hypertension 11(34.4%) and chronic obstructive airway disease 5(15.6%) were the most common co-existing illnesses. Compared with the patients who did not meet the primary outcome, patients who met the primary outcome were more likely to be having at least 1 underlying comorbidity (p-0.03), diabetes (p-0.003) and hypertension (p-0.03). Common symptoms included dyspnea 29(90.6%) followed by cough 27(84.4%), fever 22(68%), bodyache and myalgias 14(43.75%). Median time from symptom onset to hospital admission was 3 days. The most common pattern on chest X-ray was bilateral patchy nodular or interstitial infiltration seen in 30(93.8%) patients. Leucopenia was present in 10(31.2%) of the patients, with majority of patients presenting with lymphocytopenia, 24(75%) [lymphocyte count (1106 cells/ dL), interquartile range {IQR}, (970-1487)]. Thrombocytopenia was seen in 14(43.8%) patients, pancytopenia in 10(31.2%) patients and anemia was seen in 14(43.8%) patients. Hypoalbuminemia was present in 22(68.8%) cases. Raised CK-MB was seen in 7(21.9%) patients. The primary composite end-point occurred in 12(37.5%) patients, including 9(28.13%) patients who required mechanical ventilation and subsequently expired. 3(9.3%) of these patients who recovered, were subsequently shifted to COVID-19 ward from the ICU. The patients who met the primary outcome were older in age (56.5 years vs 50 years), had significantly higher SOFA scores (6 vs 3.5), were in shock (41.7% vs 5%), in higher respiratory distress (66.7% vs 10%), had lower mean arterial oxygen saturation (85% vs 89.5%), had higher CK-MB values (66 vs 26)U/L [6(54.5%) vs 2(9.5%)], had hypoalbuminemia (100% vs 50%) and acute kidney injury 8(72.7%) vs 5(23.8%) on admission. Of the 50 non-COVID-19 SARI patients in our study cohort, 13 (26%) patients met the primary composite outcome. Of them 9 (18%) patients expired and remaining 4 patients have subsequently recovered. As on 17th May 2020, 23 patients were still hospitalized, recovering in COVID-19 ward. In this single-center case series from New Delhi, out of 82 patients of SARI, 32 patients were confirmed NCIP, with a COVID-19 positivity of 39%. 75% of NCIP presented in severe pneumonia and 37.5% required ICU care. The case fatality rate was 28%." }, { "id": "pubmed23n0573_4597", "title": "[Chronic obstructive pulmonary disease in the setting of hospital at home. Study of 522 episodes].", "score": 0.00980392156862745, "content": "To assess the effectiveness, respiratory status, services of origin and outcome of patient with exacerbated COPD attended in Hospital at Home (HaH) regimen. Study of patients with an exacerbated COPD in HaH from Vitoria-Gasteiz, Spain during the period March 1999-October 2004, in whom hospital admission had been recommended after medical assessment. We studied: age, gender, patient's stay, oxygen-saturation or arterial blood gas analysis, FEV1 (basal), dyspnea status (basal and current), coexisting diseases, exacerbation causes, Services of origin, use of home nebulizers and oxygen therapy, intravenous drugs, course (discharges/admissions/deaths). We analyzed the number of visits to the Emergency Department and hospital admissions 90 days before and after discharge from Hospital at home. A total of 302 patients who generated 522 cases with exacerbated COPD were accepted, 81% of whom are men. Means stay was 11 days (0-111). Three hundred ninety six (76%) of the cases were discharge from HaH, 111 (21%) had to be hospitalized for different reasons, on 13 (2.5%) died. Of these, 43% came from the Respiratory Department and 39% from the Emergency one. Mean FEV1 was 45.4. A total of 89% of the patients had dyspnea 4/4 and 34% 3/4 when seen and 9% of the patients had pneumonia. During the 90 days following discharge from Hospital at Home, the number of visits to the Emergency Department and the rate of hospital admissions decreased significantly (p &lt; 0.001). Our data confirm that Hospital at Home is a good alternative to conventional hospital admission for the management of patients with exaxerbated COPD." }, { "id": "pubmed23n1007_14583", "title": "A successful management after preterm delivery in a patient with severe sepsis during third-trimester pregnancy.", "score": 0.009708737864077669, "content": "A 33-year-old woman visited the emergency department presenting with fever and dyspnea. She was pregnant with gestational age of 31 weeks and 6 days. She had dysuria for 7 days, and fever and dyspnea for 1 day. The vital signs were as follows: blood pressure 110/70 mmHg, heart rate 118 beats/minute, respiratory rate 28/minute, body temperature 38.7℃, and oxygen saturation by pulse oximetry 84% during inhalation of 5 liters of oxygen by nasal prongs. Crackles were heard over both lung fields. There were no signs of uterine contractions. Chest X-ray and chest computed tomography scan showed multiple consolidations and air bronchograms in both lungs. According to urinalysis, there was pyuria and microscopic hematuria. She was diagnosed with community-acquired pneumonia and urinary tract infection (UTI) that progressed to severe sepsis and acute respiratory failure. We found extended-spectrum beta-lactamase producing <iEscherichia coli</i in the blood culture and methicillin-resistant Staphylococcus aureus in the sputum culture. The patient was transferred to the intensive care unit with administration of antibiotics and supplementation of high-flow oxygen. On hospital day 2, hypoxemia was aggravated. She underwent endotracheal intubation and mechanical ventilation. After 3 hours, fetal distress was suspected. Under 100% fraction of inspired oxygen, her oxygen partial pressure was 87 mmHg in the arterial blood. She developed acute kidney injury and thrombocytopenia. We diagnosed her with multi-organ failure due to severe sepsis. After an emergent cesarean section, pneumonia, UTI, and other organ failures gradually recovered. The patient and baby were discharged soon thereafter." }, { "id": "pubmed23n1010_3450", "title": "The admission of patients with pneumonia directly from the Emergency Department to Hospital in the Home.", "score": 0.009708737864077669, "content": "Acute respiratory infection is often the commonest reason for patients to be admitted to hospital from the Emergency Department (ED). Hospital in the Home Units (HHUs) deliver acute hospital type care to patients at home. This study sought to review the safety and effectiveness of HHU care for patients with pneumonia referred directly from an ED to a HHU using standard selection criteria. A retrospective clinical audit of all patients with acute pneumonia referred from the ED to the HHU from March 2000 to March 2002. 45 episodes in 44 patients were identified. 19 patients were female and the mean age was 53 years. Seven (15.6%) patients were residents of nursing homes.In 23 (51.1%) episodes, patients had presented to ED already taking oral antibiotics for their current condition. In 30 patients, significant co-morbidities were identified.The mean temperature on presentation was 37.7° Centigrade. The range of oxygen saturation was 89-100%, with a mean of 95%. Positive chest xray findings were reported in 41 (91.1%) of 45 episodes. In 9 (20%) cases an effusion was also reported.Length of stay ranged from 1-20 days with a mean of 6.2 days. In all 45 episodes, patients were treated with ceftriaxone. Adjuvant oral therapy was initiated in 28 episodes. Other adjuvant therapy was initiated at admission: nebulised salbutamol (7); oral prednisolone (1).Intravenous crystalloid fluids were required at home for rehydration in 2 episodes. Antibiotic therapy was altered in two cases. Oral prednisolone was commenced in 4 episodes, nebulised salbutamol commenced in 7 episodes, and fluconazole and frusemide were each commenced in a single episode.In three cases the primary discharge diagnosis was not related to respiratory infection.In 5 episodes (11.1%), patients made an unplanned telephone call to HHU staff. In 4 (8.9%) episodes, an unplanned staff visit was required. One patient required a return to hospital to complete her inpatient treatment. Two patients were readmitted within 1 month of discharge from EHHU. Patients who present to EDs with respiratory infection requiring intravenous therapy may be safely referred directly into Hospital in the Home care." }, { "id": "pubmed23n1130_20911", "title": "A 24-Year-Old Man With Dyspnea and a Broken Left Femur.", "score": 0.009615384615384616, "content": "A 24-year-old White man presented with 1-day complaints of progressive shortness of breath and fever. He recently underwent an open reduction and internal fixation of a left midshaft femur fracture from a skiing accident 4 days ago. He denied chest pain, skin rashes, hemoptysis, hematemesis, melena, or surgical site bleeding. On arrival, the patient appeared in mild respiratory distress with a respiratory rate of 23 breaths/min, temperature of 37.8°C, heart rate of 97 beats/min, BP of 95/54 mm Hg, and peripheral saturation of 97% on 6-L/min nasal canula. His initial peripheral saturation on room air was 67%. Physical examination was unremarkable, except for diffuse rhonchi on chest auscultation. Chest radiograph on admission showed alveolar opacities predominantly in bilateral lower lobes. A chest CT angiography revealed no evidence for pulmonary embolism. However, there were findings of diffuse bilateral ground-glass opacities with areas of patchy consolidation and innumerous micronodules in both lungs (Fig 1). Laboratory examination was significant for a drop of hemoglobin by 3 g/dL and hematocrit level by 7% since his hospital discharge 4 days earlier. His renal function and urine analysis were normal. Venous blood gas on admission showed pH of 7.39 and Pco<sub2</sub of 43 mm Hg. Because of unexplained acute anemia, nonspecific CT chest findings and progressive dyspnea, a bronchoscopy with BAL was performed. Four aliquots of 60 mL saline solution were injected for lavage with fluid return (Fig 2). BAL fluid showed WBC count of 0.411 × 10<sup3</sup/mm<sup3</sup, RBC count of 318 × 10<sup3</sup/mm<sup3</sup, 100% fresh RBCs, 73% neutrophil, 24% lymphocytes, 1% monocytes, and 2% eosinophils. BAL fluid cytologic condition is shown in Figure 3. A full vasculitis workup by rheumatology was unremarkable. Ophthalmologic and skin examination were unrevealing." }, { "id": "pubmed23n0531_12149", "title": "Diagnostic value of lung auscultation in an emergency room setting.", "score": 0.009615384615384616, "content": "In daily routine, physicians use history, physical examination and technology-based information such as laboratory tests and imaging studies to diagnose the patients' disease. We determined the diagnostic value of lung auscultation in patients admitted to the Medical emergency room with chest symptoms. Two-hundred-and forty-three consecutive patients (137 males), mean age 59.2 years were included. Internal Medicine registrars had to make a presumptive diagnosis, 1) after having taken the history and 2) after having auscultated the lungs. Thereafter, routine diagnostic procedures were performed. The estimated diagnosis was compared with the final diagnosis based on the written report to the Family Practitioner. Two-hundred-eighty-seven diagnoses were made. Eighteen percent of patients suffered from left heart failure, 13% from unexplained chest pain, 10.5% from chest wall pain, and 10.5% from pneumonia. Forty-one percent of the diagnoses were already correct when based only on the patient's history. Lung auscultation improved the diagnostic yield only in 1% and worsened it in another 3%. By multiple logistic regression, normal lung auscultation (OR 0.12 [95CI% 0.053-0.29]) was the independent predictor for not having a lung or heart disease. However, elevation of B-type natiuretic peptide (BNP) (OR 1.16 per 100 pg/ml (95CI% 1.004-1.35), wheezing (OR 0.023 [0.002-0.33]) and pCO2 (OR 0.25 (0.10-0.621) were independent predictors for having a heart disease, whereas wheezing (OR 7.41 [3.26-16.83]) and CRP (OR 1.008 per 10 units [1.003-1.014]) were risk factors for having a lung disease. In contrast to history taking, abnormal lung auscultation does not appear to contribute considerably to the final diagnosis in patients presenting with chest symptoms in an emergency room setting. However, normal lung auscultation is a valuable predictor for not having a lung or heart disease, whereas wheezing is a predictor for having a lung disease and not having a heart disease." }, { "id": "wiki20220301en069_40750", "title": "Community-acquired pneumonia", "score": 0.00956959706959707, "content": "X-ray findings indicating hospitalization include: Involvement of more than one lobe of the lung Presence of a cavity Pleural effusion Prognosis The CAP outpatient mortality rate is less than one percent, with fever typically responding within the first two days of therapy, and other symptoms abating in the first week. However, X-rays may remain abnormal for at least a month. Hospitalized patients have an average mortality rate of 12 percent, with the rate rising to 40 percent for patients with bloodstream infections or those who require intensive care. Factors increasing mortality are identical to those indicating hospitalization." }, { "id": "pubmed23n1023_20929", "title": "Enterococcus faecalis-associated lung abscess in a male adolescent- a case report.", "score": 0.009523809523809525, "content": "Enterococci are rarely considered pulmonary pathogens; they are usually regarded as colonizers of the airway. The authors present the case of a previously healthy male adolescent, with complaints of fatigue and chest pain, who was diagnosed with Enterococcus faecalis-associated acute primary lung abscess. A previously healthy 17-year old boy was admitted to the pediatric ward due to a one-week history of fatigue, inspiratory left side chest pain, dry cough and nasal obstruction. On admission at the emergency department, he was afebrile, with no signs of respiratory distress, but with diminished breath sounds on the left side. A chest x-ray showed a round opacity on the posterior basal segment of the left lower lobe; he was discharged with oral amoxicillin 1000 mg three times a day with the diagnosis of community-acquired pneumonia. Due to the worsening of the productive cough with purulent stinking sputum he was re-evaluated after 4 days. Laboratory studies showed a leukocyte count of 15200/uL and a c-reactive protein of 172 mg/l. The chest computed tomography scan was suggestive of a consolidation of the left lower lobe base and a central abscess. An intravenous course of ceftriaxone and clindamycin was initiated, with a favourable clinical evolution. The bronchofibroscopy performed on day four after his admission revealed the presence of a tracheal bronchus and numerous purulent secretions. Culture examination of bronchoalveolar lavage fluid samples was positive (&gt; 10^5) for Enterococcus faecalis. No complications were registered during his stay in the pediatric ward. He was discharged after a 14-day course of intravenous ceftriaxone and clindamycin, with the recommendation to complete a four-week course of oral amoxicillin/clavulanic acid. On his reevaluation 4 weeks after his discharge, he was asymptomatic. This case report highlights the importance of considering Enterococcus faecalis as an etiologic agent in cases of non-resolving or complicated cases of pneumonia, such as lung abscesses, even in young patients with no comorbidities or risk factors." }, { "id": "pubmed23n0726_9063", "title": "Hospital at home for acute exacerbations of chronic obstructive pulmonary disease.", "score": 0.009523809523809525, "content": "Hospital at home schemes are a recently adopted method of service delivery for the management of acute exacerbations of chronic obstructive pulmonary disease (COPD) aimed at reducing demand for acute hospital inpatient beds and promoting a patient-centred approach through admission avoidance. However, evidence in support of such a service is contradictory. To evaluate the efficacy of hospital at home compared to hospital inpatient care in acute exacerbations of COPD. Trials were identified from searches of electronic databases, including CENTRAL, MEDLINE, EMBASE, and the Cochrane Airways Group Register (CAGR). The review authors checked the reference lists of included trials. The CAGR was searched up to February 2012. The additional databases were searched up to October 2010. We considered randomised controlled trials where patients presented to the emergency department with an exacerbation of their COPD. Studies must not have recruited patients for whom treatment at home is usually not viewed as an responsible option (e.g. patients with an impaired level of consciousness, acute confusion, acute changes on the radiograph or electrocardiogram, arterial pH less than 7.35, concomitant medical conditions). Two review authors independently selected articles for inclusion, assessed the risk of bias and extracted data for each of the included trials. Eight trials with 870 patients were included in the review and showed a significant reduction in readmission rates for hospital at home compared with hospital inpatient care of acute exacerbations of COPD (risk ratio (RR)0.76; 95% confidence interval (CI) from 0.59 to 0.99; P=0.04). Moreover, we observed a trend towards lower mortality in the hospital at home group, but the pooled effect estimate did not reach statistical significance (RR 0.65, 95% CI 0.40 to 1.04, P = 0.07). For health-related quality of life, lung function (FEV1) and direct costs, the quality of the available evidence is in general too weak to make firm conclusions. Selected patients presenting to hospital emergency departments with acute exacerbations of COPD can be safely and successfully treated at home with support from respiratory nurses. We found evidence of moderate quality that hospital at home may be advantageous with respect to readmission rates in these patients. Treatment of acute exacerbation of COPD in hospital at home also show a trend towards reduced mortality rate when compared with conventional inpatient treatment, but these results did not reach statistical significance (moderate quality evidence). For other outcomes than readmission and mortality rate, we assessed the evidence to be of low or very low quality." }, { "id": "pubmed23n0989_8293", "title": "What is the role of Ewingella americana in humans? A case report in a healthy 4-year-old girl.", "score": 0.009433962264150943, "content": "Ewingella americana (Ea) is a Gram-negative, lactose-fermenting, oxidase-negative and catalase-positive bacterium that was first described in 1983 as a new genus and species in the family Enterobacteriaceae. It is not known whether Ea is a true pathogen or simply an opportunistic infectious agent, as most of the cases have been described in patients at risk. A 4-year-old girl described here was hospitalized due to a productive cough over the previous 3 weeks and a fever &gt; 38 °C associated with tachypnea over the previous 2 days. Her familial and personal medical histories were negative for relevant diseases, including respiratory infections. At admission, she was febrile (axillary temperature 39.2 °C) and had dyspnea with retractions, grunting and nasal flaring. A chest examination revealed fine crackling rales in the left upper field associated with bilateral wheezing. A chest X-ray revealed segmental consolidation of the lingula of the left lung. Laboratory tests revealed leukocytosis (15.,800 white blood cells/mm<sup3</sup with 50.3% neutrophils), a slight increase in serum C-reactive protein (11.9 mg/L) and normal procalcitonin values (&lt; 0.12 ng/mL). A nasopharyngeal swab culture did not reveal viral or bacterial respiratory pathogens, including atypical bacteria. A blood culture revealed the presence of a Gram-negative, lactose-fermenting rod that was oxidase negative and catalase positive. The isolate was identified by means of the VITEK®2 identification system (bioMérieux, Firenze, Italy) as Ea. This identification was confirmed by sequencing the 16 s ribosomal deoxyribonucleic acid (rDNA). The pathogen was sensitive to aminoglycoside, fluoroquinolones, carbapenems, cefotaxime, and ceftazidime but was intermediate against sulfametoxazole/trimethoprim and resistant to amoxicillin-clavulanic acid, fosfomycin, and oxacillin. The child was immediately treated orally with amoxicillin-clavulanic acid and erythromycin. Based on the results of a blood culture and sensitivity tests, the amoxicillin-clavulanic acid medication was stopped after 3 days. Erythromycin was continued for a total of 10 days, and the child was discharged after 3 days in the hospital. Follow-up visit 1 month later did not reveal any respiratory problems. This case shows that Ea infections in healthy subjects are mild even in pediatric age, and the need for antibiotic therapy is debated. Cases occurring in subjects with underlying chronic disease can be significantly more complicated and require appropriate antibiotic therapy." }, { "id": "pubmed23n0072_22976", "title": "[Amoxicillin as a 1st choice: 275 acute focal pneumopathies treated on an outpatient basis].", "score": 0.009433962264150943, "content": "From December 1986 to January 1988, 100 General Practitioners and Pneumologists working outside hospital included in open unmatched series 275 patients who were diagnosed as having pneumonia at home. The study consisted of 53.2% men with an average age of 49.3 plus or minus 19.3. Their temperature on the first day (J1) was in 72.7% of cases greater than 38.5 degrees Centigrade. The doctors felt that the general state was good in 66.5% of the cases. Cough was present in 83.5% of cases but was dry in one out of every two. The patients received Amoxycillin in a dose of 2 grams per day orally (66.9%), or by injection (33.1%). On the third day (J3) 90% of the patients had a temperature below 38.5 degrees Centigrade. Their general state was improved in 94.6% of cases. The diagnosis of pneumonia at home was confirmed radiologically on 219 of the films available, confirming the good specificity of the clinical diagnosis of pneumonia at home. Ten patients were hospitalised. The apparent treatment of Amoxycillin was given in 247 cases (89.8% of cases). In 28 cases (10.2%) the treatment was changed by the addition or substitution of a Macrolide (15), or another antibiotic (5), and in 80 cases a change of treatment was not specified. 25 of these 28 cases were reviewed on the 14th day (J14) and no failures were observed after the change of treatment. In 247 patients in whom the treatment with Amoxycillin was followed 336 were reviewed on the 15th day and there had been four failures. Three were intolerant to the drug and there was one relapse.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n1036_15478", "title": "Helmet-based noninvasive ventilation for acute exacerbation of chronic obstructive pulmonary disease: A case report.", "score": 0.009345794392523364, "content": "Noninvasive ventilation (NIV) reduces intubation rates, mortalities, and lengths of hospital and intensive care unit stays in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Helmet-based NIV is better tolerated than oronasal mask-based ventilation, and thus, allows NIV to be conducted for prolonged periods at higher pressures with minimal air leaks. A 73-year-old man with a previous diagnosis of COPD stage 4 was admitted to our medical intensive care unit with chief complaints of cough, sputum, and dyspnea of several days' duration. For 10 mo, he had been on oxygen at home by day and had used an oronasal mask-based NIV at night. At intensive care unit admission, he breathed using respiratory accessory muscles. Hypercapnia and signs of infection were detected, and infiltration was observed in the right lower lung field by chest radiography. Thus, we diagnosed AECOPD by community-acquired pneumonia. After admission, respiratory distress steadily deteriorated and invasive mechanical ventilation became necessary. However, the patient refused this option, and thus, we selected helmet-based NIV as a salvage treatment. After 3 d of helmet-based NIV, his consciousness level and hypercapnia recovered to his pre-hospitalization level. Helmet-based NIV could be considered as a salvage treatment when AECOPD patients refuse invasive mechanical ventilation and oronasal mask-based NIV is ineffective." }, { "id": "pubmed23n0750_14039", "title": "Outpatient diagnosis of acute chest pain in adults.", "score": 0.009345794392523364, "content": "Approximately 1 percent of primary care office visits are for chest pain, and 1.5 percent of these patients will have unstable angina or acute myocardial infarction. The initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction. The physician should consider patient characteristics and risk factors to help determine initial risk. Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions. For persons in whom the suspicion for ischemia is lower, other diagnoses to consider include chest wall pain/costochondritis (localized pain reproducible by palpation), gastroesophageal reflux disease (burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth), and panic disorder/anxiety state. Other less common but important diagnostic considerations include pneumonia (fever, egophony, and dullness to percussion), heart failure, pulmonary embolism (consider using the Wells criteria), acute pericarditis, and acute thoracic aortic dissection (acute chest or back pain with a pulse differential in the upper extremities). Persons with a higher likelihood of acute coronary syndrome should be referred to the emergency department or hospital." }, { "id": "pubmed23n0944_7704", "title": "<i>Pneumocystis jiroveci</i> pneumonia in a patient taking Benepali for rheumatoid arthritis.", "score": 0.009259259259259259, "content": "We present a case of a 57-year-old woman who contracted <iPneumocystis jiroveci</i pneumonia while on Benepali, the biosimilar version of etanercept for rheumatoid arthritis. She had seropositive erosive disease. She was admitted to clinic with a 2-week history of dyspnoea, dry cough and fever. Her initial examination showed her to be hypoxic on air with saturations of 77% and left basal crackles. Her admission chest X-ray showed fine reticular shadowing, with an initial suspicion of pulmonary fibrosis. She was empirically treated for community-acquired pneumonia but continued to deteriorate with a worsening type 1 respiratory failure. She was intubated and ventilated on intensive care. The suspicion was raised of <iP. jiroveci</i pneumonia given her immunosuppression, hypoxic presentation and chest X-ray changes. This was confirmed on sputum PCR. She was treated with a 3-week course of steroids and co-trimoxazole. She was discharged home after a 2-week admission." }, { "id": "pubmed23n0705_284", "title": "Hospital admission decision for patients with community-acquired pneumonia: variability among physicians in an emergency department.", "score": 0.009259259259259259, "content": "We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes. We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined \"low severity\" as PaO(2)/FiO(2) ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics. Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions. We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data." }, { "id": "pubmed23n0321_21346", "title": "[Fulminant Mycoplasma pneumoniae pneumonia resulting in respiratory failure and a prolonged pulmonary lesion].", "score": 0.009174311926605505, "content": "A previously healthy 26-year-old woman presented with a fever and coughing on October 1, 1995. Despite treatment with beta-lactam antibiotics at another hospital, she had a high fever, coughing, and dyspnea. A chest roentgenogram showed diffuse infiltrates in both lung fields. On October 9, she was transferred to our hospital. On admission, a chest X-ray film showed marked diffusely infiltrates in both lung fields and a effusion in the left lung. Arterial blood gas analysis after inhalation of 4 liters per minute of oxygen via a nasal cannula revealed a PaO2 of 39.0 torr. Despite treatment with various antibiotics, including minocyclin and gamma-globulin, her respiratory condition rapidly deteriorated. She was mechanically ventilated by with intermittent mandatory ventilation and positive end-experiatory pressure, and received antibiotics and methylprednisolone pulse therapy. He chest X-ray and arterial blood gase findings, gradually improved. The passive hemagglutination titer for Mycoplasma rose from 1:4 on October 9, to 1:2,560 on the 14th hospital day. Acute respiratory failure due to Mycoplasma pneumoniae pneumonia was diagnosed. A chest X-ray film obtained 2 months after admission showed linear-reticular shadows in both lung fields and pulmonary-function tests revealed abnormally low vital capacity and diffusing capacity. Examination of a specimen obtained by transbronchial lung biopsy revealed focal intraalveolar exudate with fibrin and macrophages. Very mild interstitial thickening was also noted. The lymphocyte stimulation responses to PPD, PHA, and Con A were low early in the illness and became normal after recovery. Several reports have said that an enhanced pulmonary cellular immune response may be responsible for the development of severe Mycoplasma pneumoniae, resulting in a temporary decrease in the cell-mediated immune response. This case supports that hypothesis. We believe that in severe cases, steroid therapy including pulse therapy should be started as soon as possible." }, { "id": "pubmed23n0408_10028", "title": "Use of antibiotics in patients admitted to the hospital due to acute exacerbation of chronic obstructive pulmonary disease (COPD).", "score": 0.009174311926605505, "content": "BACKGROUND: The purpose of this study was to assess to what extent symptoms and signs of bacterial infection are present and evaluated in patients admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD) in relation to initiation of antibiotic treatment. METHODS: All adult patients (&gt;18 years of age) discharged from a department of internal medicine in Copenhagen in 1997 with a diagnosis of exacerbation of COPD were included in our study and their reports were retrospectively reviewed. Gender, age, number of admissions and length of hospital stay, use of antibiotics and steroids prior to admission, temperature, white blood cell (WBC) count, results of lung auscultation and X-ray examination of the thorax at admittance, and growth of sputum culture and antibiotic treatment in the hospital were all registered. RESULTS: A total of 400 admissions took place. In 104 of them, chest X-ray was compatible with pneumonia, and 99 cases were treated with antibiotics. In 44% of the remaining 296 cases, antibiotics were given. It was found that 25-45% of the patients with very little evidence of infection-i.e. the absence of, or only the presence of, one of the following indicators of infection: fever (temperature&gt;37.5 degrees C), a raised WBC count (&gt;9 billion/l), or crepitation at lung auscultation-were given antibiotics. In cases presenting with two or three of these indicators, 50-75% were given antibiotics. In 85% of the cases, penicillin or a macrolide was the initial antibiotic of choice. The median hospital stay was 6 days for the entire group of patients. CONCLUSION: These data suggest that, in patients with acute exacerbation of COPD, a relatively high number of patients with only weak symptoms or signs of bacterial infection are treated with antibiotics." }, { "id": "pubmed23n0399_3554", "title": "Cases from the medical grand rounds of the Osler Medical Service at Johns Hopkins University.", "score": 0.00909090909090909, "content": "A 77-year-old man was in good health until he complained of fatigue 3 weeks before presentation. Two weeks before admission, he developed gradually worsening shortness of breath. One week before admission, he developed a cough that initially was nonproductive but later was associated with hemoptysis.His past medical history was remarkable for a history of colon cancer (Dukes' stage III), for which he underwent a hemicolectomy and treatment with adjuvant chemotherapy in 1993. He had a myocardial infarction in 1986 and underwent coronary artery bypass surgery in 1999. He also had a history of hypertension, type 2 diabetes, and gout. He smoked in the past but had stopped more than 30 years ago.He was initially evaluated by his primary care physician, who noted that he complained of diaphoresis but denied fevers, chills, or contact with others who were ill. His physical examination was remarkable for bilateral crackles that were more pronounced on the right. A chest radiograph demonstrated bilateral pulmonary infiltrates (Figure 1). He was treated with amoxicillin. The next day, however, his physician noted that his dyspnea had worsened and that his oxygen saturation on room air was poor. He was therefore admitted for further evaluation. The amoxicillin was discontinued, and he was treated with levofloxacin, followed by ceftriaxone and azithromycin as his pulmonary status continued to deteriorate. He received intravenous diuretic agents, which failed to improve his respiratory status. During the initial phase of hospitalization, he was anemic, with a hematocrit of 21.3%. His serum creatinine level, which had been 1.0 mg/dL in 1999, was now 2.5 mg/dL. Urinalysis was remarkable for the presence of numerous red blood cells. His oxygen requirement increased, and he eventually required a 100% nonrebreather mask. A computed tomographic scan of the chest demonstrated prominent alveolar opacities throughout the right upper, middle, and lower lobes, with similar opacities in the left upper and left lower lobes (Figure 2). An echocardiogram showed an ejection fraction of 50%, as well as mild mitral regurgitation. Serologies were remarkable for an antinuclear antibody titer of 1:320 and a P-antineutrophil cytoplasmic antibody (P-ANCA) titer of greater than 1:320. C-ANCA was negative. Anti-glomerular basement membrane and anti-human immunodeficiency virus antibodies were undetectable." }, { "id": "pubmed23n0526_13710", "title": "[Clinical and radiological diagnosis of community-acquired pneumonia in adults].", "score": 0.00909090909090909, "content": "Community acquired pneumonia in adults is an acute disease characterized by worsening in general conditions, fever, chills, cough, mucopurulent sputum and dyspnea; associated with tachycardia, tachypnea, fever and focal signs in pulmonary examination. The probability of pneumonia in a patient with acute respiratory symptoms depends on the disease prevalence in the environment where it is acquired and on clinical features. It is estimated that pneumonia prevalence is 3-5% in patients with respiratory disease seen in outpatient facilities. Clinical diagnosis of pneumonia without radiological confirmation lacks specificity because clinical presentation (history and physical examination) does not allow to differentiate pneumonia from other acute respiratory diseases (upper respiratory infections, bronchitis, influenza). Diagnosis must be based in clinical-radiological findings: clinical history and physical examination suggest the presence of pulmonary infection but accurate diagnosis is established when chest X ray confirms the existence of pulmonary infiltrates. Clinical findings and chest X ray do not permit to predict with certainty the etiology of pulmonary infection. Radiology is useful to confirm clinical suspicion, it establishes pneumonia location, its extension and severity; furthermore, it allows differentiation between pneumonia and other diseases, to detect possible complications, and may be useful in follow up of high risk patients. The resolution of radiological infiltrates often ensues several weeks or months after clinical recovery, especially in the elderly and in multilobar pneumonia cared for in intensive care units." }, { "id": "pubmed23n0362_8157", "title": "[Levofloxacin-induced eosinophilic pneumonia complicated by bronchial asthma].", "score": 0.009009009009009009, "content": "A 76-year-old woman who had complained of cough and productive sputum since mid-January, 1999, was admitted to our hospital with fever and dyspnea on February 4, 1999. She had been treated with levofloxacin at an outpatient clinic. On admission, she had orthopnea, and auscultation revealed coarse crackles and wheeze in the bilateral lung fields. Chest x-ray and CT films showed non-segmental infiltration in bilateral lung fields. Laboratory data revealed eosinophilia in peripheral blood (= 24%) and sputum (= 10%), airflow limitation, hypoxemia (PaO2: 46 Torr), and increased airway responsiveness to methacholine (Dmin: 0.127 units). A bronchoalveolar lavage (BAL) fluid showed increased total cells and a 55% increase in eosinophils, and CD4/CD8 ratio was decreased to 0.8. In addition, IL-5 was increased in BAL fluid. Transbronchial lung biopsy specimens revealed infiltrations of eosinophils in the alveolar and interstitial compartments. Histological features of the bronchial biopsy specimens included increased eosinophils in the submucosa and goblet cell metaplasia. The woman was diagnosed with eosinophilic pneumonia complicated by bronchial asthma. She was given theophylline, pranlukast hydrate, and an inhaled beta 2 receptor agonist (procaterol hydrochloride), and pre-admission drugs including Levofloxacin were discontinued. Her symptoms were improved, peak expiratory flow rate and PaO2 increased, airway responsiveness to methacholine decreased (Dmin: 0.615 units), and radiographic abnormalities disappeared without steroid therapy. A leukocyte migration test for levofloxacin was weakly positive. An environmental provocation test in the patient's home gave negative results. A challenge test for levofloxacin was not performed due to a lack of informed consent. Based on these findings, we diagnosed this case as levofloxacin-induced lung injury manifesting as eosinophilic pneumonia complicated by bronchial asthma. Levofloxacin should be added to the list of agents that can produce eosinophilic pneumonia." }, { "id": "pubmed23n0824_2161", "title": "Clinical and Laboratory Findings in Patients With Acute Respiratory Symptoms That Suggest the Necessity of Chest X-ray for Community-Acquired Pneumonia.", "score": 0.009009009009009009, "content": "Pneumonia is a common illness in all parts of the world and is considered as a major cause of death among all age groups. Nevertheless, only about 5% of patients referring to their primary care physicians with acute respiratory symptoms will develop pneumonia. This study was performed to derive practical criteria for performing chest radiographs for the evaluation of community-acquired pneumonia (CAP). A total of 420 patients with acute respiratory symptoms and positive findings on chest radiograph were evaluated from December 2008 to December 2009. The subjects were referred to outpatient clinics or emergency departments of Birjand's medical university hospitals, Iran, and were enrolled as positive cases. A checklist was completed for each patient including their demographic information, clinical signs and symptoms (cough, sputum production, dyspnea, chest pain, fever, tachycardia, and tachypnea), abnormal findings in pulmonary auscultation and laboratory findings (erythrocyte sedimentation rate, C-reactive protein levels, and white blood cell count). An equal number of age-matched individuals with acute respiratory symptoms, but insignificant findings on chest radiography, were included as the control group. Finally, the diagnostic values of different findings were compared. The data showed that vital signs and physical examination findings are useful screening parameters for predicting chest radiograph findings in outpatient settings. Therefore, by implementing a prediction rule, we would be able to determine which patients would benefit from a chest X-Ray (sensitivity, 94% and specificity, 57%). This study's findings suggest that requesting chest radiographs might not be necessary in patients with acute respiratory symptoms unless the vital signs and/or physical examination findings are abnormal. Considering the 94% sensitivity of this rule for predicting CAP, a chest radiograph is required for patients with unreliable follow-ups or moderate to high likelihood of morbidity if CAP is not initially detected." }, { "id": "wiki20220301en021_58663", "title": "Chest pain", "score": 0.008992442306915087, "content": "Hospital care Hospital care of chest pain begins with initial survey of a person's vital signs, airway and breathing, and level of consciousness. This may also include attachment of ECG leads, cardiac monitors, intravenous lines and other medical devices depending on initial evaluation. After evaluation of a person's history, risk factors, physical examination, laboratory testing and imaging, management begins depending on suspected diagnoses. Depending upon the diagnosis, a person may be placed in the intensive care unit, admitted to the hospital, or be treated outpatient. For persons with suspected cardiac chest pain or acute coronary syndrome, or other emergent diagnoses such as pneumothorax, pulmonary embolism, or aortic dissection, admission to the hospital is most often recommended for further treatment." }, { "id": "pubmed23n1014_25586", "title": "<b>S</b>plenic vein thrombosis: rare cause of abdominal pain.", "score": 0.008928571428571428, "content": "-An 83-year-old woman with a history of hypertension, diabetes and paroxysmal atrial fibrillation anticoagulated with acenocoumarol was brought to the emergency department due to dyspnoea. At admission, the patient reported a 1-week history of malaise, shortness of breath and non-productive cough. She denied fever but reported pain on the left flank. On examination, auscultation showed arrhythmic tones and crackles in the left lower lung field. Laboratory findings showed leucocytosis of 15.32×10<sup3</sup/μL, and the C reactive protein was 177 mg/L. The activated partial thromboplastin time was 54.8 s, and the international normalised ratio was 7.09. A chest X-ray showed left lower lobe consolidation with pleural effusion. Point-of-care ultrasound was performed using a low-frequency curved transducer (2-5 MHz). The probe was placed in the left posterior axillary showing a pulmonary consolidation, but also a hypoechoic lesion in the spleen was found (figure 1).emermed;37/1/30/F1F1F1Figure 1Ultrasound image of the spleen in longitudinal section demonstrating a large, hypoechoic, wedge-shaped lesion. QUESTION: What is the most likely diagnosis?Splenic abscessSubcapsular splenic haematomaSplenic infarctionSplenic hydatid cyst <iFor answer see page 2</i." }, { "id": "pubmed23n0555_6682", "title": "[Critical evaluation and predictive value of clinical presentation in out-patients with acute community-acquired pneumonia].", "score": 0.008928571428571428, "content": "Diagnostic probability of community-acquired pneumonia (CAP) depends on data related to age and clinical and radiological findings. The critical evaluation of data in the literature leads to the following conclusions: 1) the prevalence of CAP in a given population with acute respiratory disease is 5% in outpatients and 10% in an emergency care unit. This could be as low as 2% in young people and even higher than 40% in hospitalized elderly patients; 2) the collection of clinical data is linked to the way the patient is examined and to the expertise of the clinician. The absolute lack of \"vital signs\" has a good negative predictive value in CAP; presence of unilateral crackles has a good positive predictive value; 3) there is a wide range of X-ray abnormalities: localized alveolar opacities; interstitial opacities, limited of diffused. The greatest radiological difficulties are encountered in old people with disorders including chronic respiratory or cardiac opacities and as a consequence of the high prevalence of bronchopneumonia episodes at this age; 4) among patients with lower respiratory tract (LRT) infections, the blood levels of leukocytes, CRP and procalcitonine are higher in CAP patients, mainly when their disease has a bacterial origin. Since you have not a threshold value reliably demonstrated in large populations with LRT infections or acute respiratory disease, presence or absence of these parameters could only be taken as a slight hint for a CAP diagnosis." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 119, 199 ] ], "word_ranges": [ [ 22, 34 ] ], "text": "(noninvasive ventilation is not indicated because it does not secure the airway)" }, "2": { "exist": true, "char_ranges": [ [ 1750, 1968 ] ], "word_ranges": [ [ 292, 327 ] ], "text": "However, in real life, the course of action will depend on the stability of the patient when we have applied the treatments indicated in option 2: adequate analgesia, oxygen therapy and initiation of blood transfusion." }, "3": { "exist": true, "char_ranges": [ [ 206, 307 ] ], "word_ranges": [ [ 36, 50 ] ], "text": "(observation in these cases, waiting for worsening, only leads to increased morbidity and mortality)." }, "4": { "exist": true, "char_ranges": [ [ 1969, 2299 ] ], "word_ranges": [ [ 327, 388 ] ], "text": "If by optimizing the patient we manage to stabilize him and assess that it is safe to transfer him, the performance of a body CT scan will define in much greater detail the lesions he has, and will help to ensure that the surgery he will probably end up undergoing will be a definitive surgery and not just damage control surgery." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Institute noninvasive mechanical ventilation and request blood transfusion.", "2": "Analgesia, oxygen therapy, request blood transfusion and indicate urgent surgery.", "3": "Orotracheal intubation, request blood transfusion and observation for, in case of worsening, indicate surgical intervention.", "4": "Orotracheal intubation and urgent CT scan for accurate assessment of lesions.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0753_3228", "title": "Case 1/2013: 69-year-old male patient with sudden back and lower right limb pain and shock.", "score": 0.018672919923571306, "content": "The patient, MSM, a 69-year-old man, sought medical care due to left dorsal and right lower limb pain. The chest x-ray showed mediastinal enlargement. He was undergoing examination when he lost consciousness and went into shock. Subcutaneous emphysema was observed in the left hemithorax, as well as abolition of breath sounds at auscultation. Tracheal intubation was performed with draining of blood-tinged fluid from the left hemithorax. Echocardiography showed left ventricle with 44/29 mm; septum, 12 mm; posterior wall, 13 mm; mild aortic root dilation, dissection of the lamina and periaortic hematoma. The valves and pericardium were normal. The patient was transferred to Instituto do Coraçao - InCor. Physical examination (21 Oct 2004: 10:45) showed that the patient was sedated with tracheal intubation, pale, heart rate at 90 bpm, blood pressure 130 x 80 mmHg, bloody drainage in the chest tube. Electrocardiogram - frequency 90 bpm, sinus rhythm, low voltage in the frontal plane and decreased voltage in left leads (Fig. 1). Computed tomography showed bilateral subcutaneous emphysema, thoracic aorta with inaccurate borders in its descending portion (from the subclavian artery to the middle portion), collapsed left lung and extensive collection of hematic characteristics in same hemithorax and middle and posterior mediastinum. Small right pneumothorax; small right pleural effusion with underlying parenchymal alterations. The analysis of the heart was impaired by the presence of hemothorax. While undergoing computed tomography, the patient showed no pulse, mydriasis, with asystole unresponsive to resuscitation and died (21 Oct 2011; 15:00 h)." }, { "id": "pubmed23n0303_20857", "title": "[A case report of spontaneous hemopneumothorax].", "score": 0.018362533692722373, "content": "A 55-year-old man was admitted to the private hospital with chief complaints of left chest pain and increasing dyspnea. Chest X ray on admission revealed a collapsed lung and an air fluid line in the left hemothorax. A chest tube drainage was carried out, but hemorrhagic pleural fluid of 1,000 ml was drainaged. So was the patient transferred to our hospital for surgical treatment. Following blood transfusion because of hemorrhagic pleural fluid of 1,500 ml, urgent surgery was carried out. At the operation under thoracoscope, the bleeding from the apex of the thoracic cavity was noted. The bleeding was controlled with endoscopic surgical clip. As it was, however, very difficult to remove massive blood clots under endoscopic surgery, a small thoracotomy was carried out in addition to the thoracoscopic surgery, then the bulla in the apex of left lung was resected and also removed a large amount of blood clots." }, { "id": "pubmed23n0307_22025", "title": "[Re-expansion pulmonary edema after emergency thoracotomy for spontaneous hemopneumothorax: a case report].", "score": 0.017427884615384616, "content": "A 44-year-old man was admitted to out hospital complaining of chest pain and increasing dyspnea. Chest X-ray on admission revealed a collapsed lung and an air fluid line in the left hemothorax. Following blood transfusion because of 2,000 ml hemorrhagic pleural fluid, emergent surgery was carried out. At operation, a bleeding artery originating from the apex of the thoracic cavity and a bulla on the upper lobe were noticed. After extubation of endotracheal tube, he offered severe dyspnea with hypoxia. The chest X-ray showed figure of pulmonary edema in the left lower lobe. Patient was managed by oxygen, steroid, and urinastatin. On the 3rd operative day, pulmonary edema was disappeared. It should be kept in the mind that the re-expansion pulmonary edema occurred in patients with spontaneous hemopneumothorax of less than 3 days of duration." }, { "id": "pubmed23n0273_4123", "title": "[Treatment of hemopneumothorax under thoracoscopic guidance: a case report].", "score": 0.016390179163901793, "content": "A 32-year-old man was admitted to our hospital complaining of chest pain and increasing dyspnea. Chest X-ray on admission revealed a collapsed lung and an air fluid line in the left hemithorax. Shock developed following drainage of 1,500 ml hemorrhagic pleural fluid. Following blood transfusion, emergency surgery was carried out. At operation under thoracoscopic guidance, a bleeding artery originating from the apex of the thoracic cavity and a bulla on the upper lobe were noted. The artery was successfully ligated with surgical clip, and the bulla was resected using EndoGIA. This case report indicates that hemopneumothorax can be safely operated on under thoracoscopic guidance after the patient has recovered from shock by adequate blood transfusion." }, { "id": "pubmed23n0410_15301", "title": "[Blood reflux through the catheter when trying catheterization of the subclavian vein is not a reliable sign in case of hemothorax].", "score": 0.015148247978436658, "content": "A 36-year-old man suffered chest and neurovascular trauma, soft-tissue injury to the left arm, and trauma to facial bones and extremities. He was hemodynamically unstable and responded poorly to blood transfusion and vasoactive medication. Pneumothorax was suspected. When a tube was inserted into the left hemithorax, 1500 mL of blood was drained. A chest film revealed hemothorax and a contusion on the left lung, but no rib fractures. An attempt to catheterize the left subclavian vein yielded reflux, and blood was then transfused. The patient continued to be highly unstable and an additional 1000 mL of blood was drained. Exploratory thoracotomy revealed a ruptured subclavian vein, location of the venous catheter in the pleural cavity, and a fracture of the first left rib. After chest injury leading to hemothorax, reflux upon catheterization of the ipsilateral subclavian vein is not a sure sign of correct tip placement. Additional means for checking placement, such as assessing pressure wave morphology, should be used. A fracture of the first rib, which may not be evident on a chest x-ray, often causes a vascular lesion and thoracic hemorrhage. Incorrect insertion of a subclavian catheter may then follow." }, { "id": "pubmed23n1102_8729", "title": "Right lung complete atelectasis: an endotracheal tube displacement complication.", "score": 0.014381635060339352, "content": "A 78-year-old, overweight woman with a severe individual history of the cardiovascular system was admitted in the intensive care unit with acute pulmonary edema. Despite appropriate emergency treatment, the patient did not show any clinical improvement and emergency intubation was decided. Post-intubation physical examination revealed dullness to percussion, absent breath sounds and reduced chest excursion of the right hemithorax combined with a gradual drop in blood pressure and oxygen saturation. An emergency chest X-ray showed opacification of the entire right lung and an ipsilateral shift of the mediastinum. Improvement of the patient's respiratory and hemodynamic status was observed immediately after the partial withdrawal of the tube. Tube displacement is a relative frequent complication and concerns mainly the right main bronchus due to anatomical procedures. However, the above case is a rare case of tube displacement in the left main bronchus, which led to total atelectasis of the rightlung." }, { "id": "pubmed23n1055_1198", "title": "[Experience on single-lung mechanical ventilation combined with damage control in treatment of patients with severe multiple trauma].", "score": 0.013100619454210614, "content": "On April 6, 2020, a case of severe crush injuries in head, neck, chest and right upper extremity was admitted to Qingzhou Hospital Affiliated to the First Medical University of Shandong Province. In addition to the crush injuries, the case also suffered from shock, crush syndrome, trauma-induced coagulopathy (TIC), and acute respiratory distress syndrome (ARDS). The female patient was 44 years old, and was admitted to the hospital at 07:00 on April 6, 2020 due to traffic accident with head, neck, chest, right upper limb injuries with disturbance of consciousness for 1 hour. Admission physical examination: body temperature was 35.6 centigrade. The patient was drowsy, with swelling and cyanosis around the right orbit and right cheek. The skin was severely abraded with blood seepage. The conjunctiva was pale. The lips were slightly cyanotic. The right chest collapsed and deformed with abnormal breathing. The skin of chest wall was blue and purple with extensive feeling of holding snow under the skin. The breath sound of right lung was low and dry and wet rales could be heard. Laboratory examination: routine blood test showed that white blood cell count (WBC) was normal, red blood cell count (RBC), hemoglobin (Hb) and platelet count (PLT) decreased, blood glucose increased; urine routine examination showed glucose +++, urine occult blood +++, urinary protein +++, visible transparent and granular tube type; coagulation indicators and blood biochemical examination were abnormal. Arterial blood gas analysis showed that pH and arterial partial pressure of oxygen (PaO<sub2</sub) decreased. X-ray showed comminuted fracture of distal humerus and proximal end of right ulna and radius with dislocation of right elbow joint. CT showed swelling of soft tissue around the right orbit and depressed fracture of inner wall. After admission, single-lung ventilation, tracheotomy and prone ventilation were applied to increase oxygenation level and relieving ARDS. Fluid of damage control for resuscitation was applied to reverse shock and blood transfusion was used to control hemorrhage and TIC. According to the patient's conditions and theory of damage control surgery, right chest drainage and amputation of the right upper extremity amputation were performed in time. Then, the resection in the middle and lower part of right lung, lung repairment, and internal rib fixation were performed. Finally, selective operation was performed to cover the open wound with healing dressing, using negative pressure for suction and carrying out \"stamp\" skin grafting on the right chest. After treatment, the patient was out of danger, and satisfactory clinical results were achieved in the end." }, { "id": "InternalMed_Harrison_20572", "title": "InternalMed_Harrison", "score": 0.01211548839719374, "content": "Difficulty in ventilation during resuscitation or high peak inspiratory pressures during mechanical ventilation strongly suggest the diagnosis. The diagnosis is made by physical examination showing an enlarged hemithorax with no breath sounds, hyperresonance to percussion, and shift of the mediastinum to the contralateral side. Tension pneumothorax must be treated as a medical emergency. If the tension in the pleural space is not relieved, the patient is likely to die from inadequate cardiac output or marked hypoxemia. A large-bore needle should be inserted into the pleural space through the second anterior intercostal space. If large amounts of gas escape from the needle after insertion, the diagnosis is confirmed. The needle should be left in place until a thoracostomy tube can be inserted." }, { "id": "First_Aid_Step2_1165", "title": "First_Aid_Step2", "score": 0.011570542162547045, "content": "If open pneumothorax is identified, an occlusive dressing must be applied immediately. This must be secured on three sides only to prevent the development of tension pneumothorax. Massive hemothorax is diagnosed through chest tube placement and is defined as > 1000 cc of immediate blood return or > 200/hour for > 2–4 hours. The treatment for massive hemothorax is volume resuscitation followed by surgery to repair the site of bleeding. The treatment for flail chest is supportive, followed by surgical fixation of the chest wall. Circulation: Apply direct pressure to any actively bleeding wounds. Place a 16-gauge IV in each antecubital fossa. Isotonic fluids (LR or NS) are repleted in a 3:1 ratio (fluid to blood loss). Start with a fluid bolus of 1–2 L in adults; then recheck vitals and continue repletion as indicated. If the patient remains tachycardic or hypotensive after the first 2 L of isotonic fluid, transfusion with packed RBCs may be indicated." }, { "id": "wiki20220301en056_29774", "title": "Hemothorax", "score": 0.01093278863923743, "content": "Ultrasound can detect blood in the pleural cavity. Blood in the thorax is shown by a uniform area without flocculation. Pleural effusions without blood are usually hypoechoic. Echogenicity is indicated by cellular debris and/or fibrin. Bloody pleural effusions are shows by a swirling, hyperechoic pattern. When a stethoscope is used (auscultation), the heartbeat sounds are faint. When percussion is performed, it produces a dull area. However, especially in traumatic cases, percussion may be painful. Although nonspecific, physical examinations may show reduced lung sounds and muffled, widespread heart sounds. Similar signs and symptoms may occur when other fluids are in the pleural cavity." }, { "id": "wiki20220301en009_161903", "title": "Emergency department", "score": 0.010191936970916101, "content": "Asthma and COPD Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive pulmonary disease (COPD), are assessed as emergencies and treated with oxygen therapy, bronchodilators, steroids or theophylline, have an urgent chest X-ray and arterial blood gases and are referred for intensive care if necessary. Noninvasive ventilation in the ED has reduced the requirement for tracheal intubation in many cases of severe exacerbations of COPD. Special facilities, training, and equipment An ED requires different equipment and different approaches than most other hospital divisions. Patients frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to work quickly and effectively even with minimal information." }, { "id": "wiki20220301en226_8878", "title": "Obstructive shock", "score": 0.010143304970891179, "content": "A chest X-ray can rapidly identify a pneumothorax, seen as absence of lung markings. Ultrasound can show the lack of lung sliding. However, imaging should not delay treatment. CT angiography is the standard of diagnosis of pulmonary embolism. Clots appear in the vasculature as filling defects. Treatment In any type of shock, rapid treatment is essential. Delays in therapy increase the risk of mortality. This is often done as diagnostic assessment is still occurring. Resuscitation addresses the ABC's - airway, breathing, and circulation. Supplemental oxygen is given, and intubation is performed if indicated. Intravenous fluids can increase blood pressure and maintain blood flow to organs." }, { "id": "pubmed23n0570_16784", "title": "[Diagnosis of pleurisy in an emergency setting].", "score": 0.009900990099009901, "content": "In a medical context, it is important to precise if the pleurisy is associated with signs of tamponnade, and/or clinical presentation of ominous organic distress (acute respiratory failure, septic, haemorragic, or cardiogenic shock) or pulmonary embolism. Presence of pleural tamponnade leads to immediate decompression pleural puncture which improves rapidly in general the clinical tolerance, and later permits etiologic treatment. In more severe conditions, pleural evacuation is done in parallel with cardiopulmonary resuscitation maneuvers. If hydropneumothorax is present, immediate drainage with a chest tube will be performed. In other situations, the presence of an abundant pleural effusion with clear fluid necessitates partial needle evacuation to authorize secondarily complementary investigations with pleural biopsy. If purulent pleurisy is discovered, immediate evacuation of pus is mandatory, with needle pleural lavage or chest tube. In all cases, the pleural fluid requires complete haematological, biochemical, and cytologic as well as bacteriological analysis. In the surgical emergency ward, if an opened wound is discovered (gun shot, blunt object or weapon), cardiocirculatory resuscitation is often mandatory, with immediate transfer to the operation ward for an exploratory thoracotomy. If a closed thoracic trauma is present, the problem is generally the management of an hemo(pneumo)thorax with chest tube drainage leading sometimes if the pleural bleeding persists to thoracotomy." }, { "id": "pubmed23n0941_15930", "title": "Report of a lung carcinoma extended to the left atrium through pulmonary vein.", "score": 0.00980392156862745, "content": "Lung cancers may extend along or grow through the pulmonary veins to invade or lie within the left atrium (LA). A 62-year-old man, previously healthy, presented with 1-month ventilatory-independent right hemithorax back pain, dry cough and large effort dyspnea. He also referred weight loss of 12 kg in 10 months and denied hemoptysis. As antecedents, he smoked for 40 years and moderate daily alcoholism. On physical examination, the patient was in good general condition, hydrated and regular respiration at rest [blood pressure (BP) =120/80 mmHg; heart rate (HR) =90 bpm; respiratory rate (RR) =16 rpm]. Cardiac auscultation revealed two standard rhythmic sounds without murmurs. Pulmonary auscultation revealed a slightly diminished vesicular murmur in the lower 1/3 of the right hemithorax without adventitious noises. Chest radiography showed a mass over the right lower lung. A CT scan confirmed the radiography image with the mass extending along the right inferior pulmonary vein and a tumor in the LA. Transthoracic and transesophageal echocardiography revealed large mass within the LA (occupying almost the entire cavity), measuring about 10 cm × 3 cm at its largest diameter, prolapsing into the left ventricle. Bronchoscopy, head CT scan, and whole-body bone scintigraphy investigation did not show any distant metastasis. The patient was successfully operated removing the intracardiac and inferior pulmonary vein tumor with the aid of cardiopulmonary bypass, followed by a right inferior lobectomy carried out after 25 days. After 30 days from surgery presented seizures associated a brain metastasis evidenced by CT when adjuvant radio and chemotherapy was started. During the next 90 days, the clinical conditions worsened, and the patient died 4 months after the surgical treatment. The case report has two primary justifications, even considering the poor outcome: (I) rarity and (II) the possibility of the surgical treatment." }, { "id": "pubmed23n0074_18196", "title": "[Peroperative pneumothorax in thoracotomy: the value of pulse oximetry].", "score": 0.00980392156862745, "content": "Two cases of pneumothorax occurring during thoracotomy under one-lung ventilation are reported. One case occurred before pneumonectomy was carried out. The decrease in Spo2 shown by pulse oximetry, together with the increase in airway pressures, rapidly led to the diagnosis of pneumothorax. In the other case, the accident occurred after pneumonectomy, with a suddenly impossible ventilation, and a drastic decrease in Spo2 leading to hypoxic circulatory arrest. Hypoxaemia occurring during one-lung ventilation may be due to different causes. Shunting in the upper part of the lung is the main cause, but other diagnoses must be discussed, such as airway obstruction by blood or sputum, displacement of the selective endotracheal tube, bronchospasm, and pneumothorax. Monitoring of Spo2 by pulse oximetry would therefore seem to be mandatory during thoracic surgery, in order to allow an early diagnosis of hypoxaemia and speed up the treatment of its cause." }, { "id": "pubmed23n0482_11991", "title": "An open question.", "score": 0.009787030390045467, "content": "The lungs are surrounded by the pleural membranes. The visceral pleura directly covers the lung and is separated from the parietal pleura by a layer of surfactant, which reduces friction during respiratory movement. A potential space exists between these two layers, and they may become separated by fluid or air. A lung can collapse to the size of a fist under pressure from either. Standard treatment in the field for an open chest wound is an occlusive dressing. The first thing that can be used to occlude the wound is a gloved hand. After placing the dressing, evaluate the breath sounds and determine if they have improved. The dressing should be taped down on three sides, leaving one side open to relieve the pressure during exhalation (one-way valve). \"Burping\" the dressing involves lifting one side to make sure any pressure buildup is relieved, as occasionally the dressing can become adhered to the skin, which may lead to a tension pneumothorax. If, after ensuring the occlusive dressing is properly in place, the respiratory rate increases, distress level worsens, oxygen saturations fall and breath sounds decrease, then needle decompression is required. A neurovascular bundle is located underneath each rib, and it is important to avoid damage to that bundle by performing a decompression over the top of a rib. If the patient is intubated before the development of a tension pneumothorax, carefully evaluate the breath sounds (especially if the left-side sounds are diminished) to determine if the ET tube needs to be withdrawn a centimeter. The rescuer performing ventilation will usually recognize a tension pneumothorax by the difficulty in bagging the patient. Remember, when you perform a needle thoracentesis, you are creating an open chest wound. Early signs and symptoms of a tension pneumothorax include diminished or absent breath sounds, severe dyspnea, narrowing pulse pressure, tachycardia and restlessness. Neck veins may be distended, but this can be a normal finding in a supine patient. The classic sign is a deviated trachea; the trachea shifts toward the \"good\" lung as the buildup of pressure collapses the \"bad\" lung. This is a late sign and suggests the tension pneumothorax has been developing for some time. One sign that does not normally accompany a plain pneumothorax is hypotension. In this case, the persistent low BP, combined with cool, mottled skin and a delayed capillary refill time, led providers to suspect that a hemothorax was developing as well. With endotracheal intubation and pleural decompression, the positive-pressure ventilations allowed the affected right lung to inflate more fully, utilize more of the available alveolar space and \"bag out\" some of the blood pooling at the base. The patient's vital signs and saturation improved. He needed surgical treatment and removal of the blood in the pleural space before ventilation and oxygenation could normalize." }, { "id": "pubmed23n0298_20190", "title": "[The effect of performance of diagnostic and therapeutic procedures on successful treatment of hemopneumothorax in isolated thoracic trauma].", "score": 0.009708737864077669, "content": "Influence of performed diagnostic and therapeutic procedures on the outcome of the treatment of traumatic hemopneumothorax during isolated chest trauma. The aim of this study is the assessment of the influence of performed diagnostic and therapeutic procedures on the outcome of hemopneumothorax as a part of isolated chest trauma. The main group consists of 51 patients with hemopneumothorax. Patients with pneumothorax without effusion represent the first control group; the second control group consist of patients treated because of iatrogenic pneumothorax. In the main and control groups the analysis of clinical, roentgenographic and functional parameters was made, together with the analysis of particular therapeutic procedures, the estimation of the success of the treatment was based on roentgenographic and functional parameters. The higher incidence of hemopneumothorax compared with control groups during chest trauma in the analyzed material is statistically significant. The occurrence of bilateral hemopneumothorax in 10% of cases emphasizes the need of adequate roentgenographic assessment of injured patients. Regardless of the intensity of the trauma, symptoms do not always indicate the existence of hemopneumothorax. The number of fractured ribs is not of significant importance in terms of the occurrence of hemopneumothorax or pneumothorax. Severe dyspnea can be accompanied even with a smaller collapse of the lung independently of the amount of blood in the pleural cavity. Oxygenation in the arterial blood is impaired with the great and small pulmonary collapse. Hemodynamic disorders existed in 14% all cases. The higher frequency of operative treatment in the main group is statistically significant. The majority of cases of traumatic hemopneumothorax can be successfully treated by the conservative treatment. Accompanying complications do not have greater influence on the outcome." }, { "id": "wiki20220301en200_20677", "title": "Acute chest syndrome", "score": 0.009615384615384616, "content": "Diagnosis The diagnosis of acute chest syndrome is made difficult by its similarity in presentation with pneumonia. Both may present with a new opacification of the lung on chest x-ray. The presence of fevers, low oxygen levels in the blood, increased respiratory rate, chest pain, and cough are also common in acute chest syndrome. Diagnostic workup includes chest x-ray, complete cell count, reticulocyte count, ECG, and blood and sputum cultures. Patients may also require additional blood tests or imaging (e.g. a CT scan) to exclude a heart attack or other pulmonary pathology. Prevention Hydroxyurea is a medication that can help to prevent acute chest syndrome. It may cause a low white blood cell count, which can predispose the person to some types of infection. Treatment Broad spectrum antibiotics to cover common infections such as Streptococcus pneumoniae and mycoplasma, pain control, and blood transfusion. Acute chest syndrome is an indication for exchange transfusion." }, { "id": "pubmed23n0589_512", "title": "Explosive pleuritis.", "score": 0.009523809523809525, "content": "The objective of the present paper is to describe the clinical and computed tomography features of 'explosive pleuritis', an entity first named by Braman and Donat in 1986, and to propose a case definition. A case report of a previously healthy, 45-year-old man admitted to hospital with acute onset pleuritic chest pain is presented. The patient arrived at the emergency room at 15:00 in mild respiratory distress; the initial chest x-ray revealed a small right lower lobe effusion. The subsequent clinical course in hospital was dramatic. Within 18 h of admission, he developed severe respiratory distress with oxygen desaturation to 83% on room air and dullness of the right lung field. A repeat chest x-ray, taken the morning after admission, revealed complete opacification of the right hemithorax. A computed tomography scan of the thorax demonstrated a massive pleural effusion with compression of pulmonary tissue and mediastinal shift. Pleural fluid biochemical analysis revealed the following concentrations: glucose 3.5 mmol/L, lactate dehydrogenase 1550 U/L, protein 56.98 g/L, amylase 68 U/L and white blood cell count 600 cells/mL. The pleural fluid cultures demonstrated light growth of coagulase-negative staphylococcus and viridans streptococcus, and very light growth of Candida albicans. Cytology was negative for malignant cells. Thoracotomy was performed, which demonstrated a loculated parapneumonic effusion that required decortication. The patient responded favourably to the empirical administration of intravenous levofloxacin and ceftriaxone, and conservative surgical methods in the management of the empyema. This report also discusses the patient's rapidly progressing pleural effusion and offers a potential case definition for explosive pleuritis. Explosive pleuritis is a medical emergency defined by the rapid development of a pleural effusion involving more than 90% of the hemithorax over 24 h, which causes compression of pulmonary tissue and mediastinal shift to the contralateral side." }, { "id": "pubmed23n0752_22359", "title": "Emergency thoracotomies: Two center study.", "score": 0.009523809523809525, "content": "Emergency thoracotomy is performed either immediately at the scene of injury, in the emergency department or in the operating room. It aims to evacuate the pericardial tamponade, control the haemorrhage, to ease the open cardiac massage and to cross-clamp the descending thoracic aorta to redistribute blood flow and maybe to limit sub-diaphragmatic haemorrhage, bleeding and iatrogenic injury are the common risk factors. We aimed to review our experience in the field of emergency thoracotomies, identify the predictors of death, analyze the early results, detect the risk factors and asses the mortalities and their risk factors. Our hospital records of 197 patients who underwent emergency thoracotomy were reviewed. We retrospectively analyzed a piece of the extensive experience of the Mansoura University Hospitals and Mansoura Emergency Hospital; Egypt and Saudi German Hospitals; Jeddah in the last 12 years in the management of trauma cases for whom emergency thoracotomy. The aim was to analyse the early results of such cases and to detect the risk factors of dismal prognosis. Our series included 197 cases of emergency thoractomies in Mansoura; Egypt and SGH; Jeddah; KSA in the last 12 years. The mean age of the victims was 28 years and ranged between 5 and 62 years. Of the 197 patients with emergency thoracotomy, the indications were both penetrating and blunt chest trauma, iatrogenic and postoperative hemodynamito a surgical cause. The commonest indication was stab heart followed by traumatic diaphragmatic ruptures. The results of emergency thoracotomy in our series were cooping with the results of other reports, mainly due to our aggressive measures to achieve rapid stabilization of the hemodynamic condition. We emphasize the importance of emergency medicine education programs on rapid diagnosis of traumatic injuries with early intervention, and adequate hemodynamic and respiratory support. Emergency thoracotomy has an important role in emergency big volume hospitals and can save a lot of lives. Outcome can be improved by increasing the learning curve and the integrated cooperation of the emergency and surgical teams." }, { "id": "wiki20220301en227_13415", "title": "Transfusion associated circulatory overload", "score": 0.009498612074947952, "content": "The management of TACO includes immediate discontinuation of the transfusion, supplemental oxygen if needed, and medication to remove excess fluid. Symptoms and signs The primary symptoms of TACO are signs of respiratory distress (shortness of breath, low oxygen levels in the blood) along with signs of excess fluid within the circulatory system (leg swelling, high blood pressure, and an elevated heart rate). On physical exam, patients may present with crackles when listening to the lungs, a murmur (S-3 murmur) when listening to the heart, leg swelling, and distended veins in the neck (jugular venous distension)." }, { "id": "wiki20220301en091_17682", "title": "Transfusion-related acute lung injury", "score": 0.009434598018734416, "content": "Transfusion-related acute lung injury (TRALI) is the serious complication of transfusion of blood products that is characterized by the rapid onset of excess fluid in the lungs. It can cause dangerous drops in the supply of oxygen to body tissues. Although changes in transfusion practices have reduced the incidence of TRALI, it was the leading cause of transfusion-related deaths in the United States from fiscal year 2008 through fiscal year 2012. Signs and symptoms It is often impossible to distinguish TRALI from acute respiratory distress syndrome (ARDS). The typical presentation of TRALI is the sudden development of shortness of breath, severe hypoxemia (O2 saturation <90% in room air), low blood pressure, and fever that develop within 6 hours after transfusion and usually resolve with supportive care within 48 to 96 hours. Although low blood pressure is considered one of the important signs for diagnosing TRALI, in some cases high blood pressure can occur." }, { "id": "pubmed23n0920_9330", "title": "Dabigatran-Induced Massive Spontaneous Hemothorax.", "score": 0.009345794392523364, "content": "Spontaneous hemothorax due to anticoagulant use is extremely rare in clinical practice. Dabigatran is a novel anticoagulant to prevent stroke or thromboembolic episodes in patients with nonvalvular atrial fibrillation. We report on an 83-year-old man who received dabigatran therapy (110 mg twice daily) for 7 months and developed massive spontaneous hemothorax and acute renal failure. The patient was admitted to the hospital with complaint of a dull ache in the chest and dyspnea. Chest computed tomography scan revealed massive pleural effusion in the left hemithorax with atelectasis. Acute renal failure was observed 4 days later after admission. Almost 2500 mL of blood was repeatedly drained by ultrasound-guided thoracocentesis, followed by a dramatic decrease in serum red blood cell count, hemoglobin and hematocrit. After excluding other possible causes, diagnostic withdrawal was performed for dabigatran, and plasma transfusion was conducted to supply the lost blood volume. A causal relationship was established, because the patient's renal function gradually improved and no further pleural effusion developed after dabigatran was discontinued. This is a rare case report of massive spontaneous hemothorax caused by dabigatran. Therefore, practitioners should be aware of hemothorax as a potential complication of dabigatran therapy." }, { "id": "pubmed23n0253_9914", "title": "[A case of spontaneous hemopneumothorax occurred after thoracocentesis].", "score": 0.009345794392523364, "content": "A 41-year-old man was admitted to our hospital complaining of severe right chest pain and dyspnea. Soon after, right thoracocentesis was done and pleural free air was aspirated. Twenty minutes later he fell into a shock status. Chest roentgenogram showed massive right pleural fluid collection. Chest drainage revealed that massive bleeding continued. Therefore, emergent thoracotomy was performed. Bleeding point was a ruptured stump of pleural adhesion of the apical parietal pleura. His postoperative course was almost good, and discharged on the tenth postoperative day. Careful observation after thoracic aspiration is necessary in the treatment of spontaneous pneumothorax." }, { "id": "pubmed23n0755_5702", "title": "Multiloculated pleural effusion detected by ultrasound only in a critically-ill patient.", "score": 0.009259259259259259, "content": "Multiloculated pleural effusion is a life-threatening condition that needs early recognition. Drainage by chest tube might be difficult which necessitates a surgical intervention. While x-ray typically does not show loculations, CT scan might not also identify the loculations. Ultrasound has a high sensitivity in detecting pleural diseases including multiloculated pleural effusion. A 55-year-old female presented with dyspnea, cough and yellowish sputum for 3 days. Her heart rate was 136 bpm ,O2 saturation 88%, and WBC 21,000/mcL. Chest x-ray showed complete opacification of right lung. A chest tube insertion was unsuccessful. CT scan of the chest showed large pleural effusion occupying the right hemithorax with collapse of the right lung. Bedside ultra-sound showed a multiloculated pleural effusion with septations of different thickness. The patient subsequently underwent thoracotomy which showed multiple, fluid-filled loculations with significant adhesions. The loculations were dissected along with decortications of thick a pleural rind. Blood and pleural fluid cultures grew Streptococcus pneumoniae and the patient was treated successfully with Penicillin G. We advocate bedside ultrasound in patients with complete or near complete opacification of a hemithorax on chest x-ray. CT scan is less likely to show septations within pleural effusions compared to ultrasounnd. Therefore, CT scan and ultrasound are complementary for the diagnosis of empyema and multiloculated pleural effusion." }, { "id": "pubmed23n1155_22131", "title": "[Hemothorax].", "score": 0.009259259259259259, "content": "Hemothorax is defined as blood accumulation in the pleural cavity with a hematocrit value of the effusion exceeding 50%. Symptoms and severity vary, ranging from asymptomatic to an imminent state of threatened cardiac arrest. This paper presents the etiology, initial work-up, and treatment of hemothorax, with an emphasis on massive hemothorax requiring an emergent thoracotomy for hemostasis. The etiology of hemothorax can be traumatic, iatrogenic, and non-traumatic/non-iatrogenic. Regardless of the etiology, the initial medical examination should be performed as in the initial trauma examination to evaluate the urgency, the amount of bleeding in the chest cavity, and the coexistence of pneumothorax. If massive hemothorax or tension pneumothorax is present, thoracic tube drainage should be started immediately. Contrast-enhanced computed tomography (CT) should be performed to identify the source of bleeding. Treatment includes fluid and blood transfusions to stabilize the circulation. Anticoagulants and antiplatelet agents should be neutralized, reduced, or withdrawn. Emergent thoracotomy for hemostasis is indicated for massive hemothorax with unstable circulation. Anterior-parasternal thoracotomy performed in the supine position has the advantage of rapid thoracotomy and good visualization. Endovascular therapy is effective when contrast-enhanced CT identifies the source of bleeding." }, { "id": "pubmed23n0642_18492", "title": "[Diagnosis and treatment of parapneumonic effusions--case 10/2009].", "score": 0.009174311926605505, "content": "We report on a 47-year-old male patient who was admitted for exercise-induced dyspnea and easy fatigability. Physical examination revealed reduced breath and percussion sounds of the left basal lung. Laboratory investigations revealed leucocytosis and elevated C-reactive protein levels. Chest X-ray showed an area of increased opacity of the left lower hemithorax. Computed tomography (CT) confirmed an encapsulated, septated pleural effusion. The aspirate was purulent with abundant neutrophil granulocytes and a pH value of 7.1. A diagnosis of left-sided pleural empyema was made, most probably following pneumonia. Antibiotic treatment with amoxicillin and clavulan acid was initiated and after insertion of a chest drain pleural irrigation with daily 200,000 I.U. streptokinase was performed for five days. The drainage was removed after ten days and after four months CT showed a complete remission of the lef-sided pleural empyema. Parapneumonic effusions are frequent with broad clinical range from trivial to life-threatening. Therapy decision is based on the characteristics of the effusion and the patient's clinical status and should be made within an interdisciplinary cooperation between internists and (thoracic) surgeons." }, { "id": "pubmed23n0602_20133", "title": "[Treatment indication with endothoracic drainage tube in parapneumonic effusions by partial pressure of carbon dioxide measurement in pleural fluid].", "score": 0.00909090909090909, "content": "Parapneumonic effusions with pH &lt; 7.20 or glucose &lt; 0.40 g/l or lactate dehydrogenase (LDH) &gt; 1000 U/l have indication of treatment with endothoracic drainage tube (EDT). The aim of the present study was to determine the accuracy of partial pressure of carbon dioxide (pCO2) measurement in pleural fluid for the subsequent treatment indication with EDT in parapneumonic effusions, by analyzing the area under curve ROC (AUC) and determining the optimal cut off value. 207 pleural fluids were studied. Glucose, LDH, pCO2, and pH were measured, and data concerning the etiology of pleural effusion and whether EDT treatment was needed were collected after patients were discharged from hospital. Forty-six out of 207 pleural fluids studied were parapneumonic effusions. Thirty-two were treated with EDT. AUC values were 0.888 (p &lt; 0.0001), 0.890 (p &lt; 0.0001), 0.816 (p &lt; 0.0001), and 0.801 (p &lt; 0.0001) for pCO2, pH, glucose, and LDH, respectively. No significant differences were found among them. Optimal cut off value for pCO2 was 48.6 mmHg, exhibiting 90.6% sensitivity and 78.6% specificity. All parapneumonic effusions showing pCO2 &gt; 60.9 mmHg were treated with EDT. Remarkably, 3 out of 46 parapneumonic effusions (6.5%) that had been improperly treated following pH, glucose or LDH values, were correctly treated following pCO2. pCO2 determination in pleural fluid appears to be the best way to decide the indication of EDT in parapneumonic effusions." }, { "id": "pubmed23n1161_2681", "title": "A large pericardial cystic lymphangioma presenting as acute-onset respiratory distress in a child: a case report.", "score": 0.009009009009009009, "content": "Lymphangiomas are rare benign malformations of the lymphatics that occur due to blockage of the lymphatic system during fetal development. They commonly occur in the neck and axilla, while involvement of the pericardium is rare. We report herein the case of a 16-month-old Sri Lankan child with a large pericardial cystic lymphangioma presenting with sudden-onset shortness of breath. A 16-month-old Sri Lankan boy presented with sudden-onset dyspnea for 1-day duration following a febrile illness that lasted 2 days. On examination, he was afebrile and had subcostal, intercostal, and suprasternal recessions, with a respiratory rate of 50 breaths per minute. He had a loud expiratory grunt. The chest expansion was reduced on the right side, which was dull to percussion. Auscultation revealed a marked reduction of air entry over the right lower and mid zones. Chest X-ray showed a well-demarcated opacity involving the lower and mid zones of the right hemithorax associated with a tracheal shift to the opposite side. Ultrasound scan of the chest revealed fluid-filled right hemithorax suggesting a septate pleural effusion. A contrast-enhanced computed tomography scan of the thorax showed a large multiloculated extrapulmonary cystic lesion involving the right hemithorax with a mediastinal shift towards the left side associated with displacement of the right-side mediastinal structures. He underwent mini-thoracotomy and surgical excision of the cyst. A large cyst originating from the pericardium was observed and excised during surgery. Histological examination revealed a lesion composed of cysts devoid of a lining epithelium but separated by connective tissue, mature adipose tissue, and lymphoid aggregates. The child showed complete recovery postoperatively with full expansion of the ipsilateral lung. We report the case of a patient with cystic lymphangioma who was perfectly well and asymptomatic until 16 months of age. This case report presents the very rare occurrence of a large cystic lymphangioma originating from the pericardium. It highlights the importance of considering rare possibilities and performing prompt imaging in situations of diagnostic uncertainty to arrive at an accurate diagnosis that can be lifesaving." }, { "id": "pubmed23n1029_22119", "title": "Airway obstruction during pneumonectomy using a single lumen tube: A case report.", "score": 0.009009009009009009, "content": "Endotracheal intubation is an essential step for airway management during general anesthesia. When surgeons carry out thoracic surgery such as pneumonectomy, they usually request lung isolation to secure a clear surgical view. A double lumen endotracheal tube is used for lung isolation in routine thoracic surgeries. A 56-year-old man was previously diagnosed with left Aspergilloma, a tuberculosis destroyed lung, and diabetes mellitus. According to his chest x-ray and chest computed tomography, his left lung was nearly collapsed, and the result of a pulmonary function test was severely restricted. The patient's diffusing capacity for carbon monoxide was 63% and predicted postoperative forced expiratory volume in 1 second was 23.5% DIAGNOSES:: Due to his previous history, radiologic findings and laboratory test results, he was diagnosed with left Aspergilloma and tuberculosis destroyed lung. Due to recurrence of Aspergilloma in his left lung, the patient was scheduled for a left pneumonectomy. Since the patient's partial oxygen concentration was adequate despite his left lung being nearly totally collapsed, we thought that we would be capable of performing the pneumonectomy using a single lumen tube (SLT). For a better surgical view, we planned lung isolation via insertion of a SLT deep into the bronchus. During pneumonectomy, after tracheal suction was performed, we tried a lung recruitment maneuver. Suddenly end-tidal carbon dioxide did not show on the monitor. The patient's blood pressure dropped and heart rate was decreasing. We thought that cardiopulmonary resuscitation was needed and an approximately 2 cm sized hematoma was removed from the endotracheal tube after vigorous suctioning. After getting rid of the hematoma, we changed the single tube to a double lumen tube (DLT). This case led us to the conclusion that a DLT should be used for safety when carrying out thoracic surgery. We report a rare case of an airway obstruction using a SLT during pneumonectomy." }, { "id": "pubmed23n0728_8490", "title": "Spontaneous haemopneumothorax.", "score": 0.008928571428571428, "content": "An 18-year-old man presented with a 2 day history of breathlessness and left-sided chest pain, with no preceding trauma. He had no medical history of note, and had never smoked. He was in hypovolaemic shock, with Hb of 8.1 g/dl, and received fluid resuscitation. Chest x-ray (CXR) revealed left-sided hydropneumothorax, with the effusion of blood-consistency on CT thorax. Tube thoracostomy drained 1.7 litres of blood immediately. He remained haemodynamically stable after 4 units of blood transfusion on the first day with post-transfusion Hb 11 g/dl. Following cardiothoracic surgeon advice, tube was removed on day 5 draining total of 3.5 litres, with good response clinically and radiologically. Patient was well when followed up at 1 week after hospital discharge, with no recurrence and complete re-expansion of left lung on CXR." }, { "id": "pubmed23n0629_23361", "title": "[Anesthesia in obstetric patient with sickle cell anemia and thalassemic trait after plasmapheresis: case report].", "score": 0.008849557522123894, "content": "Plasmapheresis is the technique of choice for severe hemolytic anemia patients. A consequence is plasma cholinesterase depletion, which interferes with metabolism of some neuromuscular blockers currently used in anesthesiology. Pregnant patient, 26 years old, physical status ASA IV, 30 weeks and 3 days gestational age, with sickle cell anemia, thalassemic trait and allo-immunization for high frequency antigens. Patient presented sickling crisis being transfused with incompatible blood. Patient evolved with massive hemolysis being admitted with 3 g/dL hemoglobin and 10% hematocrit, severe jaundice, tachycardia, apathic and pale. Hematological evaluation has concluded for the inexistence of compatible blood for transfusion. Patient was treated with steroids, immunoglobulins and plasmapheresis. In the second admission day patient evolved with acute renal failure and pulmonary edema, general state worsening and hemodynamic instability. Gestation resolution was indicated due to patient's clinical conditions and consequent acute fetal suffering. Patient was admitted to the operating room conscious, pale, with dyspnea, jaundice, 91% SpO2 in room air, heart rate of 110 bpm and blood pressure of 110 x 70 mmHg, under dopamine (1 microg.kg-1.min-1) and dobutamine (10 microg.kg-1.min-1). We decided for balanced general anesthesia with alfentanil (2.5 mg), etomidate (14 mg), atracurium (35 mg) and isoflurane. There were no anesthetic-surgical intercurrences. Patient was referred to ICU after surgery completion under tracheal intubation and vasoactive drugs, being extubated 3 hours later. This case was a challenge for the team since patient was hemodynamically instable with coagulogram abnormalities counterindicating regional anesthesia. In addition, plasmapheresis potentially depletes plasma cholinesterase reserves, interfering with anesthesia. However, available drug armamentarium has allowed for the safe management of this situation." } ] } } }

{ "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, 129 ] ], "word_ranges": [ [ 0, 21 ] ], "text": "She is going to have myeloma. For diagnosis, a sample (bone marrow) and electrophoresis to determine the type of monoclonal peak." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Radiological bone series and bone marrow aspirate.", "2": "Serum and urine electrophoresis and renal function tests.", "3": "Bone marrow aspirate and serum calcium concentration.", "4": "Bone marrow aspirate and serum and urine electrophoresis.", "5": "Biopsy of the pathological fracture and radiological bone series." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0971_4377", "title": "Approach to the treatment of the older, unfit patient with myeloma from diagnosis to relapse: perspectives of a US hematologist and a geriatric hematologist.", "score": 0.01778827233372688, "content": "Mrs. A. is a 73-year-old woman who has developed increasing fatigue and lower back pain over the past year. The pain limits her exercise tolerance such that she can now walk only 1 block. She is a retired schoolteacher who does volunteer efforts in her community but has limited her activities due to fatigue. Karnofsky performance status is 70%. She has a history of chronic hypertension treated with a diuretic, adult-onset diabetes mellitus treated with metformin, and hypothyroidism treated with levothyroxine. Initial evaluation reveals anemia, renal dysfunction, an elevated total protein, and an L2 compression fracture on lumbosacral radiographs. Results of initial and subsequent evaluation are shown below, and she is referred to a hematologist for further evaluation, which revealed the following: calcium 9.0 mg/dL, creatinine 3.2 mg/dL with estimated creatinine clearance using the Modification of Diet in Renal Disease equation of 15 mL/min, hemoglobin 9.6 g/dL, total protein 11 g/dL, albumin 3.2 g/dL, immunoglobulin A (IgA) λ M protein 6.8 g/dL, total IgA 7.2 g/dL, IgG 0.4g/dL, IgM 0.03 g/dL, free κ &lt;0.01 mg/L, free λ 1000 mg/L, serum free light chain ratio &lt;0.01, β-2-microglobulin 4.2, viscosity 3.0, lactate dehydrogenase 200 U/L, urine protein electrophoresis: 125 mg/dL with 30% M protein, and urine immunofixation: λ light chain. Skeletal bone survey showed lytic lesions in femurs and humeri and diffusely in ribs bilaterally as well as compression fractures at T4, T6, and L2. Bone marrow biopsy revealed λ-restricted plasma cells comprising 50% of the bone marrow core. Fluorescence in situ hybridization testing on marrow showed that del 17p was present in 80% of the plasma cells. Mrs. A. is informed of the diagnosis of multiple myeloma and the need for therapy. She requests consultation with 2 of the leading world experts. However, she wants to be treated near her home and does not want treatment on a clinical trial." }, { "id": "pubmed23n0949_7506", "title": "Treatment of Relapsed Myeloma in a Patient With Renal Insufficiency.", "score": 0.017252918866661707, "content": "The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 45-year-old man was diagnosed in March 2010 with stage III immunoglobulin G kappa multiple myeloma (MM) after presenting with bone pain as a result of multiple lytic bone lesions and T12 vertebral collapse. Laboratory work-up showed a serum M protein of 72 g/L and a 24-hour kappa light-chain urine protein excretion of 730 mg, hemoglobin of 10.2 g/dL, serum albumin of 49 g/L, serum β<sub2</sub-microglobulin of 6.4 mg/L, serum creatinine level of 1.6 mg/dL with an estimated glomerular filtration rate (eGFR) of 47 mL/min/1.73 m<sup2</sup, and normal serum calcium and lactate dehydrogenase (LDH) levels. His bone marrow contained 58% plasma cells, which showed the 17p deletion abnormality (Fig 1). He was treated with vertebroplasty and alternating chemotherapy with carmustine, vincristine, cyclophosphamide, melphalan, and prednisone and vincristine, carmustine, doxorubicin and dexamethasone. Because of progressive disease, salvage therapy with bortezomib and dexamethasone was administered with no response. The patient was then switched to lenalidomide and dexamethasone, which yielded minimal response. He underwent autologous stem-cell transplantation (ASCT) with melphalan 200 mg/m<sup2</sup as high-dose therapy in February 2011, which led to a partial response, but in December 2011, progressive disease was documented, and the patient was enrolled in a clinical trial of carfilzomib monotherapy, with stable disease for 33 cycles. In October 2014 serum M protein rose to 38.6 g/L, with 24-hour kappa light-chain urine protein excretion of 840 mg, serum creatinine of 2.1 mg/dL, and an eGFR of 41 mL/min/1.73 m<sup2</sup. He presented to discuss ongoing treatment options." }, { "id": "pubmed23n0361_11979", "title": "Biclonal gammopathy in multiple myeloma: a case report.", "score": 0.017095234703326447, "content": "Monoclonal gammopathy is a group of B-cell disorders which result in the production of a specific and unique monoclonal immunoglobulin (M-component). Biclonal gammopathy is characterized by the simultaneous appearance of two different M-components. The incidence is about 1% of all monoclonal gammopathy. This paper reports on a 48-year-old male who had a chief complaint of back-pain beginning 7 months earlier. A physical examination was unremarkable, except for anemia and tenderness in the back. Hemoglobin was 5.4 g/dl, white blood cells 4.5 x 10(3)/microliter, platelets 157 x 10(3)/microliter, and reticulocytes 0.9%. Serum iron was 79 mg/dl, and total iron-binding capacity was 210 mg/dl. A blood smear showed the formation of rouleaux, but no plasma cells were found. Serum creatinine was 5.4 mg/dl, with a creatinine clearance of 18.1 ml/min. Serum electrolytes were normal except for serum calcium which was 14.4 mg/dl. The urinalysis showed strongly positive proteinuria (+2), with negative Bence Jones protein. Serum protein electrophoresis showed an increase and a spike pattern of beta-2 globulin (2.8 g/dl) and alpha-2 globulin (1.5 g/dl), with normal gamma globulin. By nephelometry technique, serum IgG was normal (1388 mg/dl), IgA was high (900 mg/dl), and IgM was also high (517 mg/dl). Advanced and extensive osteolytic lesions were found in the clavicle, ribs, skull, humerus, femur, and columna vertebralis. Plasma cells (myeloma cells) in bone marrow were 32%. The clinical diagnosis was multiple myeloma (biclonal gammopathy) stage IIIB (Durie and Salmon staging system). Clinical response was good after two series of conventional chemotherapy, with normal serum electrophoresis, decreasing serum creatinine and serum calcium. Based on the above data, the diagnosis of multiple myeloma with biclonal gammopathy was confirmed. This is a rare case with a combination of IgA and IgM M-components." }, { "id": "wiki20220301en013_91234", "title": "Multiple myeloma", "score": 0.016612399494983054, "content": "Diagnostic criteria In 2003, the IMG agreed on diagnostic criteria for symptomatic myeloma, asymptomatic myeloma, and MGUS, which was subsequently updated in 2009: Symptomatic myeloma (all three criteria must be met): Clonal plasma cells >10% on bone marrow biopsy or (in any quantity) in a biopsy from other tissues (plasmacytoma) A monoclonal protein (myeloma protein) in either serum or urine and it has to be more than 3g/dL (except in cases of true nonsecretory myeloma) Evidence of end-organ damage felt related to the plasma cell disorder (related organ or tissue impairment, CRAB): HyperCalcemia (corrected calcium >2.75 mmol/l, >11 mg/dl) Renal failure (kidney insufficiency) attributable to myeloma Anemia (hemoglobin <10 g/dl) Bone lesions (lytic lesions or osteoporosis with compression fractures)" }, { "id": "pubmed23n0559_8106", "title": "Should bone marrow examination be routinely performed for the diagnosis of monoclonal gammopathy of undetermined significance?", "score": 0.0155842683894367, "content": "Monoclonal gammopathy of undetermined significance is defined by the presence of: low serum and/or urine monoclonal protein level; less than 10% plasma cells in bone marrow; normal serum calcium, creatinine and hemoglobinlevels; and no bone lesions on full skeletal X-ray survey. To study the necessity of bone marrow examination for the diagnosis and clinical course of MGUS. We retrospectively screened the medical records of all patients in whom monoclonal protein was found in the serum during 2001-2002 in the medical laboratories of Meir Medical Center. Asymptomatic patients who had serum monoclonal immunoglobulin G &lt; 3.0 g/dl or IgA &lt; 2.0 g/dl or IgM &lt; 1.0 g/dl without anemia, renal failure, hypercalcemia or any bone lesions on skeletal survey were eligible. Full records of patients who were evaluated in the hematology clinic were available (group 1). The remaining patients were followed by their family physicians; thus we had access only to their electronic files including laboratory results and new diagnoses (group 2). Demographic and clinical parameters as well as clinical course werewere evaluated. Both groups (57 and 255 patients, respectively) had similar demographic, laboratory and clinical characteristics. Bone marrow examination was performed in 30 of 57 patients (group 1): 16 were normal, 8 had an excess of normal plasma cells, and 6 had excess of pathologic plasma cells. However, only in two of the latter six could a diagnosis of multiple myeloma be established. All group 1 patients were followed for 22 +/- 11 months and onlytwo developed overt multiple myeloma. During the same period, 6 of 255 patients (group 2) were diagnosed as multiple myeloma and 3 as MGUS in other hospitals. The rest had a stable course with no change in their laboratory values. Our findings suggest that bone marrow examination should not be performed routinely in patients who fulfill strict clinical and laboratory criteria of MGUS." }, { "id": "article-25360_16", "title": "Multiple Myeloma -- Evaluation", "score": 0.015288919893035694, "content": "Historically, we have diagnosed MM if clonal bone marrow plasma cells were greater than or equal than 10% on bone marrow biopsy (or if a biopsy-proven plasmacytoma was present) in addition to at least one of the following CRAB criteria: Serum calcium level greater than 0.25 mmol/L (greater than 1 mg/dL) higher than the upper limit of normal or greater than 2.75 mmol/L (greater than 11 mg/dL) Renal insufficiency (creatinine greater than 2 mg/dL [greater than 177 micromol/L] or creatinine clearance less than 40 mL per minute) Anemia (hemoglobin less than 10 g/dL or hemoglobin greater than 2 g/dL below the lower limit of normal) One or more osteolytic bone lesions on skeletal radiography, CT, or PET-CT often described as punched-out, round, radiolucent lesions" }, { "id": "pubmed23n0971_4376", "title": "Treatment approach for the older, unfit patient with myeloma from diagnosis to relapse: perspectives of a European hematologist.", "score": 0.015063540753724802, "content": "Mrs. A. is a 73-year-old woman who has developed increasing fatigue and lower back pain over the past year. The pain limits her exercise tolerance such that she can now walk only 1 block. She is a retired schoolteacher who does volunteer efforts in her community but has limited her activities due to fatigue. Karnofsky performance status is 70%. She has a history of chronic hypertension treated with a diuretic, adult-onset diabetes mellitus treated with metformin, and hypothyroidism treated with levothyroxine. Initial evaluation reveals anemia, renal dysfunction, an elevated total protein, and an L2 compression fracture on lumbosacral radiographs. Results of initial and subsequent evaluation are shown below, and she is referred to a hematologist for further evaluation, which revealed the following: calcium 9.0 mg/dL, creatinine 3.2 mg/dL with estimated creatinine clearance using the Modification of Diet in Renal Disease equation of 15 mL/min, hemoglobin 9.6 g/dL, total protein 11 g/dL, albumin 3.2 g/dL, immunoglobulin A (IgA) λ M protein 6.8 g/dL, total IgA 7.2 g/dL, IgG 0.4 g/dL, IgM 0.03 g/dL, free κ &lt;0.01 mg/L, free λ 1000 mg/L, free light chain ratio &lt;0.01, β-2-microglobulin 4.2, viscosity 3.0, lactate dehydrogenase 200 U/L, urine protein electrophoresis: 125 mg/dL with 30% M protein, and urine immuno-electrophoresis: λ light chain. Skeletal bone survey showed lytic lesions in femurs and humeri and diffusely in ribs bilaterally as well as compression fractures at T4, T6, and L2. Bone marrow biopsy revealed λ-restricted plasma cells comprising 50% of the bone marrow core. Fluorescence in situ hybridization testing on marrow showed that del(17p) was present in 80% of the plasma cells. Mrs. A. is informed of the diagnosis of multiple myeloma and the need for therapy. She requests consultation with 2 of the leading world experts. However, she wants to be treated near her home and does not want treatment on a clinical trial." }, { "id": "wiki20220301en013_91208", "title": "Multiple myeloma", "score": 0.014268207282913165, "content": "Signs and symptoms Because many organs can be affected by myeloma, the symptoms and signs vary greatly. Fatigue and bone pain are the most common symptoms at presentation. The CRAB criteria encompass the most common signs of multiple myeloma: Calcium: serum calcium >0.25 mmol/l (>1 mg/dl) higher than the upper limit of normal or >2.75 mmol/l (>11 mg/dl) Renal insufficiency: creatinine clearance <40 ml per minute or serum creatinine >1.77 mol/l (>2 mg/dl) Anemia: hemoglobin value of >2g/dl below the lowest limit of normal, or a hemoglobin value <10g/dl Bone lesions: osteolytic lesions on skeletal radiography, CT, or PET/CT Bone pain" }, { "id": "pubmed23n0074_210", "title": "[Nonproducing myeloma without evident bone lesion].", "score": 0.014055472263868066, "content": "A 76-year-old female was admitted to our hospital because of anemia. Complete blood count was as follows: RBC 2.37 X 10(6)/microliters, Hb 7.7 g/dl, WBC 2,600/microliters, Plt 105 X 10(3)/microliters. A bone marrow aspirate revealed 40.8% plasmacytoid cells showing the characteristics of plasma cells by electron microscopy. Total serum protein was 5.4 g/dl. Monoclonal protein was not observed by electrophoresis. On immunoelectrophoresis, M-bow was not observed in the serum or in 50-fold concentrated urine. The plasma cells were negative for cytoplasmic IgG, M, A, E, D, kappa or lambda by immunoperoxidase studies. Although radiologic studies of the bones did not reveal destructive or punched out lesions, we diagnosed this case as a nonproducing myeloma and the patient responded to MP therapy. This case was considered interesting as regards the pathological entity of myeloma." }, { "id": "pubmed23n0083_17241", "title": "[An autopsy case of IgE myeloma].", "score": 0.013210689681277917, "content": "An autopsy case of IgE myeloma, 85-year-old male is reported. He was admitted to our hospital on November 17, 1987 due to pain of left humerus. Osteolytic and osteoporotic foci were found in left humerus, ribs, spinal column and femurs. Complete blood countings were as follows: RBC 3.23 x 10(12)/L, Hb 11.3 g/dl, WBC 6.3 x 10(9)/L, platelet 173 x 10(9)/L. Blood smear showed red cell rouleaux formation without myeloma cells. Examination of bone marrow revealed hypoplasia with 52% myeloma cells which were stained with anti-IgE and antilambda antisera by peroxidase anti-peroxidase method. Total serum protein level was 7.7 g/dl. Monoclonal protein was observed at fast gamma-region by cellulose-acetate electrophoresis. On immunoelectrophoresis, this monoclonal protein made specific M-bow against anti-IgE and anti-lambda antisera. The IgE level in serum and urine were 7.8 x 10(6) IU/ml and 2.4 x 10(3) IU/ml by radio-immunoassay respectively. He was died owing to renal failure on September 7, 1988. Postmortem examination showed infiltration of myeloma cells in bone marrow, spleen, kidneys, lungs and generalized lymph nodes." }, { "id": "pubmed23n0792_3201", "title": "Spurious hyperphosphatemia in a case of multiple myeloma.", "score": 0.01141365388701697, "content": "A 50 year old male was admitted in our hospital with anemia and impaired renal function. He was subsequently found to have extremely elevated serum phosphate level (24 mg/dL, reference interval: 2.5-4.5 mg/dL) with normal serum calcium when assayed on a Beckman Coulter AU 480(®) analyser. Clinico-biochemical discrepancy led to the suspicion of spurious hyperphosphatemia. Serum total protein was grossly elevated with gross reversal of albumin to globulin ratio. Serum electrophoresis revealed a large M band and was confirmed as Ig G-Kappa type on immunofixation. Subsequently a bone marrow aspiration biopsy confirmed the diagnosis of multiple myeloma. The patient serum was then reassayed for phosphate on a Vitros(®) 250 Dry Chemistry platform and the result was within normal reference interval. Paraproteinemias are a common cause of analytical interference in clinical biochemistry laboratories and as multilayered film technology platforms like Vitros(®) assay most routine analytes on a protein free filtrate they are unaffected by paraprotein interference. Clinically discordant patient results should always be interpreted keeping such interferences in mind. " }, { "id": "wiki20220301en060_69607", "title": "Primary hyperparathyroidism", "score": 0.01114163614163614, "content": "Serum calcium concentration of 1.0 mg/dL (0.25 mmol/L) or more above the upper limit of normal Creatinine clearance that is reduced to <60 mL/min Bone density at the hip, lumbar spine, or distal radius that is more than 2.5 standard deviations below peak bone mass (T score <-2.5) and/or previous fragility fracture Age less than 50 years" }, { "id": "pubmed23n0906_12722", "title": "Atypical sarcoidosis diagnosed by bone marrow biopsy during renal workup for possible multiple myeloma.", "score": 0.011084500122819946, "content": "Sarcoidosis is a multi-organ disease of unknown etiology characterized by non-caseating granulomas. Here we report the case of a 78-year-old white male with a past medical history of diabetes mellitus, hypertension, and chronic kidney disease stage III with a baseline serum creatinine of 2.5 mg/dl. The patient had a prior admission history for acute kidney injury (AKI) attributed to dehydration and medication-induced nephro-toxicities. He presented to the renal clinic for follow-up with acute worsening of chronic kidney failure with a serum creatinine level of 3.5 mg/dl. Examination revealed that he was anemic and mildly hypercalcemic with suppressed parathyroid hormone and had proteinuria of 1.3 g per day. The computed tomography scan of the abdomen revealed right renal pelvic non-obstructing calculi. Serum protein electrophoresis revealed gammopathy with two distinct monoclonal peaks consisting of immunoglobulin G (IgG) kappa and IgG lambda, respectively. The kappa/lambda ratio was within normal limits, and urine protein electrophoresis showed no evidence of a monoclonal peak or Bence Jones proteins. Further workup for multiple myeloma, including bone marrow (BM) biopsy, revealed polyclonal plasma cells and B cells with no clonality. No morphological and immune-phenotypic evidence of plasma cell dyscrasia was found, but BM biopsy did show numerous non-caseating granulomas consistent with sarcoidosis. Skin biopsy from non-scaly 6-mm skin colored papule also showed non-caseating granulomas. The patient had elevated angiotensin-converting enzyme levels (165 ug/l) and an erythrocyte sedimentation rate of 27 mm/h. Kidney biopsy did not show granulomas. The hypercalcemia, proteinuria, and AKI responded well after 2 weeks of 60 mg oral prednisone daily." }, { "id": "pubmed23n0657_3956", "title": "Acute lymphoblastic leukemia complicated by acute renal failure: a case report and review of the literature.", "score": 0.010691717445271948, "content": "The patient, a previously healthy woman, presenting with acute renal failure and anemia, was admitted to our hospital. Her serum creatinine (Scr) had increased from 0.79 - 2.69 mg/dl over three days and hemoglobin had decreased from 12.1 - 7.8 g/dl over 4 weeks. Mild compression fracture and degeneration of the lumbar vertebra and skull were observed in X-ray. The renal biopsy showed acute proximal tubular lesions induced by multiple calcium deposition. A bone marrow biopsy showed that primitive lymphocyte was up to 92.5%. After making a diagnosis of acute lymphoblastic leukemia complicated with acute kidney injury induced by hypercalcemia, CRRT (continued renal replacement therapy) and chemotherapy were used immediately. Ten days later, the blood calcium had gradually decreased from 3.88 to normal range (1.8 mmol/l) and the renal function was back to normal (Scr 0.93 mg/dl). This unusual case shows that a patient who has a syndrome of acute renal failure, electrolyte disturbances, anemia, and elevated LDH needs bone marrow puncture to eliminate renal injury caused by hematologic diseases." }, { "id": "pubmed23n0755_2263", "title": "Hypophosphatemic rickets: A case of recurrent pathological fractures.", "score": 0.01056493434844974, "content": "Renal phosphate-wasting disorders are the most common form of hereditary rickets and osteomalacia in western countries, but are rarely reported in India. Therefore, we report here a case of hypophosphatemic rickets. To report a case of hypophosphatemic rickets presenting with recurrent pathological fractures. A 34-year-old premenopausal lady presented with recurrent pathological fractures, bone pain, and muscle weakness since 14 years of age. A thorough history was taken followed by clinical examination, and relevant biochemical and radiological investigations were done. Height was 125 cm, arm span 145 cm, body weight 30 kg, and body mass index (BMI) 19.2 kg/m(2). Dental caries, kyphoscoliosis, shortening of left lower limb, bilateral coxa vara deformity of knee, muscle weakness, and bone tenderness were present. Calcium was 9.4 mg/dL, phosphorus: 1.8 mg/dL, albumin: 4.0 gm/dL, alkaline phosphatase: 360 U/L, creatinine: 0.4 mg/dL, a normal ammonium chloride (NH4Cl) loading test,24-hour urine calcium excretion: 102 mg/day, 25-hydroxyvitamin D3 [25(OH)D3]: 21.6 ng/mL, intact parathyroid hormone (PTH): 43.74 pg/mL, fraction excretion of phosphate (PO4): 40%, tubular maximum reabsorption of phosphate per unit of glomerular filtrate (TmP/GFR): 0.65 mg/dL, and fibroblast growth factor (FGF)23: 321.4 RU/mL. Skeletal X-rays showed multiple old fractures and pseudofractures. Magnetic resonance imaging (MRI) of the whole body showed no evidence of tumor. Fludeoxyglucose ((18)F)-positron emission tomography (FDG-PET) computed tomography (CT) scan revealed metabolically active marrow with multiple areas of fracture and FDG-avid lesions in both lungs but no CT-based findings. Hypophosphatemic rickets or osteomalacia, possibly hereditary, is a rare cause of recurrent pathological fractures." }, { "id": "wiki20220301en188_29387", "title": "Myeloma protein", "score": 0.010387725482065105, "content": "Serum free light-chain measurement can detect free light chains in the blood. Monoclonal free light chains in the serum or urine are called Bence Jones proteins. Interpretation upon detection Blood serum paraprotein levels of more than 30 g/l is diagnostic of smouldering myeloma, an intermediate in a spectrum of step-wise progressive diseases termed plasma cell dyscrasias. Elevated paraprotein level (above 30 g/l) in conjunction with end organ damage (elevated calcium, kidney failure, anemia, or bone lesions) or other biomarkers of malignancy, is diagnostic of multiple myeloma, according to the diagnostic criteria of the International Myeloma Working Group, which were updated in 2014. Detection of paraprotein in serum of less than 30 g/l is classified as monoclonal gammopathy of undetermined significance in cases where clonal plasma cells constitute less than 10% on bone marrow biopsy and there is no myeloma-related organ or tissue impairment." }, { "id": "pubmed23n0049_4408", "title": "[Primary macroglobulinemia with hypercalcemia, renal failure and systemic amyloidosis].", "score": 0.009912578225767927, "content": "This report deals with an unusual case of primary macroglobulinemia with hypercalcemia, chronic renal failure and systemic amyloidosis. In May 1990, a 63-year-old male was transferred to our hospital because of hypercalcemia (13.5 mg/dl) and renal failure. Clinical examinations showed anemia, macroglossia, lymph node swellings and hepatomegaly. Laboratory findings included Bence-Jones (kappa type) proteinuria (0.8 g/day), a monoclonal gammopathy of the IgM-kappa type (2.8 g/dl), a proliferation of lymphoid cells in the peripheral blood (5%) and the bone marrow (59.6%), and lymphomatous involvement of an inguinal lymph node. Serum creatinine concentration was 8.5 mg/dl. The serum levels of parathormone and vitamin D3 metabolites were normal. The roentgenogram of bones showed a compression fracture of the lumbar spine and systemic osteoporosis. The treatment included eel calcitonin, prednisolone and the CHOP regimen, followed by hemodialysis and plasmapheresis. The serum level of IgM increased to 4.6 g/dl. The patient died three months later and postmortem examination demonstrated marked systemic amyloidosis." }, { "id": "wiki20220301en056_14615", "title": "Monoclonal gammopathy of undetermined significance", "score": 0.009871884871884873, "content": "Management The protein electrophoresis test should be repeated annually, and if there is any concern for a rise in the level of monoclonal protein, then prompt referral to a hematologist is required. The hematologist, when first evaluating a case of MGUS, will usually perform a skeletal survey (X-rays of the proximal skeleton), check the blood for hypercalcemia and deterioration in renal function, check the urine for Bence Jones protein and perform a bone marrow biopsy. If none of these tests are abnormal, a patient with MGUS is followed up once every 6 months to a year with a blood test (serum protein electrophoresis). Although patients with MGUS have sometimes been reported to suffer from peripheral neuropathy, a debilitating condition which causes bizarre sensory problems to painful sensory problems, no treatment is indicated." }, { "id": "wiki20220301en060_69608", "title": "Primary hyperparathyroidism", "score": 0.009708737864077669, "content": "Operative intervention can be delayed in patients over 50 years of age who are asymptomatic or minimally symptomatic and who have serum calcium concentrations <1.0 mg/dL (0.2 mmol/L) above the upper limit of normal, and in patients who are medically unfit for surgery More recently, three randomized controlled trials have studied the role of surgery in patients with asymptomatic hyperparathyroidism. The largest study reported that surgery resulted in an increase in bone mass, but no improvement in quality of life after one to two years among patients in the following groups: Untreated, asymptomatic primary hyperparathyroidism Serum calcium between 2.60–2.85 mmol/liter (10.4–11.4 mg/dl) Age between 50 and 80 yr No medications interfering with Ca metabolism No hyperparathyroid bone disease No previous operation in the neck Creatinine level < 130 μmol/liter (<1.47 mg/dl) Two other trials reported improvements in bone density and some improvement in quality of life with surgery." }, { "id": "pubmed23n0822_7638", "title": "[Infectious pleurisy as first sign of multiple myeloma in a young 28 years old].", "score": 0.009708737864077669, "content": "Multiple myeloma is a malignant proliferation of plasma cells, mainly affecting the bone marrow. It rarely occurs in young patients. The medical observation study reveals multiple myeloma discovered through a purulent pleurisy in a 28-year-old subject. This patient was admitted to the pneumology service of the Mohamed V military hospital in Rabat for a fever and dyspnea evolving into a context of poor general condition. Clinical examination found a right pleural fluid effusion syndrome. The pleural puncture reveals a germ-free exudative purulent fluid without plasma cells. The myeloma diagnosis was suspected due to the combination of an aplastic normochromic normocytic anemia at 4.5g/dL of hemoglobin, an accelerated erythrocyte sedimentation rate, hypercalcemia, renal failure and osteolytic lesions located mainly in the skull and pelvis area, oriented by electrophoresis and serum protein immunosubstraction revealing a narrow peak in monoclonal beta-2 globulin at 70.56g/L with a lambda monoclonal gammopathy with immunoglobulin G, and confirmed by the myelogram showing a 74% rate of bone marrow plasma cells. The occurrence of myeloma at a young age is rare and the purulent pleurisy without plasma cells is a rare form of presentation and represents a poor prognosis." }, { "id": "Surgery_Schwartz_12625", "title": "Surgery_Schwartz", "score": 0.009646456566949287, "content": "(RANKL) in the bone marrow. RANKL induces osteoclast differentiation and acti-vation. Myeloma cells inhibit osteoblast differentiation and activity. Serum and urine electrophoresis detect the M protein. Workup also includes complete blood cell count, erythrocyte sedimentation rate, calcium levels, renal function assessment, β2-microglobulin levels, and a skeletal survey. X-ray will show multiple punched out lytic lesions. Bone scans may be cold in about 30% of cases. The SPEP, UPEP, and bone marrow biopsy are helpful in diagnosis. Histology will show atypical plasma cells with eccentric nuclei, its appearance resembles a “signet ring (Fig. 43-49).” Plasmacytoma is a solitary tumor with a negative bone marrow biopsy, usually treated with radiation to the lesion. Myeloma is treated with bisphosphonates, chemo-therapy, stem cell transplantation, and radiation therapy. Surgi-cal stabilization and irradiation is done for pathologic fractures or impending fractures. Many patients with" }, { "id": "wiki20220301en013_91237", "title": "Multiple myeloma", "score": 0.009615384615384616, "content": "Asymptomatic/smoldering myeloma: Serum M protein >30 g/l (3 g/dl) or Clonal plasma cells >10% on bone marrow biopsy and No myeloma-related organ or tissue impairment Monoclonal gammopathy of undetermined significance (MGUS): Serum paraprotein <30 g/l (3 g/dl) and Clonal plasma cells <10% on bone marrow biopsy and No myeloma-related organ or tissue impairment or a related B-cell lymphoproliferative disorder Related conditions include solitary plasmacytoma (a single tumor of plasma cells, typically treated with irradiation), plasma cell dyscrasia (where only the antibodies produce symptoms, e.g., AL amyloidosis), and peripheral neuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes." }, { "id": "pubmed23n0686_16836", "title": "[Laboratory diagnostic and prognostic factors: Multiple myeloma in Morocco].", "score": 0.009615384615384616, "content": "ObjectivesThe purpose of this retrospective study was to clarify the factors for a laboratory diagnosis of multiple myeloma (Kahler's disease) and assess their prognostic value.MethodsThe study of all 10 patients with multiple myeloma seen during 2009 in the department of internal medicine and the haematology laboratory of HASSAN II University Hospital Centre in Fez. Work-ups for all patients included hemograms, sedimentation speed, electrophoresis of serum and urinary proteins, myelograms, creatinemia, calcemia, ß2-microglobulin, LDH and CRP.ResultsIn this series, the average age of the patients was 59 years and the sex ratio 1.3 (men). The laboratory tests showed anemia below 12 g/dl in 80% of the cases, with IgG accounting for 50% of the cases. The median concentration of the monoclonal component was 28 g/l. The prognostic assessments showed an increase in ß2-microglobulins and creatinemia in one case. CRP was elevated in all patients.ConclusionThe results from this study are consistent with those from other series. Protein electrophoresis and myelography results are major diagnostic elements, because they make it possible to rule out a monoclonal gammopathy of undetermined significance, for which treatment differs completely from that for multiple myeloma. ß2-microglobulin and CRP are independent prognostic factors providing important information about survival." }, { "id": "pubmed23n1012_8473", "title": "Rare case of non-producer variant of plasma cell dyscrasias with circulating plasma cells.", "score": 0.009524673439767779, "content": "Non-producing variant of plasma cell disorders with circulating plasma cells is an aggressive variant of plasma cell dyscrasias with relatively poor outcomes. A 75-year-old man was admitted due to anaemia (90 g/L) and thrombocytopenia (9×10<sup9</sup/L). Comprehensive metabolic panel showed creatinine of 1.34 mg/dL, total protein of 6 g/dL, and corrected calcium was normal. Peripheral smear review showed 8% circulating atypical plasmacytoid cells. Bone marrow biopsy (BMB) confirmed plasma cell myeloma involving 90%-95% of bone marrow cellularity. Serum protein electrophoresis showed no monoclonal protein. Due to aggressive biology of non-producer variant and outcomes based on circulating plasma cells, he was started on VD-PACE (bortezomib, dexamethasone, cisplatin, doxorubicin, cyclophosphamide and etoposide) chemotherapy. BMB after cycle 1 chemotherapy showed no morphologic, immunophenotypic, or flow cytometric features of a plasma cell neoplasm. Given excellent treatment response cycle 2 was changed to VRD (bortezomib, lenalidomide and dexamethasone). Following two cycles of VRD, he underwent autologous haematopoietic cell transplantation. Day 80 BMB suggested stringent complete response." }, { "id": "InternalMed_Harrison_8900", "title": "InternalMed_Harrison", "score": 0.009523809523809525, "content": "chains are useful for detecting and characterizing M spikes, supplemented by immunoelectrophoresis, which is especially sensitive for identifying low concentrations of M components not detectable by protein electrophoresis. A 24-h urine specimen is necessary to quantitate Bence Jones protein excretion. Serum alkaline phosphatase is usually normal even with extensive bone involvement because of the absence of osteoblastic activity. It is also important to quantitate serum β2-microglobulin and albumin (see below)." }, { "id": "wiki20220301en019_111566", "title": "Glomerular filtration rate", "score": 0.009433962264150943, "content": "For creatinine in μmol/L: For creatinine in mg/dL: Creatinine levels in μmol/L can be converted to mg/dL by dividing them by 88.4. The 32788 number above is equal to 186×88.41.154. A more elaborate version of the MDRD equation also includes serum albumin and blood urea nitrogen (BUN) levels: where the creatinine and blood urea nitrogen concentrations are both in mg/dL. The albumin concentration is in g/dL. These MDRD equations are to be used only if the laboratory has NOT calibrated its serum creatinine measurements to isotope dilution mass spectrometry (IDMS). When IDMS-calibrated serum creatinine is used (which is about 6% lower), the above equations should be multiplied by 175/186 or by 0.94086. Since these formulae do not adjust for body size, results are given in units of mL/min per 1.73 m2, 1.73 m2 being the estimated body surface area of an adult with a mass of 63 kg and a height of 1.7m." }, { "id": "pubmed23n1051_21838", "title": "An atypical presentation of multiple myeloma in a young patient with pathological fracture.", "score": 0.009433962264150943, "content": "We report a case of a 34-year-old male with a history of pulmonary tuberculosis and pathological fracture of shaft of long bone presented with symptoms of lower respiratory tract infection. The patient did not have any typical symptoms of multiple myeloma or hypercalcemia on presentation. Throughout his hospitalization, his serum globulin level was very high along with mild normocytic normochromic anemia and mild renal function derangement without apparent cause. Acute phase markers of inflammation, for example, erythrocyte sedimentation rate (ESR) were not elevated in this patient and there was no lytic lesion in bone radiographs. He was eventually diagnosed as a case of stage 3 multiple myeloma by immuno-fixation electrophoresis and bone marrow study. Multiple myeloma represents a pathology of diverse distribution and has varied unusual presenting symptoms. We consider it an underdiagnosed disease often missed especially in young because it is not considered by clinicians." }, { "id": "wiki20220301en033_21959", "title": "Acute pancreatitis", "score": 0.009345794392523364, "content": "Alternative Ranson score Ranson's score of ≥ 8 Organ failure Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT) Interpretation If the score ≥ 3, severe pancreatitis likely. If the score < 3, severe pancreatitis is unlikely Or Score 0 to 2 : 2% mortality Score 3 to 4 : 15% mortality Score 5 to 6 : 40% mortality Score 7 to 8 : 100% mortality APACHE II score \"Acute Physiology And Chronic Health Evaluation\" (APACHE II) score > 8 points predicts 11% to 18% mortality Hemorrhagic peritoneal fluid Obesity Indicators of organ failure Hypotension (SBP <90 mmHG) or tachycardia > 130 beat/min PO2 <60 mmHg Oliguria (<50 mL/h) or increasing BUN and creatinine Serum calcium < 1.90 mmol/L (<8.0 mg/dL) or serum albumin <33 g/L (<3.2.g/dL)>" }, { "id": "article-96562_10", "title": "Pathologic Fractures -- Evaluation", "score": 0.009345794392523364, "content": "Laboratory analysis should include a complete blood count, comprehensive metabolic panel (with special attention to serum calcium and alkaline phosphatase), prothrombin/INR, activated partial thromboplastin, erythrocyte sedimentation rate, urinalysis, urinary protein electrophoresis, and serum protein electrophoresis. Disease-specific markers, including prostate-specific antigen (PSA) and carcinoembryonic antigen (CEA), etc., may also be considered. Laboratory abnormalities may exist secondary to malignancy and may elucidate the source of malignancy. For example, a urinalysis may provide some insight into the primary pathology. If hematuria is present, renal cell or uroepithelial carcinoma should be considered. If Bence-Jones proteins are present, multiple myeloma is likely the diagnosis. Pregnancy tests should also be obtained in women of child-bearing age prior to imaging." }, { "id": "wiki20220301en178_38961", "title": "Ranson criteria", "score": 0.009259259259259259, "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": "pubmed23n0629_6807", "title": "Importance of serum albumin level in the preoperative tests conducted in elderly patients with hip fracture.", "score": 0.009259259259259259, "content": "Preoperative testing is commonly performed in patients undergoing surgery for hip fractures. The purpose of this study was to determine the appropriate preoperative tests after implementation of the case-payment reimbursement system and clinical pathway. We analysed 242 patients admitted to a regional hospital for hip fracture. Preoperative comorbidities and laboratory test results were measured and evaluated for their association with the occurrence of postoperative adverse outcomes. Univariate analysis showed that abnormal chest X-ray, haemoglobin, albumin, and total protein were associated with concomitant pulmonary diseases. Abnormal electrocardiogram (ECG), Na, creatinine, and aspirate aminotransferase (AST) levels were associated with heart disease. On the base of the univariate analysis, the significant preoperative variables for increased postoperative complications at 30 days included abnormal chest X-ray (odds ratio, 4.45; 95% confidence interval (CI), 2.24-8.84), ECG (odds ratio, 3.95; 95% CI, 1.96-7.95), Hct (odds ratio, 2.22; 95% CI, 0.96-5.16), Hb (odds ratio, 2.68; 1.29-5.58), blood urine nitrogen (odds ratio, 2.69; 95% CI, 1.34-5.42), creatinine (odds ratio, 4.49; 2.31-8.75), albumin (odds ratio, 9.68; 95% CI, 3.16-29.65), and AST (odds ratio, 2.36; 95% CI, 1.12-4.98). After adjustment for age, sex, and comorbidities, the risk factors that improved the predictability of postoperative complications were found to be abnormal chest X-ray (odds ratio, 6.03; 95% CI, 1.84-19.82) and albumin level (odds ratio, 6.23; 95% CI, 1.90-20.42). Serum albumin level and preoperative chest X-rays should be included in the preoperative routine tests recommended for elderly patient with hip fracture." }, { "id": "wiki20220301en442_324", "title": "Latent iron deficiency", "score": 0.009174311926605505, "content": "Latent iron deficiency (LID), also called iron-deficient erythropoiesis, is a medical condition in which there is evidence of iron deficiency without anemia (normal hemoglobin level). It is important to assess this condition because individuals with latent iron deficiency may develop iron-deficiency anemia. Additionally, there is some evidence of a decrease in vitality and an increase in fatigue among individuals with LID. Diagnosis Diagnostic tests for latent iron deficiency LID complete blood count hemoglobin serum iron total iron binding capacity serum ferritin bone marrow examination (rarely) Note: Iron therapy must be suspended 48 hours beforehand to ensure valid test results. The normal range for hemoglobin is 13.8 to 17.2 grams per deciliter (g/dL) for men and 12.1 to 15.1 g/dL for women. Low hemoglobin indicates anemia but will be normal for LID." } ] } } }

{ "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": [ [ 0, 178 ] ], "word_ranges": [ [ 0, 31 ] ], "text": "In a patient with a low symptomatic COPD that could probably be classified as GOLD 2, the starting treatment can be either with inhaled tiotropium or with a long-acting beta two." } }

{ "1": "Daily inhaled corticosteroid.", "2": "Home oxygen therapy with portable oxygen source for ambulation.", "3": "Oral leukotriene antagonist.", "4": "Oral corticosteroid for three months.", "5": "Inhaled tiotropium." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en187_4321", "title": "Obstructive lung disease", "score": 0.01890999910801891, "content": "The diagnosis of COPD is established through spirometry although other pulmonary function tests can be helpful. A chest X-ray is often ordered to look for hyperinflation and rule out other lung conditions but the lung damage of COPD is not always visible on a chest x-ray. Emphysema, for example, can only be seen on CT scan. The main form of long term management involves the use of inhaled bronchodilators (specifically beta agonists and anticholinergics) and inhaled corticosteroids. Many patients eventually require oxygen supplementation at home. In severe cases that are difficult to control, chronic treatment with oral corticosteroids may be necessary, although this is fraught with significant side effects." }, { "id": "pubmed23n0371_17121", "title": "[Clinical examinations for COPD].", "score": 0.015714943587381992, "content": "The natural history of COPD such as pulmonary emphysema demonstrates that FEV1 rapidly declines in smokers who are susceptible to cigarette smoke. The susceptible smokers who quit smoking do not regain only a little, but the rate of the FEV1 decline is no longer steep. These have been interpreted that early detection of this obstructive impairment is the most important issue to prevent the progression to severe emphysema. Pulmonary function tests, at least a measure of FEV1, in the all middle-aged smokers have been particularly recommended. The smokers with abnormal FEV1 defect should be advised to quit smoking. In moderate and severe cases, after staging of the disease by pulmonary function and exercise tests, assessments of complicated factors such as eosinophilic bronchitis are clinically important for constructing therapeutic strategies. Asthmatic component can be assessed by eosinophil count in the sputum and/or reversibility of the pulmonary function after challenging of bronchodilater inhalations. In the severe stage of the disease, examinations such as arterial blood gas analysis and pulse oxymetric measure are critical because oxygen therapy for the patients with respiratory failure has been known to improve survival prognosis. Portable devices which can assess arterial oxygen saturation during daily activity will be useful to decide its indication or to titrate oxygen. In conclusion, clinical examination in COPD, particularly in pulmonary emphysema in this paper, should appropriately be planned in each stage of the disease, or in each clinical purpose." }, { "id": "pubmed23n0621_575", "title": "[Acute exacerbations of chronic obstructive pulmonary disease].", "score": 0.01552757793764988, "content": "Acute exacerbation of chronic obstructive pulmonary disease (COPD) is defined by modification of the usual COPD symptoms, dyspnea, coughing and sputum, beyond daily variations, with a sudden onset, and requiring modification of the usual treatment. Exacerbations stud the course of COPD. Their frequency is variable, averaging 1-2 per year. Their frequency generally increases with COPD severity. Exacerbations impair patients' quality of life and aggravate disease prognosis by accelerating the decline in FEV1, the primary indicator of respiratory function. The most frequent causes of exacerbations are viral and bacterial respiratory infections and pollution. No cause is identified for nearly one third of all exacerbations. Most exacerbations can be treated at home, if a careful search for signs of clinical severity is negative. Treatment combines inhaled bronchodilator agents (beta-2 agonists, combined if necessary with anticholinergics) and oral corticosteroid therapy (prednisone: 0.5 mg/kg/d for 1 week) when the COPD is severe or signs of severity accompany the exacerbation. Antibiotic therapy is justified when the sputum appears purulent. Severe exacerbation may require oxygen therapy in cases of severe hypoxemia (PaO(2)&lt;60 mm Hg) or mechanically assisted ventilation, essentially by noninvasive ventilation in cases of respiratory acidosis (pH&lt;7.35). Noninvasive ventilation improves dyspnea and respiratory acidosis, diminishes respiratory frequency, intubation, duration of hospitalization, nosocomial infections, and mortality. Pulmonary follow-up is necessary after an exacerbation, especially to prevent the recurrence of exacerbations by measures that have been demonstrated to be effective, including help in smoking cessation, adaptation of COPD treatment, vaccination against influenza and pneumonia (pneumococci), and respiratory rehabilitation. Early diagnosis and rapid treatment of exacerbations can limit their impact, improve quality of life, and reduce the risk of hospitalization." }, { "id": "wiki20220301en332_33595", "title": "Chronic obstructive pulmonary disease", "score": 0.015094554568238779, "content": "Spirometry measures the amount of airflow obstruction present and is generally carried out after the use of a bronchodilator, a medication to open up the airways. Two main components are measured to make the diagnosis, the forced expiratory volume in one second (FEV1), which is the greatest volume of air that can be breathed out in the first second of a breath, and the forced vital capacity (FVC), which is the greatest volume of air that can be breathed out in a single large breath. Normally, 75–80% of the FVC comes out in the first second and a FEV1/FVC ratio less than 70% in someone with symptoms of COPD defines a person as having the disease. Based on these measurements, spirometry would lead to over-diagnosis of COPD in the elderly. The National Institute for Health and Care Excellence criteria additionally require a FEV1 less than 80% of predicted. People with COPD also exhibit a decrease in diffusing capacity of the lung for carbon monoxide due to decreased surface area in the" }, { "id": "pubmed23n0879_17352", "title": "Respiratory Conditions Update: Chronic Obstructive Pulmonary Disease.", "score": 0.014581694204038816, "content": "Chronic obstructive pulmonary disease (COPD) is defined as persistent airflow limitation due to irritant-induced chronic inflammation. A postbronchodilator forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) ratio of 0.7 or less is diagnostic in a patient with dyspnea, chronic cough or sputum production, and a history of irritant exposure. Tobacco smoking is the most significant etiology, and smoking cessation is the only intervention shown to slow disease progression. Long-acting beta2-agonists and long-acting muscarinic antagonists are first-line treatments for patients with persistently symptomatic COPD with an FEV1 of 80% or less of predicted. When COPD is uncontrolled with a long-acting bronchodilator, combination therapy with a long-acting muscarinic antagonist-long-acting beta2-agonist or long-acting beta2-agonist-inhaled corticosteroid should be prescribed. Patients with COPD and reduced exercise tolerance should undergo pulmonary rehabilitation and be evaluated for supplemental oxygen therapy. Other treatment options for persistently symptomatic COPD include inhaler triple therapy (ie, long-acting muscarinic antagonist, long-acting beta2-agonist, inhaled corticosteroid), phosphodiesterase type 4 inhibitors, oxygen, and surgical interventions." }, { "id": "wiki20220301en187_4320", "title": "Obstructive lung disease", "score": 0.013772175536881419, "content": "In COPD, there is an increase in airway resistance, shown by a decrease in the forced expiratory volume in 1 second (FEV1) measured by spirometry. COPD is defined as a forced expiratory volume in 1 second divided by the forced vital capacity (FEV1/FVC) that is less than 0.7 (or 70%). The residual volume, the volume of air left in the lungs following full expiration, is often increased in COPD, as is the total lung capacity, while the vital capacity remains relatively normal. The increased total lung capacity (hyperinflation) can result in the clinical feature of a barrel chest – a chest with a large front-to-back diameter that occurs in some individuals with emphysematous COPD. Hyperinflation can also be seen on a chest X-ray as a flattening of the diaphragm. The most common cause of COPD is cigarette smoking. COPD is a gradually progressive condition and usually only develops after about 20 pack-years of smoking. COPD may also be caused by breathing in other particles and gases." }, { "id": "pubmed23n0867_13796", "title": "Clinical Significance of Symptoms in Smokers with Preserved Pulmonary Function.", "score": 0.013573700954400848, "content": "Currently, the diagnosis of chronic obstructive pulmonary disease (COPD) requires a ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of less than 0.70 as assessed by spirometry after bronchodilator use. However, many smokers who do not meet this definition have respiratory symptoms. We conducted an observational study involving 2736 current or former smokers and controls who had never smoked and measured their respiratory symptoms using the COPD Assessment Test (CAT; scores range from 0 to 40, with higher scores indicating greater severity of symptoms). We examined whether current or former smokers who had preserved pulmonary function as assessed by spirometry (FEV1:FVC ≥0.70 and an FVC above the lower limit of the normal range after bronchodilator use) and had symptoms (CAT score, ≥10) had a higher risk of respiratory exacerbations than current or former smokers with preserved pulmonary function who were asymptomatic (CAT score, &lt;10) and whether those with symptoms had different findings from the asymptomatic group with respect to the 6-minute walk distance, lung function, or high-resolution computed tomographic (HRCT) scan of the chest. Respiratory symptoms were present in 50% of current or former smokers with preserved pulmonary function. The mean (±SD) rate of respiratory exacerbations among symptomatic current or former smokers was significantly higher than the rates among asymptomatic current or former smokers and among controls who never smoked (0.27±0.67 vs. 0.08±0.31 and 0.03±0.21 events, respectively, per year; P&lt;0.001 for both comparisons). Symptomatic current or former smokers, regardless of history of asthma, also had greater limitation of activity, slightly lower FEV1, FVC, and inspiratory capacity, and greater airway-wall thickening without emphysema according to HRCT than did asymptomatic current or former smokers. Among symptomatic current or former smokers, 42% used bronchodilators and 23% used inhaled glucocorticoids. Although they do not meet the current criteria for COPD, symptomatic current or former smokers with preserved pulmonary function have exacerbations, activity limitation, and evidence of airway disease. They currently use a range of respiratory medications without any evidence base. (Funded by the National Heart, Lung, and Blood Institute and the Foundation for the National Institutes of Health; SPIROMICS ClinicalTrials.gov number, NCT01969344.)." }, { "id": "wiki20220301en022_69275", "title": "Pulmonology", "score": 0.012518587681986375, "content": "Surgical procedures Major surgical procedures on the heart and lungs are performed by a thoracic surgeon. Pulmonologists often perform specialized procedures to get samples from the inside of the chest or inside of the lung. They use radiographic techniques to view vasculature of the lungs and heart to assist with diagnosis. Treatment and therapeutics Medication is the most important treatment of most diseases of pulmonology, either by inhalation (bronchodilators and steroids) or in oral form (antibiotics, leukotriene antagonists). A common example being the usage of inhalers in the treatment of inflammatory lung conditions such as asthma or chronic obstructive pulmonary disease. Oxygen therapy is often necessary in severe respiratory disease (emphysema and pulmonary fibrosis). When this is insufficient, the patient might require mechanical ventilation." }, { "id": "InternalMed_Harrison_20122", "title": "InternalMed_Harrison", "score": 0.012510885341074019, "content": "The diagnosis of asthma is usually apparent from the symptoms of variable and intermittent airways obstruction, but must be confirmed by objective measurements of lung function. Lung Function Tests Simple spirometry confirms airflow limitation with a reduced FEV1, FEV1/FVC ratio, and PEF (Fig. 309-6). Reversibility is demonstrated by a >12% and 200-mL increase in FEV1 15 min after an inhaled short-acting β2-agonist or in some patients by a 2to 4-week trial of oral corticosteroids (OCS) (prednisone or prednisolone 30–40 mg daily). Measurements of PEF twice daily may confirm the diurnal variations in airflow obstruction. Flow-volume loops show reduced peak flow and reduced maximum expiratory flow. Further lung function tests are rarely necessary, but whole-body plethysmography shows increased airway resistance and may show increased total lung capacity and residual volume. Gas diffusion is usually normal, but there may be a small increase in gas transfer in some patients." }, { "id": "wiki20220301en332_33625", "title": "Chronic obstructive pulmonary disease", "score": 0.0108138711960368, "content": "Management of exacerbations People with COPD can experience exacerbations (flare-ups) that are commonly caused by respiratory tract infections. The symptoms that worsen are not specific to COPD and differential diagnoses need to be considered. Acute exacerbations are typically treated by increasing the use of short-acting bronchodilators including a combination of a short-acting inhaled beta agonist and short-acting anticholinergic. These medications can be given either via a metered-dose inhaler with a spacer or via a nebulizer, with both appearing to be equally effective. Nebulization may be easier for those who are more unwell. Oxygen supplementation can be useful. Excessive oxygen; however, can result in increased levels and a decreased level of consciousness. Corticosteroids given orally can improve lung function and shorten hospital stays but their use is recommended for only five to seven days; longer courses increase the risk of pneumonia and death." }, { "id": "wiki20220301en010_120229", "title": "Shortness of breath", "score": 0.010608713564733752, "content": "Asthma Asthma is the most common reason for presenting to the emergency room with shortness of breath. It is the most common lung disease in both developing and developed countries affecting about 5% of the population. Other symptoms include wheezing, tightness in the chest, and a non productive cough. Inhaled corticosteroids are the preferred treatment for children, however these drugs can reduce the growth rate. Acute symptoms are treated with short-acting bronchodilators. Pneumothorax Pneumothorax presents typically with pleuritic chest pain of acute onset and shortness of breath not improved with oxygen. Physical findings may include absent breath sounds on one side of the chest, jugular venous distension, and tracheal deviation." }, { "id": "pubmed23n0903_6343", "title": "Chronic Obstructive Pulmonary Disease: Diagnosis and Management.", "score": 0.00980392156862745, "content": "The diagnosis of chronic obstructive pulmonary disease (COPD) should be suspected in patients with risk factors (primarily a history of smoking) who report dyspnea at rest or with exertion, chronic cough with or without sputum production, or a history of wheezing. COPD may be suspected based on findings from the history and physical examination, but must be confirmed by spirometry to detect airflow obstruction. Findings that are most helpful to rule in COPD include a smoking history of more than 40 pack-years, a self-reported history of COPD, maximal laryngeal height, and age older than 45 years. The combination of three clinical variables-peak flow rate less than 350 L per minute, diminished breath sounds, and a smoking history of 30 pack-years or more-is another good clinical predictor, whereas the absence of all three of these signs essentially rules out airflow obstruction. Pharmacotherapy and smoking cessation are the mainstays of treatment, and pulmonary rehabilitation, long-term oxygen therapy, and surgery may be considered in select patients. Current guidelines recommend starting monotherapy with an inhaled bronchodilator, stepping up to combination therapy as needed, and/or adding inhaled corticosteroids as symptom severity and airflow obstruction progress." }, { "id": "InternalMed_Harrison_20384", "title": "InternalMed_Harrison", "score": 0.009757312794535905, "content": "Airflow limitation, also known as airflow obstruction, is typically determined by spirometry, which involves forced expiratory maneuvers after the subject has inhaled to total lung capacity. Key parameters obtained from spirometry include the volume of air exhaled within the first second of the forced expiratory maneuver (FEV1) and the total volume of air exhaled during the entire spirometric maneuver (forced vital capacity [FVC]). Patients with airflow obstruction related to COPD have a chronically reduced ratio of FEV1/FVC. In contrast to asthma, the reduced FEV1 in COPD seldom shows large responses to inhaled bronchodilators, although improvements up to 15% are common. Asthma patients can also develop chronic (not fully reversible) airflow obstruction." }, { "id": "pubmed23n0524_10706", "title": "World Trade Center dyspnea: bronchiolitis obliterans with functional improvement: a case report.", "score": 0.009708737864077669, "content": "Bronchiolitis obliterans is a severe, often progressive, lung disease characterized by cough, exertional dyspnea, and airflow obstruction. It has been ascribed to specific causes such as lung or bone marrow transplant, medications for rheumatoid disease, and most recently in association with exposure to environmental agents. A 42-year-old, previously healthy New York City Highway Patrol officer who arrived at the World Trade Center (WTC), \"ground zero,\" early on September 11, 2001 was evaluated. He has been followed for over 2 years with serial chest radiographs, CT scans, and pulmonary function studies. He eventually underwent an open lung biopsy. His dyspnea started on September 12, 2001 and progressed despite aggressive therapy with inhaled bronchodilator as well as oral and inhaled corticosteroids. At no time did he have any radiographic evidence of pulmonary disease. His forced vital capacity (FVC) decreased from 5.32 L in October 2001 to 2.86 L in January 2003. He underwent an open lung biopsy because of the persistent exertional dyspnea coupled with the loss of over 2 L of lung volume. The pathological findings were chronic bronchiolitis with focal obliterative bronchiolitis and rare non-necrotizing granuloma. Symptoms and pulmonary function improved after therapy with Azithromycin was added to his treatment. This process is believed to be secondary to his massive exposure to the cloud of dust that followed the collapse of the WTC. It is our conviction that many of those present at the WTC on September 11 who have persistent dyspnea and deterioration of pulmonary function may have a similar pathologic process despite absence of abnormalities on CT of the chest. In view of the many signs and symptoms seen in first responders we feel that these findings provide important information about the pathophysiology and treatment of progressive disease resulting from this exposure." }, { "id": "pubmed23n0771_4414", "title": "The Changes of Pulmonary Function in COPD During Four-Year Period.", "score": 0.009708737864077669, "content": "none declared. COPD (chronic obstructive pulmonary disease) is characterized by airflow limitation that is not fully reversible. to show the changes of pulmonary function in COPD during the 4 -year evolution of illness. The research was done on patients suffering from COPD treated at the Clinic \"Podhrastovi\" during 2006 and 2007. The tested parameters were examined from the date of receiving patient with COPD to hospital treatment in 2006 and 2007 and then followed prospectively until 2010 or 2011 (the follow-up period was 4 years). There were total 199 treated patients who were chosen at random and regularly attended the control examinations. The study was conducted on adult patients of both sexes, different age group. In each patient the duration of illness was recorded so is sex, age, data of smoking habits, information about the regularity of taking bronchodilator therapy during remissions of disease, about the treatment of disease exacerbations, results of pulmonary functional tests as follows: FVC (forced vital capacity), FEV1 (forced expiratory volume in one second) and bronchodilator reversibility testing. All these parameters were measured at the beginning and at the end of each hospital treatment on the apparatuses of Clinic \"Podhrastovi\". We took in elaboration those data obtained in the beginning of the first hospitalization and at the end of the last hospitalization or at the last control in outpatient department when patient was in stable state. Patients were divided into three groups according to the number of exacerbations per year. airflow limitation in COPD is progressive; both FVC and FEV1 shows the statistically significant decrease during follow-up period of 4 years (p values / for both parameters/ =0.05) . But in patients regularly treated in phases of remission and exacerbations of illness the course of illness is slower. The fall of FVC and FEV1 is statistically significantly smaller in those received regular treatment in phases of remissions and exacerbations of illness (p values / for both parameters/ =0.01). The number of patients responding properly to bronchodilators decreased statistically significantly in patients with COPD during follow-up period (p=0.05). COPD is characterized with airflow limitation which is progressive in the course of illness, but that course may be made slower using appropriate treatment during remission and exacerbations of diseases." }, { "id": "InternalMed_Harrison_20167", "title": "InternalMed_Harrison", "score": 0.009682768114128394, "content": "Clinical Features Patients are aware of increasing chest tightness, wheezing, and dyspnea that are often not or poorly relieved by their usual reliever inhaler. In severe exacerbations, patients may be so breathless that they are unable to complete sentences and may become cyanotic. Examination usually shows increased ventilation, hyperinflation, and tachycardia. Pulsus paradoxus may be present, but this is rarely a useful clinical sign. There is a marked fall in spirometric values and PEF. Arterial blood gases on air show hypoxemia, and PCO2 is usually low due to hyperventilation. A normal or rising PCO2 is an indication of impending respiratory failure and requires immediate monitoring and therapy. A chest roentgenogram is not usually informative but may show pneumonia or pneumothorax." }, { "id": "wiki20220301en266_12814", "title": "Acute exacerbation of chronic obstructive pulmonary disease", "score": 0.00967937084089534, "content": "The symptoms of acute exacerbations are treated using short-acting bronchodilators. A course of corticosteroids, usually in tablet or intravenous rather than inhaled form, can speed up recovery. The IV and oral forms of steroids have been found to be equivalent. Antibiotics are often used but will only help if the exacerbation is due to an infection. Antibiotics are indicated when a patient notes increased sputum production, purulent sputum, increased dyspnea, has an elevated white count, or is febrile. Examples of first-line antibiotics are amoxicillin, doxycycline, and co-trimoxazole. Mechanical ventilation Severe exacerbations can require hospital care where treatments such as oxygen and mechanical ventilation may be required. Mechanical ventilation can be invasive (endotracheal intubation) or non-invasive forms of ventilation such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP)." }, { "id": "pubmed23n1065_19044", "title": "Shrinking lung syndrome treated with rituximab in pediatric systemic lupus erythematosus: a case report and review of the literature.", "score": 0.009615384615384616, "content": "Shrinking lung syndrome (SLS), a rare complication of systemic lupus erythematosus (SLE) characterized by dyspnea, low lung volumes, and a restrictive pattern on pulmonary function tests (PFTs), has only been reported in a few children. Given the rarity of SLS there is a paucity of literature regarding its optimal treatment. Outcomes are variable, with case reports documenting some improvement in most patients treated with corticosteroids, with or without additional immunosuppressive agents. However, most reported patients did not recover normal lung function. We report full recovery of a child with SLE and SLS following treatment with rituximab and review the current literature. An 11-year-old boy presented with a malar rash, myositis, arthritis, oral ulcers, leukopenia, anemia, positive lupus autoantibodies and Class II nephritis. He was diagnosed with SLE and treated with corticosteroids, hydroxychloroquine, azathioprine, and subsequently mycophenolate with symptom resolution. At age 14, his SLE flared coincident with a viral chest infection. He presented with a malar rash, polyarthritis, increased proteinuria and pleuritis which all improved with corticosteroids and ongoing treatment with mycophenolate. Six weeks later he presented with severe dyspnea, markedly decreased lung volumes, but otherwise normal chest X-ray (CXR) and high-resolution chest computed tomography (HRCT). He was found to have severely restricted PFTs (FEV1 27%, FVC 29%; TLC 43%). After additional investigations including echocardiography, pulmonary CT angiography, and diaphragmatic fluoroscopy, he was diagnosed with SLS and treated with rituximab and methylprednisolone. At 1 month his symptoms had improved, but he still had dyspnea with exertion and severely restricted PFTs. At 6 months his FVC and TLC had improved to 51 and 57% respectively, and were 83 and 94% respectively at 4 years. He had returned to all baseline activities, including competitive hockey. Although extremely rare, it is important to recognize SLS as a possible cause of dyspnea and chest pain in a child with SLE. Optimal treatment strategies are unknown. This is the second reported case of a child treated with rituximab for SLS who recovered normal lung function. International lupus registries should carefully document the occurrence, treatment and outcome of patients with SLS to help determine the optimal treatment for this rare complication." }, { "id": "pubmed23n0566_22037", "title": "COPD--moving beyond bronchodilation.", "score": 0.009615384615384616, "content": "The burden of chronic obstructive pulmonary disease (COPD) remains very high. Till recently clinical approach of COPD patients was focused on measuring airflow limitation during exercise and treating airway obstruction with inhaled bronchodilators and corticosteroids. This approach stems from an old definition of COPD, mainly consisting of airflow limitation with poor reversibility after bronchodilation. The concept of COPD has changed strikingly in the last years. Many recent studies have shown that COPD is a systemic disease affecting not only the lungs but many other organs of the patient. Laboratory cardiopulmonary exercise testing assesses physiological and biological reserves. However, it is not the most suitable test to assess the functional state of a systemic disease such as COPD. We need simpler exercise tests that can be used on larger scales. The 6-minute walk test has been shown to be highly reproducible and reflects real life limitations of these patients better. It allows precise measurements of medical intervention and is a good predictor of mortality, provided clinicians respect the defined standards of this test. It should be associated with a more systemic index such as the BODE index to better find disease-modifying interventions and improve the outcome of COPD patients. On the other hand routine measurement of spirometry in the general population by primary care physicians should be promoted as it decreases smoking habits and helps better detecting and management of COPD patients. Specialists should support primary care physicians to spread these new concepts of COPD throughout the medical community." }, { "id": "wiki20220301en075_55370", "title": "Airway obstruction", "score": 0.009523809523809525, "content": "Lower airway obstruction Lower airway obstruction is mainly caused by increased resistance in the bronchioles (usually from a decreased radius of the bronchioles) that reduces the amount of air inhaled in each breath and the oxygen that reaches the pulmonary arteries. It is different from airway restriction (which prevents air from diffusing into the pulmonary arteries because of some kind of blockage in the lungs). Diseases that cause lower airway obstruction are termed obstructive lung diseases. Lower airway obstruction can be measured using spirometry. A decreased FEV1/FVC ratio (versus the normal of about 80%) is indicative of airway obstruction, as the normal amount of air can no longer be exhaled in the first second of expiration. An airway restriction would not produce a reduced FEV1/FVC ratio, but would reduce the vital capacity. The ventilation is therefore affected leading to a ventilation-perfusion mismatch and hypoxia. Consequences" }, { "id": "pubmed23n0722_18183", "title": "[Diagnosis and therapy of COPD exacerbation].", "score": 0.009523809523809525, "content": "The acute exacerbation of COPD (AECOPD) is a life-threatening clinical situation. This review summarizes the definition of AECOPD, the severity assessment, typical clinical signs and symptoms, and refers to clinical pitfalls of diagnosis and therapy. Important aspects of clinical history and physical examination in severe exacerbations are reported. The necessary accompanying examinations like chest X-ray, blood gas analysis, ECG and echocardiography and their differential diagnosis as well as therapeutic significance are described. The most important lab examinations are summarized and controversial parameters, e.g., procalcitonin, are commented upon. The differentiated need for a microbiological sputum screening is emphasized. The authors place special weight on the essential components of the therapeutic management of severe AECOPD. Practical aspects of uncontrolled oxygen therapy, drug selection, and application form of inhalative acute therapy, dose, and duration of glucocorticoids, the indication for antibiotics, mechanical ventilation, and also opiates are summarized." }, { "id": "pubmed23n0501_12356", "title": "Tiotropium bromide. A review of its use as maintenance therapy in patients with COPD.", "score": 0.009433962264150943, "content": "Tiotropium bromide (Spiriva) is a long-acting anticholinergic bronchodilator that maintains bronchodilation for at least 24 hours, allowing once-daily administration. The active moiety is the tiotropium cation (tiotropium); tiotropium bromide 22.5 micrograms is equivalent to 18 micrograms of tiotropium cation. Greater improvements in lung function from baseline (primary endpoint mean trough FEV(1)) were observed with inhaled tiotropium 18 micrograms once daily than with placebo in 6-month and 1-year randomized, double-blind trials in patients with COPD. Tiotropium improved lung function (trough FEV(1) response) more effectively than ipratropium bromide (ipratropium) 40 micrograms four times daily in 1-year clinical trials, and was at least as effective as salmeterol 50 micrograms 12-hourly in 6-month trials. Preliminary data suggest that tiotropium alone or in combination with once-daily formoterol has a greater bronchodilator effect than twice-daily formoterol in patients with COPD. Improvements in patients' perception of health-related quality of life (HR-QOL) or dyspnea were greater with tiotropium than with placebo or ipratropium, and were similar to those with salmeterol. Reductions in the frequency and severity of acute exacerbations and in the use of rescue medication were also greater with tiotropium than with ipratropium or placebo. There was no evidence of tachyphylaxis with tiotropium during 1-year clinical trials. Inhaled tiotropium was generally well tolerated in clinical trials. Apart from dry mouth, the type and incidence of adverse events with tiotropium were similar to those with ipratropium, salmeterol or placebo in patients with COPD. In conclusion, inhaled tiotropium 18 micrograms once daily improved lung function, dyspnea, and HR-QOL, and decreased the incidence of acute COPD exacerbations and the use of rescue medication relative to placebo or ipratropium in clinical trials in patients with COPD. Tiotropium was at least as effective as salmeterol in terms of bronchodilator efficacy and improvements in dyspnea or HR-QOL. With the exception of dry mouth, the tolerability profile of tiotropium was similar to that with placebo, ipratropium, or salmeterol. Consequently, inhaled tiotropium is likely to be a valuable option for first-line, long-term maintenance therapy in the management of bronchoconstriction in patients with symptomatic COPD. Tiotropium bromide has a quaternary ammonium structure and acts as an anticholinergic bronchodilator; the active moiety is the tiotropium cation (tiotropium). A 22.5 micrograms dose of tiotropium bromide provides 18 micrograms of tiotropium. Orally inhaled tiotropium bromide antagonizes the muscarinic M(1), M(2), and M(3) receptors located in airway smooth muscle, reversing vagally mediated bronchoconstriction. Receptor binding assays and in vitro tests indicate that tiotropium bromide is kinetically selective for M(1) and M(3) receptors over the M(2) receptor, unlike ipratropium bromide, which is nonselective. Animal and in vitro studies showed that tiotropium bromide was more potent ( approximate, equals 20-fold) than ipratropium bromide in displacing [(3)H]N-methylscopolamine (NMS) from muscarinic receptors, and had a more sustained protective effect (&gt;70% inhibition) against NMS binding. Tiotropium bromide was a more potent inhibitor of bronchial contraction than atropine ( approximate, equals 23-fold), and had a slower onset and markedly longer duration of action than atropine or an equipotent dose of ipratropium bromide. Aerosol particle penetration is improved with tiotropium, without delaying mucus clearance from the lungs. Tiotropium 4.5-36 micrograms once daily for 4 weeks increased mean trough and average FEV(1) and FVC and mean PEFR values from baseline compared with placebo, with no evidence of tachyphylaxis. Improvements in trough FEV(1) from baseline with tiotropium 4.5-36 micrograms were not dose dependent. Based on a lack of dose response, the optimal once-daily tiotropium dosage is 18 micrograms. Steady-state trough FEV(1) values are achieved within 48 hours of commencing tiotrochodilation (for &gt;/=24 hours) and an attenuation of the nocturnal decline in FEV(1) that were unaffected by timing of the daily tiotropium dose were seen in randomized, double-blind, placebo-controlled studies in patients with stable COPD. The drug improved static and dynamic lung hyperinflation (evidenced by reduced trapped air volume and increased tidal volume and end-of-exercise inspiratory capacity), and improved exertional dyspnea (during activities of daily living and exertion) and exercise tolerance compared with placebo in randomized, double-blind studies. In patients with stable COPD, improved sleep-related oxygen desaturation that was unaffected by the timing of the daily dose was seen with tiotropium but not with placebo. Clinically significant treatment-related disorders of conduction or rhythm, or changes in heart rate were not observed with tiotropium in this patient group. Mean maximal plasma concentrations (C(max)) were observed within 5 minutes of inhalation of a single dose of tiotropium 18 micrograms in patients with COPD. Plasma drug levels declined to minimum concentrations (C(min)) within 1 hour of treatment in healthy volunteers. Mean steady-state C(max) concentrations (16 ng/L) were achieved after 2-3 weeks of once-daily inhaled tiotropium 18 micrograms in elderly patients with COPD; tiotropium does not appear to accumulate once steady-state has been achieved.The estimated absolute bioavailability of tiotropium at steady state in healthy volunteers was approximately 20-25%, and approximately 72% of the drug is bound to plasma proteins. Excretion of tiotropium is predominantly renal (through active secretion by the kidneys), although in vitro studies suggest that cytochrome P450 (CYP) oxidation (possibly involving CYP2D6 and CYP3A4 enzymes) may have a minor role. In patients with COPD, renal excretion of the unchanged drug at 24 hours (Ae(24)) was approximately 7%. The mean plasma elimination half-life after single or multiple doses in healthy volunteers and elderly patients with COPD was approximately 5-6 days. The renal clearance and urinary excretion of tiotropium decrease with increasing age; however, these changes are not considered to be clinically significant. Because of altered steady-state C(max), C(min), area under the concentration-time curve, and Ae(24) values, caution is required with tiotropium administration in patients with moderate-to-severe renal impairment. The pharmacokinetics of tiotropium in patients with severe renal or hepatic impairment have not been studied. Tiotropium does not interact with drugs such as cimetidine or ranitidine, which are also eliminated by active renal secretion. Orally inhaled tiotropium bromide has been evaluated as a bronchodilator for the management of patients with COPD in randomized, double-blind 6-month and 1-year trials, and in several shorter studies. In clinical trials, COPD was diagnosed according to the American Thoracic Society guidelines. The bronchodilator effect was expressed as the trough FEV(1) response (the mean change in FEV(1) from baseline measured 1 hour prior to and immediately before a scheduled dose), and was the primary endpoint in all but two clinical trials. The bronchodilator effect with tiotropium 18 micrograms once daily was superior to that with placebo in several well designed trials in patients with COPD. Moreover, greater improvements in mean peak and average FEV(1) responses occurred with tiotropium but not with placebo. Mean trough, peak, and average FVC responses, and weekly mean morning and evening PEFR values were also improved to a greater extent with tiotropium than with placebo. Tiotropium demonstrated a greater bronchodilator effect than ipratropium bromide (hereafter referred to as ipratropium when used at approved dosages) 40 micrograms four times daily in two 1-year trials in patients with COPD. Mean peak and average FEV(1), mean trough FVC responses, and weekly mean morning and evening PEFR values were also increased to a greater extent with tiotropium than with ipratropium. In one of the two 6-month trials that compared the efficacy of tiotropium with that of inhaled salmeterol 50 micrograms twice daily, greater improvements from baseline in mean trough, peak, and average FEV(1) and FVC responses were seen with tiotropium than with salmeterol. Increases in weekly mean evening, but not morning, PEFR values were generally greater with tiotropium than salmeterol. In the second trial, improvement in the primary endpoint (mean trough FEV(1) response from baseline) with tiotropium or salmeterol was similar, although peak and average responses were superior with tiotropium. Preliminary results from a 6-week crossover study in patients with COPD suggested that tiotropium alone or in combination with once-daily formoterol improved mean trough and average FEV(1) and trough FVC values from baseline to a greater extent than twice-daily formoterol. More patients achieved a clinically important improvement (increase of &gt;/=1 unit) in the transitional dyspnea index focal score (a measure of dyspnea-related impairment) with tiotropium than with placebo in the 1-year trials. Tiotropium was superior to ipratropium in 1-year trials, and was at least as effective as salmeterol in 6-month trials, in achieving a clinically important improvement in focal scores. Tiotropium recipients experienced fewer COPD exacerbations than placebo or ipratropium recipients and had fewer and shorter COPD-related hospitalizations compared with placebo recipients. Unlike salmeterol, tiotropium lengthened the time to onset of the first exacerbation and decreased the number of exacerbations compared with placebo in two 6-month trials. Similar proportions of tiotropium, salmeterol, and placebo recipients required COPD-related hospitalizations. (ABSTRACT TRUNCATED)" }, { "id": "pubmed23n0880_15697", "title": "Asymptomatic Unilateral Hyperlucent Lung in a Prospective Kidney Donor.", "score": 0.009345794392523364, "content": "A 50 year old lady, prospective kidney donor was referred to our department for opinion in view of abnormal clinical findings during preoperative evaluation. She was asymptomatic from respiratory point of view. Her vital parameters were normal and on auscultation found to have decreased breath sounds and fine crackles throughout left hemithorax. Chest x-ray (CXR) showed left sided hyperlucency with small hilum (Figure 1). High resolution computed tomography (HRCT) showed scattered areas of bronchiectasis with associated air trapping throughout left lung with small left pulmonary artery (Figure 2). Sputum for acid fast bacilli (AFB) was negative. Spirometry showed moderate obstructive abnormality with forced expiratory volume in one second (FEV1) - 51% predicted, forced vital capacity (FVC) - 60% and FEV1/FVC - 76% with no bronchodilator reversibility. On post bronchodilator study there was paradoxical fall in FEV1/FVC to 72% consistent with small airway disease. Arterial blood gas analysis was normal. Technetium (Tc) 99m MAA lung perfusion scan (Figure3) showed normal perfusion of right lung contributing 75.4% of relative function and left lung contributing only 24.6%. Diagnosis of Swyer-James-MacLeod syndrome (SJMS) probably due to a childhood viral infection was made. Operative complications in such cases like difficult weaning and extubation, post-operative respiratory infections, collapse and respiratory failure are likely. However, our patient had an uneventful operative and post-operative course. SJMS is characterized by unilateral hyperlucency of a part of or the entire lung which was first described in 1953 by Swyer and James and later in 1954 by Macleod.1,2 It is considered to be an acquired disease as a result of post-infectious obliterative bronchiolitis. Productive cough, shortness of breath and sometimes hemoptysis are presenting symptoms. Some patients are asymptomatic and not diagnosed until they are adults.3 Radiologically it presents as predominant unilateral hyperlucency. Hence other causes of unilateral hyperlucent lung like pneumothorax, idiopathic giant bullae, congenital lobar emphysema, pulmonary artery hypoplasia, pulmonary embolism and bronchial obstruction due to foreign body or mucus plugs should be considered. Treatment is supportive with early control of super-added infections along with influenza and pneumococcal vaccination. Bronchodilators can be useful, especially if the spirometry shows obstructive abnormality. " }, { "id": "pubmed23n1156_6534", "title": "[COPD: Guidelines for primary care physicians].", "score": 0.009345794392523364, "content": "Chronic obstructive pulmonary disease (COPD) is common and should be suspected in any patient with chronic dyspnea, cough, or sputum with a history of exposure to tobacco or harmful particles. Spirometry is used for diagnosis. Full evaluation includes the severity of obstruction and clinical data, following the Global Initiative for Chronic Obstructive Lung Disease guidelines. Although the only treatments that have an impact on mortality are tobacco cessation, pulmonary rehabilitation and, for advanced disease, oxygen therapy, new symptomatic treatment have recently been made available. The duration of antibiotic and corticosteroid treatment for exacerbations has been shortened. The new diagnostic and management recommendations are summarized in this article." }, { "id": "pubmed23n0629_15736", "title": "[Combined pulmonary fibrosis and emphysema - case report and literature review].", "score": 0.009259259259259259, "content": "We describe the case of a 61-year-old male patient, in which the search for the cause of chronic respiratory failure, severe pulmonary hypertension and secondary erythrocytosis resulted in a diagnosis of combined pulmonary fibrosis and emphysema (CPFE). This is a unique, recently characterised syndrome with upper-lobe emphysema and pulmonary fibrosis of the lower lungs. The cause is unknown, but one of the main risk factor remains smoking. The patient was a heavy smoker (over 40 pack-years). He complained of dyspnoea on exertion and cough. Physical examination revealed basal crackles and cyanosis. The patient had severe reduction in diffusing capacity, out of proportion to his lung volumes (DLCO 27% of predicted value, FEV1 2.95 l (100%), FVC 4.41 l (118%), FEV1/FVC (66%). The blood gas showed hypoxemia (pO2 37 mm Hg), hypocapnia and respiratory alkalosis. Diagnosis was based on chest computer tomography, which revealed upper lobe emphysema and lower lobe ground glass changes and honeycombing. Severe pulmonary hypertension (SPAP 80 mm Hg) was confirmed by echocardiography and right cardiac catherisation. The patient received long-term oxygen therapy, inhaled corticosteroid and Ca-blocker." }, { "id": "pubmed23n0521_20955", "title": "Shortness of breath--is it chronic obstructive pulmonary disease?", "score": 0.009259259259259259, "content": "Of all the major diseases, chronic obstructive pulmonary disease (COPD) is the one for which the burden is increasing the fastest. This article discusses the diagnoses and assessment of COPD, and provides management guidelines including smoking cessation, bronchodilator therapy, the use of inhaled corticosteroids, combination therapies, oxygen therapy, and rehabilitation. Diagnosis is by clinical suspicion in patients with an appropriate clinical history and airflow obstruction is confirmed using spirometry. Although smoking cessation and oxygen in selected individuals are the only interventions known to alter the natural history of COPD, many other treatments can significantly lessen breathlessness, reduce exacerbations, and improve exercise and quality of life." }, { "id": "pubmed23n0093_4324", "title": "Pneumocystis Carinii pneumonia in an AIDS patient with dramatic response to inadvertent steroid therapy--a case report.", "score": 0.009174311926605505, "content": "A 28 year-old homosexual man had one month history of intermittent high fever, nonproductive cough and progressive shortness of breath. He not only had immunity deficits, with decrease CD4 cells decreased CD8 cells and inverted CD4/CD8 ratio, but also presented with evidence of human immunodeficiency virus infection (positive ELISA antibody tests and Western blot tests). Chest X-ray showed diffuse pulmonary infiltration. The arterial blood gases revealed hypoxemia. The PaO2 was 69 mmHg. Spirometry showed FVC 2.28 L (45% predicted), FEV1 2.21 L (49% predicted), FEV1/FVC 93%, and MMEF 4.41 L/sec (90% predicted). The configuration of the Flow-Volume loop was consistent with a restrictive ventilatory defect. Transthoracic lung biopsy demonstrated pneumocystis carinii pneumonia (PCP). He had inadvertent steroid therapy and showed some clinical, pulmonary function and chest X-ray improvement before the diagnosis was established. Steroids might be as adjunctive therapy for a short period of time in treatment of PCP associated with acquired immunodeficiency syndrome (AIDS) at respiratory failure." }, { "id": "pubmed23n1010_12135", "title": "Respiratory Conditions: Chronic Obstructive Pulmonary Disease.", "score": 0.009174311926605505, "content": "Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease characterized by cough, dyspnea, and sputum production caused by inhalation of harmful chemicals, such as tobacco smoke. COPD should be suspected in patients with a significant smoking history, shortness of breath, and sputum production. The diagnosis is made by spirometry. A forced expiratory volume in the first second of expiration to forced vital capacity (FEV<sub1</sub/FVC) ratio of less than 0.7 after bronchodilator administration confirms the diagnosis. Therapy for patients with stable COPD should include a bronchodilator, either a long-acting beta<sub2</sub-agonist (LABA) or a long-acting muscarinic antagonist (LAMA). For patients who continue to experience dyspnea with a single bronchodilator, dual therapy with a LABA and LAMA is appropriate. For patients with continued exacerbations, inhaled corticosteroids can be added to LABA-LAMA therapy. Acute exacerbations are characterized by a worsening of symptoms that requires additional therapy. Short-acting beta2-agonists with or without short-acting muscarinic antagonists are the basic therapy for acute exacerbations of COPD. Systemic glucocorticoids have been shown to shorten exacerbations and improve lung function. Antibiotics have been shown to reduce rates of treatment failure and sputum purulence. Noninvasive mechanical ventilation is preferred for patients with respiratory failure." }, { "id": "pubmed23n0849_10174", "title": "Traumatic Inhalation due to Merapi Volcanic Ash.", "score": 0.00909090909090909, "content": "Pneumonoultramicroscopicsilicovolcanoconiosis is fibrotic lung diseases of the pulmonary parenchyma following chronic inhalation of inorganic dusts containing crystalline silicon dioxide. The acute manifestations observed after heavy ashfalls include attacks of asthma and bronchitis, with an increased reporting of cough, breathlessness, chest tightness, and wheezing due to irritation of the lining of the airways. The chronic health condition of most concern is silicosis, a diffuse nodular fibrosis of the lungs, develops slowly, usually appearing 10 to 30 years after first exposure. A 35 years old male was admitted to Sardjito Hospital, Yogyakarta with complaints of progressive dyspnoea, right side chest pain since last 3 month and periodic episodes of dry cough. He had history of exposure to volcanic ash at the location around volcano eruption for about 10 month. Examination revealed hyperresonant note, diminished vesicular breath sounds in lower right side of the chest. The chest X-ray presence leads to bleb. Based on the clinical and radiological suspicion of pneumoconiosis the patient was submitted to computed tomography of the chest and revealed bilateral multiple bullae mainly at the right lung field. The biopsy specimen verified the diagnosis of anthrocosilicosis. There is no proven specific therapy for any form of silicosis. Symptomatic therapy should include treatment of airflow limitation with bronchodilators, aggressive management of respiratory tract infection with antibiotics, and use of supplemental oxygen (if indicated) to prevent complications of chronic hypoxemia." }, { "id": "article-21034_14", "title": "Emphysema -- History and Physical", "score": 0.00909090909090909, "content": "Most patients present with very nonspecific symptoms of chronic shortness of breath and cough with or without sputum production. As the disease process advances, the shortness of breath and cough progressively get worse. Initially, there is exertional dyspnea with significant physical activity, especially arm work at or above shoulder level, with progression to dyspnea with simple daily activities and even at rest. Some patients may present with wheezing because of airflow obstruction." }, { "id": "Pediatrics_Nelson_1800", "title": "Pediatrics_Nelson", "score": 0.009083793359149706, "content": "Initial assessment Brief history, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate), PEF or FEV1, oxygen saturation, and other tests as indicated Severe exacerbation FEV1 or PEF <40% predicted/personal best Physical exam: severe symptoms at rest, accessory muscle use, chest retraction History: high-risk patient No improvement after initial treatment  Oxygen  Nebulized SABA plus Ipratropium, hourly or continuous  Oral systemic corticosteroids  Consider adjunct therapies Moderate exacerbation FEV1 or PEF 40–69% predicted/personal best Physical exam: moderate symptoms  Inhaled SABA every 60 minutes  Oral systemic corticosteroid  Continue treatment 1–3 hours, provided there is improvement; make admit decision in <4 hours" }, { "id": "pubmed23n0827_9352", "title": "Predictors of treatment with antibiotics and systemic corticosteroids for acute exacerbations of asthma and chronic obstructive pulmonary disease in primary care.", "score": 0.009009009009009009, "content": "Antibiotic and oral corticosteroid prescribing rate in patients suffering from acute exacerbations of chronic obstructive pulmonary disease (COPD) or asthma in general practice are only sparsely described. Our aim was to identify predictors for such prescribing when results from CRP testing, spirometry, and pulse oximetry are available. Patients aged 40 years or more diagnosed with asthma, COPD or both, the previous five years from seven general practice offices in Norway, were invited to a baseline examination and asked to visit their GPs during exacerbations the following 12 months. At all visits, symptoms, chest findings, and results from spirometry, pulse oximetry and CRP testing were registered. Out of the 376 who took part in baseline examination, 95 patients with an exacerbation were included in the analysis. Based on the diagnosis made by GPs, 46 patients (48.4%) were only registered with asthma, and 49 (51.6%) with COPD (or both diagnosis). 11 patients had taken antibiotics and 16 had taken systemic corticosteroids prior to their visit to their GPs. After excluding those already treated, antibiotics were prescribed in 34.9% and systemic corticosteroids in 42.5% of patients diagnosed with COPD compared to 14.6% and 30.8% respectively in patients only diagnosed with asthma (P = 0.02, P = 0.2). In the COPD group, antibiotic prescribing was not significantly associated with purulence or other respiratory symptoms, but increased phlegm was a significant predictor of antibiotic prescribing in the whole sample (P = 0.04). Prolonged expiration, wheezes and diminished breath sounds also predicted the prescribing of both antibiotics and systemic corticosteroids in the whole sample with P values &lt; 0.01. The prescribing rate of antibiotics and systemic corticosteroids also increased with increasing CRP value (P = 0.001 and P = 0.01, respectively) and with decreasing oxygen saturation (P = 0.01 and P = 0.003, respectively). FEV1/FVC &lt; 0.7 at baseline was as significant predictor in patients with COPD and in the whole sample of patients regarding treatment with antibiotics (P = 0.004 and P = 0.001, respectively) and treatment with systemic corticosteroids (P = 0.004 and P = 0.001, respectively). Chest findings, raised CRP value and decreased oxygen saturation were stronger predictors of prescribing of antibiotics and systemic corticosteroids than were respiratory symptoms. Further evaluation of the importance of these findings to guide treatment of asthma and COPD exacerbations is warranted." } ] } } }

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{ "1": "Viral meningitis.", "2": "Bacterial meningitis.", "3": "Tuberculous meningitis.", "4": "Mononucleosis syndrome.", "5": "Guillain-Barre syndrome." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en009_127257", "title": "Viral meningitis", "score": 0.014578408195429472, "content": "The diagnosis of viral meningitis is made by clinical history, physical exam, and several diagnostic tests. Kernig and Brudzinski signs may be elucidated with specific physical exam maneuvers, and can help diagnose meningitis at the bedside. Most importantly however, cerebrospinal fluid (CSF) is collected via lumbar puncture (also known as spinal tap). This fluid, which normally surrounds the brain and spinal cord, is then analyzed for signs of infection. CSF findings that suggest a viral cause of meningitis include an elevated white blood cell count (usually 10-100 cells/µL) with a lymphocytic predominance in combination with a normal glucose level. Increasingly, cerebrospinal fluid PCR tests have become especially useful for diagnosing viral meningitis, with an estimated sensitivity of 95-100%. Additionally, samples from the stool, urine, blood and throat can also help to identify viral meningitis. CSF vs serum c-reactive protein and procalcitonin have not been shown to elucidate" }, { "id": "pubmed23n0319_20053", "title": "[Laboratory and clinical variables in the differential diagnosis of aseptic and pyogenic meningitis in children].", "score": 0.01424775517683709, "content": "We reviewed the charts of 573 children with a final diagnosis of pyogenic or aseptic meningitis, who were hospitalized in a large reference hospital for the treatment of infectious disease, from January 1990 to December 1992. Seizures, decreased consciousness, nuchal rigidity were more frequent in bacterial than in aseptic meningitis. A cerebrospinal fluid (CSF) glucose level lower than 45 mg/dL, a protein level equal or greater than 140 mg/dL and cell count greater than 600/mm3 were predictors of pyogenic meningitis. Receiver operating characteristic curve analysis was used to assess the best point in CSF measures of leukocytes, glucose and protein that could predict bacterial meningitis. These results suggest that clinicians should differentiate bacterial from aseptic meningitis in children with greater accuracy utilizing only clinical and simple CSF data." }, { "id": "pubmed23n0343_17083", "title": "C-reactive protein is useful in distinguishing Gram stain-negative bacterial meningitis from viral meningitis in children.", "score": 0.013621142184813105, "content": "To clarify to what extent Gram stain-negative bacterial meningitis can be distinguished from viral meningitis by assessment of cerebrospinal fluid (CSF) and blood indices and serum C-reactive protein (CRP) in children over 3 months of age. Common CSF indices, blood leukocyte counts, and serum CRP values were compared between patients with bacterial meningitis who had a positive CSF bacterial culture but a negative Gram stain and patients with viral meningitis. Three hundred twenty-five consecutive patients with CSF culture-proven bacterial meningitis, for whom Gram stain was negative in 55 cases, and 182 children with proven or presumed viral meningitis. Significant differences between patients with bacterial and viral meningitis were found in all indices with large overlap in all except serum CRP. In patients with bacterial meningitis, the mean CSF glucose concentration, protein concentration, leukocyte count, blood leukocyte count, and serum CRP were 2.9 mmol/L (52 mg/dL), 1.88 g/L, 4540 x 10(6)/L, 18.0 x 10(9)/L, and 115 mg/L; and in those with viral meningitis, mean values were 3.3 mmol/L (59 mg/dL), 0.52 g/L, 240 x 10(6)/L, 10.6 x 10(9)/L, and &lt;20 mg/L, respectively. Of the tests investigated in this study, only serum CRP was capable of distinguishing Gram stain-negative bacterial meningitis from viral meningitis on admission with high sensitivity (96%), high specificity (93%), and high negative predictive value (99%). Exclusion of bacterial meningitis with only the conventional tests is difficult. Combined with careful physical examination and CSF analyses, serum CRP measurement affords substantial aid." }, { "id": "wiki20220301en250_3066", "title": "Meningitis", "score": 0.01321250691754289, "content": "The concentration of glucose in CSF is normally above 40% of that in blood. In bacterial meningitis it is typically lower; the CSF glucose level is therefore divided by the blood glucose (CSF glucose to serum glucose ratio). A ratio ≤0.4 is indicative of bacterial meningitis; in the newborn, glucose levels in CSF are normally higher, and a ratio below 0.6 (60%) is therefore considered abnormal. High levels of lactate in CSF indicate a higher likelihood of bacterial meningitis, as does a higher white blood cell count. If lactate levels are less than 35 mg/dl and the person has not previously received antibiotics then this may rule out bacterial meningitis." }, { "id": "Neurology_Adams_114", "title": "Neurology_Adams", "score": 0.01273148148148148, "content": "The protein content of the CSF in bacterial meningitis may reach 500 mg/dL or more. Viral infections induce a less intense and mainly lymphocytic reaction and a lesser elevation of protein—usually 50 to 100 mg/dL but sometimes up to 200 mg/dL; in some instances of viral meningitis and encephalitis the protein content is normal. Brain tumors, by opening the blood–CSF barrier, can raise the total protein. Protein values as high as 500 mg/dL are found in exceptional cases of the Guillain-Barré syndrome and in chronic inflammatory demyelinating polyneuropathy. Values in the lumbar CSF of 1,000 mg/dL or more usually indicate a block to CSF flow, typically in the spinal canal; the fluid is then deeply yellow and clots readily because of the presence of fibrinogen, a phenomenon called Froin syndrome. Partial CSF blocks by ruptured discs or tumor may elevate the protein to 100 to 200 mg/dL. Low CSF protein values are sometimes found in meningismus (a febrile illness in children with signs of" }, { "id": "pubmed23n0387_2063", "title": "Aseptic meningitis in a large MMR vaccine campaign (590,609 people) in Curitiba, Paraná, Brazil, 1998.", "score": 0.012329503460323861, "content": "The aseptic meningitis after Measles-Mumps-Rubella vaccine (MMR) is a well recognized complication, and different incidences have been observed in several studies. We retrospectively analyzed forty cases of aseptic meningitis, during a large public immunization campaign (1998) in Curitiba, Southern Brazil (590,609 people), admitted in our Service. The vaccine utilized was Leningrad-3-Zagreb mumps strain, Edmonston-Zagreb measles strain, and RA 27#3 rubella strain. In all county, a total number of 87 cases were reported, resulting in a incidence of 1.7 cases per 10,000 given doses. The mean age was 23.7 +/- 12.8 years. The female:male ratio was 1.35:1. Severe headache with meningismus (92.5%), fever (87.5%), nausea/vomiting (82.5%) were the most common clinical findings. Three cases (7.5%) developed mild mumps. All patients underwent cerebrospinal fluid (CSF) tap with the following findings: mononuclear pleocytosis from 100 to 500 cells/mm(3) in 17 cases (42.5%; 257.5 +/- 260.6 cells/mm3); increased protein 28 cases (67.5%; 92.1 +/- 76.9 mg/dL); glucose was normal in all cases (56.8 +/- 11.2 mg/dL) except in 4 (10%) cases, which presented less than 44 mg/dL. All serological tests (latex to bacterial meningitis, Cryptococcus, cysticercosis, VDRL) and bacteriological cultures were negative. Virus identification were also negative in 8 samples. None of the patients had neurological deficits or related symptoms after one year of onset. We believe the benefit of vaccination clearly outweighs the incidence of benign vaccine-associated meningitis." }, { "id": "wiki20220301en257_32597", "title": "CSF albumin", "score": 0.012329174093879977, "content": "CSF albumin is a measurement used to determine the levels of albumin in cerebrospinal fluid. A closely related test, CSF total protein is a measurement used to determine the levels of protein in cerebrospinal fluid. It combines the albumin, IgG, and other proteins. It can be useful in distinguishing among causes of Meningitis. It is more likely to be elevated in bacterial meningitis than in viral meningitis. The upper normal range is 150 mg/dl in neonates, and 50 mg/dl in adults. References Body fluids CSF tests" }, { "id": "wiki20220301en369_6049", "title": "Neonatal meningitis", "score": 0.012293334596617557, "content": "Laboratory features Laboratory features that are characteristic of neonatal bacterial meningitis include: Isolation of a bacterial pathogen from the cerebrospinal fluid by culture and/or visualization by Gram stain Increased cerebrospinal fluid white blood cell count (typically >1000 white blood cells/μL, but may be lower, especially with Gram-positive bacteria), usually with a predominance of neutrophils Elevated cerebrospinal fluid]] protein concentration (>150 mg/dL in preterm (premature birth) and >100 mg/dL in term infants) Decreased cerebrospinal fluid glucose concentration (<20 mg/dL [1.1 mmol/L] in preterm (premature birth) and <30 mg/dL [1.7 mmol/L] in term (on time) infants) Causes" }, { "id": "pubmed23n0723_16983", "title": "Clinical prediction rule for differentiating tuberculous from viral meningitis.", "score": 0.01215738284703802, "content": "The Professor Dr Matei Bals National Institute of Infectious Diseases, Bucharest, Romania. To create a prediction rule to enable clinicians to differentiate patients with tuberculous meningitis (TBM) from those with viral meningitis. We retrospectively analysed patients admitted to a tertiary care facility between 2001 and 2011 with viral meningitis and TBM. Patients were defined as having TBM according to a recently published consensus definition, and as viral meningitis if a viral aetiology was confirmed, or after ruling out bacterial, fungal and non-infectious causes of meningitis. We identified 433 patients with viral meningitis and 101 TBM patients and compared their clinical and laboratory features. Multivariable analysis showed a statistically significant association between TBM and the following variables: duration of symptoms before admission of ≥5 days, presence of neurological impairment (altered consciousness, seizures, mild focal signs, multiple cranial nerve palsies, dense hemiplegia or paraparesis), cerebrospinal fluid/blood glucose ratio &lt; 0.5 and cerebrospinal fluid protein level &gt; 100 mg/dl. We propose a diagnostic score based on the coefficients derived from the logistic regression model with a sensitivity and specificity for TBM of respectively 92% and 94%. Our study suggests that easily available clinical and laboratory data are very useful for differentiating TBM from other causes of meningitis." }, { "id": "pubmed23n0515_20542", "title": "Accuracy and test characteristics of ancillary tests of cerebrospinal fluid for predicting acute bacterial meningitis in children with low white blood cell counts in cerebrospinal fluid.", "score": 0.012034868592245642, "content": "To determine whether ancillary tests of cerebrospinal fluid (CSF), specifically, the total protein concentration, glucose concentration, and percent neutrophils, provide information for diagnosing acute bacterial meningitis among children with low white blood cell (WBC) count in CSF. The authors retrospectively reviewed CSF from children aged 1 month to 18 years undergoing lumbar puncture at Children's Hospital in Boston from 1993 to 1999. Data were supplemented with CSF test results obtained from children with 0-30 WBCs/mm(3) in CSF diagnosed with acute bacterial meningitis at the same institution from 1984 to 1992. For each test, the incremental value of ancillary tests was estimated by calculating indices of performance such as the area under receiver operator characteristic curves (AUC) and interval likelihood ratios that are relatively insensitive to disease prevalence. Among children with 0-30 WBCs/mm(3) in CSF who met study criteria, acute bacterial meningitis was identified in ten of 7,701 (0.1%) for the period from 1993 to 1999 and supplemented with 11 additional cases for the period from 1984 to 1992. AUC values for ancillary tests were 0.61 for total protein concentration, 0.69 for glucose concentration, and 0.90 for percent neutrophils. Interval likelihood ratios were unremarkable for mildly abnormal test results. In contrast, interval likelihood ratios for markedly abnormal test results were higher: 22 for total protein concentration &gt;120 mg/dL, 57 for neutrophils &gt;75%, 15 for glucose concentration &lt;20 mg/dL, and 20 for glucose concentration &gt;120 mg/dL. When markedly abnormal, results of CSF total protein concentration, glucose concentration, and percent neutrophils have value for diagnosing acute bacterial meningitis, even among children with a low WBC count in CSF." }, { "id": "article-24970_13", "title": "Viral Meningitis -- Evaluation", "score": 0.01153983778625954, "content": "In adults, researchers have studied individual predictors of bacterial rather than viral meningitis. In one study, these predictors included CSF glucose less than 34 mg/dL, CSF WBC over 2000 cells/mm3, CSF neutrophils greater than 1180, CSF protein over 220 mg/dL, and a ratio of CSF to blood glucose less than 0.23.15. [17] CSF lactate has been shown to be a good indicator to differentiate bacterial from aseptic meningitis. [18] [19] The combination of CSF results, such as enterovirus and lactate, with the BMS, can increase sensitivity and specificity. [20] [21]" }, { "id": "Neurology_Adams_5845", "title": "Neurology_Adams", "score": 0.011406454783748361, "content": "Laboratory findings suggest certain organisms as the cause of aseptic meningitis. Most cases of infectious mononucleosis can be identified by the blood smear and specific serologic tests (heterophil or others). LCM should be suspected if there is an intense lymphocytic pleocytosis. Counts above 1,000 cells/mm3 in the spinal fluid, particularly if the cells are all lymphocytes, are most often due to LCM but may occur occasionally with mumps or echovirus 9. In the last of these agents, neutrophils may predominate in the CSF for a week or longer. Slightly depressed glucose in the spinal fluid is consistent with mumps meningitis and with the viruses mentioned earlier, but it is more often indicative of bacterial or fungal infection." }, { "id": "Neurology_Adams_8256", "title": "Neurology_Adams", "score": 0.011144411144411146, "content": "The CSF contains a moderate number of white blood cells, mostly lymphocytes and mononuclear cells, and the protein content is in the range of 100 to 400 mg/dL (i.e., a higher protein content than all other neonatal infections except bacterial meningitis). The glucose values are normal. Fewer than 10 percent of infected children recover; the others are developmentally delayed to varying degrees, with seizures and paralysis. In those without symptoms of infection at birth, the outcome is better." }, { "id": "InternalMed_Harrison_10964", "title": "InternalMed_Harrison", "score": 0.010416666666666668, "content": "LABORATORY DIAGNOSIS CSF Examination The most important laboratory test in the diagnosis of viral meningitis is examination of the CSF. The typical profile is a pleocytosis, a normal or slightly elevated protein concentration (0.2–0.8 g/L [20–80 mg/dL]), a normal glucose concentration, and a normal or mildly elevated opening pressure (100–350 mmH2O). Organisms are not seen on Gram’s stain of CSF. The total CSF cell count in viral meningitis is typically 25–500/μL, although cell counts of several thousand/μL are occasionally seen, especially with infections due to lymphocytic choriomeningitis virus (LCMV) and mumps virus. Lymphocytes are typically the predominant cell. Rarely, PMNs may predominate in the first 48 h of illness, especially with infections due to echovirus 9, West Nile virus, eastern equine encephalitis (EEE) virus, or mumps. A PMN pleocytosis occurs in 45% of patients with West Nile virus (WNV) meningitis and can persist for a week or longer before shifting to a" }, { "id": "article-24970_12", "title": "Viral Meningitis -- Evaluation", "score": 0.010400186133085156, "content": "Because of the lack of clinical findings to help distinguish between viral and bacterial meningitis and the risk of untreated bacterial meningitis, there has been much interest in identifying predictors of bacterial meningitis. The bacterial meningitis score (BMS) was originally developed for and validated in children with meningitis. The score is comprised of four laboratory predictors (positive Gram stain, CSF protein over 80 mg/dL, peripheral absolute neutrophil count greater than 10000 cells/mm3, CSF absolute neutrophil count over 1000 cells/mm3) and one clinical predictor (seizure at or before the presentation). A positive Gram stain is worth 2 points, and the other predictors are worth 1 point each if present. The negative predictive value for a score of 0 was 100%; a score of more than 2 predicted bacterial meningitis with 87% sensitivity. [15] The BMS has also undergone validation in adults with meningitis. [16]" }, { "id": "article-24964_17", "title": "Aseptic Meningitis -- Evaluation", "score": 0.010363520408163265, "content": "Typical CSF results in patients with aseptic meningitis include: Opening pressure either normal (<180 mmH2O) or slightly elevated, glucose normal to mildly decreased, protein normal to mildly elevated (<200mg/dL), cell count of 10-1000 cells per microliter (initially neutrophils (>50%) may predominate with a gradual shift toward lymphocytes (>80%). [2] [3] [6] Numerous differences have been found between adults and children concerning their presentation and their laboratory findings. [6]" }, { "id": "pubmed23n0118_17042", "title": "Mumps meningo-encephalitis.", "score": 0.009900990099009901, "content": "Between July 1981 and June 1985, 49 cases (36 boys (73%) and 13 girls (27%] of mumps meningo-encephalitis confirmed by culture of the virus from the cerebrospinal fluid (CSF) were seen. Patients presented particularly in the late spring and early summer. A CSF cell count greater than 500 X 10(6)/l was obtained in 14 cases (28%), a total CSF protein greater than 0.8 g/l in 6 cases (12%) and a CSF glucose of less than 2.2 mmol/l in 2 cases (4%). Two cases are reported to illustrate the diagnostic problems which the infection may cause, particularly when the CSF changes resemble those of tuberculous meningitis. In 1 case neurogenic pulmonary oedema developed after a convulsion; this caused further diagnostic uncertainty." }, { "id": "pubmed23n0411_13646", "title": "[Guillain-Barré syndrome as a rare cause of acute respiratory insufficiency].", "score": 0.00980392156862745, "content": "Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating disease of peripheral nerves. Antibodies acting against antigens on the myelin or the axons seem to play a causative role. In up to 80 % the onset of GBS follows an antecedent respiratory or gastrointestinal infection. An 20 month old boy was referred to our hospital because of meningism and aspiration pneumonia. 10 days earlier the patient had experienced a period of fever. Because of respiratory insufficiency the patient was intubated, sedated and received mechanical ventilation. That's why a major neurological examination was not possible. The patient demonstrated a flaccid tetraplegic paralysis and autonomic dysfunction with elevated blood pressure, tachycardia, elevated ADH level and hyperglycaemia. Decreased motor nerve conduction and an increased CSF protein with normal CSF cell count confirmed diagnosis of GBS. Active CMV infection was diagnosed by PCR as the possible trigger factor. Intravenous immunoglobulins were given and the patient reached a complete remission except a slight disturbance of peroneal nerve. IVIG and PP therapy are equally effective in GBS. In contrast corticosteroids are not of benefit. Prognosis of childhood GBS is good. Only 4 % of affected children demonstrate persistent muscular weakness. The long interval between admission and diagnosis in the reported case emphasized the importance of neurological examination especially in sedated patients." }, { "id": "First_Aid_Step2_457", "title": "First_Aid_Step2", "score": 0.009767049161453736, "content": "TABLE 2.8-4. CSF Prof les Normal < 10 < 5 ∼2/3 of serum 15–45 10–20 Clear 3–12 Bacterial meningitis ↔ ↑ (> 1000 PMNs) ↓ ↑ ↑ Cloudy ↔ or ↑ Viral meningitis ↔ ↑ (monos/ lymphs) ↔ ↔ or ↑ ↔ or ↑ Most often clear ↔ or ↑ Aseptic meningitis ↔ ↑ ↔ ↔ or ↑ ↔ Clear ↔ SAH ↑↑ ↑ ↔ ↑ ↔ or ↑ Yellow/red ↔ or ↑ Guillain-Barré syndrome ↔ ↔ ↔ or ↑ ↑↑ ↔ Clear or yellow (high protein) ↔ MS ↔ ↔ or ↑ ↔ ↔ ↔ Clear ↑↑ Pseudotumor cerebri ↔ ↔ ↔ ↔ ↑↑↑ Clear ↔ Antibiotics should be administered rapidly (see Table 2.8-5) and may be given empirically up to two hours before an LP is performed. Some cases of viral meningitis can be treated with supportive care and close follow-up. Close contacts of patients with meningococcal meningitis should receive rifampin, ciprofoxacin, or ceftriaxone prophylaxis." }, { "id": "wiki20220301en178_38961", "title": "Ranson criteria", "score": 0.009708737864077669, "content": "Acute pancreatitis not secondary to gallstones At admission: Blood glucose > 11.11 mmol/L (> 200 mg/dL) Age > 55 years Serum LDH > 350 IU/L Serum AST > 250 IU/L WBC count > 16000 cells/mm3 Within 48 hours: Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit decreased by > 10% Oxygen (hypoxemia with PaO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration Base deficit (negative base excess) > 4 mEq/L Sequestration of fluids > 6 L Acute pancreatitis secondary to gallstones At admission: Glucose > 220 mg/dl Age > 70 years LDH > 400 IU/L AST > 250 IU/ 100 ml WBC count > 18000 cells/mm3 Within 48 hours: Serum calcium < 8 mg/dL Hematocrit decreased by > 10% Base deficit > 4 mEq/L BUN increased by > 2 mg/dL Sequestered fluid > 6L" }, { "id": "InternalMed_Harrison_15507", "title": "InternalMed_Harrison", "score": 0.009708737864077669, "content": "pleocytosis; the CSF cell count shows a shift from neutrophil to lymphocyte predominance within 1 day of presentation, and the total cell count does not exceed 1000/μL. The CSF glucose level is usually normal (in contrast to the low CSF glucose level in mumps), with a normal or slightly elevated protein concentration. Partially treated bacterial meningitis may be particularly difficult to exclude in some instances. Enteroviral meningitis is more common in summer and fall in temperate climates, while viral meningitis of other etiologies is more common in winter and spring. Symptoms ordinarily resolve within a week, although CSF abnormalities can persist for several weeks. Enteroviral meningitis is often more severe in adults than in children. Neurologic sequelae are rare, and most patients have an excellent prognosis." }, { "id": "Neurology_Adams_9783", "title": "Neurology_Adams", "score": 0.009615384615384616, "content": "children younger than 2 years of age; in older children, it is more likely to develop in recurrent and less severe episodes. This clinical syndrome must be distinguished from tuberculous meningitis, viral meningoencephalitis, and the various conditions causing acute increased intracranial pressure. Usually, in lead encephalopathy, the CSF is under increased pressure with manifest papilledema, and there may be a slight lymphocytic pleocytosis and elevated protein but normal glucose values. It follows that lumbar puncture should be done with caution and only if it is essential for diagnosis." }, { "id": "article-24970_11", "title": "Viral Meningitis -- Evaluation", "score": 0.009598707032481866, "content": "A lumbar puncture is necessary unless there are contraindications such as focal neurologic deficits, papilledema, recent seizures, age 60 or greater. [1] [11] Indications for imaging before performing a lumbar puncture include focal neurological signs, papilledema, continuous or uncontrolled seizures, or a Glasgow Coma Score less than 12. [12] Cerebrospinal fluid (CSF) analysis, including cell count and differential, glucose, protein, culture, and molecular diagnostics as available, should be performed. Viral meningitis characteristically has a CSF mononuclear pleocytosis, although there may initially be a neutrophilic predominance. [1] This neutrophilic predominance is not limited to the first 24 hours of illness and is not a reliable indicator between viral and bacterial meningitis. [1] [13] Polymerase chain reaction (PCR) tests can be used to diagnose some causes of viral meningitis, such as enterovirus, VZV, and HSV. Serum white blood cell count and C-reactive protein do not reliably distinguish viral and bacterial meningitis. [1] CSF C-reactive protein and procalcitonin have not been shown to differentiate viral vs. bacterial meningitis compared to serum levels. [14]" }, { "id": "Neurology_Adams_5896", "title": "Neurology_Adams", "score": 0.009534534534534535, "content": "The CSF is typically under increased pressure and almost invariably shows a pleocytosis (range 10 to 200 cells/mm3; infrequently greater than 500 cells/mm3). The cells are mostly lymphocytes, but there may be a significant number of neutrophils early on. In a few cases, 3 to 5 percent in some large series, the spinal fluid was normal in the first days of the illness, only to become abnormal when reexamined. The hemorrhagic nature of brain tissue destruction with this infection is infrequently reflected in the spinal fluid. In fact, in only a minority of cases, red cells, sometimes numbering in the thousands but usually far fewer, and xanthochromia are found. The protein content is increased in most cases. Rarely, the CSF glucose levels may be reduced to slightly less than 40 mg/dL, creating confusion with tuberculous and fungal meningitides. The cerebral imaging appearance, giving highly characteristic features, is discussed later in the section on “Diagnosis.”" }, { "id": "pubmed23n0043_6726", "title": "[Nested polymerase chain reaction for the diagnosis and follow-up of tuberculous meningitis: a case report].", "score": 0.009523809523809525, "content": "We presented a case of tuberculous meningitis in which a nested polymerase chain reaction was useful for its rapid diagnosis and follow-up. A 5-month-old girl was hospitalized for gastrointestinal complaints of 4 days' duration. She initially had no meningeal signs, but showed a bulging of the anterior fontanel on the 10th day of her illness. Cerebrospinal fluid examination revealed a cell count of 886/3 microliters (80% lymphocytes), protein of 20 mg/dl, and glucose of 27 mg/dl. Tuberculous meningitis was suspected clinically and an antituberculous therapy was commenced on the 13th day. Although repeated attempts to culture Mycobacterium tuberculosis were negative, the DNA of the organism was detected sequentially from the cerebrospinal fluid of the 13th and 16th day by the method of a nested polymerase chain reaction. The final diagnosis of tuberculous meningitis was established on the basis of the positive results of the nested polymerase chain reaction, a positive tuberculin test, and typical cerebrospinal fluid findings. She recovered rapidly in response to the therapy and was discharged from the hospital without any neurological sequelae on the 89th day. The follow-up samples of the nested polymerase chain reaction resulted as negative after the 26th day of the illness." }, { "id": "pubmed23n0316_9375", "title": "[The value of C-reactive protein for the differentiation of bacterial meningitis from viral meningitis].", "score": 0.009523809523809525, "content": "In order to differentiate bacterial meningitis versus viral meningitis, we have comparatively tested the efficacy of the following tests: C-reactive protein (CRP), erythrocytes sedimentation rate (ESR), fever, level of glucose in cerebro-spinal fluid (CSF), glucose in CSF/glycemia ratio, number of white blood cells in peripheric blood, percentage of neutrophils in peripheric blood, level of proteins in CSF and number of nucleated cells in CSF for a group of 49 patients, both children and adults with central nervous system infection (37 patients with bacterial meningitis and 12 with viral meningitis) hospitalised between May 1993 and July 1994 in Clinical Hospital for Infectious Diseases in Iaşi. The mean value of CRP in bacterial meningitis patients was 8.78 mg%, contrasting with the mean value of CRP = 1.92 mg% recorded in patients with viral meningitis. Ten out of 37 bacterial meningitis patients presented a CRP concentration &lt; 1.85 mg%. All these 10 patients have already had an antibiotic treatment at the moment of the assay. One out of 12 cases of viral meningitis had a value of CRP = 3.3 mg%, all the remainder cases having values under 1.85 mg%. We recorded highly significant differences between the two patient groups for CRP (p &lt; 0.001), ESR (p &lt; 0.01), protein concentration in CSF (p &lt; 0.001) and number of nucleated cells in CSF (p &lt; 0.001). Differences recorded for fever, concentration of glucose in CSF, glucose in CSF/glycemia ratio, number of leucocytes in peripheric blood and percentage of neutrophils in peripheric blood, were not significant (p &gt; 0.5). Data were analysed also by box-plot method which facilitates the visual appraisal of the differences recorded between the two aetiological groups. In conclusion, assays of CRP and ESR may be used as differentiation tests for bacterial meningitis versus viral meningitis, when assay is done before the antibiotic treatment, being sufficient sensitive, and easy to perform." }, { "id": "pubmed23n0115_1668", "title": "[Tuberculoma and tuberculous meningitis mimicking metastatic brain tumor and meningeal carcinomatosis--case report].", "score": 0.009433962264150943, "content": "A 45-year-old man was well until February 1986, when he experienced gait disturbance and psychiatric symptoms. On February 11 he fell down several times and developed generalized convulsion on the following day. He was admitted to a hospital in a delirious condition. The chest X-ray film showed infiltration in the left upper lobe, but computed tomographic (CT) scan of the head revealed no abnormality. Cerebrospinal fluid obtained by lumbar puncture contained 155 cells/mm3, all of which were lymphocytes, and protein and glucose concentrations were 372 mg/dl and 68 mg/dl respectively. In spite of negative smear tests of sputum and cerebrospinal fluid for tubercle bacilli he was administered antituberculosis drugs on the suspicion of pulmonary tuberculosis and tuberculous meningitis. His level of consciousness gradually returned to normal but the follow-up CT scans showed a low density area with contrast enhancement in the right thalamus and obliteration of the right quadrigeminal cistern which was also enhanced with contrast medium. He was transferred to our hospital on March 28 for further evaluation. On admission to our hospital he was alert and oriented, his pupils were equal and reactive to light and he had mild left hemiparesis, left hyperreflexia and left hemihypesthesia. Cell count of the cerebrospinal fluid was 243/mm3, 90% of which were lymphocytes and protein and glucose contents were 340 mg/dl and 42 mg/dl respectively. Both smear and culture of the cerebrospinal fluid were negative for tubercle bacilli and other organisms. Cytological examination of the cerebrospinal fluid demonstrated clusters of cells of various sizes with high N/C ratio which suggested these cells were malignant.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0299_4932", "title": "[Clinical and laboratory characteristics of 62 tuberculous meningoencephalitis cases].", "score": 0.009433962264150943, "content": "The authors present clinical, demographic and laboratory characteristics of 62 patients with proven tuberculous meningoencephalitis admitted at Couto Maia Hospital, reference for patients with infectious diseases in the State of Bahia. The patients' age varied from 2 months to 50 years, 59.7% of the cases with ages ranging from 0 to 4 years, no sex predominance. The time length for the disease varied from 0 to 90 days, average around 13 days. The most common signs and symptoms were fever and neck stiffness in 86.7 and 81.8% of the cases respectively. The cerebrospinal fluid showed cells varying from 4 to 1549/mm3, average of 406; glucose from 20 to 70 mg/dL, average of 37.3, protein from 30 to 500 mg/dL, average of 203; lymphocyte predominance occurred in most cases, however in 21.3% there was predominance of neutrophils." }, { "id": "wiki20220301en024_49919", "title": "Leptospirosis", "score": 0.009345794392523364, "content": "For those with liver involvement, transaminases and direct bilirubin are elevated in liver function tests. The Icterohaemorrhagiae serogroup is associated with jaundice and elevated bilirubin levels. Hemolytic anemia contributes to jaundice. A feature of leptospirosis is acute haemolytic anaemia and conjugated hyperbilirubinemia, especially in patients with glucose-6-phosphate dehydrogenase deficiency. Abnormal serum amylase and lipase levels (associated with pancreatitis) are found in those who are admitted to hospital due to leptospirosis. Impaired kidney function with creatinine clearance less than 50 ml/min is associated with elevated pancreatic enzymes. For those with severe headache who show signs of meningitis, a lumbar puncture can be attempted. If infected, cerebrospinal fluid (CSF) examination shows lymphocytic predominance with a cell count of about 500/mm3, protein between 50 and 100 mg/ml and normal glucose levels. These findings are consistent with aseptic meningitis." }, { "id": "Neurology_Adams_121", "title": "Neurology_Adams", "score": 0.009208809761338348, "content": "The CSF glucose concentration is normally in the range of 45 to 80 mg/dL, that is, about two-thirds of that in the blood (0.6 to 0.7 of serum concentrations). Higher levels parallel the blood glucose in this proportion; but with marked hyperglycemia, the ratio of CSF to blood glucose is reduced (0.5 to 0.6). With extremely low serum glucose, the ratio becomes higher, approximating 0.85. In general, CSF glucose values below 35 mg/dL are abnormal. After the intravenous injection of glucose, 2 to 4 h is required to reach equilibrium with the CSF; a similar delay follows the lowering of blood glucose. For these reasons, samples of CSF and blood for glucose determinations should ideally be drawn simultaneously in the fasting state or the serum should be obtained a few hours before the puncture but (this is often not practical). Low values of CSF glucose (hypoglycorrhachia) in the presence of pleocytosis usually indicate bacterial, tuberculous, or fungal meningitis, although similar" }, { "id": "pubmed23n0955_1904", "title": "An infant in whom contrast-enhanced fluid attenuated inversion recovery (FLAIR) MRI was useful for the diagnosis of meningitis and devising a treatment strategy.", "score": 0.009174311926605505, "content": "A 3-month-old male was brought to our hospital due to fever, poor sucking, and a bulging anterior fontanel. His general condition was poor. Analysis of the cerebrospinal fluid (CSF) showed increases in the cell count (8/μl) and the polymorphonuclear leukocyte count (2/μl) but normal sugar (66 mg/dl) and protein (28 mg/dl) levels. A CSF smear showed no bacterial cells. The administration of antibacterial drugs was initiated, and head MRI was performed on the next day. Plain images revealed no abnormalities. However, contrast-enhanced fluid-attenuated inversion recovery (FLAIR) MRI showed clear contrast enhancement along the brain surface in the meninges of the left and right frontal and left parietal lobes and fluid retention accompanied by contrast enhancement in a part of the adjacent subdural space. These findings could be confirmed only by contrast-enhanced FLAIR MRI. A diagnosis of bacterial meningitis with an unknown cause was made, and the administration of 2 antibacterial drugs was continued. MRI on day 8 of the illness showed the disappearance of contrast enhancement, and plain FLAIR also facilitated a diagnosis of a subdural hygroma. The treatment was effective. At present, the patient is 1 year and 6 months old without sequelae. The diagnosis of bacterial meningitis in infants is difficult based on only symptoms. In its early stage with few abnormal findings in the CSF, diagnosis is sometimes difficult. Antibacterial drug administration should be immediately initiated. However, definite findings are necessary for the continuation of large amounts of antibacterial drugs. Contrast-enhanced FLAIR allows the sensitive visualization of meningeal inflammation and is useful as a complementary diagnostic method for meningitis. In addition, this technique can reveal marked inflammatory lesions such as a subdural hygroma in the early stage, providing information useful for making a diagnosis of bacterial meningitis." }, { "id": "Pediatrics_Nelson_2219", "title": "Pediatrics_Nelson", "score": 0.009137972328156378, "content": "Table 100-2 Cerebrospinal Fluid (CSF) Findings in Various Central Nervous System Disorders CONDITION PRESSURE LEUKOCYTES (/µL) PROTEIN (mg/dL) GLUCOSE (mg/dL) COMMENTS Normal 50–180 mm H2O <4; 60%–70% lymphocytes, 30%–40% monocytes, 1%–3% neutrophils 20–45 >50% of serum glucose HSV, Herpes simplex virus; IGRA, interferon gamma release assay for tuberculosis; PCR, polymerase chain reaction; PMNs, polymorphonuclear leukocytes; TST, tuberculin skin test." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 0, 309 ] ], "word_ranges": [ [ 0, 53 ] ], "text": "I think the correct answer is 2 although the treatment for acute cholecystitis is cholecystectomy, for this it is necessary that the patient is a surgical candidate, in this case it is an elderly patient, with previous diseases that increase the surgical risk and would be an ASA IV for an urgent intervention." }, "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": "Surgical treatment (urgent cholecystectomy).", "2": "Biliary drainage by percutaneous cholecystostomy.", "3": "Substitute metronidazole + cefotaxime for piperacillin/tazobactam.", "4": "Replace piperacillin/tazobactam with amikacin+clindamycin.", "5": "Add gentamicin." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "InternalMed_Harrison_10725", "title": "InternalMed_Harrison", "score": 0.00995490513060495, "content": "for 14 days) also is effective for treatment of acute uncomplicated pyelonephritis if the uropathogen is known to be susceptible. If the pathogen’s susceptibility is not known and TMPSMX is used, an initial IV 1-g dose of ceftriaxone is recommended. Oral β-lactam agents are less effective than the fluoroquinolones and should be used with caution and close follow-up. Options for parenteral therapy for uncomplicated pyelonephritis include fluoroquinolones, an extended-spectrum cephalosporin with or without an aminoglycoside, or a carbapenem. Combinations of a β-lactam and a β-lactamase inhibitor (e.g., ampicillin-sulbactam, ticarcillinclavulanate, piperacillin-tazobactam) or imipenem-cilastatin can be used in patients with more complicated histories, previous episodes of pyelonephritis, or recent urinary tract manipulations; in general, the treatment of such patients should be guided by urine culture results. Once the patient has responded clinically, oral therapy should be substituted" }, { "id": "wiki20220301en059_34174", "title": "Piperacillin", "score": 0.009900990099009901, "content": "Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as initial empiric treatment for people with suspected neutropenic sepsis. Piperacillin is used to treat patients diagnosed with various internal infections such as abdominal, bacteremia, gynecological, respiratory, and urinary, mainly caused by Pseudomonas aeruginosa and other infectious bacteria. They are primarily used in current and former neutropenic patients, and patients with biliary tract infections. Other uses include applications in surgical infection prophylaxis; in biliary surgery, a single dose of piperacillin is administered intravenously to inhibit the development of acute cholangitis and prevent wound infections. The combination of piperacillin and an aminoglycoside is commonly used to treat severe infections, but due to the incompatibilities in drug interaction, they are administered separately." }, { "id": "wiki20220301en109_29982", "title": "Spanish conquest of the Aztec Empire", "score": 0.009900990099009901, "content": "1520" }, { "id": "wiki20220301en166_44924", "title": "WHO Model List of Essential Medicines", "score": 0.00980392156862745, "content": "Antischistosomals and other antinematode medicines Praziquantel Triclabendazole Oxamniquineα Cysticidal medicines Albendazoleα Mebendazoleα Praziquantelα Antibacterials Access group antibiotics Amikacin Amoxicillin Amoxicillin/clavulanic acid (amoxicillin + clavulanic acid) Ampicillin Benzathine benzylpenicillin Benzylpenicillin Cefalexin Cefazolin Chloramphenicol Clindamycin Cloxacillin Doxycycline Gentamicin Metronidazole Nitrofurantoin Phenoxymethylpenicillin (penicillin V) Procaine benzylpenicillin Spectinomycin Sulfamethoxazole/trimethoprim (sulfamethoxazole + trimethoprim) Trimethoprim Watch group antibiotics Azithromycin Cefixime Cefotaxime Ceftriaxone Cefuroxime Ciprofloxacin Clarithromycin Piperacillin/tazobactam (piperacillin + tazobactam) Vancomycin Ceftazidimeα Meropenemα Vancomycinα" }, { "id": "pubmed23n0026_3569", "title": "[Comparative clinical studies of the effectiveness of the most frequently used antibiotics in the period of 1961-1970].", "score": 0.00980392156862745, "content": "The results from the treatment of 1086 patients, treated at the Therapeutic Clinic, HMI- Sofia were followed up for the period 1961-1970 incld. Acute bacterial and vuris-bacterial pneumonias were found in 318 patients, 475 of the patients were with exacerbated chronic bronchitis and bronchiectasis, with exacerbated chronic pyelo-nephritis -216 patients and with exacerbated chronic cholecystitis and cholangiohepatitis --92 patients. The effect of the treatment was determined according to a three-stage scale \"good\" with complete clinical healing (in acute pneumonia), with \"improvement\"--with complete clinical remission (in chronic infections) and \"without effect\". Clinical and paraclinical indices were used as criteria in the determination of the effectiveness. The data are statistically processed according to the method of variation analysis. In patients with acute pneumonia the- best effectiveness was manifested by tetraolean (88,7 per cent), tetracylins (77,8 per cent), chloramphenicol (76,8 per cent), penicillin (72,5 per cent), the combination penicillin-streptomycin (71,9 per cent); in patients with exacerbated chronic bronchitis--tetraolean (88,0 per cent), chloramphenicol (73,2 per cent), tetracylins (65,3 per cent); in patients with exacerbated chronic pyelonephritis - chloramphenicol (65,5 per cent); in patients with exacerbated chronic cholecystitis and cholecysto-cholangiohepatitis-tetraolean (70,7 per cent), tetracyclins (66,7 per cent), chloramphenicol (66,1 per cent)." }, { "id": "wiki20220301en059_34208", "title": "Piperacillin/tazobactam", "score": 0.009708737864077669, "content": "Piperacillin/tazobactam was approved for medical use in the United States in 1993. It is on the World Health Organization's List of Essential Medicines. It is available as a generic medication. Medical uses Its main uses are in intensive care medicine (pneumonia, peritonitis), some diabetes-related foot infections, and empirical therapy in febrile neutropenia (e.g., after chemotherapy). The drug is administered intravenously every 6 or 8 hr, typically over 3–30 min. It may also be administered by continuous infusion over four hours. Prolonged infusions are thought to maximize the time that serum concentrations are above the minimum inhibitory concentration (MIC) of the bacteria implicated in infection. Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as first-line therapy for the treatment of bloodstream infections in neutropenic cancer patients." }, { "id": "wiki20220301en109_29985", "title": "Spanish conquest of the Aztec Empire", "score": 0.009708737864077669, "content": "1521" }, { "id": "wiki20220301en521_16277", "title": "WHO Model List of Essential Medicines for Children", "score": 0.009615384615384616, "content": "Antifilarials Albendazole Diethylcarbamazine Ivermectin Antischistosomals and other antinematode medicines Praziquantel Triclabendazole Oxamniquine Antibiotics Access group antibiotics Amikacin Amoxicillin Amoxicillin/clavulanic acid (amoxicillin + clavulanic acid) Ampicillin Benzathine benzylpenicillin Benzylpenicillin Cefalexin Cefazolin Chloramphenicol Clindamycin Cloxacillin Doxycycline Gentamicin Metronidazole Nitrofurantoin Phenoxymethylpenicillin (penicillin V) Procaine benzylpenicillin Sulfamethoxazole/trimethoprim (sulfamethoxazole + trimethoprim) Watch group antibiotics Azithromycin Cefixime Cefotaxime Ceftriaxone Cefuroxime Ciprofloxacin Clarithromycin Piperacillin/tazobactam (piperacillin + tazobactam) Vancomycin Ceftazidime Meropenem Vancomycin Reserve group antibiotics Ceftazidime/avibactam (ceftazidime + avibactam) Colistin Fosfomycin Linezolid Polymyxin B Antileprosy medicines Clofazimine Dapsone Rifampicin" }, { "id": "wiki20220301en109_30079", "title": "Spanish conquest of the Aztec Empire", "score": 0.009615384615384616, "content": "Secondary sources" }, { "id": "wiki20220301en084_10424", "title": "Chorioamnionitis", "score": 0.009523809523809525, "content": "Treatment The American College of Obstetricians and Gynecologists' Committee Opinion proposes the use of antibiotic treatment in intrapartum mothers with suspected or confirmed chorioamnionitis and maternal fever without an identifiable cause. Intrapartum antibiotic treatment consists of: Standard Ampicillin + gentamicin Alternative Ampicillin/sulbactam Ticarcillin/clavulanate Cefoxitine Cefotetan Piperacillin/tazobactam Ertapenem Cesarean delivery Ampicillin and gentamicin plus either clindamycin or metronidazole Penicillin-allergy Vancomycin + gentamicin Gentamicin + clindamycin" }, { "id": "wiki20220301en062_67208", "title": "Aztec Empire", "score": 0.009523809523809525, "content": "Goddesses" }, { "id": "wiki20220301en059_34180", "title": "Piperacillin", "score": 0.009433962264150943, "content": "Following two studies conducted in 1986 and 2006, piperacillin was found to inhibit the removal of methotrexate in animal kidneys. Furthermore, in the presence of piperacillin-tazobactam, the decay time for methotrexate triples in comparison to the normal half-life, leaving the patient exposed to cytotoxic effects produced by the chemical agent. While penicillin antibiotics generally work synergistically with aminoglycosides by enhancing their penetration of bacterial membranes, they can also work adversely by inactivating them. A reformulation of ethylenediaminetetraacetic acid and piperacillin-tazobactam has produced results showing an increase in their affinity with amikacin and gentamicin in vitro, enabling the process of simultaneous Y-site infusion to occur. However, tobramycin was found to be incompatible as a combination through Y-site infusion." }, { "id": "pubmed23n0357_8911", "title": "[A trial of using augmentin (amoxicillin/clavulanate) in surgical practice].", "score": 0.009433962264150943, "content": "The experience with the use of augmentin (amoxycillin/clavulane) in abdominal surgery for prophylaxis of postoperative purulent complications was analyzed. The drug was used in 44 patients after relatively pure operations, 37 of them having various risk factors. In 2 patients (4.5 per cent) of that group postoperative pyoinflammatory complications were recorded. For comparison the results of the prophylactic use of cefoperazone, cefamandole or ceftazidime in the group of 78 patients after relatively pure operations on the abdominal cavity organs were analyzed. Postoperative complications in the latter group amounted to 7.4 per cent (4 patients). The results of the treatment of patients in two groups after contaminated operations were also compared. The patients of one group (41 patients) were treated prophylactically with augmentin in a dose of 1200 mg intraoperatively followed by the drug use in a dose of 600 mg thrice daily for 1 to 2 days after the operation. Postoperative pyoinflammatory complications were recorded in 4 patients of that group (9.7 per cent). 78 patients of the other group were treated prophylactically with ceftazidime or cefoperazone in a dose of 2 g and metronidazole intraoperatively or cefoperazone in a dose of 2 g twice daily and metronidazole in a dose of 500 mg twice daily for 1 to 2 days after the operation. Postoperative infectious complications were recorded in 8 patients of that group (10 per cent). In the group of patients with acute cholecystitis treated with ciprofloxacin in a dose of 400 mg in combination, with metronidazole before the operation and for 1 to 2 days after the operation postoperative complications were recorded in 4 patients (17 per cent)." }, { "id": "wiki20220301en195_22213", "title": "Febrile neutropenia", "score": 0.009345794392523364, "content": "In 2010, updated guidelines were issued by the Infectious Diseases Society of America, recommending use of cefepime, carbapenems (meropenem and imipenem/cilastatin), or piperacillin/tazobactam for high-risk patients and amoxicillin-clavulanic acid and ciprofloxacin for low-risk patients. Patients who do not strictly fulfill the criteria of low-risk patients should be admitted to the hospital and treated as high-risk patients. Research to compare antibiotic treatments currently recommended in consensus guidelines identified 44 studies comparing different antibiotics. Significantly higher mortality was reported for cefepime compared to all other antibiotics combined. Piperacillin/tazobactam resulted in lower mortality than other antibiotics. Piperacillin/tazobactam might be the preferred antibiotic for the treatment of cancer patients with fever and neutropenia, while cefepime should not be used." }, { "id": "wiki20220301en633_21607", "title": "History of the Later Roman Empire", "score": 0.009345794392523364, "content": "Divided empire" }, { "id": "wiki20220301en014_2042", "title": "Cholecystitis", "score": 0.00929100529100529, "content": "Other Supportive measures may be instituted prior to surgery. These measures include fluid resuscitation. Intravenous opioids can be used for pain control. Antibiotics are often not needed. If used they should target enteric organisms (e.g. Enterobacteriaceae), such as E. coli and Bacteroides. This may consist of a broad spectrum antibiotic; such as piperacillin-tazobactam, ampicillin-sulbactam, ticarcillin-clavulanate (Timentin), a third generation cephalosporin (e.g.ceftriaxone) or a quinolone antibiotic (such as ciprofloxacin) and anaerobic bacteria coverage, such as metronidazole. For penicillin allergic people, aztreonam or a quinolone with metronidazole may be used." }, { "id": "wiki20220301en059_34178", "title": "Piperacillin", "score": 0.009259259259259259, "content": "Adverse effects Common side effects associated with the administration of piperacillin-tazobactam include: Gastrointestinal: constipation, diarrhea, nausea, vomiting Dermatologic: erythema, pain, phlebitis, rash Neurologic: headaches, insomnia Prolonged periods of piperacillin-tazobactam therapy have been associated with the potential development of hematologic adversities such as leukopenia (16.3%), neutropenia (10%), and eosinophilia (10%) in adult patients. The combination of piperacillin-tazobactam with other antibiotics was found to be a major risk factor for leukopenia as well. Additionally, the chances of developing these illnesses increases in younger patients suffering from fewer conditions, prolonging their time to recover." }, { "id": "InternalMed_Harrison_11649", "title": "InternalMed_Harrison", "score": 0.009259259259259259, "content": "For outpatient management, amoxicillin (1 g every 8 h) provides effective treatment for virtually all cases of pneumococcal pneumonia. Neither cephalosporins nor quinolones, which are far more expensive, offer any advantage over amoxicillin. Levofloxacin (500–750 mg/d as a single dose) and moxifloxacin (400 mg/d as a single dose) also are highly likely to be effective in the United States except in patients who come from closed populations where these drugs are used widely or who have themselves been treated recently with a quinolone. Clindamycin (600–1200 mg/d every 6 h) is effective in 90% of cases and azithromycin (500 mg on day 1 followed by 250–500 mg/d) or clarithromycin (500–750 mg/d as a single dose) in 80% of cases. Treatment failure resulting in bacteremic disease due to macrolide-resistant isolates has been amply documented in patients given azithromycin empirically. As noted above, rates of resistance to all these antibiotics are relatively low in some countries and much" }, { "id": "pubmed23n0545_11961", "title": "[Controlled, open, parallel-group study of the clinical and microbiological efficacy of piperacillin-tazobactam versus metronidazole + gentamicin in urgent colorectal surgery].", "score": 0.009174311926605505, "content": "Antibiotic treatment is an important element in infection control after urgent abdominal surgery. The aim of this study was to determine the therapeutic efficacy of piperacillin-tazobactam versus a combination of 2 antibiotics (metronidazole and gentamicin) in patients undergoing urgent appendicular and/or colorectal surgery. The study period comprised December 1998 to December 2002. A total of 183 patients who required urgent surgery for colon disease and/or severe acute appendicitis were prospectively and randomly included. Patients were randomly distributed in 2 groups. Group A received piperacillin-tazobactam (4/0.5/8 h/i.v.) and group B received metronidazole (500 mg/i.v./8 h) plus gentamicin (5 mg/kg/i.v./24 h). Treatment was started between 30 and 60 minutes prior to surgery and was continued for at least 3 days. The incidence of wound infection in patients who underwent surgery for colon disease and acute appendicitis was lower when they were treated with piperacillin-tazobactam (P&lt; .05). The incidence of intraperitoneal abscess in the group of patients who underwent surgery for severe acute appendicitis was lower when they were treated with piperacillin-tazobactam. Microbiological analyses revealed that there was a predominance of infection due to Escherichia coli. The association of piperacillin-tazobactam was more effective than that of metronidazole and gentamicin in the prevention and treatment of local infection in the treated groups. Therapeutic failure was mainly related to the presence of gram-negative bacteria." }, { "id": "wiki20220301en052_964", "title": "Age of Empires", "score": 0.009174311926605505, "content": "Historical elements" }, { "id": "wiki20220301en059_34175", "title": "Piperacillin", "score": 0.00909090909090909, "content": "Pneumonia The piperacillin-tazobactam (piptaz) antibiotic commonly used with an aminoglycoside retains similar levels of drug safety and efficacy as other antibiotic combinations such as ceftazidime with the aminoglycoside tobramycin in the treatment of patients with hospital acquired pneumonia. In a clinical comparison primarily targeting patients not initially placed in intensive care units, piperacillin-tazobactam was found to produce higher clinical and microbiological rates of success. By contrast, the drug efficacy of ceftazidime and piperacillin-tazobactam resulted in similar response rates (61.5% and 63.9 respectively) when tobramycin was added into both groups. Identical evaluations are shown when compared to the imipenem and tobramycin combination, where the administration of piperacillin-tazobactam on patients (especially those under mechanical ventilation) was only consisted of a slightly higher response rate." }, { "id": "wiki20220301en093_44301", "title": "History of penicillin", "score": 0.00909090909090909, "content": "Early scientific evidence" }, { "id": "wiki20220301en337_7076", "title": "Anaerobic infection", "score": 0.009009009009009009, "content": "Empiric antibiotic therapy for health care-associated intra-abdominal should be driven by local microbiologic results. Empiric coverage of likely pathogens may require multidrug regimens that include agents with expanded spectra of activity against gram-negative aerobic and facultative bacilli. These include meropenem, imipenem-cilastatin, doripenem, piperacillin-tazobactam, or ceftazidime or cefepime in combination with metronidazole. Aminoglycosides or colistin may be required. Antimicrobial regimens for children include an aminoglycoside-based regimen, a carbapenem (imipenem, meropenem, or ertapenem), a beta-lactam/beta-lactamase-inhibitor combination (piperacillin-tazobactam or ticarcillin-clavulanate), or an advanced-generation cephalosporin (cefotaxime, ceftriaxone, ceftazidime, or cefepime) with metronidazole." }, { "id": "wiki20220301en257_17830", "title": "List of Empire ships (G)", "score": 0.009009009009009009, "content": "Empire Galloper" }, { "id": "pubmed23n0250_20393", "title": "Results of the North American trial of piperacillin/tazobactam compared with clindamycin and gentamicin in the treatment of severe intra-abdominal infections. Investigators of the Piperacillin/Tazobactam Intra-abdominal Infection Study Group.", "score": 0.008928571428571428, "content": "A total of 192 men and 139 women aged 15 to 89 years with diagnosed intra-abdominal infection were randomised in a 2:1 ratio to treatment with either intravenous piperacillin/tazobactam (3 g/375 mg every six hours) or clindamycin (600 mg every six hours) plus gentamicin (2.5 mg to 5.0 mg/kg every eight to 12 hours) in a multicentre trial. Of 147 evaluable patients with microbiologically confirmed infections, 104 were treated with piperacillin/tazobactam and 43 with clindamycin plus gentamicin. The diagnoses of perforated appendicitis (n = 79), other peritonitis (n = 32), cholecystitis/cholangitis (n = 18), intraabdominal abscess (n = 14), and diverticulitis (n = 3), were distributed proportionately between the two therapeutic groups. Ninety one of 104 patients (88%) in the piperacillin/tazobactam group and 33 of 43 patients (77%) in the clindamycin plus gentamicin group were considered cured or improved (p = 0.13). In the piperacillin/tazobactam group, 80 of 88 (91%) Bacteroides fragilis group organisms and 68 of 74 (92%) E coli isolates were eradicated; in the clindamycin plus gentamicin group, 21 of 25 (84%) Bacteroides fragilis group isolates and 23 of 30 (76%) E coli isolates were eradicated. Eleven evaluable patients in the piperacillin/tazobactam group had beta-lactamase-producing organisms that were resistant to piperacillin but susceptible to piperacillin/tazobactam; in 10 of these patients (91%) bacteria were eradicated. We conclude that piperacillin/tazobactam is an effective antimicrobial drug for monotherapy of intra-abdominal infections, with efficacy similar to or better than standard aminoglycoside/anti-anaerobe combinations." }, { "id": "pubmed23n0327_6217", "title": "[Our experience in introducing current antibiotic prophylaxis into abdominal surgery--the initial results].", "score": 0.008928571428571428, "content": "Over a one-year period (Nov. 1996-Nov. 1997), a total of 154 patients are admitted on an emergency basis, with deferred emergency and for routine treatment in the Clinic of Emergency Surgery. They are distributed in three groups, as follows: patients not requiring perioperative antibiotic prophylaxis and postoperative antibiotic therapy--27, patients subjected to perioperative parenteral antibiotic prophylaxis under adequate hospital conditions--121, and patients undergoing antibiotic prophylaxis in conditions inappropriate for its application--six. The drug schemes elaborated are in conformity with worldwide and Bulgarian experience along this line, and with the concrete hospital and economical conditions in this country. In all patient indicated for antibiotic prophylaxis the listed below antibacterial agents (presented as drug schemes) are administered i.v. a single time prior to anesthesia induction: in operations on the gastrointestinal tract except for interventions in acute appendicitis: cephalotin/cefazolin 2.0 g and metronidazole 0.5 g i.v.; in operations for acute appendicitis: amoxicillin/clavulanate 1.2 g and petronidazole 0.5 f i.v.; biliary surgery free of extrahepatic cholestasis: cephalotin/cefazolin 2.0 g i.v.; biliary surgery with present or preceding extrahepatic cholestasis: cefotetan 2 g i.v.; contaminated liver cysts (parasitic and nonparasitic): cefotetan 2 g i.v.; abdominal trauma without perforation of a hollow organ: cefotetan 2 g i.v.; in plastic repair of the anterior abdominal wall (congenital defects, postoperative eventration) and in poor risk patients (local and general status: cephalotin/cefazolin 2.0 g i.v. In 135 patients the postoperative period runs a course free of complications worthy of notice. Complications directly linked to introduction of the method proposed are recorded in ten cases: operative wound suppuration (4) and hospital infection (6). Complications not related directly to the procedure are observed in nine cases: urinary tract infection (4), bronchopneumonia (2), fever with unknown source of infection (including negative hemoculture) necessitating additional antibiotic therapy (2) and secondary infection (within a week of intervention) necessitating further therapy with antibiotics. The specific features of antibiotic prophylaxis used in the various types of operative interventions are discussed from microbiological, clinical and pharmacotherapeutic viewpoints. The obtained results are compared with pertinent literature data on the issue with a special reference to the clinical efficacy attained. They mirror the approach against the background of the concrete hospital conditions in this country. The method developed is fully consistent with the level of surgical expertise in Bulgaria. All efforts should be aimed at intrahospital environment improvement by means of meticulous asepsis and antisepsis." }, { "id": "wiki20220301en059_34209", "title": "Piperacillin/tazobactam", "score": 0.008849557522123894, "content": "Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as first-line therapy for the treatment of bloodstream infections in neutropenic cancer patients. For β-lactam antipseudomonal antibiotics, including piperacillin/tazobactam, prolonged intravenous infusion is associated with lower mortality than bolus intravenous infusion in persons with sepsis due to Pseudomonas aeruginosa. Adverse effects The most common adverse effect is diarrhea (7–11%). Another adverse effect is inhibition of platelets (thrombocytopenia). Society and culture Trade names Apart from Tazocin and Zosyn, the drug is marketed in various countries under other trade names such as Tazact, Biopiper TZ, Brodactam, Piptaz, Maxitaz, Kilbac, Trezora, Du-Tazop, Tazopen, Sytaz, Tazin, and Inzalin TZ." }, { "id": "wiki20220301en140_52527", "title": "Gajapati Empire", "score": 0.008849557522123894, "content": "History" }, { "id": "pubmed23n0251_18812", "title": "Piperacillin/tazobactam in comparison with clindamycin plus gentamicin in the treatment of intra-abdominal infections.", "score": 0.008771929824561403, "content": "Concerned about the inactivation of piperacillin by beta-lactamase and the risk of aminoglycoside-induced nephrotoxicity and clindamycin-induced enterocolitis, we conducted the following phase III clinical trial. Between November 1991 and March 1993, 77 surgical patients with intraabdominal infections were enrolled and randomly assigned in a 3:2 ratio to receive either piperacillin/tazobactam or clindamycin plus gentamicin to compare safety, tolerance and efficacy between both two treatment groups. There were 76 clinically and 50 bacteriologically evaluable patients with 80 isolated pathogens. The demographic data were comparable in both groups. There was no statistically significant difference of clinical response at any time-point of treatment, with 97.8% favorable clinical response rate in piperacillin tazobactam group and 96.6% in clindamycin plus gentamicin group at endpoint. The bacteriological eradication rates were similar, with 97.7% in piperacillin/tazobactam group and 94.4% in clindamycin plus gentamicin group at pathogen level, and 96.7% in piperacillin/tazobactam group and 95.0% in clindamycin plus gentamicin group at patient level. By susceptibility tests, only 3 (4%) isolated pathogens were resistant to piperacillin/tazobactam, which was much superior to the use of piperacillin, clindamycin or gentamicin alone in antimicrobial activity. The piperacillin tazobactam-related adverse experiences included 1 (2.1%) urticaria and 2 (4.3%) diarrhea. However, there were no significant differences in the adverse experiences between these two groups. This study has demonstrated that piperacillin/tazobactam is comparable with clindamycin plus gentamicin in efficacy, safety and tolerance in the treatment of surgical patients with intra-abdominal infections. The combination of piperacillin/tazobactam could potentially be the treatment of choice in adjunt to surgical management in intra-abdominal infection." }, { "id": "wiki20220301en178_3549", "title": "Phenoxymethylpenicillin", "score": 0.008771929824561403, "content": "History" }, { "id": "wiki20220301en059_34173", "title": "Piperacillin", "score": 0.008695652173913044, "content": "Medical uses Piperacillin is used almost exclusively in combination with the beta lactamase inhibitor tazobactam for the treatment of serious, hospital-acquired infections. This combination is among the most widely used drug therapies in United States non-federal hospitals, accounting for $388M in spending in spite of being a low-cost generic drug. Piperacillin-tazobactam is recommended as part of a three-drug regimen for the treatment of hospital-acquired pneumonia suspected as being due to infection by multi-drug resistant pathogens. It is also one of several antibacterial drugs recommended for the treatment of infections known to be caused by anaerobic Gram-negative rods. Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as initial empiric treatment for people with suspected neutropenic sepsis." }, { "id": "wiki20220301en627_9736", "title": "Grampian 23", "score": 0.008695652173913044, "content": "Operational history" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 189 ] ], "word_ranges": [ [ 0, 27 ] ], "text": "Positive Lasegue's sign, reappearance of the symptoms when performing the extension maneuver of the affected limb, compatible with involvement of nerve roots at the lumbosacral spine level." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Gouty arthritis of the left hip.", "2": "Left coxofemoral arthrosis.", "3": "Radiated low back pain / lumbosciatica.", "4": "Claudication due to canal stenosis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en029_55324", "title": "Sacroiliac joint", "score": 0.015396323615501698, "content": "Signs and symptoms The following are signs and symptoms that may be associated with an SI joint (SIJ) problem: Mechanical SIJ dysfunction usually causes a dull unilateral low back pain. The pain is often a mild to moderate ache around the dimple or posterior superior iliac spine (PSIS) region. The pain may become worse and sharp while doing activities such as standing up from a seated position or lifting the knee towards the chest during stair climbing. Pain is typically on one side or the other (unilateral PSIS pain), but the pain can occasionally be bilateral. When the pain of SIJ dysfunction is severe (which is infrequent), there can be referred pain into the hip, groin, and occasionally down the leg, but rarely does the pain radiate below the knee. Pain can be referred from the SIJ down into the buttock or back of the thigh, and rarely to the foot. Low back pain and stiffness, often unilateral, that often increases with prolonged sitting or prolonged walking." }, { "id": "wiki20220301en132_2144", "title": "Greater trochanteric pain syndrome", "score": 0.012593970394481903, "content": "More often the lateral hip pain is caused by disease of the gluteal tendons that secondarily inflames the bursa. This is most common in middle-aged women and is associated with a chronic and debilitating pain which does not respond to conservative treatment. Other causes of trochanteric bursitis include uneven leg length, iliotibial band syndrome, and weakness of the hip abductor muscles. Greater trochanteric pain syndrome can remain incorrectly diagnosed for years, because it shares the same pattern of pain with many other musculoskeletal conditions. Thus people with this condition may be labeled malingerers, or may undergo many ineffective treatments due to misdiagnosis. It may also coexist with low back pain, arthritis, and obesity. Signs and symptoms The primary symptom is hip pain, especially hip pain on the outer (lateral) side of the joint. This pain may appear when the affected person is walking or lying down on that side. Diagnosis" }, { "id": "article-28772_10", "title": "Sciatica -- History and Physical", "score": 0.012498392696412498, "content": "Further, a straight leg raise (SLR) test is a neurological maneuver performed while examining a patient presenting with lower back pain. This test is conducted with the patient lying supine while keeping the symptomatic leg straight by flexing the quadriceps. The examiner elevates the leg progressively at a slow pace. The test is deemed positive if it reproduces the patient's symptoms (pain and paresthesia) at an angle lower than 70° with radiation below the knee (Lasegue sign). This test is most helpful in diagnosing L4, L5, and S1 radiculopathies. The patient is asked to dorsiflex the foot while the examiner raises the leg (Bragaad sign) to increase the test's sensitivity. When executing the straight leg raise test, the examiner will slightly bend the patient's knee by 20° to 30°, which will lessen the pain. Then, manual pressure is applied in the popliteal fossa. The Bowstring sign is considered positive if it causes the same level of discomfort that the patient feels during a straight leg raise. [8] The Naffziger test involves reproducing pain via coughing. [9]" }, { "id": "pubmed23n0272_22133", "title": "The piriformis muscle syndrome: a simple diagnostic maneuver.", "score": 0.012481231231231231, "content": "Current maneuvers to diagnose the piriformis syndrome are less than ideal. Freiberg's maneuver of forceful internal rotation of the extended thigh elicits buttock pain by stretching the piriformis muscle, and Pace's maneuver elicits pain by having the patient abduct the legs in the seated position, which causes a contraction of the piriformis muscle. This report describes a maneuver performed by the patient lying with the painful side up, the painful leg flexed, and the knee resting on the table. Buttock pain is produced when the patient lifts and holds the knee several inches off the table. The maneuver produced deep buttock pain in three patients with piriformis syndrome. In 100 consecutive patients with surgically documented herniated lumbar discs, the maneuver often produced lumbar and leg pain but not deep buttock pain. In 27 patients with primary hip abnormalities, pain was often produced in the trochanteric area but not in the buttock. The maneuver described in this report was helpful in diagnosing the piriformis syndrome. It relies on contraction of the muscle, rather than stretching, which the author believes better reproduces the actual syndrome." }, { "id": "article-28772_9", "title": "Sciatica -- History and Physical", "score": 0.012150502402795981, "content": "A straight-leg raise has variable sensitivity and specificity and may or may not be present depending on the underlying cause. The straight-leg test is a passive examination where the patient first lies in a relaxed, supine position. The examiner then lifts the leg from the posterior aspect, flexing at the hip joint and keeping the knee in full extension or keeping the leg straight. Typically, pain that is reproduced between 30° to 70° of hip flexion and experienced primarily in the back is likely due to a lumbar disc herniation. Pain and parenthesis felt in the leg are possible due to lateralizing compression of a peripheral nerve. While not absolute, musculoskeletal causes of the pain usually reproduce pain above 70° of flexion and below 30° of flexion." }, { "id": "article-24453_19", "title": "Lumbar Disc Herniation -- History and Physical", "score": 0.011837808417997097, "content": "A straight leg raise test is a neurological maneuver performed while examining a patient presenting with lower back pain. It is conducted with the patient lying supine while keeping the symptomatic leg straight by flexing the quadriceps. The examiner slowly elevates the leg progressively at a slow pace. The test is positive when it reproduces the patient's symptoms (pain and paresthesia) at an angle lower than 45 degrees with radiation below the knee (Lasegue sign). It is most helpful in diagnosing L4, L5, and S1 radiculopathies. The patient is asked to dorsiflex the foot while the examiner is raising the leg (Bragaad's sign) to increase the sensitivity of the test." }, { "id": "article-20584_16", "title": "Disc Herniation -- History and Physical -- Physical Examination", "score": 0.011486194995685936, "content": "L5 Nerve - back, radiating into buttock, lateral thigh, lateral calf, and dorsum foot, great toe; sensory loss on the lateral calf, dorsum of the foot, webspace between first and second toe; weakness on hip abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot inversion and eversion; decreased semitendinosus/semimembranosus reflex. S1 Nerve - back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot; sensory loss on the posterior calf, lateral or plantar aspect of foot;  weakness on hip extension, knee flexion, plantar flexion of the foot; Achilles tendon; Medial buttock, perineal, and perianal region; weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction. S2-S4 Nerves - sacral or buttock pain radiating into the posterior aspect of the leg or the perineum; sensory deficit on the medial buttock, perineal, and perianal region; absent bulbocavernosus, anal wink reflex." }, { "id": "pubmed23n0414_16669", "title": "[Diagnosis and treatment of lumbar spinal canal stenosis].", "score": 0.011396011396011397, "content": "Lumbar spinal canal stenosis (LSCS) was first described in 1954 by Verbiest, followed by the currently accepted international classification of LSCS in 1976 by Arnoldi. Briefly, LSCS is a nervous system syndrome that is characterized by neural symptoms in the lower extremities due to tightened cauda equina and spinal nerve root involvement. LSCS international classification consists of: (1) degenerative, (2) congenital developmental, (3) combined, (4) spondylolytic spondylolisthesis, (5) iatrogenic and (6) post traumatic stenosis. Degenerative stenosis-the most common type of LSCS-is caused by disc degeneration, osteoarthritis of the facet joint and hypertrophy of the ligamentum flavum. LSCS may also be the result of intervertebral disc degeneration, protruded intervertebral disc and/or bony spur compress cauda equina and spinal nerve root anteriorally, while degenerated facet joint and hypertrophied the ligamentum flavum compress cauda equina and spinal nerve root posteriorally? Most often, spondylolytic spondylolisthesis occurs at the fourth lumbar vertebrae in middle-aged women. As a result of a slipping forward of the vertebra, cauda equina and spinal nerve roots can be tightened between the edge behind the top of lower vertebra and frontal edge of the lower part of upper lamina. Typical clinical symptoms of LSCS are low back pain, leg pain and intermittent claudication. Low back pain is chronic with secondary radiating pain in the buttock. The leg pain is called \"sciatica\", which tends to appear on the back of thigh, in the lateral aspect of lower leg and calf muscles, and which intensifies when the patient is fatigued. Intermittent claudication is a symptom associated with this syndrome. Often, patients with LSCS find it impossible to walk because of increased numbness and pain in their leg. Many patients report that after squatting for a few minutes they are able to resume walking. LSCS patients may also report dysaesthesia in the perineum area, and may also report urinary dysfunction ranging from extreme urgency to urinary delay. Patients who present with symptoms of LSCS should be seen by an orthopedic surgeon. Correct diagnosis by imaging and clinical examination, with appropriate conservative or operative treatment in a timely fashion should be encouraged in order to prevent irreversible nerve damage." }, { "id": "wiki20220301en023_60316", "title": "Low back pain", "score": 0.011248981638152534, "content": "Low back pain may be classified based on the signs and symptoms. Diffuse pain that does not change in response to particular movements, and is localized to the lower back without radiating beyond the buttocks, is classified as nonspecific, the most common classification. Pain that radiates down the leg below the knee, is located on one side (in the case of disc herniation), or is on both sides (in spinal stenosis), and changes in severity in response to certain positions or maneuvers is radicular, making up 7% of cases. Pain that is accompanied by red flags such as trauma, fever, a history of cancer or significant muscle weakness may indicate a more serious underlying problem and is classified as needing urgent or specialized attention." }, { "id": "wiki20220301en191_24071", "title": "GALS screen", "score": 0.011195652173913044, "content": "Now ask the patient to do the following noting any painful, restricted or asymmetrical movements: Test rotation of the thoracic and lumbar spine. Gently hold the patient's hips still and ask them to: \"Turn your shoulders round as far as you can to the left, then do the same to the right.\" Test lateral flexion of the thoracic and lumbar spine: \"Stand up straight and then slide the palm of your right hand down your thigh towards your knee, bending your shoulder down to the side.\" \"Now do the same with your left hand down your left leg.\" \"Bend your left ear down towards your left shoulder and then your right ear down towards your right shoulder\" to test for pain free cervical spine lateral flexion. Now test for stiffness or pain flexing or extending the cervical spine: \"bend your neck forwards to try to touch your chin against your chest.\" \"bend your neck back to lift your chin.\"" }, { "id": "pubmed23n0626_20486", "title": "Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment.", "score": 0.011124456646076412, "content": "Greater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity. Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail." }, { "id": "article-24477_15", "title": "Lumbosacral Facet Syndrome -- History and Physical", "score": 0.010971492873218304, "content": "In most presentations, facetogenic lumbosacral pain often presents secondary to chronic pain alone. It should, however, be noted that facet joint pain may be referred distally into the lower limb, thus mimicking sciatica. In these cases of \"pseudo-radicular\" lumbar pain, patients typically experience radiation into the unilateral or bilateral buttocks and the trochanteric region (from L4 and L5 levels), the groin and thighs (from L2 to L5), ending above the knee, and without any neurologic deficits. At times, pain may radiate further down the lower extremity reaching the foot, thus mimicking sciatic pain. This may occur especially in the setting of rather large synovial cysts causing direct mechanical compression and creating ensuing inflammation to further irritate the surrounding nerve roots. [15] Facet joint pain is typically worse in the mornings and following periods of inactivity. Stress exercise, lumbar spinal extension or rotary motions, standing or sitting positions, and facet joint palpation may also elicit lumbar facetogenic pain. [2]" }, { "id": "article-28194_14", "title": "Radicular Back Pain -- History and Physical", "score": 0.010957655972761712, "content": "L2, L3, and L4 lumbar radiculopathies are considered a group. This group has a marked overlap of the innervation of the anterior thigh muscles. [1] An acute injury in the distribution of L2, L3, and L4 will most commonly present with the patient experiencing radiating back pain to the anterior aspect of the thigh, which may progress into their knee, and possibly radiate to the medial aspect of the lower leg, into the foot. On examination, patients can have weakness during knee extension, hip adduction, and or hip flexion. There is often a loss of sensation over the anterior thigh along the area of pain. The patient may show a reduced patellar reflex (L4). [1] Activities that can make the symptoms worse include coughing, leg straightening, or sneezing." }, { "id": "InternalMed_Harrison_31210", "title": "InternalMed_Harrison", "score": 0.010923377390198484, "content": "2692 LATERAL FEMORAL CUTANEOUS NEUROPATHY (MERALGIA PARESTHETICA) The lateral femoral cutaneous nerve arises from the upper lumbar plexus (spinal levels L2/3), crosses through the inguinal ligament near its attachment to the iliac bone, and supplies sensation to the anterior lateral thigh. The neuropathy affecting this nerve is also known as meralgia paresthetica. Symptoms and signs consist of paresthesias, numbness, and occasionally pain in the lateral thigh. Symptoms are increased by standing or walking and are relieved by sitting. There is normal strength, and knee reflexes are intact. The diagnosis is clinical, and further tests usually are not performed. EDx is only needed to rule out lumbar plexopathy, radiculopathy, or femoral neuropathy. If the symptoms and signs are classic, EMG is not necessary. Symptoms often resolve spontaneously over weeks or months, but the patient may be left with permanent numbness. Treatment consists of weight loss and avoiding tight belts. Analgesics" }, { "id": "article-22895_7", "title": "Greater Trochanteric Pain Syndrome -- History and Physical", "score": 0.01084280303030303, "content": "Patients with greater trochanteric pain syndrome usually have lateral hip pain, tenderness over and around the greater trochanter, pain at end-range hip rotation, abduction or adduction, pain with resisted hip abduction, and a positive Patrick-FABER (flexion abduction external rotation) test. Patients usually suffer from chronic back pain radiating to the posterolateral aspect of the thigh, leg paresthesias, and tenderness over the iliotibial tract. [6] They will often complain of the inability to lay on the affected hip. The mean duration of symptoms before treatment ranges from 7.1 weeks to 4.4 years. Young adults (18 to 35 years old) with hip pain often present with non-specific symptoms and vague findings from the history and physical examination, which may lead to a misdiagnosis of GTPS or trochanteric bursitis. [1] [4]" }, { "id": "Neurology_Adams_10553", "title": "Neurology_Adams", "score": 0.010762017278298753, "content": "The most characteristic syndrome affects the lumbar roots. Pain, which can be severe, begins in the low back or hip and spreads to the thigh and knee on one side; the discomfort has a deep, aching character with superimposed lancinating jabs and there is a propensity for pain to be most severe at night. Weakness and later atrophy are evident in the pelvic girdle and thigh muscles, although the distal muscles of the leg may also be affected. The weakness can progress for days or weeks (rarely, months). The patellar reflex is lost on the affected side. Curiously, we have found the opposite patellar reflex to be absent in some patients, without explanation. Deep and superficial sensation may be intact or mildly impaired, conforming to either a multiple nerve or multiple adjacent root distribution (i.e., L2 and L3, or L4 and L5). The pain lasts for several days and then gradually abates. Motor recovery is the rule although months and even years may elapse before it is complete. The same" }, { "id": "Surgery_Schwartz_6384", "title": "Surgery_Schwartz", "score": 0.010688172043010754, "content": "heavy-muscled athletesVenous claudicationEntire leg, but usually worse in thigh and groinTight, bursting painAfter walkingSubsides slowlyRelief speeded by elevationHistory of iliofemoral deep venous thrombosis, signs of venous congestion, edemaNerve root compression (e.g., herniated disk)Radiates down leg, usually posteriorlySharp lancinating painSoon, if not immediately after onsetNot quickly relieved (also often present at rest)Relief may be aided by adjusting back positionHistory of back problemsSymptomatic Baker’s cystBehind knee, down calfSwelling, soreness, tendernessWith exercisePresent at restNoneNot intermittentIntermittent claudication (hip, thigh, buttock)Hip, thigh, buttocksAching discomfort, weaknessAfter same degree of exerciseQuickly relievedNoneReproducibleHip arthritisHip, thigh, buttocksAching discomfortAfter variable degree of exerciseNot quickly relieved (and may be present at rest)More comfortable sitting, weight taken off legsVariable, may relate to activity" }, { "id": "article-29356_9", "title": "Spinal Stenosis -- History and Physical", "score": 0.010027328147992433, "content": "Stenosis in the lumbar spine can lead to neurogenic claudication, myeloradiculopathy symptoms, sensory disturbances, motor weakness, and pathologic reflexes. Patients will present with complaints of cramping pain in the leg, calf, and or buttocks. They might report an increase in pain with walking or standing for prolonged periods and relief when sitting or leaning forward while using a shopping cart. [9] Disk herniation is most common at the L4-5 and L5-S1 levels. A herniated disk at L5-S1 can lead to plantarflexion weakness, decrease sensation in the lateral foot, and cause pain in the posterior leg. A disk herniation at L4-5 can lead to a foot drop and numbness in the large toe web and dorsal aspect of the foot. Lastly, an L3-4 disk herniation can lead to knee extension weakness, numbness in the medial foot, and pain in the anterior thigh." }, { "id": "pubmed23n1089_19591", "title": "Spinal gouty tophus presenting as an epidural mass lesion - A case report.", "score": 0.009951763218283146, "content": "Gout is a metabolic disease secondary to an increased body pool of urate with hyperuricemia. Gout typically affects the peripheral joints and rarely involves the intra-spinal area. A 43-year-old man, who had metabolic syndrome s/p bariatric surgery and gout suffered from severe left low back pain with radiation to the lateral side of his left thigh and anterior side of his left leg for more than 7 days. His L-spine MRI showed an abnormal posterior epidural space occupying lesion at L4-L5 level. For tissue diagnosis and neural structures decompression, he underwent surgical removal of the epidural mass lesion. The surgical specimen showed a picture of gout and he got a good recovery after operation. The differential diagnoses of an epidural mass includes synovial cysts, ligament cyst, cystic neuromas, tumors, hematomas and abscesses. Gout in the spinal canal is difficult to diagnosis before surgery because it is rare and its clinical presentation and radiologic findings mimic tumor, abscess, tuberculosis, and degenerative spinal diseases. Patients with spinal gout may present with axial pain and a variety of neurological symptoms. Spinal gouty tophus should be considered in the different diagnoses of spinal epidural masses especially in patients with systemic gout. Surgery is needed for final diagnosis. If spinal gouty tophus is highly suspected during the surgery, the specimen should not be preserved with Formalin because birefringent crystals under polarized light is a unique feature for gouty tophus but they dissolve in Formalin." }, { "id": "pubmed23n0222_2576", "title": "[Acromegaly and spinal canal stenosis].", "score": 0.009900990099009901, "content": "A rare case of acromegaly with radiculomyelopathy due to spinal canal stenosis is reported. A long history of acromegalic deformity was seen on this 55 years old acupuncture therapist for the last 18 years, while he had developed unusually increased appetite, profuse perspiration and gained weight. Fifteen years ago, acromegalic tendency became prominent and was accompanied by low back and knee pain. In 1974 CB-154 was administered in several occasions beside 4000 rads irradiation to the sella. After radiation therapy was completed his outlook was somewhat improved, although low back pain was aggravated and associated with atrophy of the left lower extremity. The neurological examination at admission in 1980 revealed acromegalic feature, increased DTRs on both upper and lower extremities, dysesthesia of feet and atrophy of the leg muscles in general, mainly due to diffuse atrophy. Patient bended knees due to pain and unable to walk. He had radiating pain in the postero-lateral aspect of the left lower extremity and some dysesthesia of feet, although no specific root lesion was identifiable. Spinal roentgenograms disclosed diffuse ossification of anterior and posterior longitudinal ligaments, and marked spondylotic changes. Although the low back pain was impending complaint of the patient, the hypophyseal tumor was advised to remove and transsphenoidal hypophyseal adenomectomy was performed. A good amount of softend tumor tissue was removed however, adenoma found markedly fibrotic. Low back pain and knee were decreased gradually, but intermittent claudication was evident. Acromegaly in association with spinal canal stenosis were reviewed in literature, and the relationship of growth hormone and therapeutic problems were discussed." }, { "id": "article-28194_19", "title": "Radicular Back Pain -- History and Physical", "score": 0.009856809856809857, "content": "A straight leg raising can be helpful in lumbosacral radiculopathy. The mechanism of pain during a straight leg raise is increased dural tension placed upon the lumbosacral spine during the test. Patients lay supine during the test. The physician will flex the patient's quadriceps with the leg in extension as well as dorsiflex the patient's foot on the symptomatic side. Pain or reproduction of paresthesias is considered a positive test (Lasegue's sign). A Bowstring sign relieves this underlying radicular pain with flexion of the patient's knee on the affected side. The straight leg raising test is most helpful in the diagnosis of L4 and S1 radiculopathies. [11] [3]" }, { "id": "pubmed23n1017_12062", "title": "Diabetic amyotrophy, not your typical back pain.", "score": 0.00980392156862745, "content": "A 49-year-old man presented to the hospital for spinal cord decompression surgery with left buttock and left leg pain. The patient described an acute burning pain radiating down from his left buttock to left lateral leg. He also noted a 13.6 kg weight loss in recent months. Physical examination showed decreased muscle bulk of the left thigh, decreased strength of the left hip, left knee flexors and extensors. Recent MRI spine showed mild canal narrowing and cord flattening in the lower thoracic spine. Serologic testing showed an elevated glucose of 17.9 mmol/L and haemoglobin A1c of 9.8%. Electromyography showed denervation of scattered muscles of the left knee flexors, hip flexors and adductors. In the setting of newly diagnosed diabetes mellitus, he was diagnosed with diabetic amyotrophy, started on insulin therapy, and his surgery was cancelled." }, { "id": "pubmed23n0977_21644", "title": "Comparison of the history and physical examination for hip osteoarthritis and lumbar spinal stenosis.", "score": 0.00980392156862745, "content": "Leg pain associated with walking is sometimes incorrectly attributed to hip osteoarthritis (OA) or lumbar spinal stenosis (LSS). This study compared physicians' values of signs and symptoms for diagnosing and differentiating hip OA and LSS to their clinical utility. Musculoskeletal physicians were surveyed with online questionnaires. Patients were recruited from hip and spine specialty practices. Seventy-seven hip OA and 79 LSS patients. Signs and symptoms of hip OA and LSS. Fifty-one of 66 invited musculoskeletal physicians completed online surveys about the values of 83 signs and symptoms for diagnosing hip OA and LSS. Of these, the most valued 32 symptoms and 13 physical examination items were applied to patients with symptomatic hip OA or LSS. Positive likelihood ratios (+LR) were calculated for each items' ability to differentiate hip OA from LSS, with a +LR&gt;2 set as indicating usefulness for favoring either diagnosis. Positive LRs were compared with surveyed physicians' values for each test. All symptoms were reported by some patients with each diagnosis. Only 11 of 32 physician-valued symptoms were useful for discriminating hip OA from LSS. Eight symptoms favored hip OA over LSS: groin pain (+LR=4.9); knee pain (+LR=2.2); pain that decreased with continued walking (+LR=3.9); pain that occurs immediately with walking (+LR=2.4); pain that occurs immediately with standing (+LR=2.1); pain getting in/out of a car (+LR=3.3); pain with dressing the symptomatic leg (+LR=3.1); and difficulty reaching the foot of the symptomatic leg while dressing (+LR=2.3). Three symptoms favored LSS over hip OA: pain below the knee (+LR=2.3); leg tingling and/or numbness (+LR=2.7); and some pain in both legs (+LR=2.5). Notable symptoms that did not discriminate hip OA from LSS included: pain is less while pushing a shopping cart (+LR=1.0); back pain (+LR=1.1); weakness and/or heaviness of leg (+LR=1.1); buttocks pain (+LR=1.2); poor balance or unsteadiness (+LR=1.2); pain that increased with weight-bearing on the painful leg (+LR=1.3), and step to gait on stairs (+LR=1.7). Consistent with physicians' expectations, 7 of 13 physical examination items strongly favored hip OA over LSS: limited weight-bearing on painful leg when standing (+LR=10); observed limp (+LR=9); and painful and restricted range-of-motion with any of five hip maneuvers (+LR range 21-99). Four of five tested neurological deficits (+LR range 3-8) favored the diagnosis of LSS over hip OA. There is substantial crossover of symptoms between hip OA and LSS, with some physician-valued symptoms useful for differentiating these disorders whereas others were not. Physicians recognize the value of the examination of gait, the hip, and lower extremity neurological function for differentiating hip OA from LSS. These tests should be routinely performed on all patients for which either diagnosis is considered. Awareness of these findings might reduce diagnostic errors." }, { "id": "pubmed23n1147_26703", "title": "Pudendal tumor mimicking cauda equina syndrome and acute radiculopathy: case report.", "score": 0.009708737864077669, "content": "Cauda equina syndrome (CES) is most caused by lumbar disc herniation, and the associated treatment involves prompt surgical decompression. Rarer causes of CES include perineural (Tarlov) cysts. A 62-year-old female with history of rheumatoid arthritis, hip and knee replacements, and chronic low back pain presented with worsening back pain, left leg weakness and pain for 6 weeks, and bowel/bladder incontinence with diminished sensation in the perianal region for 24 h prior to presentation. MRI demonstrated severe spinal stenosis at L4-S1, central disc herniation at L5-S1, and compression of the cauda equina, consistent with CES. A lumbar decompression was performed. Patient did well at 2-week follow up, but presented 5 weeks post-discharge with increased left leg pain/weakness and genitalia anesthesia. Imaging was unremarkable. Two months later, the patient presented with diminished sensation in the buttocks and bilateral lower extremities and bowel/bladder incontinence. Imaging demonstrated a large cystic presacral mass with involvement of the left sciatic foramen and S3 neural foramen. A team of plastic, orthopedic, and neurological surgeons performed an S3 sacral laminectomy, foraminotomy, partial sacrectomy, and S3 rhizotomy, and excision of the large left hemorrhagic pudendal mass. Final pathology demonstrated a perineural cyst with organizing hemorrhage. On follow-up, the patient's pain and weakness improved. CES-like symptoms were initially attributed to a herniated disk. However, lumbar decompression did not resolve symptoms, prompting further radiographic evaluation at two separate presentations. This represents the first reported case of a pudendal tumor causing symptoms initially attributed to a herniated disc." }, { "id": "pubmed23n0681_16103", "title": "Does this older adult with lower extremity pain have the clinical syndrome of lumbar spinal stenosis?", "score": 0.009708737864077669, "content": "The clinical syndrome of lumbar spinal stenosis (LSS) is a common diagnosis in older adults presenting with lower extremity pain. To systematically review the accuracy of the clinical examination for the diagnosis of the clinical syndrome of LSS. MEDLINE, EMBASE, and CINAHL searches of articles published from January 1966 to September 2010. Studies were included if they contained adequate data on the accuracy of the history and physical examination for diagnosing the clinical syndrome of LSS, using a reference standard of expert opinion with radiographic or anatomic confirmation. Two authors independently reviewed each study to determine eligibility, extract data, and appraise levels of evidence. Four studies evaluating 741 patients were identified. Among patients with lower extremity pain, the likelihood of the clinical syndrome of LSS was increased for individuals older than 70 years (likelihood ratio [LR], 2.0; 95% confidence interval [CI], 1.6-2.5), and was decreased for those younger than 60 years (LR, 0.40; 95% CI, 0.29-0.57). The most useful symptoms for increasing the likelihood of the clinical syndrome of LSS were having no pain when seated (LR, 7.4; 95% CI, 1.9-30), improvement of symptoms when bending forward (LR, 6.4; 95% CI, 4.1-9.9), the presence of bilateral buttock or leg pain (LR, 6.3; 95% CI, 3.1-13), and neurogenic claudication (LR, 3.7; 95% CI, 2.9-4.8). Absence of neurogenic claudication (LR, 0.23; 95% CI, 0.17-0.31) decreased the likelihood of the diagnosis. A wide-based gait (LR, 13; 95% CI, 1.9-95) and abnormal Romberg test result (LR, 4.2; 95% CI, 1.4-13) increased the likelihood of the clinical syndrome of LSS. A score of 7 or higher on a diagnostic support tool including history and examination findings increased the likelihood of the clinical syndrome of LSS (LR, 3.3; 95% CI, 2.7-4.0), while a score lower than 7 made the diagnosis much less likely (LR, 0.10; 95% CI, 0.06-0.16). The diagnosis of the clinical syndrome of LSS requires the appropriate clinical picture and radiographic findings. Absence of pain when seated and improvement of symptoms when bending forward are the most useful individual findings. Combinations of findings are most useful for identifying patients who are unlikely to have the diagnosis." }, { "id": "article-24453_17", "title": "Lumbar Disc Herniation -- History and Physical", "score": 0.009621429070335964, "content": "L5 nerve root exits at the L5-S1 foramina. When compressed by a herniated disc, it causes back pain that radiates into the buttock, lateral thigh, lateral calf, the dorsum of the foot, and the great toe. Sensory loss is present on the web space between the big toe and second toe, the dorsum of the foot, and lateral calf. There is a weakness in hip abduction, knee flexion, foot dorsiflexion, big toe dorsiflexion, foot inversion, and eversion. Patients present with decreased semitendinosus/semimembranosus reflex. Weakness in foot dorsiflexion makes it challenging to walk on the heels. Chronic L5 radiculopathy may cause atrophy of the extensor digitorum brevis and the tibialis anterior of the anterior leg." }, { "id": "pubmed23n0621_10286", "title": "Bilateral periprosthetic stress fractures in a juvenile chronic arthritis patient secondary to bilateral genu valgum.", "score": 0.009615384615384616, "content": "Lateral insufficiency fractures following total hip replacement have been reported with the femoral stems positioned in varus, together with osteopenia of the lateral femoral cortex. Any abnormal alignment of the lower limbs, such as genu valgum, will alter the load distribution across the femoral cortices, and repetitive loading during walking will predispose the bones to stress fractures at any stress riser point, such as the tip of a femoral component. Bilateral femoral stress fractures post total hip replacements have not been previously described. We present a 55-year-old woman, diagnosed with juvenile idiopathic arthritis, who had undergone bilateral total hip replacements and bilateral knee replacements. The knees 15 years postoperatively were in valgus and the left knee was extremely stiff, flexing to just 5. The patient presented with bilateral thigh pain, with plain radiographs confirming bilateral periprosthetic fractures of the femur at the tip of well-fixed femoral components. There was no history of injury and her hips were functioning well up to this time. The patient required revision of both hips to long-stem uncemented components, bypassing the fractures, and revision of both knees to stemmed semi-constrained implants, thereby correcting the alignment of both lower limbs. Both fractures healed and the patient is currently pain-free and mobile with walking aids. Surgeons must remain aware that when implants are in situ, abnormal alignments will lead to abnormal forces, and stress fractures are likely to occur at any stress riser around the implant. Avoiding malalignment will avoid this complication." }, { "id": "article-27291_20", "title": "Plantar Heel Pain -- History and Physical -- S1 Radiculopathy", "score": 0.009615384615384616, "content": "Patients with heel pain may have a history of chronic lower back pain. Clinically, radicular involvement will present as pain and numbness radiating from the lower back down to the heel of the foot. Patients may have decreased sensation over the skin of the sole, heel, or lateral foot and weakness of the gastrocnemius, gluteus maximus, hamstring, peroneal, and foot muscles with a diminished ankle reflex. Perform the positive straight leg raise test (Lasègue test) with the patient in the supine position. Pain with passive hip flexion while lifting the leg suggests stretching the lower lumbar and sacral roots. [21] Perform a crossed straight leg raise test, eliciting pain on the contralateral side with the same motion. Results from new studies suggest that these exams may not be as reliable as we once thought. [22]" }, { "id": "wiki20220301en175_10188", "title": "Neurogenic claudication", "score": 0.009592490842490843, "content": "Knee to chest stretch - Laying down on the back, bring one leg up and pull it towards the chest and hold for 30–45 seconds. Posterior pelvic tilt (bridges) - Laying on the back, bend both legs and place your feet on the floor. Raise stomach from the ground, lifting the back and pelvis, until the back is straight. Hold for 5–10 seconds and relax. Neural Stretching of the legs - Laying on the back, bring one leg up with a stretching band until a stretch is felt in the legs. Ensure your legs are straight. Once the stretch is felt, hold for 30–45 seconds and relax. Hip-flexor stretch - To stretch the right hip-flexor, bring the left leg forward, and kneel on the right knee. Push the pelvis forward (lean forward), whilst keeping the upper body straight. Hold the position for 30–45 seconds and relax. To stretch the left hip-flexor, bring swap the positions of the legs." }, { "id": "pubmed23n0553_3822", "title": "Deep vein thrombosis in an athletic military cadet.", "score": 0.009523809523809525, "content": "Resident's case problem. A 21-year-old healthy athletic male military cadet with complaint of worsening diffuse left knee pain was evaluated 4 days after onset. The knee pain began 2 hours after completing a long car trip, worsened over the subsequent 3 days, and became almost unbearable during the return trip. The patient reported constant pain, limited knee motion, and difficulty ambulating. In addition, he was unable to perform physical military training or attend academic classes due to the severe left knee pain. Past medical history revealed a mild left lateral calf strain 21/2 weeks prior, which completely resolved within 24 hours of onset. Our physical examination led us to either monoarticular arthritis, pseudothrombophlebitis (ruptured Baker's cyst), or a lower leg deep vein thrombosis (DVT) as the cause of knee pain. Diagnostic imaging of this patient revealed a left superficial femoral vein thrombosis and popliteal DVT, with bilateral pulmonary emboli (PE). A systematic differential diagnosis was undertaken to rule out a potentially fatal DVT diagnosis as the cause of knee pain, despite minimal DVT risk factors. The physical therapist in a direct-access setting must ensure timely evaluation and referral of a suspected DVT, even when patient demographics cause the practitioner to question the likelihood of this diagnosis. The physical examination findings, clinical suspicion, and established clinical prediction rules can accurately dictate the appropriate referral action necessary." }, { "id": "pubmed23n0374_2491", "title": "What was the disease of the legs that afflicted King Asa?", "score": 0.009523809523809525, "content": "The elderly have suffered from pain in their legs, which may be associated with various diseases, for thousands of years. This report analyzes the disease that afflicted the biblical King Asa (the third king of the house of Judah who reigned between 867 and 906 BCE). The sentence 'Nevertheless in the time of his old age he was diseased in his legs' indicates that King Asa suffered from disease in his legs. Among numerous diseases, peripheral vascular disease, gout, and degenerative osteoarthritis were most likely to affect the King's legs. And among these diseases, the diagnosis of peripheral vascular disease is the most acceptable. This report shows that the roots of contemporary modern gerontology can be traced back to biblical times." }, { "id": "pubmed23n0839_300", "title": "Multiple Venous Thromboses Presenting as Mechanical Low Back Pain in an 18-Year-Old Woman.", "score": 0.009433962264150943, "content": "The purpose of this case report is to describe a patient who presented with acute musculoskeletal symptoms but was later diagnosed with multiple deep vein thrombosis (DVT). An 18-year-old female presented to a chiropractic clinic with left lumbosacral pain with referral into the posterior left thigh. A provisional diagnosis was made of acute myofascial syndrome of the left piriformis and gluteus medius muscles. The patient received 3 chiropractic treatments over 1 week resulting in 80% improvement in pain intensity. Two days later, a sudden onset of severe abdominal pain caused the patient to seek urgent medical attention. A diagnostic ultrasound of the abdomen and pelvis were performed and interpreted as normal. Following this, the patient reported increased pain in her left leg. Evaluation revealed edema of the left calf and decreased left lower limb sensation. A venous Doppler ultrasound was ordered. Doppler ultrasound revealed reduction of the venous flow in the femoral vein area. An additional ultrasonography evaluation revealed an extensive DVTs affecting the left femoral vein and iliac axis extending towards the vena cava. Upon follow-up with a hematologist, the potential diagnosis of May-Thurner syndrome was considered based on the absence of blood dyscrasias and sustained anatomical changes found in the left common iliac vein at its junction with the right common iliac artery. A week following discharge, she presented with chest pain and was diagnosed with venous thromboembolism. The patient was successfully treated with anticoagulation therapy and insertion of a vena cava filter. Although DVTs are common in the general population, presence in low-risk individuals may be overlooked. In the presence of subtle initial clinical signs such as those described in this case report, clinicians should keep a high index of suspicion for a DVT. Rapid identification of such clinical signs in association with a lack of objective examination findings warrants further evaluation due to potentially negative outcomes." } ] } } }

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{ "1": "Fine needle aspiration of pancreatic necrosis guided by ultrasound or CT.", "2": "Bronchoalveolar aspirate, urine culture and blood cultures.", "3": "Abdominal MRI.", "4": "Urgent cholecystectomy.", "5": "Echoendoscopy with puncture of the necrosis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en033_21942", "title": "Acute pancreatitis", "score": 0.016560678325384208, "content": "Computed tomography Regarding the need for computed tomography, practice guidelines state: CT is an important common initial assessment tool for acute pancreatitis. Imaging is indicated during the initial presentation if: the diagnosis of acute pancreatitis is uncertain there is abdominal distension and tenderness, fever >102 F (38,9 C), or leukocytosis there is a Ranson score > 3 or APACHE score > 8 there is no improvement after 72 hours of conservative medical therapy there has been an acute change in status: fever, pain, or shock CT is recommended as a delayed assessment tool in the following situations: acute change in status to determine therapeutic response after surgery or interventional radiologic procedure before discharge in patients with severe acute pancreatitis Abdominal CT should not be performed before the first 12 hours of onset of symptoms as early CT (<12 hours) may result in equivocal or normal findings." }, { "id": "pubmed23n0315_15335", "title": "Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis.", "score": 0.01647457627118644, "content": "Early detection of infected pancreatic necrosis has a major impact on further management and outcome in acute pancreatitis. The aim of this study was to evaluate the clinical value of ultrasonographically guided fine-needle aspiration cytology (FNAC) in patients with necrotizing pancreatitis over an 8-year period. From January 1988 to September 1996 193 (mean 2.0 (range 1-9) aspirations per patient) prospectively assessed FNACs guided ultrasonographically were performed in 98 patients with necrotizing pancreatitis proven by contrast-enhanced computed tomography. Aspirates were considered infected if either Gram stain and/or culture revealed micro-organisms. Ultrasonographically guided FNAC correctly diagnosed infection in 29 of 33 patients with infected necrosis a median of 13 days after onset of symptoms. Of 61 patients with sterile necrosis 55 were identified correctly as sterile by FNAC. There were six false-positive and four false-negative aspirates of which nine occurred during the first week of the disease. In four patients who did not undergo operation FNAC revealed Gram-negative organisms; however, in the absence of repeated aspirations, the positive results remained unconfirmed. An overall sensitivity of 88 per cent and a specificity of 90 per cent was obtained. No difference was found in biochemical and clinical parameters indicating systemic inflammatory response syndrome before each FNAC between patients with proven sterile or infected necrosis. All patients tolerated the procedure well and no major complications were observed. Ultrasonographically guided FNAC is a fast and reliable technique for the diagnosis of infected necrosis. As complication rates are very low, the procedure can be repeated at short intervals to improve the diagnostic accuracy. Ultrasonographically guided FNAC is recommended for all patients with necrotizing pancreatitis in whom systemic inflammatory response syndrome persists beyond the first week after onset of symptoms." }, { "id": "pubmed23n0289_10046", "title": "[Technique and outcome of surgical therapy in acute pancreatitis].", "score": 0.015247283211355067, "content": "The most important diagnostic step in the management of patients with acute pancreatitis is to discriminate between interstitial edematous and necrotizing pancreatitis. Measurement of necroses indicating parameters in the serum, like CRP and PMN-elastase are useful in detecting the necrotizing course of acute pancreatitis. While patients with acute edematous pancreatitis can be treated on a regular ward, patients with a necrotizing course of disease should be treated in the intensive-care unit. Patients with biliary acute pancreatitis should be examined by ERCP with the performance of a papillotomy with stone removal in case of impacted ampullary stones within 24 hours. Surgical decision-making in patients with necrotizing pancreatitis should be based on the development of septic signs due to infected pancreatic necrosis. The information about infected pancreatic necrosis can be easily obtained by a bedside ultrasound-guided fine needle aspiration and bacteriological examination of the aspirate [gram stain plus culture]. Patients without organ complications and with focal necroses should be treated conservatively while patients with persisting organ insufficiencies or progressive multiple organ failure despite maximum intensive care measures are candidates for surgical therapy. The procedure of choice in necrotizing pancreatitis is the careful removal of necrotic tissue [necrosectomy] followed and supplemented by a postoperative regimen for the continuous evacuation of further necrotic debris. For this postoperative therapeutical concept three comparable procedures are available today, the closed continuous lavage, the 'open packing technique' and the management by planned, staged re-laparotomies. Hospital mortality in severe acute pancreatitis has been reduced to less than 15% by these procedures in experienced hands." }, { "id": "pubmed23n0289_10044", "title": "[Acute pancreatitis: diagnosis].", "score": 0.015079865489701555, "content": "In the differential diagnosis of abdominal pain, acute pancreatitis may be diagnosed by its clinical features together with blood determinations and ultrasonographic findings. The primary diagnostic steps include the differentiation between biliary or non-biliary etiology of the disease. In biliary acute pancreatitis, ERCP with endoscopic sphincterotomy is recommended, although the benefit of this procedure has only been shown in patients with severe clinical courses. An early discrimination between edematous-interstitial pancreatitis [mild clinical course] and necrotizing pancreatitis [severe clinical course associated with local and systemic complications] is possible by daily CRP-monitoring. In necrotizing pancreatitis, contrast-enhanced computed tomography is the next diagnostic step, and the patient should be transferred to an intensive care unit. To differentiate between severe sterile pancreatitis and infected pancreatic necrosis, ultrasonographic or CT-guided fine needle aspiration of the pancreatic inflammatory mass is suggested. Infected pancreatic necroses are associated with systemic septic complications, which are the main mortality factor and the major reason for operative treatment of necrotizing pancreatitis." }, { "id": "pubmed23n0123_4159", "title": "[Prognostic value of x-ray computed tomography in acute pancreatitis: contribution of the injection of intravenous contrast media].", "score": 0.015, "content": "Thirty seven patients suffering from acute pancreatitis were explored using contrast-enhanced computed tomography (CT). The authors found a good concordance between the extension of the lesions on the initial CT examination, prognostic criteria on admission and the course of the disease. In addition, a new prognostic CT sign was reported in the early phase of parenchymal contrast perfusion, i.e. the lack of contrast-enhancement in a limited portion of the pancreas. This sign was present in 8 patients, all with severe clinical symptoms. These 8 patients showed the highest morbidity rate in the series with abscess-type complications occurring in all, compared with 24 p. 100 among the 29 other patients who did not exhibit this CT sign. Moreover, these 8 patients showed the highest mortality rate (25 p. 100 compared with 3.5 p. 100 among the other patients). An histological analysis of partial pancreatectomy specimens was performed in 7 out of the 8 patients. Devitalized pancreatic tissue, at the site of the parenchymal abnormalities on CT scan, was found in all cases. One false negative case was reported. Contrast-enhanced CT scan seems to be the most reliable method for diagnosing pancreatic necrosis during acute severe pancreatitis. It appears to be an useful prognostic predictor of morbidity. It can improve the outcome of the disease by depicting and guiding needle aspiration of a fluid collection, and/or surgery in case of clinical findings suggesting abscess formation." }, { "id": "wiki20220301en033_21958", "title": "Acute pancreatitis", "score": 0.014387464387464386, "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": "wiki20220301en033_21953", "title": "Acute pancreatitis", "score": 0.014325768860071848, "content": "The risks of ERCP are that it may worsen pancreatitis, it may introduce an infection to otherwise sterile pancreatitis, and bleeding. Surgery Surgery is indicated for (i) infected pancreatic necrosis and (ii) diagnostic uncertainty and (iii) complications. The most common cause of death in acute pancreatitis is secondary infection. Infection is diagnosed based on 2 criteria Gas bubbles on CT scan (present in 20 to 50% of infected necrosis) Positive bacterial culture on FNA (fine needle aspiration, usually CT or US guided) of the pancreas. Surgical options for infected necrosis include: Minimally invasive management – necrosectomy through small incision in skin (left flank) or abdomen Conventional management – necrosectomy with simple drainage Closed management – necrosectomy with closed continuous postoperative lavage Open management – necrosectomy with planned staged reoperations at definite intervals (up to 20+ reoperations in some cases)" }, { "id": "pubmed23n0665_17559", "title": "Clinical, biochemical, and radiologic parameters at admission predicting formation of a pseudocyst in acute pancreatitis.", "score": 0.013745866792631081, "content": "To evaluate clinical, biochemical, and radiologic parameters at admission, which predict the development of acute pseudocyst (AP) after acute pancreatitis. There is limited data on factors that predict the development of AP. Seventy-five consecutive patients with AP were prospectively enrolled and subjected to clinical, laboratory, and radiologic investigation. The patients were followed up for a period of 4 weeks and then investigated radiologically for the development of AP. After exclusion, 65 patients (44 males) were studied. The median age was 37 years (40.9±15.5 y). Etiology of acute pancreatitis was alcohol in 24 patients, gallstones in 18, both in 4, drugs in 4, pancreas divisum in 2, postendoscopic retrograde cholangiopancreatography in 1, trauma in 1, and idiopathic in 11 patients. On admission, acute fluid collections were observed in 34 (52.31%) patients. Necrosis was noted in 38 (58.46%) patients (&lt;30% necrosis, 30% to 50% necrosis, and &gt;50% necrosis was observed in 36.8%, 26.3%, and 36.8% patients, respectively). On follow-up, 34 (52.3%) patients developed a pseudocyst. On univariate analysis, the factors significantly associated with pseudocyst formation were male sex, palpable mass, blood sugar greater than 150 mg/dL, necrosis, sepsis, acute fluid collections, presence of ascites, pleural effusion, a high grade of pancreatitis, and a high computed tomography severity index (CTSI) score. Multivariate regression analysis showed that male sex, presence of a palpable abdominal mass, ascites, and a high CTSI score were associated with the development of AP. Male sex, palpable mass, ascites, and a high CTSI score at admission can predict the development of a pseudocyst after an attack of acute pancreatitis. Acute pancreatitis patients with these parameters at admission should be closely followed for the development of a pseudocyst." }, { "id": "wiki20220301en033_21938", "title": "Acute pancreatitis", "score": 0.013542376732560781, "content": "Diagnosis Acute pancreatitis is diagnosed using clinical history and physical examination, based on the presence of at least 2 of 3 criteria: abdominal pain, elevated serum lipase or amylase, and abdominal imaging findings consistent with acute pancreatitis. Additional blood studies are used to identify organ failure, offer prognostic information, and determine if fluid resuscitation is adequate and whether ERCP is necessary. Blood investigations – complete blood count, kidney function tests, liver function, serum calcium, serum amylase and lipase Imaging – A triple phase abdominal CT and abdominal ultrasound are together considered the gold standard for the evaluation of acute pancreatitis. Other modalities including the abdominal x-ray lack sensitivity and are not recommended. An important caveat is that imaging during the first 12 hours may be falsely reassuring as the inflammatory and necrotic process usually requires 48 hours to fully manifest." }, { "id": "pubmed23n0391_9136", "title": "[CT guided percutaneous fine needle aspiration for early diagnosis of pancreatic infection after acute necrotizing pancreatitis].", "score": 0.013461369814960975, "content": "To assess CT-guided percutaneous fine needle aspiration (FNA) for early diagnosis of pancreatic infection after acute necrotizing pancreatitis. CT-guided percutaneous FNA was employed to diagnose pancreatic infection after acute necrotizing pancreatitis in 14 patients. The aspirates were smeared, cultured and subjected polymerase to chain reaction (PCR) for detecting bacteria. Ten patients were diagnosed as having pancreatic infection and 4 non-pancreatic infection. FNA was totally performed for 15 times: left retroperitoneal route for 12 times, left and right retroperitoneal route for one time, and transperitoneal route for two times. The sensitivity of smear, PCR, culture to diagnose pancreatic infection was 7/10, 9/10, 10/10, respectively. Their specificity was 4/4, and the time for obtaining the results was 30 minutes, 4 hours, 3 days respectively. Retroperitoneal approach can be used for most patients with acute necrotizing pancreatitis when performing CT guided-percutaneous FNA. PCR of aspirates is a rapid and accurate method to diagnose pancreatic infection." }, { "id": "wiki20220301en311_4434", "title": "Pancreatic abscess", "score": 0.013433075933075932, "content": "Some of the imaging tests are more commonly used to diagnose this condition. Abdominal CT scans, MRIs and ultrasounds are helpful in providing clear images of the inside of the abdomen and successfully used in the diagnosing process. These tests may reveal the presence of infected necrosis which has not yet developed into an abscess and as a result, doctors usually order repeated imaging tests in patients with acute pancreatitis whose abdominal pain worsens and who develop signs of abdominal obstruction. Also, it is recommended that patients who have a prolonged clinical response are tested repeatedly as a prevention method to avoid the development of an abscess that may rupture. Prevention In some cases, abscesses may be prevented by draining an existing pseudocyst which is likely to become inflamed. However, in most cases the developing of abscesses cannot be prevented." }, { "id": "InternalMed_Harrison_24396", "title": "InternalMed_Harrison", "score": 0.01328729402508851, "content": "necrosis The management of necrosis requires a multidisciplinary team approach. Percutaneous aspiration of necrosis with Gram stain and culture should be performed if there are ongoing signs of possible pancreatic infection such as sustained leukocytosis, fever, or organ failure. There is currently no role for prophylactic antibiotics in necrotizing pancreatitis. It is reasonable to start broad-spectrum antibiotics in a patient who appears septic while awaiting the results of Gram stain and cultures. If cultures are negative, the antibiotics should be discontinued to minimize the risk of developing opportunistic or fungal superinfection. Repeated fine-needle aspiration and Gram stain with culture of pancreatic necrosis may be done every 5–7 days in the presence of persistent fever. Repeated CT or MRI imaging should also be considered with any change in clinical course to monitor for complications (e.g., thromboses, hemorrhage, abdominal compartment syndrome)." }, { "id": "wiki20220301en311_4432", "title": "Pancreatic abscess", "score": 0.013133395398324244, "content": "Pancreatic abscess is a late complication of acute necrotizing pancreatitis, occurring more than 4 weeks after the initial attack. A pancreatic abscess is a collection of pus resulting from tissue necrosis, liquefaction, and infection. It is estimated that approximately 3% of the patients suffering from acute pancreatitis will develop an abscess. According to the Balthazar and Ranson's radiographic staging criteria, patients with a normal pancreas, an enlargement that is focal or diffuse, mild peripancreatic inflammations or a single collection of fluid (pseudocyst) have less than 2% chances of developing an abscess. However, the probability of developing an abscess increases to nearly 60% in patients with more than two pseudocysts and gas within the pancreas. Signs and symptoms Patients with pancreatic abscesses may experience abdominal pain, chills and fever or the inability to eat. Whereas some patients present an abdominal mass, others do not. Nausea and vomiting may also occur." }, { "id": "pubmed23n0361_3260", "title": "[Severe acute pancreatitis. Clinical and therapeutic contribution of diagnostic imaging].", "score": 0.01302215457466599, "content": "Ultrasonography and dynamic tomography are used in the study of acute pancreatitis, thus helping to interpret the diverse anatomophysiopathologic variables. We present 41 patients studied by ultrasonography, on admission and twenty-four hours later or more. After seventy-two hours, a dynamic tomography was performed. We did a clinicotomographic correlation assessing necrosis, and multiple Ranson criteria, being complemented with the anatomopathologic study of specimens both in the complications and in the elective biliary surgery. There were three puncture aspirates for bacteriology. Eight (19.5%) patients developed local complications and four (9.75%) presented organ failure. Ultrasonography showed biliopancreatic hypertension in 45% of cases of biliary pancreatitis and was reversible in nature. Dynamic tomography was important in defining morphology and pancreatic necrotic involvement. There were two patients with intrapancreatic necrosis, six with intra and extrapancreatic necrosis and eleven patients who presents a dissemination of the process into the extrapancreatic tissues. The prevalence of glandular necrosis was 24%. Both, ultrasonography and dynamic tomography allowed to the identify a spectrum of lesions representative of cavitated extrapancreatic necrosis and enzymatic pericholecystitis. Likewise, they contributed to define medical treatment as well as indications, opportunities and approaches in the surgical and/or percutaneous treatment of septic complications." }, { "id": "InternalMed_Harrison_24367", "title": "InternalMed_Harrison", "score": 0.012922138135263678, "content": "An abdominal ultrasound is recommended in the emergency ward as the initial diagnostic imaging modality and is most useful to evaluate for gallstone disease and the pancreatic head. The revised Atlanta criteria have clearly outlined the morphologic features of acute pancreatitis on computed tomography (CT) scan as follows: (1) interstitial pancreatitis, (2) necrotizing pancreatitis, (3) acute pancreatic fluid collection, (4) pancreatic pseudocyst, (5) acute necrotic collection (ANC), and (6) walled-off pancreatic necrosis (WON) (Table 371-2 and Fig. 371-1). Radiologic studies useful in the diagnosis of acute pancreatitis are discussed in Chap. 370 and listed in Table 370-1." }, { "id": "pubmed23n0809_23386", "title": "Can early endoscopic ultrasound predict pancreatic necrosis in acute pancreatitis?", "score": 0.012738608374384237, "content": "Presence of pancreatic/extrapancreatic necroses (PN/EPN) is an important prognostic indicator in acute pancreatitis (AP) and their early detection is a challenge. Endoscopic ultrasound (EUS) provides high resolution images of pancreas but there is paucity of data on its role in AP. Consecutive patients with AP seen at our center from December 2012-November 2013 and presenting within 5 days of onset of symptoms were prospectively enrolled. EUS was done on the day of admission with a radial echoendoscope and pancreatic/peripancreatic findings were compared with the abdominal computed tomography (CT) findings performed on day 7. Of the 46 patients evaluated, 14 were excluded, and 32 patients (22 male; age 40.68±12.46 years) underwent EUS at admission. The etiology of AP was alcohol in 16, gallstones in 13, and idiopathic in 3 patients. Necrotizing pancreatitis was present in 20 (62%) patients, and mean CT severity index was 6.45±2.96. In patients without PN (n=12), EUS revealed normal echo pattern in 6 patients and diffusely hyperechoic and enlarged pancreas in 6 patients. In patients with PN/EPN, EUS revealed multiple hypoechoic areas (&gt;5 mm) in 5 patients, multiple hyperechoic areas (&gt;5 mm) in 7 patients and mixed hypo and hyperechoic areas in 8 patients. Also, 13 of these patients had peripancreatic hypoechoic areas that correlated with EPN. Moreover, EUS detected common bile duct (CBD) stones in two patients, pleural effusion in 17 patients, and ascites in 15 patients. EUS done at admission can reliably detect PN and co-existent disorders like CBD stones." }, { "id": "wiki20220301en033_21944", "title": "Acute pancreatitis", "score": 0.012212787212787214, "content": "The principal value of CT imaging to the treating clinician is the capacity to identify devitalised areas of the pancreas which have become necrotic due to ischaemia. Pancreatic necrosis can be reliably identified by intravenous contrast-enhanced CT imaging, and is of value if infection occurs and surgical or percutaneous debridement is indicated. Magnetic resonance imaging While computed tomography is considered the gold standard in diagnostic imaging for acute pancreatitis, magnetic resonance imaging (MRI) has become increasingly valuable as a tool for the visualization of the pancreas, particularly of pancreatic fluid collections and necrotized debris. Additional utility of MRI includes its indication for imaging of patients with an allergy to CT's contrast material, and an overall greater sensitivity to hemorrhage, vascular complications, pseudoaneurysms, and venous thrombosis." }, { "id": "article-28233_14", "title": "Ranson Criteria -- Other Issues", "score": 0.01185693560986497, "content": "It is important to understand that imaging is not indicated to assess a patient with mild acute pancreatitis unless the patient is suspected of having a malignancy. However, a CT scan of the abdomen is always indicated in patients with severe acute pancreatitis and is the imaging modality of choice in patients with complications. The CT scan is rarely needed within the first three days of admission unless the diagnosis is in doubt because most inflammatory alterations are often not visible on the scan at this time. Finally, in some patients with severe acute pancreatitis, image-guided aspiration may be required to differentiate sterile necrosis from a purulent infection." }, { "id": "pubmed23n0352_15590", "title": "Treatment of patients with severe acute necrotizing pancreatitis based on prospective evaluation.", "score": 0.011372815094827307, "content": "To examine the impact of a prospectively applied diagnostic and treatment protocol in patients with severe acute necrotizing pancreatitis. During a 4-year period (1993-1996), 26 patients were treated for necrotizing pancreatitis, as documented by contrast-enhanced computed tomography (CE-CT). All patients were prospectively treated by medical means. Patients with persistent systemic inflammatory response syndrome underwent fine-needle aspiration for bacterial cultures. In case of positive results operative intervention was followed, while in negative results the conservative management was continued. Fine-needle aspiration was repeated every 5-7 days if systemic inflammatory response syndrome persisted or worsened. Sixty-five patients hospitalized during the preceding 11 years (1982-1992), when such a treatment was not constantly applied, served as controls. Infected pancreatic necrosis was demonstrated in 7 of the 26 patients (27%) and was treated by open drainage and/or post-operative lavage with a mortality rate of 14.2%. Thirteen patients in whom fine-needle aspiration was not necessary and 6 with negative cultures after fine-needle aspiration (73%) followed conservative treatment and the mortality rate was 5.2%. The total mortality rate of 7.7% was significantly lower than the mortality rate of 26.2% observed in the control group (p = 0.05). Recent evolution made in the management of severe necrotizing acute pancreatitis can lead to better results in the context of a strictly applied treatment protocol. Such protocols may improve mortality and serve as controls in future study." }, { "id": "pubmed23n0745_8689", "title": "Pancreatic pseudocyst after endoscopic ultrasound-guided fine needle aspiration of pancreatic mass.", "score": 0.010882249970825066, "content": "Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is well known as a safe diagnostic procedure. We report the first case of pancreatic pseudocyst after EUS-FNA of the pancreatic body mass. A 60-year-old male underwent EUS-FNA for incidentally detected pancreatic solid mass which was suspected as neuroendocrine tumor. Two weeks later, the patient visited emergency room with acute abdominal pain and right upper quadrant tenderness; leukocytosis and elevated C-reactive protein, amylase, and lipase levels were noted. Computed tomography discovered newly developed 11.5×9.5 cm sized cystic mass communicating with the main pancreatic duct. Cyst fluid analysis revealed amylase level of 3,423 U/L and fluid culture isolated Streptococcus parasanguinis. The cystic mass corresponds with pancreatic pseudocyst. FNA induced main pancreatic duct injury and fluid leakage may cause it. Endoscopists who perform EUS-FNA must remember that pancreatic main duct injury can occur as one of severe complications and that it could be treated successfully with endoscopic internal drainage." }, { "id": "pubmed23n1138_12725", "title": "Volume, but Not the Location of Necrosis, Is Associated with Worse Outcomes in Acute Pancreatitis: A Prospective Study.", "score": 0.010806749884419787, "content": "<iBackground and Objectives</i: The course and clinical outcomes of acute pancreatitis (AP) are highly variable. Up to 20% of patients develop pancreatic necrosis. Extent and location of it might affect the clinical course and management. The aim was to determine the clinical relevance of the extent and location of pancreatic necrosis in patients with AP. <iMaterials and Methods</i: A cohort of patients with necrotizing AP was collected from 2012 to 2018 at the Hospital of Lithuanian University of Health Sciences. Patients were allocated to subgroups according to the location (entire pancreas, left and right sides of pancreas) and extent (&amp;lt;30%, 30-50%, &amp;gt;50%) of pancreatic necrosis. Patients were reviewed for demographic features, number of performed surgical interventions, local and systemic complications, hospital stay and mortality rate. All contrast enhanced computed tomography (CECT) scans were evaluated by at least two experienced abdominal radiologists. All patients were treated according to the standard treatment protocol based on current international guidelines. <iResults</i: The study included 83 patients (75.9% males (<in</i = 63)) with a mean age of 53 ± 1.7. The volume of pancreatic necrosis exceeded 50% in half of the patients (<in</i = 42, 51%). Positive blood culture (<in</i = 14 (87.5%)), multiple organ dysfunction syndrome (<in</i = 17 (73.9%)) and incidences of respiratory failure (<in</i = 19 (73.1%)) were significantly more often diagnosed in patients with pancreatic necrosis exceeding 50% (<ip</i &amp;lt; 0.05). Patients with &amp;gt;50% of necrosis were significantly (<ip</i &amp;lt; 0.05) more often diagnosed with moderately severe (<in</i = 24 (41.4%)) and severe (<in</i = 18 (72%)) AP. The number of surgical interventions (<in</i = 18 (72%)) and ultrasound-guided interventions (<in</i = 26 (65%)) was also significantly higher. In patients with whole-pancreas necrosis, incidence of renal insufficiency (<in</i = 11 (64.7%)) and infected pancreatic necrosis (<in</i = 19 (57.6%)) was significantly higher (<ip</i &amp;lt; 0.05). <iConclusions</i: The clinical course and outcome were worse in the case of pancreatic necrosis exceeding 50%, rendering the need for longer and more complex treatment." }, { "id": "InternalMed_Harrison_24372", "title": "InternalMed_Harrison", "score": 0.010620915032679739, "content": "FIGURE 371-1 Acute pancreatitis: computed tomography (CT) evolution. A. Contrast-enhanced CT scan of the abdomen performed on admission for a patient with clinical and biochemical parameters suggestive of acute pancreatitis. Note the abnormal enhancement of the pancreatic parenchyma (arrow) suggestive of interstitial pancreatitis. B. Contrast-enhanced CT scan of the abdomen performed on the same patient 6 days later for persistent fever and systemic inflammatory response syndrome. The pancreas now demonstrates significant areas of nonenhancement consistent with development of necrosis, particularly in the body and neck region (arrow). Note that an early CT scan obtained within the first 48 h of hospitalization may underestimate or miss necrosis. C. Contrast-enhanced CT scan of the abdomen performed on the same patient 2 months after the initial episode of acute pancreatitis. CT now demonstrates evidence of a fluid collection consistent with walled-off pancreatic necrosis (arrow)." }, { "id": "wiki20220301en033_21959", "title": "Acute pancreatitis", "score": 0.010419455600178491, "content": "Alternative Ranson score Ranson's score of ≥ 8 Organ failure Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT) Interpretation If the score ≥ 3, severe pancreatitis likely. If the score < 3, severe pancreatitis is unlikely Or Score 0 to 2 : 2% mortality Score 3 to 4 : 15% mortality Score 5 to 6 : 40% mortality Score 7 to 8 : 100% mortality APACHE II score \"Acute Physiology And Chronic Health Evaluation\" (APACHE II) score > 8 points predicts 11% to 18% mortality Hemorrhagic peritoneal fluid Obesity Indicators of organ failure Hypotension (SBP <90 mmHG) or tachycardia > 130 beat/min PO2 <60 mmHg Oliguria (<50 mL/h) or increasing BUN and creatinine Serum calcium < 1.90 mmol/L (<8.0 mg/dL) or serum albumin <33 g/L (<3.2.g/dL)>" }, { "id": "wiki20220301en033_21961", "title": "Acute pancreatitis", "score": 0.010287041645926663, "content": "Glasgow score The Glasgow score is valid for both gallstone and alcohol induced pancreatitis, whereas the Ranson score is only for alcohol induced pancreatitis. If a patient scores 3 or more it indicates severe pancreatitis and the patient should be considered for transfer to ITU. It is scored through the mnemonic, PANCREAS: P - PaO2 <8kPa A - Age >55-years-old N - Neutrophilia: WCC >15x10(9)/L C - Calcium <2 mmol/L R - Renal function: Urea >16 mmol/L E - Enzymes: LDH >600iu/L; AST >200iu/L A - Albumin <32g/L (serum) S - Sugar: blood glucose >10 mmol/L BISAP score Predicts mortality risk in pancreatitis with fewer variables than Ranson's criteria. Data should be taken from the first 24 hours of the patient's evaluation. BUN >25 mg/dL (8.9 mmol/L) Abnormal mental status with a Glasgow coma score <15 Evidence of SIRS (systemic inflammatory response syndrome) Patient age >60 years old Imaging study reveals pleural effusion" }, { "id": "wiki20220301en033_21960", "title": "Acute pancreatitis", "score": 0.010280054644808743, "content": "Balthazar score Developed in the early 1990s by Emil J. Balthazar et al., the Computed Tomography Severity Index (CTSI) is a grading system used to determine the severity of acute pancreatitis. The numerical CTSI has a maximum of ten points, and is the sum of the Balthazar grade points and pancreatic necrosis grade points: Balthazar grade Necrosis score CTSI's staging of acute pancreatitis severity has been shown by a number of studies to provide more accurate assessment than APACHE II, Ranson, and C-reactive protein (CRP) level. However, a few studies indicate that CTSI is not significantly associated with the prognosis of hospitalization in patients with pancreatic necrosis, nor is it an accurate predictor of AP severity. Glasgow score" }, { "id": "pubmed23n0291_6120", "title": "Labeled granulocyte scanning for the diagnosis of infected necrosis in acute pancreatitis: what kind of labeling should be used?", "score": 0.010269643985675163, "content": "Clinical and laboratory data or imaging results cannot provide a positive diagnosis of septic complications of pancreatic and peripancreatic necrosis in patients with acute pancreatitis. Confirmation can be obtained only after percutaneous computed tomography (CT)-guided aspiration of the necrotic tissues or fluid collection; although the important role of 99Tc(m)-HMPAO-labeled granulocyte scintigraphy has been recently emphasized. The aim of this study was to determine the sensitivity and specificity of 99m-technetium-hexamethylpropyleneamine oxime (99Tc(m)-HMPAO)- or 111In-oxine-labeled granulocyte scintigraphy for the diagnosis of infection in pancreatic or peripancreatic necrosis to define the ideal label for diagnosis. Thirty-six scintigraphic examinations were performed in 34 consecutive patients (mean age, 58 +/- 2 years) 20 +/- 2 days after the onset of acute pancreatitis (Balthazar classes A-C, n = 7; classes D and E, n = 29). The scintigraphic study included scintigraphic tomography and static acquisition 1 and 3 h, respectively, after reinjection of the autologous 99Tc(m)-labeled granulocytes and static images 3-4 and 24 h after the simultaneous reinjection of 111In-oxine-labeled autologous granulocytes. The diagnosis of infected pancreatic or peripancreatic necrosis was confirmed with percutaneous CT-guided aspiration (14 positive aspirates among 20 performed) and sterile necrosis after negative aspiration (6 negative aspirates) or after a 6 +/- 1-month follow-up free of clinical or biological signs of ongoing sepsis. The sensitivity and specificity were 86 and 73%, respectively, for scintigraphic tomography, 100 and 55% for 3-h 111In images, 93 and 68% for 3-4-h 111In images, and 100 and 64% for 24-h 111In images. The fall in splenic activity between the 3-4 and the 24-h 111In images was 26 +/- 3% in patients with septic pancreatic and peripancreatic necrosis (n = 14) and 16 +/- 3% in those with sterile necrosis (n = 22) (p &lt; 0.01). Labeled granulocyte scintigraphy was thus shown to be an effective tool for the diagnosis of infection in pancreatic and/or peripancreatic necrosis due to acute pancreatitis, especially when the scintiscans are performed early after injection of 99Tc(m) or when the fall in splenic activity over the 24 h following reinjection of 111In is measured in particularly difficult cases. These promising preliminary results should be confirmed by a prospective study." }, { "id": "InternalMed_Harrison_24392", "title": "InternalMed_Harrison", "score": 0.010147581125499107, "content": "Special Considerations Based on Etiology A careful history, review of medications, selected laboratory studies (liver profile, serum triglycerides, serum calcium), and an abdominal ultrasound are recommended in the emergency ward to assess for etiologies that may impact acute management. An abdominal ultrasound is the initial imaging modality of choice and will evaluate the gallbladder and common duct and assess the pancreatic head. Gallstone pancreatitis Patients with evidence of ascending cholangitis (rising white blood cell count, increasing liver enzymes) should undergo ERCP within 24–48 h of admission. Patients with gallstone pancreatitis are at increased risk of recurrence, and consideration should be given to performing a cholecystectomy during the same admission or within 4–6 weeks of discharge. An alternative for patients who are not surgical candidates would be to perform an endoscopic biliary sphincterotomy before discharge." }, { "id": "pubmed23n0370_17729", "title": "Correlation between admission laboratory values, early abdominal computed tomography, and severe complications of gallstone pancreatitis.", "score": 0.00980392156862745, "content": "Our previous study demonstrated that Balthazar grade D or E pancreatitis on early abdominal computed tomography (CT) scan correlated with severe complications of gallstone pancreatitis (GP). To compare the efficacy of individual admission laboratory criteria, multiple criteria scoring systems and CT scan for predicting severe complications of GP. Consecutively admitted patients with GP underwent selective early CT scanning (&lt;72 hours). All patients were prospectively monitored for severe complications. Of the 66 patients studied, 21 (32%) did not undergo for early CT scanning and underwent cholecystectomy with no complications. Forty-five patients (68%) had an early abdominal CT scan. Of the 12 patients with grade E pancreatitis, 6 (50%) developed severe complications versus only 2 of 33 (6%) with grade A to D pancreatitis (P = 0.002). A significant correlation was found between admission white blood cell count &gt; or =14.5 x 10(9)/L and grade E pancreatitis on early CT scan (P = 0.002). However, admission glucose &gt; or =150 mg/dL was the best predictor of complications (sensitivity 100%, negative predictive value 100%). Although Balthazar grade E on early CT scan correlates with severe complications of GP, admission glucose &gt; or =150 mg/dL has a better sensitivity and negative predictive value, is quicker to use, and is more cost-effective as a prognostic indicator." }, { "id": "pubmed23n0320_18848", "title": "[Computer tomography and interventional radiologic methods in the diagnosis of acute pancreatitis].", "score": 0.009708737864077669, "content": "The authors supervised the case record of 51 patients admitted between 1994 January and 1996 March suffering from acute pancreatitis. Diagnosis was made upon clinical signs, laboratory findings, abdominal ultrasound and CT examinations. In total 121 CT examinations were made mostly by using contrast material. Patients were classified with the help of Balthazar's grade. The authors emphasize that CT currently is the most accurate single imaging modality for diagnosis, staging the severity of the inflammatory process, and detecting complications of acute pancreatitis. They suggest that the first CT examination should be done within 3 days from the onset of the illness. In cases falling under group \"C\", \"D\" or \"E\" of Balthazar's grade, the CT examination should at least be repeated within 10 days. With 6 patients in septic state the bacteriological findings gained by fine needle aspiration was of great value for the further treatment." }, { "id": "pubmed23n1052_8943", "title": "Infected Pancreatic Necrosis Mimicking Pancreatic Cancer.", "score": 0.009523809523809525, "content": "Although infected pancreatic necrosis can develop as a result of rare conditions involving trauma, surgery, and systemic infection with an uncommon pathogen, it usually occurs as a complication of pancreatitis. Early phase of acute pancreatitis can be either edematous interstitial pancreatitis or necrotizing pancreatitis. The late complications of pancreatitis can be divided into pancreatic pseudocyst due to edematous interstitial pancreatitis or walled-off necrosis due to necrotizing pancreatitis. During any time course of pancreatitis, bacteremia can provoke infection inside or outside the pancreas. The patients with infected pancreatic necrosis may have fever, chills, and abdominal pain as inflammatory symptoms. These specific clinical presentations can differentiate infected pancreatic necrosis from other pancreatic diseases. Herein, I report an atypical case of infected pancreatic necrosis in which abdominal pain, elevation of white blood cell, and fever were not found at the time of admission. Rather, a 10-kg weight loss (from 81 to 71 kg) over 2 months nearly led to a misdiagnosis of pancreatic cancer. The patient was finally diagnosed based on endoscopic ultrasound-guided fine-needle aspiration. This case highlights that awareness of the natural course of pancreatitis and infected pancreatic necrosis is important. In addition, endoscopic ultrasound-guided fine-needle aspiration should be recommended for the diagnosis and treatment of indeterminate pancreatic lesions in selected patients." }, { "id": "pubmed23n0981_250", "title": "[Treatment of acute necrotizing pancreatitis].", "score": 0.009523809523809525, "content": "Acute pancreatitis (AP) has an annual incidence of 30-45 per 100,000 inhabitants. In Germany approximately one third of the cases are of biliary or alcoholic origin. The diagnosis is based on the typical epigastric pain with radiation and a threefold increase of lipase or amylase in serum. Imaging procedures only rarely need to be included for the primary diagnostics. An early risk assessment is important to be able to allocate patients with severe AP to surveillance in an intensive care unit (ICU). Elevation of blood urea nitrogen, hematocrit and blood glucose are early predictors of poor outcome.The removal of impacted gall-stones by endoscopic retrograde cholangiography (ERC) is the only causal treatment of biliary AP, which must be carried out when there are signs of cholangitis and in severe biliary AP. Pain management and early fluid substitution are the most important symptomatic approaches. In the early phase of AP 150-250 ml/h of crystalloid solution should be administered to compensate for the extravasal loss of fluid. In certain cases, the initial fluid requirement might be even higher. In the ICU setting echocardiography and advanced hemodynamic monitoring are available for guidance. Prophylactic antibiotic treatment is not recommended in mild AP and it is a matter of debate even in severe AP. Early enteral nutrition has been shown to improve the outcome. Even in cases of fluid collection and necrosis a primary surgery approach should be avoided in favor of a \"step-up\" procedure with radiologically guided drainage as well as endoscopic and if necessary video-assisted percutaneous retroperitoneal débridement. Surgery remains an option for complications and for infected necrosis which cannot be reached by any other means." }, { "id": "pubmed23n0975_21190", "title": "[A CASE OF PULMONARY TUBERCULOSIS WITH PANCREATIC LESION].", "score": 0.009433962264150943, "content": "A 52-year-old woman was referred to our hospital presenting with epigastric pain and weight loss. A contrast- enhanced abdominal computed tomography (CT) scan showed a low-density mass in the body of the pancreas, indicative of a malignancy. Endoscopic ultrasound-guided fine needle aspiration of the pancreatic mass was performed three times and showed no specific findings. A distal pancreatectomy was performed, and a pathological examination revealed epitheli- oid cell granulomas and necrosis. Ziehl-Neelsen staining did not reveal acid-fast bacilli in the pancreatic mass. A diagnosis of tuberculosis or sarcoidosis of the pancreas was con- sidered; however, the patient chose to undergo a follow-up examination without therapeutic intervention because the pancreatic mass had been removed completely and she had recovered well. Four months after the operation, the patient was readmitted to our hospital for insulin therapy for pancreatic diabetes. She presented with a fever and a productive cough, and a chest CT scan showed multiple nodules in both upper lobes. A bronchoscopy was performed and bronchoalveolar lavage fluid cultures for Mycobacterium tuberculosis were positive. The patient received antitubercular quadri-therapy and showed symptomatic and radiologic improvement. At the initial examination, we had been unable to establish the correct diagnosis; however, the detection of pulmonary lesions led to the time-delayed diagnosis of pancreatic tuber- culosis. Owing to its rarity, it is difficult to diagnose pancreatic tuberculosis using clinical symptoms and radiological imaging modalities; thus, pathologic and bacteriologic confirmation is essential. To avoid performing an unnecessary laparotomy in patients with pancreatic tuberculosis, increased vigilance and an accurate diagnostic approach are required." } ] } } }

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{ "1": "Administer metformin.", "2": "Prescribe a sulfonylurea.", "3": "Behavioral changes. Diet and physical exercise.", "4": "Insulin before each meal.", "5": "Take acarbose at night, before going to bed." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0659_10790", "title": "[Sequential treatment with insulin glargine and metformin, and exenatide in a patient with newly diagnosed type-2 diabetes].", "score": 0.01761642156862745, "content": "HISTORY AND ADMISSIONS FINDINGS: A 54-year-old man was admitted to hospital for treatment of a newly diagnosed type 2 diabetes. He had polydipsia and polyuria and had lost 11 kg in weight over four weeks. Further diagnoses were visceral obesity and arterial hypertension. Laboratory tests revealed highly elevated blood glucose parameters (HbA1c 14,9 %, fasting glucose 280 mg/dl, maximal postprandial glucose 430 mg/dl and 320 mg/dl before the meal) and triglyceride (2219 mg/dl). The patient was initially treated with a combination of insulin glargine and metformin. After a few days exenatide was added, as the patient wanted to be able to go without insulin. He was given a structured diabetes education and motivated to have five to six hours' of physical activity and a low glycemic diet. After a few days normal glucose levels had been achieved. After one month the insulin treatment was discontinued. The continuing treatment with metformin, 1000 mg twice daily, and exenatide, 5 mg twice daily, prolonged remission of beta-cell dysfunction and maintained normal blood glucose levels for seven months. After reduction of the metformin dosage (500 mg twice daily) and discontinuance of exenatide as well as a reduction of his physical activity (because of joint pain) for six months, the glucose control worsened. When exenatide was administered again, good control of postprandial blood glucose, but not of fasting glucose was achieved. Initial combination treatment with insulin glargine, metformin and exenatide may be beneficial in a subgroup of patients with newly diagnosed type 2 diabetes, markedly elevated blood glucose and free fatty acid levels (glucolipotoxicity). This should be further investigated in randomized controlled trials." }, { "id": "pubmed23n0650_13044", "title": "[Therapeutic behavior to follow in the following clinical case: treatment of type 2 diabetes].", "score": 0.016420361247947456, "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": "pubmed23n0136_11664", "title": "Short-term treatment of glucose intolerance in middle-aged subjects by diet, exercise and sulfonylurea.", "score": 0.016056478820442335, "content": "In a screening survey of women and men 47-54 years old for detection of glucose intolerance (GI), with 75 g oral glucose tolerance tests (OGTT), 25 subjects with GI were randomly selected for a therapeutic trial for normalization of the GI. A control group of 18 GI subjects was chosen randomly from the same health survey and given no treatment for 5-10 months; no significant changes in OGTT variables, body mass index, blood pressure or blood lipids were found in this group during follow-up. The treatment group was given advice concerning a low-sucrose, low-fat, high-fiber and energy-restricted (when overweight) diet and also concerning exercise - single-handed (16 subjects) or in an exercise group (9 subjects). The GI improved in the 25 treated subjects after 6 months of this therapy. Thus the total area under the glucose curve and the 1-h and the 2-h glucose values had decreased, the mean 2-h glucose value was restored to normal (less than 7.0 mmol X l-1) and 48% of the treated subjects had a normal 2-h glucose value. Body mass index, systolic blood pressure, serum cholesterol and serum triglycerides were also reduced at the follow-up. The 6-month result was similar in the subgroup of nine GI subjects who followed the dietary advice and exercised in a group for at least one hour per week during at least three months. Physical working capacity was increased, although non-significantly. Glipizide, 1.25 mg daily, was added at breakfast to ten GI-subjects who still had pathological 2-h glucose values after 6 months of dietary and exercise treatment. After a further 6 months of treatment of these 10 subjects, the total glucose area and the 2-h glucose value were reduced, while the mean 2-h glucose value had not required the normal level. Body mass index was unchanged. Another four subjects in this subgroup now showed a normal 2-h glucose value. In conclusion, the 2-h glucose value was restored to normal in totally 64% of all treated GI subjects after short-term treatment with a diet, exercise and, in some cases, added glipizide." }, { "id": "pubmed23n0371_21436", "title": "Acarbose vs. bedtime NPH insulin in the treatment of secondary failures to sulphonylurea-metformin therapy in type 2 diabetes mellitus.", "score": 0.015925925925925927, "content": "To evaluate the efficacy of acarbose in the treatment of secondary failures to sulphonylurea-metformin therapy, its comparison against bedtime NPH insulin, and to measure the changes in postprandial metabolism resulting from both treatments. One hundred type 2 diabetic patients in a secondary failure were included. The study begun with a run-in diet period of 6 weeks, in which an isocaloric diet was prescribed. Only subjects who continued hyperglycaemic were randomly assigned to placebo and acarbose (n = 17) or bedtime NPH insulin (n = 12). Acarbose (300 mg/day) or placebo were administered using a randomized, double blind, crossover design. Treatment periods of 3 months were separated by a 3-week washout period. Insulin was administered during 3 months. At the beginning and the end of each treatment period, an i.v. glucose tolerance test and a meal test were performed. Safety tests were done every 4 weeks. Acarbose resulted in a small but significant improvement in fasting plasma glucose (13.5 +/- 2.4 vs. 11.3 +/- 3.9 mmol/l, p = 0.05), HbA1c (11.1 +/- 3.4 vs. 10.3 +/- 2.5%, P = 0.3) and in a decreased plasma glucose during the meal test. Bedtime insulin significantly decreased fasting plasma glucose (13.1 +/- 2.9 vs. 8.2 +/- 2.3 mmol/l, p &lt; 0.01), HbA1c (11.7 +/- 2.9 vs. 9.4 +/- 2.7%, p &lt; 0.01) and plasma cholesterol. No change in insulin secretion resulted from insulin and acarbose treatment. Acarbose decreases blood glucose in secondary failure to sulphonylurea-metformin therapy; however, the decrease is not enough to reach the desired metabolic control. Bedtime NPH insulin is, by far, a more effective alternative." }, { "id": "pubmed23n0789_21091", "title": "Improvement of both fasting and postprandial glycemic control by the two-step addition of miglitol and mitiglinide to basal insulin therapy: a pilot study.", "score": 0.015331296992481203, "content": "Combination therapy consisting of basal insulin and oral hypoglycemic agents (OHAs) is effective for the treatment of type 2 diabetes (T2DM) that cannot be adequately controlled using OHAs alone. Though basal insulin with metformin or sulfonylurea is an effective therapy, it cannot reduce postprandial glycemia without the risk of hypoglycemia. We examined a two-step regimen consisting of the addition of postprandial hypoglycemic agents (an alpha-glucosidase inhibitor and a glinide) in patients whose T2DM was poorly controlled using basal insulin therapy. Inpatients between the ages of 30-79 years who had T2DM and an HbA1c level of more than 7.0% were recruited. The patients were treated with once-daily insulin glargine with or without metformin, depending on the patient's age and renal function. Insulin glargine was titrated to achieve a target fasting glucose level of 70-130 mg/dL as a first step (STEP0). If the 2-hour postprandial glucose (PBG) level was higher than the target of 180 mg/dL, miglitol treatment (150 mg/day) was initiated, with dose adjustments (75-225 mg) allowed depending on abdominal symptoms and the PBG (STEP1). If the PBG of the patients remained higher than the target after 3 days of treatment, mitiglinide (30 mg/day, titrated up to 60 mg) was added (STEP2). We then evaluated the proportion of patients who achieved the target PBG before and after the two-step regimen. Continuous Glucose Monitoring (CGM) was performed throughout the two-step protocol in most of the patients. Of the 16 patients who were recruited (median age, 67.0 [58.0-71.0] years; body mass index, 25.0 [22.0-27.9] kg/m(2); HbA1c level at admission, 9.1% [8.35-10.4%]), 1 patient (6.25%) achieved the target PBG at STEP 0 and 14 patients (87.5%) had achieved the target PBG at the end of the treatment protocol (P = 0.002). CGM showed a significant decrease in the glucose level at each step of the protocol. The standard deviations in the CGM glucose levels for 24 hours, MAGE, and M-value also improved. The two-step addition of postprandial hypoglycemic agents to basal insulin therapy is potentially effective and safe for decreasing both the fasting and postprandial glucose levels." }, { "id": "pubmed23n0334_3787", "title": "Comparison of bedtime insulin regimens in patients with type 2 diabetes mellitus. A randomized, controlled trial.", "score": 0.013959504058513959, "content": "Compared with other insulin regimens, combination therapy with oral hypoglycemic agents and bedtime insulin produces similar improvement in glycemic control but induces less weight gain. To determine whether bedtime insulin regimens differ with respect to their effects on weight gain in patients with type 2 diabetes. Randomized, controlled trial. Four outpatient clinics at central hospitals. 96 patients (mean age, 58 +/- 1 years; mean body mass index, 29 +/- 1 kg/m2) whose type 2 diabetes was poorly controlled with sulfonylurea therapy (mean glycosylated hemoglobin value, 9.9% +/- 0.2%; mean fasting plasma glucose level, 11.9 +/- 0.3 mmol/L [214 +/- 5 mg/dL]). Random assignment to 1 year of treatment with bedtime intermediate-acting insulin plus glyburide (10.5 mg) and placebo, metformin (2 g) and placebo, glyburide and metformin, or a second injection of intermediate-acting insulin in the morning. Patients were taught to adjust the bedtime insulin dose on the basis of fasting glucose measurements. Body weight, biochemical and symptomatic hypoglycemias, and indices of glycemic control. At 1 year, body weight remained unchanged in patients receiving bedtime insulin plus metformin (mean change, 0.9 +/- 1.2 kg; P &lt; 0.001 compared with all other groups) but increased by 3.9 +/- 0.7 kg, 3.6 +/- 1.2 kg, and 4.6 +/- 1.0 kg in patients receiving bedtime insulin plus glyburide, those receiving bedtime insulin plus both oral drugs, and those receiving bedtime and morning insulin, respectively. The greatest decrease in the glycosylated hemoglobin value was observed in the bedtime insulin and metformin group (from 9.7% +/- 0.4% to 7.2% +/- 0.2% [difference, -2.5 +/- 0.4 percentage points] at 1 year; P &lt; 0.001 compared with 0 months and P &lt; 0.05 compared with other groups). This group also had significantly fewer symptomatic and biochemical cases of hypoglycemia (P &lt; 0.05) than the other groups. Combination therapy with bedtime insulin plus metformin prevents weight gain. This regimen also seems superior to other bedtime insulin regimens with respect to improvement in glycemic control and frequency of hypoglycemia." }, { "id": "pubmed23n0771_4412", "title": "Prevention of diabetes in family medicine.", "score": 0.013651108307803209, "content": "none declared. The incidence of diabetes type 2 (diabetes mellitus type 2 - DM 2) is rapidly increasing worldwide. Physical inactivity and obesity are the major determinants of the disease. Primary prevention of DM 2 entails health monitoring of people at risk category. People with impaired glycemic control are at high risk for development of DM 2 and enter the intensive supervision program for primary and secondary prevention. To evaluate the impact of metformin and lifestyle modification on glycemia and obesity in patients with prediabetes. The study was conducted on three groups of 20 patients each (total of 60 patients) aged from 45 to 80, with an abnormal glycoregulation and prediabetes. The study did not include patients who already met the diagnostic criteria for the diagnosis of diabetes. During the study period of 6 months, one group was extensively educated on changing lifestyle (healthy nutrition and increased physical activity), the second group was treated with 500 mg metformin twice a day, while the control group was advised about diet and physical activities but different from the first two groups. At beginning of the study, all patients were measured initial levels of blood glucose, HbA1C, BMI (Body Mass Index), body weight and height and waist size. Also the same measurements were taken at the end of the conducted research, 6 months later. For the assessment of diabetes control was conducted fasting plasma glucose (FPG) test and 2 hours after a glucose load, and HbA1C. At the beginning of the study the average HbA1C (%) values in three different groups according to the type of intervention (lifestyle changes, metformin, control group) were as follows: (6.4 ± 0.5 mmol / l), (6.5 ± 1.2 mmol / l), (6.7 ± 0.5 mmol / l). At the end of the research, the average HbA1C values were: 6.2 ± 0.3 mmol / l, 6.33 ± 0.5 mmol / l and 6.7 ± 1.4 mmol / l. In the group of patients who received intensive training on changing lifestyle or group that was treated with metformin, the average reduction in blood glucose and HbA1C remained within the reference range and there were no criteria for the diagnosis of diabetes. Unlike the control group, a group that was well educated on changing habits decreased average body weight by 4.25 kg, BMI by 1.3 and waist size by 2.5 cm. Metformin therapy led to a reduction in the average weight of 3.83 kg, BMI of 1.33 and 3.27 for waist size. Changing lifestyle (healthy diet and increased physical activity) has led to a reduction in total body weight in 60% of patients, BMI in 65% of patients, whereas metformin therapy led to a reduction of the total body weight in 50%, BMI in 45% of patients. In the control group, the overall reduction in body weight was observed in 25%, and BMI in 15% of patients. Modification of lifestyle, such as diet and increased physical activity or use of metformin may improve glycemic regulation, reduce obesity and prevent or delay the onset of developing DM 2." }, { "id": "wiki20220301en117_15048", "title": "Diet in diabetes", "score": 0.013261862219575144, "content": "Timing of meals For people with diabetes, healthy eating is not simply a matter of what one eats, but also when one eats. For insulin dependent diabetics, when they eat depends on their blood sugar level and the type of insulin they take (i.e.: long-, medium- or quick-acting insulin). If patients check their blood glucose at bedtime and find that it is low, for example below 6 millimoles per liter (108 mg/dL), it is advisable that they take some long-acting carbohydrate before retiring to bed to prevent night-time hypoglycemia. Night sweats, headaches, restless sleep, and nightmares can be a sign of nocturnal hypoglycemia, and patients should consult their doctor for adjustments to their insulin routine if they find that this is the case. Another possible sign of nocturnal hypoglycemia is morning hyperglycemia, which actually occurs in response to blood sugar getting too low at night. This is called the Somogyi effect." }, { "id": "pubmed23n1061_4543", "title": "[Short-term Glucose Lowering Effects of Sodium-glucose Cotransporter 2 Inhibitors Confirmed by Flash Glucose Monitoring in Two Outpatients with Type 1 Diabetes].", "score": 0.012877803054923627, "content": "Case 1 was a 41-year-old man with type 1 diabetes. He presented with poor glycemic control [hemoglobin A1c (HbA1c) of 8-9%] despite treatment with more than 20 units/day of insulin and 150 mg of miglitol. Before administration of sodium glucose cotransporter 2 (SGLT2) inhibitor, hyperglycemia was noted mainly at night by Flash Glucose Monitoring (FGM). Administration of ipragliflozin at 50 mg improved the hyperglycemia mainly at night (mean blood glucose, before administration: 205 mg/dl, day 6 of treatment: 119 mg/dl). Two months later, the HbA1c improved to 7.2% without hypoglycemia or ketosis. Case 2 was a 46-year-old woman with type 1 diabetes. She was morbidly obese and presented with poor glycemic control (HbA1c: 9-11%) although she was being treated with more than 50 units/day of insulin and 2,250 mg of metformin. Before administration of SGLT2 inhibitor, hyperglycemia was noted to be mainly nocturnal by FGM. Administration of dapagliflozin at 5 mg improved the hyperglycemia mainly at night on day 2 with improvement in the mean blood glucose level from 188 mg/dl before administration to 128 mg/dl on day 5. Four months later, the HbA1c improved to 8.0% without hypoglycemia and ketosis, and her body weight decreased from 92.1 to 89.8 kg. The hypoglycemic effect of SGLT2 inhibitors is independent of insulin. These agents also have various other effects, including weight loss, improvement of blood pressure and lipid metabolism. Here we report the short-term glucose lowering effects of two SGLT2 inhibitors, as confirmed by FGM, in two outpatients with type 1 diabetes." }, { "id": "pubmed23n0260_15220", "title": "Therapeutic comparison of metformin and sulfonylurea, alone and in various combinations. A double-blind controlled study.", "score": 0.012709729918239238, "content": "To assess and compare the therapeutic efficacy and safety of metformin (M) and sulfonylurea (glyburide, G), alone and in various combinations, in patients with non-insulin-dependent diabetes mellitus (NIDDM). Of 165 patients (fasting blood glucose [FBG] &gt; or = 6.7 mmol/l) initially treated with diet alone, 144 (FBG still &gt; or = 6.7 mmol/l) were randomized to double-blind, double-dummy controlled treatment with M, G, or primary combination therapy (MG). The dose was titrated, with FBG &lt; 6.7 mmol/l as target, using, at most, six dose levels. The first three dose levels comprised increasing single-drug therapy (M or G) or primary combination at increasing but low dosage (MGL), and the second three levels were composed of various high-dose combinations, i.e., add-on therapy (M/G or G/M) and primary combination escalated to high dosage (MGH). Medication was maintained for 6 months after completed dose titration. The FBG target was achieved in 9% of patients after diet alone. Single-drug therapy was insufficient in 36% and MGL in 25% (NS) of the randomized patients. There was further improvement in glucose control by the high-dose combinations. Mean FBG +/- SE was reduced (P = 0.001) from 9.1 +/- 0.4 to 7.0 +/- 0.2 mmol/l in those maintained on single-drug treatment or low-dose primary combination. Those treated with different high-dose combinations had a large mean FBG reduction, from 13.3 +/- 0.8 to 7.8 +/- 0.6 mmol/l. HbA1c levels showed corresponding reductions, and glycemic levels rose after drug discontinuation. Fasting C-peptide rose during treatment with G and MGL but not with M, while fasting insulin was not significantly changed. Meal-stimulated C-peptide and insulin levels were unchanged by M but increased by G and, to a lesser extent, by MGL. There were no significant insulin or C-peptide differences between the different high-dose combinations (M/G, G/M, and MGH). Body weight did not change following treatment with M or combination but increased by 2.8 +/- 0.7 kg following G alone. Blood pressure was unchanged. Overall effects on plasma lipids were small, with no significant differences between groups. Drug safety was satisfactory, even if the reporting of (usually modest) adverse events was high; the profile, but not the frequency, differed between groups. Dose-effect titrated treatment with either metformin or glyburide promotes equal degrees of glycemic control. The former, but not the latter, is able to achieve this control without increasing body weight or hyperinsulinemia. Near-normal glycemia can be obtained by a combination of metformin and sulfonylurea, even in advanced NIDDM." }, { "id": "wiki20220301en067_58692", "title": "Type 1 diabetes", "score": 0.012572590011614402, "content": "The mainstay of type 1 diabetes treatment is the regular injection of insulin to manage hyperglycemia. Injections of insulin – via subcutaneous injection using either a syringe or an insulin pump – are necessary multiple times per day, adjusting dosages to account for food intake, blood glucose levels and physical activity. The goal of treatment is to maintain blood sugar in a normal range – 80–130 mg/dL before a meal; <180 mg/dL after – as often as possible. To achieve this, people with diabetes often monitor their blood glucose levels at home. Around 83% of type 1 diabetics monitor their blood glucose by capillary blood testing – pricking the finger to draw a drop of blood, and determining blood glucose with a glucose meter. The American Diabetes Association recommends testing blood glucose around 6–10 times per day: before each meal, before exercise, at bedtime, occasionally after a meal, and any time someone feels the symptoms of hypoglycemia. Around 17% of people with type 1" }, { "id": "wiki20220301en138_42886", "title": "Richard K. Bernstein", "score": 0.01213289180826231, "content": "Diabetes treatment Bernstein's diet is extremely low-carbohydrate in that it completely eliminates all simple sugars and starches, and restricts other carbohydrates to 30 grams a day spread out over 3 small meals (6g at breakfast, 12g at lunch and 12g at dinner), with gaps of around 4 hours between meals to enable more accurate postprandial blood glucose tracking. This diet is combined with exercise with an emphasis on resistance-based muscle-building exercise, and supported by medication if needed. For insulin-dependent diabetics, he advocates taking insulin as small doses before each meal, to exactly cover that meal. The goal of the program is to simulate the blood sugars of non-diabetics, which according to Bernstein are close to 83 mg/dl or 4.6 mmol/l most of the time. If this goal can be reached and maintained, further complications due to high blood sugar would stop, though earlier damage cannot be reversed. Diabetes is perfectly controlled, in effect \"cured\". (Bernstein 2011)" }, { "id": "pubmed23n0507_6066", "title": "NIDDM: new once-daily intervention for type 2 diabetes mellitus: Diaprel MR.", "score": 0.011844724618447246, "content": "Pharmacological treatment of hyperglycemia should address to both abnormalities in T2DM treatment, that is reduction of insulin resistance and restoration of normal insulin secretion. Gliclazide is a sulfonylurea compound oral hypoglycemic drug that has a unique feature of restoring the first-phase insulin secretion, which is lost in T2DM being one of the early features of disease. Laboratoires Servier conducted in Romania a an open non randomized surveillance on the efficacy and safety of Diaprel MR in type 2 diabetic patients. 199 patients in 14 treatment centers were enrolled. Eligibility criteria were as it follows: men and women with diabetes, previously on diet alone and not treated with other OAD, over 35 years old with FPG (mg/dl) at enrollment between 126 and 180. The clinical trial lasted for 16 weeks. During this period the doctors examined the patients 6 times. First visits were at a 2 weeks interval and the last two visits at a 4 weeks interval. At each visit the doctor renewed the prescription for the subsequent period according to the following protocol: the starting dose was 30 mg Diaprel MR/day, if the FPG (mg/dl) was over 140 (at the next visit) the dosage was increased with 30 mg Diaprel MR/day, if the FPG (mg/dl) was under 140 the dosage remained the same as the previous dosage. The maximum dosage was 120 mg Diaprel MR/day. The following parameters were measured on first and last (seventh) visit: blood pressure (systolic and diastolic), heart rate (bpm), body mass index-BMI (kg/m2), fasting plasma glucose FPG (mg/dl and mmol/l), glycated hemoglobin HbA1c (%) and Hb-Hct (mg/dl-%), creatinine (mg/dl), SGPT (UI/I), cholesterol (mg/dl) and triglycerides (mg/dl). Blood pressure (systolic and diastolic), heart rate, BMI and FPG were measured from the second to sixth visit also. On each visit there was registered other data such as: associated illnesses, concomitant medication and adverse events. Primary end points. The average values of end points HbA1c (%) and PFG (mg/dl) registered a significant decrease during the 16 weeks of medication, from the enrollment moment (S0) to the last week (S16). The decrease was significant on the total sample of the main analysis group but also on subsamples of age, gender and BMI. HbA1c (%) average values decreased in the main analysis group (S16 compared to S0): with 22% on the total sample (from 7.7 to 6.0); p &lt; 0.05. FPG (mg/dl) average values decreased in the main analysis group (S16 compared to S0): with 21% on the total sample (from 159 to 126); p &lt; 0.05. Secondary end points. There were no significant changes registered in the average level of cholesterol and triglycerides, BMI, diastolic blood pressure, heart rate, creatinine, SGPT. A significant decline of the average systolic blood pressure was registered. Diaprel MR can be used safely in diabetic patients newly diagnosed, uncontrolled on diet or other oral antidiabetic drugs, overweight, safely in those with cardio-vascular disease, or in patients with creatinine clearance 50-80 ml/min." }, { "id": "wiki20220301en071_59049", "title": "Diabetes and pregnancy", "score": 0.011712738671986321, "content": "Cut down sweets, eats three small meals and one to three snacks a day, maintain proper mealtimes, and include balanced fiber intake in the form of fruits, vegetables and whole-grains. Increased physical activity - walking, swimming/aquaerobics, etc. Monitor blood sugar level frequently, doctors may ask to check the blood glucose more often than usual. The blood sugar level should be below 95 mg/dl (5.3 mmol/l) on awakening, below 140 mg/dl (7.8 mmol/l) one hour after a meal and below 120 mg/dl (6.7 mmol/l) two hours after a meal. Each time when checking the blood sugar level, keep a proper record of the results and present to the health care team for evaluation and modification of the treatment. If blood sugar levels are above targets, a perinatal diabetes management team may suggest ways to achieve targets. Many may need extra insulin during pregnancy to reach their blood sugar target. Insulin is not harmful for the baby." }, { "id": "pubmed23n0417_4312", "title": "Unrecognized hypo- and hyperglycemia in well-controlled patients with type 2 diabetes mellitus: the results of continuous glucose monitoring.", "score": 0.011416861826697891, "content": "The aim of this study was to determine the prevalence and extent of glycemic excursions (hypo- and hyperglycemic) in elderly patients with well-controlled type 2 diabetes using a Continuous Glucose Monitor System (CGMS) (Medtronic MiniMed). Elderly patients (&gt;65 years old) with type 2 diabetes were recruited if their glycosylated hemoglobin (HbA1c) was &lt;7.5% and if their oral hypoglycemic therapy included a sulfonylurea. Patients were asked to undergo two consecutive 72-h periods of continuous glucose monitoring at baseline and then again at 1 month (total 288 h). Patients were asked to record four self-monitored capillary blood glucose levels each day for calibration of the monitor and also to record meal times, exercise, and symptoms of hypoglycemia. The number of hyperglycemic (&gt;144 mg/dL), hypoglycemic (&lt;50 mg/dL), and borderline-hypoglycemic (50-65 mg/dL) events were determined (an event was defined as a glucose value that persisted for at least 15 min with or without symptoms). Twenty-five patients (21 men, four women) 73.9 +/- 4.4 years old with an HbA1c of 6.2 +/- 0.8% were each monitored for an average of 187.57 h. The mean glucose values were: fasting, 139 +/- 40 mg/dL; 2 h post-breakfast, 167 +/- 58 mg/dL; 2 h post-lunch, 157 +/- 53 mg/dL; and 2 h post-dinner, 149 +/- 49 mg/dL. Twenty patients (80%) experienced a total of 103 hypoglycemic events, and 14 of these patients experienced 54 events where the glucose levels were &lt;/=40 mg/dL. Twenty-four patients (96%) experienced borderline-hypoglycemia (n = 229 events). Patients experienced a mean of 0.62 +/- 0.72 episodes of hypoglycemia (interstitial glucose &lt;50 mg/dL) per day (four to five episodes overall), 0.35 +/- 0.6 episodes per day where the interstitial glucose was &lt;/=40 mg/dL (two to three episodes overall), and 1.37 +/- 1.22 episodes of borderline-hypoglycemia (nine to 10 episodes overall). Each episode of hypoglycemia persisted for 78 +/- 73 min, and borderline-hypoglycemia for 45 +/- 11 min. Patients were hypoglycemic 3.3% of the time and borderline-hypoglycemic 3.7% of the time. No episode of hypoglycemia was recorded by any patient in his or her daily diary. High postprandial glucose values (&gt;144 mg/dL 2 h postprandial) were recorded after 57% of all meals (breakfast 60%, lunch 57.5%, dinner 55.2%). The CGMS was generally well tolerated, but 52% of patients could not be studied for the full 12 days of monitoring. Thus hypoglycemia and excessive postprandial glycemic excursions are common in well-controlled patients with type 2 diabetes treated with a sulfonylurea with or without metformin. The CGMS is a useful research and clinical tool to assess glycemia in patients with type 2 diabetes but is not tolerated by all subjects." }, { "id": "Pharmacology_Katzung_4629", "title": "Pharmacology_Katzung", "score": 0.011243934193395668, "content": "A 66-year-old obese Caucasian man presented to an academic Diabetes Center for advice regarding his diabetes treatment. His diabetes was diagnosed 10 years previously on routine testing. He was initially given metformin but when his control deteriorated, the metformin was stopped and insulin treatment initiated. The patient was taking 50 units of insulin glargine and an average of 25 units of insulin aspartate pre-meals. He had never seen a diabetes educator or a dietitian. He was checking his glucose levels 4 times a day. He was smoking half a pack of cigarettes a day. On examination, his weight was 132 kg (BMI 39.5); blood pressure 145/71; and signs of mild peripheral neuropathy were present. Laboratory tests noted an HbA1c value of 8.1%, urine albumin 3007 mg/g creatinine (normal <30), serum creatinine 0.86 mg/dL (0.61–1.24), total choles-terol 128 mg/dL, triglycerides 86 mg/dL, HDL cholesterol 38 mg/dL, and LDL cholesterol 73 mg/dL (on atorvastatin 40 mg daily). How would you" }, { "id": "pubmed23n0343_19470", "title": "Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group.", "score": 0.009900990099009901, "content": "Treatment with diet alone, insulin, sulfonylurea, or metformin is known to improve glycemia in patients with type 2 diabetes mellitus, but which treatment most frequently attains target fasting plasma glucose (FPG) concentration of less than 7.8 mmol/L (140 mg/dL) or glycosylated hemoglobin A1c (HbA1c) below 7% is unknown. To assess how often each therapy can achieve the glycemic control target levels set by the American Diabetes Association. Randomized controlled trial conducted between 1977 and 1997. Patients were recruited between 1977 and 1991 and were followed up every 3 months for 3, 6, and 9 years after enrollment. Outpatient diabetes clinics in 15 UK hospitals. A total of 4075 patients newly diagnosed as having type 2 diabetes ranged in age between 25 and 65 years and had a median (interquartile range) FPG concentration of 11.5 (9.0-14.4) mmol/L [207 (162-259) mg/dL], HbA1c levels of 9.1% (7.5%-10.7%), and a mean (SD) body mass index of 29 (6) kg/m2. After 3 months on a low-fat, high-carbohydrate, high-fiber diet, patients were randomized to therapy with diet alone, insulin, sulfonylurea, or metformin. Fasting plasma glucose and HbA1c levels, and the proportion of patients who achieved target levels below 7% HbA1c or less than 7.8 mmol/L (140 mg/dL) FPG at 3, 6, or 9 years following diagnosis. The proportion of patients who maintained target glycemic levels declined markedly over 9 years of follow-up. After 9 years of monotherapy with diet, insulin, or sulfonylurea, 8%, 42%, and 24%, respectively, achieved FPG levels of less than 7.8 mmol/L (140 mg/dL) and 9%, 28%, and 24% achieved HbA1c levels below 7%. In obese patients randomized to metformin, 18% attained FPG levels of less than 7.8 mmol/L (140 mg/dL) and 13% attained HbA1c levels below 7%. Patients less likely to achieve target levels were younger, more obese, or more hyperglycemic than other patients. Each therapeutic agent, as monotherapy, increased 2- to 3-fold the proportion of patients who attained HbA1c below 7% compared with diet alone. However, the progressive deterioration of diabetes control was such that after 3 years approximately 50% of patients could attain this goal with monotherapy, and by 9 years this declined to approximately 25%. The majority of patients need multiple therapies to attain these glycemic target levels in the longer term." }, { "id": "pubmed23n1058_25724", "title": "[Starting insulin or not? And if so, which basal insulin?]", "score": 0.009900990099009901, "content": "A 55-year-old patient with a BMI of 30 kg/m2 is referred for uncontrolled type 2 diabetes mellitus. His HbA1c-concentration is 71 mmol/mol, despite an initial 8% weight loss and treatment with metformin and glimepiride. The general practitioner proposes to start with insulin, but the patient refuses. We discuss whether there is a good alternative for insulin such as more weight loss and the addition of more drugs. Our patient then changes his mind and agrees to start insulin treatment. Basal insulin is usually recommended in cases like this.Since there are no significant differences between different types of available basal insulin, it seems reasonable to take price into account. Our patient achieved reasonable glucose control without weight gain using a combination of basal insulin and a GLP-1 receptor agonist." }, { "id": "pubmed23n1096_13222", "title": "Reactive Hypoglycemia From Metformin Immediate-Release Monotherapy Resolved by a Switch to Metformin Extended-Release: Conceptualizing Their Concentration-Time Curves.", "score": 0.009852455833818677, "content": "Metformin rarely, if ever, causes hypoglycemia when it is used as labeled. A 55-year-old woman presented to the medicine ward with an altered level of consciousness. She had been reviewed in an outpatient department three days earlier and prescribed 500 mg two times per day of metformin immediate-release (Met IR) for newly diagnosed type 2 diabetes mellitus (T2DM), to which she had been adherent; however, she had been experiencing intermittent episodes of hypoglycemia after taking the medication prescribed to treat her T2DM. On physical examination, she was diaphoretic and disoriented but responsive to sensory stimuli. In the ward, she received 25 ml of intravenous dextrose as the initial blood glucose reading was low at 54 mg/dl, and 4 ounces of apple juice additionally two hours later as her blood glucose level fell below 70 mg/dl again. She was no longer hypoglycemic a few hours later, and there was a significant neurological improvement. The remainder of the laboratory results, including serum renal and liver function tests, were normal. Met IR was discontinued, and metformin extended-release (Met XR) 500 mg/day was initiated at discharge. The patient's hypoglycemic episodes resolved within days after the initiation of Met XR. Hypoglycemia is rarely associated with accidental or suicidal overdose of metformin, metabolic dysfunction (e.g., renal insufficiency), exercise, missed meal, acute illness, or the initiation of additional antidiabetic medication. Albeit even uncommon, metformin-associated hypoglycemia may occur with no obvious trigger. In this context, we determine to what extent Met IR may contribute to the development of hypoglycemia in an individual case, but also that the risk could be mitigated by a switch to Met XR. In a preferred embodiment, the Met XR dosage form can be administered once a day, ideally with or after a meal, preferably with or after the evening meal, and it provides therapeutic levels of the drug throughout the day with peak plasma levels being obtained between four to eight hours after the administration (T<submax</sub)." }, { "id": "pubmed23n0550_4155", "title": "Glycaemic control without weight gain in insulin requiring type 2 diabetes: 1-year results of the GAME regimen.", "score": 0.00980392156862745, "content": "Weight gain appears to be unavoidable in patients with type 2 diabetes who are switched from oral agents to insulin therapy. Peripheral hyperinsulinism induced by the use of long-acting insulin may be the key to explain this adverse effect. The aim of this study was to investigate whether a regimen free of long-acting insulin can provide long-term glycaemic control without causing weight gain. This is an uncontrolled, 1-year study comprising 58 patients with type 2 diabetes and secondary failure, age 30-75 years, BMI 25-35 kg/m(2), HbA1c &gt; 7.5% and fasting C-peptide level &gt; 0.3 mmol/l. All patients were treated with the GAME regimen, a combination of glimepiride administered at 20:00 hours for nocturnal glycaemic control, insulin aspart three times daily for meal-related glucose control and metformin. Seventy-one per cent of the patients were considered evaluable. HbA1c decreased from 10.0 +/- 0.3 to 7.4 +/- 0.1% (p &lt; 0.001). Fifty-nine per cent reached HbA1c levels &lt;or= 7.5%. Symptomatic nocturnal hypoglycaemia was not reported. Body weight tended to decrease during the first 3 months (-1.0 +/- 0.5 kg, p = 0.06), but then gradually rose to a value 0.8 +/- 0.5 kg higher than at baseline (p = 0.12). This is 4.4 +/- 0.6 kg less than predicted for conventional regimens employing long-acting insulin (p &lt; 0.001). The GAME regimen provides long-term glycaemic control as well as stabilization of body weight in about 60% of type 2 patients presenting with secondary failure." }, { "id": "pubmed23n0372_15406", "title": "Effect of acarbose on glycemic control, serum lipids and lipoproteins in type 2 diabetes.", "score": 0.009708737864077669, "content": "To assess the efficacy of acarbose monotherapy during 12-weeks treatment on the fasting glycemic level, lipid and lipoproteins profiles, in patients with type 2 diabetes mellitus. Type 2 diabetics were selected from out patient department of Baqai Diabetes and Endocrine Centre, and one other diabetic clinic of Karachi, during 1996-97. A prospective intervention trial, and a 10 days screening period with a follow-up of 12 weeks. Forty-four patients (36 men and 8 women, mean age 55.09 +/- 1.72 years) were included of whom 25 (56.81%) patients were previously treated with diet alone, 11(25%) with diet and glibenclamide, 5(11.36%) with diet and gliclazide, and 3(6.81%) with diet and chlorpropamide, more than at least 3 months known duration of diagnosed type 2 diabetes, body mass index (BMI) 23.69 +/- 0.49 kg/m2, were insufficiently controlled on diet alone, or diet plus sulfonylureas, were studied. The dosage of acarbose was started with 50 mg t.i.d with each meal, if necessary, was titrated upward on subsequent visits to 100 mg t.i.d with each meal, based on tolerability and efficacy. Fasting blood glucose, lipid and lipoprotein profiles were determined at the baseline and at the end of the study. Acarbose treatment was associated with significant reduction in fasting blood glucose from (mean +/- SE) 173.89 +/- 3.89 mg/dl at day 0 to 161.29 +/- 3.41 mg/dl at day 90 (P &lt; 0.01). The serum total triglyceride level was (mean +/- SE) 188.85 +/- 5.91 mg/dl at entry, and was also significantly decreased to 158.57 +/- 4.48 mg/dl at day 90, this reduction was found statistically significant (P &lt; 0.01). Whereas very-low density lipoprotein cholesterol reduced significantly from 33.08 +/- 1.09 mg/dl at day 0 to 31.02 +/- 0.95 mg/dl at day 90 (P &lt; 0.01). Acarbose had no significant effect on serum total cholesterol, low-density lipoprotein cholesterol, and High-density lipoprotein cholesterol concentrations. Almost, all adverse experiences, as reported by patients on acarbose, were related to the digestive system and included diarrhea, flatulence, bloating and nausea. Most symptoms were of mild to moderate intensity and tended to improve with time. Overall, acarbose was well tolerated and the adverse experience profile was clinically acceptable. In type 2 diabetic patients, acarbose as monotherapy for 12 weeks resulted in beneficial effects on glycemic control, fasting blood glucose, mean serum total triglyceride and very-low density lipoprotein cholesterol decreased significantly. Perhaps attainment of normoglycemia on a long-term basis would result in more normal lipid and lipoprotein levels. Furthermore use of acarbose can be considered as a useful alternative in such type 2 patients, if they are difficult to control with diet alone or diet plus sulfonylureas (JPMA 50:152, 2000)." }, { "id": "pubmed23n0075_10188", "title": "[Bedtime administration of metformin may reduce insulin requirements].", "score": 0.009708737864077669, "content": "The administration of metformin, as glucophage retard, at bedtime instead of supper time may improve diabetes control by reducing morning hyperglycemia. This modification of glucophage treatment was tried in 3 groups of diabetic patients: I. those with secondary failure of routine treatment with sulfonylurea (SU) and glucophage; II. those with combined SU and bedtime insulin; III. Type 1 patients with early morning hypoglycemia. The first 3 months of observation in 258 patients showed that 136 (52.7%) reacted very well to the change. In Group I the addition of insulin to SU could be postponed. In Group II, night insulin could be reduced or eliminated. In Group III, evening or night insulin could be reduced by up to 70%. There was no early morning hypoglycemia nor morning hyperglycemia. The success rate in the 2 Type 2 groups was better (72% and 60%) than in the Type 1 group (34%). 30 patients (11.6%) had to stop the treatment because of side effects of the glucophage (mainly diarrhea or nausea). So far, we have found no clinical signs that might indicate which patients might benefit from this modification of treatment. A fasting blood sugar done within 2-3 days after the change in treatment may immediately indicate whether the new treatment is effective." }, { "id": "pubmed23n0368_20958", "title": "The effect of metformin on glycemic control, serum lipids and lipoproteins in diet alone and sulfonylurea-treated type 2 diabetic patients with sub-optimal metabolic control.", "score": 0.009615384615384616, "content": "To see if Metformin Monotherapy affects glycemic control, serum lipid or lipoprotein levels in the treatment of type 2 diabetes who were poorly controlled with diet alone or despite maximal doses of (sulfonylurea) oral glucose lowering agents. A prospective, clinical intervention trial conducted between 1996-1997. Two out patient diabetic clinics of Karachi. A 12-week prospective clinical intervention trial. A total of 30 type 2 diabetic subjects were enrolled, of Whom 21 (12 men and 9 women) completed the study period. Their ages ranged between 35 and 70 years, (mean +/- SD 53.3 +/- 9.31) years, with a mean duration since diagnosis of diabetes was 4.5 +/- 2.3 years, body mass index (mean +/- SD) 26.8 +/- 3.53 kg/m2. They were previously treated with diet alone or had already been taking maximum doses of sulfonylurea monotherapy with suboptimal glycemic control, i.e., raised fasting blood glucose concentrations of 6-15 mmol/L or (108-270 mg/dL) on two occasions, with significant hyperglycemic symptoms. The patients were treated with metformin monotherapy with a follow up of 12 weeks. The initial dosage was 500 mg twice daily, and the dosage was increased to two or three tablets depending on the patient's metabolic changes. By comparing before and after 12 weeks therapy with metformin we assessed the importance of baseline parameters (glycemic control, serum lipid and lipoprotein concentrations, and measures of change in body weight and body mass index). Metformin therapy significantly decreased fasting blood glucose levels in all patients [(mean +/- SD) 227.2 +/- 37.5 to 168.6 +/- 20.5 mg/dl, p &lt; 0.001)]. Serum total cholesterol decreased marginally [(mean +/- SD) 200.3 +/- 18.7 to 181.4 +/- 19.4 mg/dl, p &lt; 0.01)]. Serum total triglycerides concentration also decreased [(mean +/- SD) 195.9 +/- 31.9 to 174.2 +/- 26.6 mg/dl, P &lt; 0.01)]. Low-density lipoproteins declined [(mean +/- SD) 123.5 +/- 16.9 to 105.5 +/- 19.1 mg/dl, P &lt; 0.01)], and very-low density lipoprotein cholesterol also decreased [(mean +/- SD) 39.2 +/- 6.4 to 34.8 +/- to 5.3 mg/dl, P &lt; 0.01)]. Whereas, high-density lipoprotein cholesterol tended to increase [(mean +/- SD) 37.7 +/- 5.1 to 39.5 +/- 4.9 mg/dl, P &lt; 0.01)], while no significant changes occurred in body weight and body mass index. Metformin treatment was effective, safe, and generally well tolerated." }, { "id": "pubmed23n0064_16420", "title": "Treatment strategies for secondary sulfonylurea failure. Should we start insulin or add metformin? Is there a place for intermittent insulin therapy?", "score": 0.009615384615384616, "content": "Which therapy should be used in non-insulin dependent diabetes mellitus (NIDDM) with secondary sulfonylurea failure? Should we start insulin therapy, try a period of intensified insulin therapy and then switch back to sulfonylurea or should we add metformin therapy? To address this question, we have compared these three treatment strategies in 36 NIDDM patients who failed on treatment with sulfonylureas during a 6 month period. Insulin (short and intermediate-acting insulin before breakfast and dinner) and the combination of 21 mg of glibenclamide and 1.5 g of metformin resulted in an equivalent 30% improvement in glycemic control without significant effects on lipids. Intensified insulin therapy (6 weeks of intermediate and short-acting insulin 3 times daily), on the other hand, initially lowered blood glucose to the same degree as during the other two treatment regimes, but after switching back to sulfonylurea therapy (21 mg of glibenclamide/day) blood glucose concentrations returned to pretreatment values. Insulin therapy resulted in a 5 kg increase in body weight, 63% of which was accounted for by an increase in fat mass. Although body weight was unchanged during glibenclamide/sulfonylurea therapy, lean body mass and energy expenditure decreased significantly (p less than 0.05). Body weight and energy metabolism remained unchanged during intermittent insulin therapy. Despite similar blood glucose lowering properties, insulin and the combination of sulfonylurea and metformin have different effects on energy metabolism and body composition. Since these effects were not observed during treatment with sulfonylurea alone, they must be ascribed to metformin." }, { "id": "Gynecology_Novak_907", "title": "Gynecology_Novak", "score": 0.009535256410256411, "content": "Initiate an ADA reducing diet (50% CHO, 30% fat, 20% protein, high fiber) with three meals a day. Maintain ideal body weight or to reduce weight by 5% to 15% in 3 months if obese. Modify risk factors (smoking, exercise, fat intake). Check fasting blood glucose by finger stick daily for 2 months. If FBS declines, no other therapy is needed. If FBG does not decline or increases, use of an oral hypoglycemic agent may be considered. ADA, American Diabetic Association; CHO, carbohydrate; FBS, fasting blood glucose. Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2000;23:S4–S42. medicines (i.e., metformin, a biguanide), insulin therapy should be initiated and referral should be considered because of the increased rate of complications." }, { "id": "pubmed23n0588_3243", "title": "Mealtime 50/50 basal + prandial insulin analogue mixture with a basal insulin analogue, both plus metformin, in the achievement of target HbA1c and pre- and postprandial blood glucose levels in patients with type 2 diabetes: a multinational, 24-week, randomized, open-label, parallel-group comparison.", "score": 0.009433962264150943, "content": "In people without diabetes, approximately 50% of daily insulin secretion is basal and the remainder is postprandial. Hence, it would be expected that insulin replacement therapy in a 50/50 ratio with each meal would mimic physiologic insulin secretion better than treatment with once-daily basal insulin in patients with diabetes mellitus. Using lispro mix (LM) 50/50 before meals may be a logical approach to achieving glycemic targets (glycosylated hemoglobin [HbA(lc)] and pre- and postprandial blood glucose [BG] concentrations) in these patients. The aim of this study was to test the hypothesis that treatment with a premixed insulin analogue containing 50/50 basal + prandial insulins administered before each meal would achieve lower overall and mealtime glycemic control than once-daily basal insulin analogue, both plus metformin (Met), in patients with type 2 diabetes mellitus. This 24-week, randomized, open-label, parallel-group trial was conducted at 38 sites across Australia, Greece, India, The Netherlands, Poland, Puerto Rico, and the United States. Male and female patients aged 35 to 75 years with type 2 diabetes mellitus and an HbA(1c) level of 6.5% to 11.0%, who were receiving metformin and/or a sulfonylurea with a stable dose of 0 to 2 daily insulin injections over the previous 3 months were eligible. Patients were randomly assigned to receive LM50/50 (50% insulin lispro protamine suspension [ILPS] and 50% lispro) TID plus metformin (to a maximally tolerated daily dosage of 500-1000 mg BID) (LM50/50 + Met) or insulin glargine QD at bedtime plus metformin (500-1000 mg BID) (G + Met) for 24 weeks. With LM50/50 + Met, the insulin dose was titrated to target a fasting BG (FBG) level of &lt;6.7 mmol/L (&lt;120 mg/dL) and a 2-hour post-prandial BG (PPBG) level of &lt;8.0 mmol/L (&lt;144 mg/dL); those who did not reach the FBG target would be switched from presupper LM50/50 to LM75/25 (75% ILPS, 25% lispro). A total of 315 patients were randomized and received treatment (158 women, 157 men; mean age, 57.7 years; mean body mass index, 32.1 kg/m2; LM50/50 + Met, 157 patients; G + Met, 158 patients). At 24 weeks, the mean (SD)HbA(1c) level was significantly lower in the LM50/50 + Met group than in the G + Met group (7.1% [0.9%] vs 7.5% [1.0%]; P&lt;0.001), and the proportion who reached an HbA(1c) target of &lt; or = 7.0% was greater (88 [56.1%] vs 63 [39.9%]; P = 0.005). The G + Met group had a lower mean (SD)FBG value (6.5 [1.6] vs 8.1 [1.8] mmol/L; P&lt;0.001). The LM50/50 + Met group had lower mean preprandial BG levels prelunch (7.4 [1.9] vs 7.9 [2.1] mmol/L; P=0.03) and presupper (8.3 [2.0] vs 8.9 [2.8] mmol/L; P=0.04). The LM50/50 + Met group also had lower mean 2-hour PPBG values postbreakfast (8.7 [2.2] vs 9.2 [2.5] mmol/L; P=0.03), postlunch (8.4 [1.9] vs 9.8 [2.6], mmol/L; p&lt;0.001), and postsupper (8.7 [2.2] vs 10.7 [3.2], mmol/L; P&lt;0.001). The mean (SD) total insulin doses at study end point were 0.7 (0.3) U/kg in the LM50/50 + Met group and 0.6 (0.3) U/kg in the G + Met group (P&lt;0.001). The mean (SD)M-value (an expression of mean glycemia and the effect of glucose swings) was statistically similar between the 2 groups at baseline but significantly lower in the LM50/50 + Met group at end point (17.3 [13.8] vs 25.1 [24.8] mmol/L; P&lt;0.001). During the entire treatment period, mean (SD) overall and nocturnal hypoglycemia rates (episodes per patient for 30 days) were statistically similar between the 2 groups (overall, 0.8 [1.4] vs 0.5 [1.0]; nocturnal, 0.2 [0.7] vs 0.3 [0.6]). At end point, the mean (SD) nocturnal hypoglycemia rates were similar between the 2 groups (0.2 [0.9] vs 0.2 [0.6]), but the overall and non-nocturnal hypoglycemia rates were higher with LM50/50 + Met (overall, 0.7 [1.7] vs 0.3 [0.8]; P=0.02; non-nocturnal, 0.5 [1.2] vs 0.1 [0.4]; P=0.002). In these patients with type 2 diabetes, mealtime LM50/50 + Met was associated with lower overall (HbA(1c)) and preprandial BG and PPBG levels (except for FBG), with similar nocturnal hypoglycemia and less glycemic variability, compared with G + Met." }, { "id": "pubmed23n0313_6311", "title": "Efficacy of 24-week monotherapy with acarbose, metformin, or placebo in dietary-treated NIDDM patients: the Essen-II Study.", "score": 0.009345794392523364, "content": "To compare the therapeutic potential of acarbose, metformin, or placebo as first line treatment in patients with non-insulin-dependent diabetes mellitus (NIDDM). Ninety-six patients with NIDDM (35-70 years of age, body mass index (BMI) &lt; or = 35 kg/m2, insufficiently treated with diet alone, glycated hemoglobin (HbA1c; 7% to 11%) were randomized into 3 groups and treated for 24 weeks with acarbose, 3 x 100 mg/day, or metformin, 2 x 850 mg/day, or placebo. Efficacy, based on HbA1c (primary efficacy criterion), fasting blood glucose (BG) and insulin, 1 hour postprandial BG and insulin (after standard meal test), postprandial insulin increase, plasma lipid profile, and tolerability, based on subjective symptoms and laboratory values were determined every 6 weeks. Analysis of covariance was performed for endvalues with adjustment on baseline values. Ninety-four patients were valid for efficacy evaluation. Both active drugs showed the same improvement of efficacy criteria compared with placebo. Baseline adjusted means at endpoint were as follows: BG, fasting and 1 hour postprandial, 9.2 mM and 10.9 mM with placebo, 7.6 mM and 8.7 mM with acarbose, and 7.8 mM and 9.0 mM with metformin; HbA1c was 9.8% with placebo, 8.5% with acarbose, and 8.7% with metformin. Comparisons: acarbose versus placebo and metformin versus placebo were statistically significant, but not acarbose versus metformin. No effect on fasting insulin could be observed. Relative postprandial insulin increase was 1.90 with placebo, 1.09 with acarbose, and 1.03 with metformin. Comparisons: acarbose versus placebo and metformin versus placebo were statistically significant, but not acarbose versus metformin. With respect to lipid profile, acarbose was superior to metformin. Low-density lipoprotein (LDL)/high-density lipoprotein (HDL) cholesterol ratio increased by 14.4% with placebo, was unchanged with metformin, but decreased by 26.7% with acarbose. Comparisons: acarbose versus placebo and acarbose versus metformin were statistically significant, but not metformin versus placebo. Slight body weight changes were observed with acarbose (-0.8 kg) and metformin (-0.5 kg), but not with placebo. Acarbose led to mild or moderate intestinal symptoms in 50% of the patients within the first 4 weeks, but in only 13.8% of the patients within the last 4 weeks. Acarbose and metformin are effective drugs for the first line monotherapy of patients with NIDDM. With respect to plasma lipid profile, especially HDL cholesterol, LDL cholesterol and LDL/HDL cholesterol ratio acarbose may be superior to metformin." }, { "id": "pubmed23n0397_3989", "title": "[Non-insulin therapy in diabetes mellitus].", "score": 0.009345794392523364, "content": "Changes to nutritional habits, including the reduction of weight, are basic therapy principles for the treatment of diabetes mellitus. With overweight patients a reduction of energy intake is important. Patients with diabetes mellitus should eat plenty of carbohydrates, the intake of fat should be limited to a maximum of 35%. Patients treated with insulin must be made to calculate carbohydrate exchange units. Unless there are contraindications, diabetic patients should be encouraged to engage in physical exercise. Educating the patients is of major importance in the treatment of diabetics; this must be undertaken by trained personnel. All diabetic patients treated with oral antidiabetic drugs or insulin should be encouraged to measure their blood glucose levels themselves, in cases of insulin therapy this is an absolutely necessity. If with the aid of basic therapy measures, which include the control of fasting blood glucose, postprandial blood glucose and HbA1c levels, the aims of the therapy are not reached, this is an indication for the use of oral antidiabetic drugs. The drug should be chosen with the dominant pathophysiological disturbance in mind. In the case of increased fasting blood glucose values (hepatic insulin resistance leading to increased glucose production by the liver), after contraindications have been excluded, the use of metformin is recommended. If there are significantly increased postprandial blood glucose values (due to an early-insulin-secretion deficiency or severe insulin resistance), the use of alpha-glucosidase-inhibitors, metformin, sulphonylureas or glinides is indicated. With obese patients alphaglucosidaseinhibitors and metformin are the drugs of choice, with patients with BMI &lt; 25 kg/m2 these are sulfonylureas or glinides. In cases of severe insulin resistance the use of glitazones in conjunction with metformin or sulphonylureas may be indicated." }, { "id": "pubmed23n0309_6746", "title": "Monitoring of metabolic control in patients with non-insulin-dependent diabetes mellitus on oral hypoglycaemic agents: value of evening blood glucose determination.", "score": 0.009259259259259259, "content": "Monitoring of metabolic control in patients with non-insulin-dependent (Type 2) diabetes (NIDDM) is usually based upon blood glucose assay in the morning (after an overnight fast) and in the postprandial state (breakfast or lunch). However, this schedule does not seek low blood glucose values, especially in the evening. We have conducted a prospective study of laboratory blood glucose profiles (8 am, 9.30 am after a 35 g carbohydrate breakfast and in the evening between 5 and 7 pm). We have included 58 consecutive NIDDM patients regularly followed in our clinic (39 men, age 60 +/- 11.5 years, diabetes duration 8.6 +/- 6.5 years, BMI 25.5 +/- 3 kg m-2), treated with the sulphonylurea gliclazide, alone (40-320 mg 24 h-1, mean 170 +/- 110 mg) (group 1, n = 32) or in combination with metformin (1000-3000 mg 24 h-1, 2400 +/- 620 mg) (group 2, n = 26). All patients were stable, with no change in dosage for at least 3 months. Mean glycaemic control was good (group 1 HbA1c: 6.5 +/- 1.1%, group 2: 6.9 +/- 0.7%). Evening blood glucose values were the lowest of the day in 26 patients of group 1 (81.3%) and in 22 of group 2 (84.6%). Mean evening blood glucose levels were lower (p = 0.001) than 8 am values (group 1: 5.8 +/- 1.4 vs 6.1 +/- 1.6 mmol l-1, group 2: 6.5 +/- 1.8 vs 6.9 +/- 1.9) and than 9.30 am values (group 1: 7.6 +/- 1.5, group 2: 12.3 +/- 2.8). No blood glucose values in the hypoglycaemic range were observed. HbA1c was strongly correlated (p = 0.002 to 0.0001) in the whole group with 8 am (r = 0.39), 9.30 am (r = 0.56), and evening blood glucose values (r = 0.42). These results indicate that, in patients treated with the sulphonylurea gliclazide, alone or in combination with metformin, the lowest blood glucose values occur in the evening more frequently (4/5) than in the morning. Therefore, evening blood glucose determination should be performed systematically in the course of the metabolic evaluation of NIDDM patients on oral hypoglycaemic agents." }, { "id": "pubmed23n0074_15213", "title": "Antidiabetic agents.", "score": 0.009174311926605505, "content": "Although either insulin or oral hypoglycemics may be used in conjunction with diet and exercise in the management of type II diabetes, drug therapy for type I diabetes involves only insulin. C-peptide levels can be tested to assess whether the patient has remaining pancreatic endocrine function. Patients being started on insulin for the first time should receive a single injection of an intermediate-acting insulin of \"human\" origin at a dose of approximately 0.5 U/kg. Thereafter, fasting, mid-morning, mid-afternoon, bedtime, and possibly early morning blood sugars should be examined periodically to determine if the insulin dose needs to be increased, decreased, split, or if the patient needs to be on a two-insulin regimen. Intensive insulin therapy has become commonplace to control plasma glucose levels in the majority of patients receiving insulin therapy. Proper patient education regarding the insulin regimen, injection techniques, blood glucose monitoring, as well as diet, exercise, and foot care are essential if the patient's diabetes is to be controlled adequately. Guidelines for \"adequate\" glycemic control are outlined in Table 6. Recent evidence suggests that tight control of plasma glucose levels may decrease the macrovascular complications of diabetes. Although there is also evidence to suggest that the onset of microvascular complications might be delayed with strict glycemic control, the data are conflicting. The benefits of strict control must be weighted against the problems of hypoglycemia experienced by many patients who attempt tight control of their blood glucose levels. Biguanide compounds are available in Europe, but the sulfonylureas comprise the only class of oral agents in the United States commercially available for the treatment of type II diabetes. The two generations of these drugs reflect their potency and possible side-effect profiles. Of the first-generation agents, tolbutamide and chlorpropamide are the most widely prescribed. Tolbutamide is the weakest of the sulfonylureas, possibly making it a good drug for initiating oral therapy in the elderly. Chlorpropamide is becoming a less popular agent because of its long duration of action and its increased incidence of side effects. Of the second-generation agents, glyburide offers a better dosing schedule (once daily compared with twice daily for glipizide); however, glyburide may produce a greater incidence of hypoglycemia, particularly in the elderly or in patients with significant renal impairment. There are few good studies comparing these two drugs so that recommending one over the other is difficult. Drug interactions are numerous with the first-generation drugs, but less so with the newer second-generation agents.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0372_15335", "title": "Troglitazone add-on therapy to a combination of sulfonylureas plus metformin achieved and sustained effective diabetes control.", "score": 0.00909090909090909, "content": "To elucidate the effect of triple combination oral agent therapy on type 2 diabetes. We performed a prospective longitudinal study on 40 patients with type 2 diabetes who had failed to achieve a glycosylated hemoglobin (HbA1c) of &lt; or = 8.0% despite optimal therapy with a combination of sulfonylureas plus metformin. Troglitazone was added and then titrated, with the intent to achieve at least a 1% reduction in HbA1c within 3 months. Responders were reassessed at 6 and 12 months. Nonresponders were reassessed at 6 months; in the absence of a significant HbA1c response, participation in the study was discontinued. Of the 40 study subjects, 25 were responders, 10 were nonresponders, and 5 were withdrawn from the study before completion of 3 months of therapy because of side effects. The 25 responders had a mean baseline HbA1c of 9.9%, which decreased significantly to 7.8% after 3 months of troglitazone therapy and to 7.4% at 6 months and at 12 months. In addition, the fasting blood glucose (FBG) in the responders decreased significantly from 168 mg/dL at baseline to 118 mg/dL at 6 months, which was sustained at 121 mg/dL at 12 months. In the responder group, a mean HbA1c &lt; or = 8% was achieved in 68% at 6 months and sustained in 65% after 1 year. Furthermore, 40% of responders achieved a mean HbA1c &lt; or = 7.0% at 6 months, and 39% sustained this degree of control at 12 months. The 10 nonresponders showed no significant change in HbA1c or FBG during the 6 months of troglitazone therapy. No difference existed in the mean baseline FBG, HbA1c, or C peptide level between the two groups. Responders, however, had a significantly lower mean body mass index (BMI) (31 kg/m2) than did nonresponders (37 kg/m2). Although responders were older than nonresponders (mean age, 65 years versus 55 years), no significant difference was noted in duration of diabetes (11.6 years versus 8.7 years). Multivariate analysis showed that male gender and BMI were the strongest predictors of a response to troglitazone add-on therapy to the prior combination of sulfonylureas plus metformin. This study showed that oral therapy with troglitazone added to sulfonylureas plus metformin achieved and sustained a significant improvement in control of diabetes in 71% of patients who had failed to achieve HbA1c &lt; or = 8% with dual oral agent therapy. The positive response was evident within 3 months, reached maximum by 6 months, and was sustained to 12 months of therapy. Therefore, patients who fail to achieve HbA1c &lt; or = 8% with sulfonylureas plus metformin should have at least 3 months of troglitazone add-on therapy before advancing to traditional insulin treatment." }, { "id": "pubmed23n0900_4966", "title": "Impact of health policy and practice on finding the best fit for patients with type 2 diabetes after metformin failure: Croatian pilot study.", "score": 0.00909090909090909, "content": "We assessed the impact of clinical practice and health policy on the choice and efficacy of different second-line therapies for the treatment of type 2 diabetes (T2DM) after failure of metformin. This retrospective database analysis included 200 patients with a follow-up period of 6 months. The primary end-point was achievement of HbA1c &lt;7% and fasting (FBG) and postprandial glucose levels (PPG) &lt;7.2mmol/L and &lt;10mmol/L, respectively after three and six months of different add-on treatments. Secondary end-points were weight change during treatment and incidence of hypoglycemia. All second-line therapeutic options, except human basal insulin (BHI) and thiazolidendions (TZD) significantly increased the proportion of patients reaching target HbA1c after 6 months (p&lt;0.01). Only sulfonylurea (SU) and dipeptidyl peptidase-4 (DPP-4) inhibitors significantly reduced all monitored parameters of glucoregulation without changing body weight and BMI after 3 and 6 months as opposed to insulin agents. However, there were no statistically significant differences between the groups when adjusting for starting HbA1c, FBG and PPG (F=1.16, p=NS), although a statistically significant difference in HbA1c levels (F=3.35, p&lt;0.01) persisted in DPP-4 inhibitor users. The incidence of hypoglycemia was significantly higher in patients treated with NPH insulin and premixed insulin than in patients treated with other agents. A more aggressive approach is needed with early treatment intensification using available agents." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 82 ] ], "word_ranges": [ [ 0, 14 ] ], "text": "More than 2 lobar pneumonias make it necessary to rule out an immunologic deficit." }, "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": "Serum immunoglobulin count and antibody production capacity test.", "2": "Phagocytosis test and oxidative metabolism of neutrophils.", "3": "Apoptosis test (programmed cell death) in the patient's circulating lymphocytes.", "4": "Study of the repertoire and clonality of T lymphocytes (alpha/beta).", "5": "In this patient it would not be appropriate to request any immunological study." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0818_22421", "title": "[A case of autoimmune lymphoproliferactive syndrome and literature review].", "score": 0.017523722069176614, "content": "To summarize the clinical characteristics, diagnosis and treatment of a case with autoimmune lymphoproliferative syndrome (ALPS) . The patient was diagnosed as autoimmune lymphoproliferactive syndrome (ALPS) after being admitted to the Department of Rheumatism and Immunology of Tianjin Children's Hospital in February 20, 2014. The clinical characteristics, physical examination, laboratory tests, gene tests, and treatment process were analyzed and related literature was reviewed. The patient was a 16-month- old boy.Since the first month of life, he started to have repeatedly fever, diarrhea, shortness of breath, lymphadenopathy, hepatosplenomegaly, anemia (HGBmin 50 g/L) and thrombocytopenia (min 35 × 10⁹/L) . But multiple exams showed a normal peripheral blood leukocyte count, hypergammaglobulinemia (IgG 19 800 mg/L, IgA 1 710 mg/L, IgM 2 590 mg/L) and significantly increased serum vitamin B12. Flow cytometric measures showed that CD3⁺ CD4⁻ CD8⁻ T lymphocytes significantly increased ( &gt; 10%) at four times. The count of CD3⁺ TCRαβ⁺ CD4⁻ CD8⁻T lymphocytes (double negative T cells; DNTs) &gt;3% twice. The genetic test showed that 309th FAS gene area showed heterozygous mutations, the boy was diagnosed as ALPS. Added examinations of lymphocytes apoptosis induced by FAS was positive. He was treated with prednisone 15 mg once daily and immunomodulator 150 mg three times a day, while in maintaining period with normal levels of hemoglobin and platelet, the dose of prednisone was reduced gradually. Till now, the patient has been treated and observed for 8 months. We retrieved the reports of ALPS in the databases at home and abroad published in recent 10 years, more than 400 cases reported from foreign countries, but there were only 5 domestic cases. Among those, 4 had onset in infancy and 1 at 6-years of age. All the cases presented servere lymphadenopathy and hepatosplenomegaly with anemia (4 of them with hemolytic anemia) and thrombocytopenia. Three cases had a history of frequent infection, one of them had glomerulonephritis. All patient with significant high level of serum immunoglobulin ( &gt; 1.5 times upper limit of normal range), in 3 of them serum vitamin B12 was &gt; 1.5 pg/L (the other 2 cases missed the exam). In 5 cases CD3⁺ CD4⁻ CD8⁻T cells &gt; 10%, and in 2 case DNTs were 8.9% and 15.7% respectively (the other 3 cases missed the exam). Three cases were clearly detected with FAS mutations. All patients were treated with corticosteroid, 2 of them were added with mycophenolate mofetil. The therapy presented effective result in early 1-3 months, but no long-term follow-up reports were available. ALPS is a disorder of disrupted lymphocyte homeostasis caused by defective Fas-mediated apoptosis, and it is one of the primary immunodeficiency diseases. The onset of the disease occurs during infancy mainly. Clinical lymphoid hyperplasia and autoimmune phenomena are outstanding signs, which can be associated with frequent infections and allergies. The level of serum vitamin B12 &gt; 1.5 pg/L and the count of CD3⁺ CD4⁻ CD8⁻ T cell show important significance. Exact diagnosis should depend on detecting DNTs and FAS gene." }, { "id": "wiki20220301en108_38711", "title": "5'-nucleotidase", "score": 0.013615795968737146, "content": "The test may also be referred to as 5'NT Levels Blood Test, CDF73 Levels Blood Test, and Ecto-5'-Nucleotidase Levels Blood Test. Lymphocyte 5'nucleotidase in immunological disorders Ecto-5'Nucleotidase is considered a maturation marker for T cells and B cells. This is due to the fact that the enzyme activity is approximately 10-times higher for peripheral T cells than thymocytes, 5-6 times higher in adult peripheral B cells than fetal B cells, and largely absent in non-T cell and non-B cell lymphocytes. In immunodeficiency diseases with arrested lymphocyte maturation, ex-5'nucleatidase activity is generally low. Such diseases include severe combined immuno-deficiency, Wiskott–Aldrich syndrome, congenital X-linked agammaglobulinemia, selective IgA deficiency and acquired immune deficiency syndrome (AIDS)." }, { "id": "pubmed23n0690_9372", "title": "Lymphocyte subsets, immunoglobulin levels, complement activity CH50, and phagocytic peroxide production in 19 Iranian patients with first episode of bacterial meningitis.", "score": 0.011849315068493151, "content": "Despite the availability of potent antimicrobial drugs, bacterial meningitis remains a serious infection with significant morbidity and mortality. In many studies, pyogenic meningitis is reported in patients with immunoglobulin (Ig) and complement deficiencies. In the present study, a broad range of immunological tests were performed to determine the relative importance of primary immunodeficiency as a predisposing cause of first episode of pyogenic meningitis without any evidence of other major infections in past medical history. We studied 19 patients with bacterial meningitis confirmed by smear, culture, and cerebrospinal fluid parameters. Immunological tests were performed within 1 to 21 days of diagnosis. Twenty healthy adults served as controls. Serum Ig levels (IgA, IgG, IgM, IgE) and total hemolytic complement (CH5O) as screening tests were done. Lymphocytes, neutrophils, and T-cells were enumerated. Nitroblue tetrazolium test was used for the assessment of neutrophil function. Thirteen patients were male and six were female. The mean age of the patients was 27.8 ± 19 years (range 5-73 years). One patient had subnormal IgA levels; five patients had subnormal IgE levels; one patient had lymphopenia and low CD4, CD3, and CD19; and one patient had subnormal IgM and IgE levels with lymphopenia and low CD4, CD3, CD8, and CD19 counts. All patients had normal complement components (C3 and C4), CH50, and nitroblue tetrazolium test. The most common immunodeficiency in our study was Ig deficiency. Our results support the recommendation that immunological evaluation, especially Ig assay, should be used in patients with bacterial meningitis even in the first episode." }, { "id": "wiki20220301en462_9307", "title": "Caspase-8 deficiency", "score": 0.009900990099009901, "content": "Diagnosis Clinical features suggesting CEDS should be investigated by immunologic studies assessing serum immunoglobulin levels, antibody function, and lymphocyte activation. Patients with CEDS have hypogammaglobulinemia, make poor antibody responses to pneumococcal polysaccharide antigens, and their B cells, T cells, and NK cells do not activate well to stimuli. Treatment Given the rarity of this condition, the prognosis and optimal treatment are unclear. Patients who have CEDS have done well while maintained on intravenous immunoglobulin and prophylactic acyclovir to decrease sinopulmonary infections and mucocutaneous herpes virus outbreaks. Investigators at the National Institute of Allergy and Infectious Diseases at the US National Institutes of Health currently have clinical protocols to study new approaches to the diagnosis and treatment of this disorder. References External links Autosomal recessive disorders Immune system disorders" }, { "id": "pubmed23n0045_10117", "title": "[Programmed death (apoptosis) of T CD4 lymphocytes and AIDS pathogenesis].", "score": 0.009900990099009901, "content": "A major characteristic of human immunodeficiency virus (HIV) infection is progressive decline in T CD4+ lymphocytes. Ten years after infection, on average, this cell subpopulation disappears and AIDS develops. In the asymptotic phase T CD4+ lymphocytes no longer respond, in vitro or in vivo, to certain memory antigens constrained by the class II histocompatibility complex, or in vitro to polyclonal activators like pokeweed mitogen. They retain, however, some proliferative response activity and constitute only a small proportion of the T CD4+ population. Indirect mechanisms of depletion are therefore sought. We have proposed a hypothesis for a single mechanism: a programmed death process, apoptosis, reactivated in mature T CD4+ lymphocytes of seropositives. Unlike necrosis, apoptosis has a role in embryogenesis, in the adult in certain cell populations and, in immature thymocytes, in T lymphocyte selection and establishment of self-tolerance. T CD4+ lymphocytes of infected subjects lose their ability to proliferate in vitro, as they undergo a form of suicide in response to certain stimuli. In vivo T CD4+ cell activation induced by various infectious agents, including HIV, progressively reduces the subpopulation, independently of the virus' cytopathogenic effect. Tests were performed that explored the T CD4+ lymphocyte response to super-antigens, which mimic and amplify the effect of memory antigens by way of CMH II molecules of Ag-presenting cells and certain nu beta chains of the alpha beta receptor for the Ag which are expressed by a third of human mature T CD4+ lymphocytes.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en033_73647", "title": "Ataxia–telangiectasia", "score": 0.00980392156862745, "content": "All individuals with A–T should have at least one comprehensive immunologic evaluation that measures the number and type of lymphocytes in the blood (T-lymphocytes and B-lymphocytes), the levels of serum immunoglobulins (IgG, IgA, and IgM) and antibody responses to T-dependent (e.g., tetanus, Hemophilus influenzae b) and T-independent (23-valent pneumococcal polysaccharide) vaccines. For the most part, the pattern of immunodeficiency seen in an A–T patient early in life (by age five) will be the same pattern seen throughout the lifetime of that individual. Therefore, the tests need not be repeated unless that individual develops more problems with infection. Problems with immunity sometimes can be overcome by immunization. Vaccines against common bacterial respiratory pathogens such as Hemophilus influenzae, pneumococci and influenza virus (the “flu”) are commercially available and often help to boost antibody responses, even in individuals with low immunoglobulin levels. If the" }, { "id": "pubmed23n0380_11872", "title": "Lymphocyte population and apoptosis in the lungs of smokers and their relation to emphysema.", "score": 0.00980392156862745, "content": "Previously, it had been shown that T-lymphocytes are the predominant inflammatory cells found in the alveolar wall of smokers and their numbers correlated with the extent of emphysema. However, the phenotype of these cells was not defined. The aim of this study was to describe the different T-cell phenotypes and investigate the possible presence of apoptosis in the lung parenchyma of smokers. Samples from lungs were obtained at surgery from 15 patients who smoked and six who had never smoked. Samples were frozen and prepared for histological and immunocytochemical examination. Slides were stained for CD3+, CD4+, CD8+, gammadelta T-cells, CD56 natural killers ((NK) cells), and elastase (neutrophils). Anti-CD95 monoclonal antibodies and in situ end-labelling techniques were used to detect Fas expression and apoptosis. Positive staining cells were expressed as cells-mm alveolar wall-, percentage of total cells, and Fas/APO and apoptosis index. Emphysema was identified macroscopically, microscopically and reported as present or absent. All subjects had pulmonary function tests before surgery. Neutrophils were the predominant cell in the lung parenchyma of nonsmokers and smokers without emphysema. In smokers with emphysema, the CD3+ and CD8+ were the predominant cells (p&lt;0.05) in the alveolar wall. gammadelta cells were increased in all smokers and no increased numbers of NK cells was found. The T-cell numbers x mm alveolar wall(-1) showed a bilinear relationship with the amount smoked increasing at an inflection point of 30 packs yr(-1) (R2= 0.345; p &lt; 0.01). Apoptosis in smokers showed a bilinear relationship with the amount smoked increasing sharply in smokers with emphysema (R2=0.3613; p &lt; 0.009). It is concluded that the pathogenesis of emphysema might be mediated by T-lymphocytes, mainly CD8+ cytolytic T-cells, and that apoptosis might be one of the mechanisms of lung destruction leading to the development of emphysema. If this is the case, it could be speculated that T-cell inflammation is a response to antigenic stimuli originating in the lung and induced by cigarette smoking." }, { "id": "wiki20220301en463_23922", "title": "Douglas R. Green", "score": 0.009708737864077669, "content": "Research After many studies on immunological tolerance, Green's work on cell death began with his discovery of activation-induced apoptosis in T lymphocytes, the role of c-Myc in this process and the finding that Bcl-2 cooperates with Myc in oncogenesis by blocking apoptosis. More recently, he discovered the process of LC3-associated phagocytosis, which links the autophagy pathway to phagosome maturation. Other areas of interest include regulated necrosis, metabolic reprogramming in T lymphocytes, and the function of the tumor suppressor, p53. As of 2014 he had published many chapters and books and over 500 papers, making him one of the world's most cited molecular biologists. He is listed in: ISI \"highly cited\" (Immunology 2003) ISI \"highly cited\" (Molecular Biology/Genetics 2014) Recognition" }, { "id": "pubmed23n0310_4100", "title": "[Characteristics of immunologic test values in the elderly].", "score": 0.009708737864077669, "content": "The immune system changes during the lifespan of man. Many described changes in the immune system of the elderly were dependent on illness or chronic diseases. To exclude these pathological changes in the immune system and to exclusively describe age-dependent changes, Ligthart et al. defined immunogerontological criteria to study the immune system in the elderly, the SENIEUR-Protocol. Most changes in the immune system of elderly are within the normal ranges of the appropriate parameter. However, there are many significant differences between the status of the immune system in healthy young and elderly individuals, within these normal ranges. The comparison between SENIEUR-elderly and healthy young and the additional comparison of these two groups with centenarians allows the discussion of potential pathological effects of these changes. In this article we summarize the described changes of the immune system in SENIEUR-elderly and centenarians. The serum levels of the immunoglobulins G, M and A increased with age, as well as the number of benign monoclonal gammopathies and the number of autoantibodies. The titers of zinc are significantly decreased in the serum of the elderly. The production of the acute phase protein C-reactive protein is not age-dependent, whereas the serum levels of alpha 2-macroglobulin are significantly increased in the elderly. The number of lymphocytes decreased and the number of neutrophils increased with aging. Monocytes, basophils, and eosinophils are without changes during life. There are many descriptions about changes of the leukocyte sub-population in aging, which are not always comparable. However, the number of T cells (CD3) decreases. Within the T cells the CD8 cells decreased more than the CD4 cells, resulting in an increased CD4/CD8 ratio. Memory T cells (CD45RO) increase during life, whereas naive T cells (CD45RA) decrease. Interestingly, centenarians have more naive T cells SENIEUR-elderly. The number of B cells (CD19) decreased also, whereas the number of natural killer (NK) cells (CD16, CD56, CD57) increases with aging. The capacity of leukocytes from the elderly to produce cytokines is also significantly different from those of the young. The release of the TH1-cytokines interleukin (IL)-2 and interferon (IFN)-gamma is decreased, whereas the production of the TH2-cytokines IL-4 and IL-10 is increased in the elderly. The production of proinflammatory cytokines such as IL-1, IL-6, IL-8, and tumor necrosis factor-alpha is increased in the elderly. In contrast, the capacity to produce the antiviral cytokine IFN-alpha is reduced in elderly individuals. In conclusion, the immune system shows many age-dependent changes, but we know little about the reason and the potential pathological effects of these changes." }, { "id": "wiki20220301en493_8376", "title": "Complement-dependent cytotoxicity", "score": 0.009615384615384616, "content": "CDC assay is usually used for performing crossmatch test. The basic version involves incubation of patient’s serum with donor’s lymphocytes and second incubation after adding rabbit complement. Presence of dead cell (positive test) means that donor isn‘t suitable for this particular patient. There are modifications available to increase test sensitivity including extension of minimal incubation time, adding antihuman globulin (AHG), removing unbound antibodies before adding complement, separation of T cell and B cell subset. Besides CDC crossmatch there is flow-cytometric crossmatch available, that is more sensitive and can detect even complement non-activating antibodies. See also Contrast with antibody-dependent cellular cytotoxicity (ADCC) References Immunology" }, { "id": "pubmed23n1026_25278", "title": "Serial tests of T-cell function predict long-term survival in an elderly cohort from a Scottish general practice.", "score": 0.009615384615384616, "content": "INTRODUCTION The care of the elderly presents serious challenges to general practice. In 1979, the first author took over the care of a general practice in Scotland where 21% of registered patients were elderly. This resulted in a high workload and prompted research into how this might be mitigated. AIM To measure serial tests of T-cell function in these individuals in order to identify those whose immune response was impaired and assess the effect of this in a long term follow up. METHODS This research comprised two phases. In the assessment phase (1979-82), patients were invited to have a 3-monthly visit from a research nurse where clinical measurements were made and blood taken for immunological tests of lymphocyte proliferation after culture with phytohaemagglutinin (PHA). For each patient, all records were surveyed and problems identified. In the follow-up phase (post 1982), all deaths were assessed with complete life-long follow up. RESULTS Of 405 people originally invited to participate in this research, 314 (78%) agreed and 246 (153 female, 93 male) entered the follow-up phase and were followed for 36.5 years. Factors significantly associated with lower survival were age, male sex, diastolic blood pressure, current smoking and poor immune function, as demonstrated by the percentage of negative responses in at least six PHA tests. Considered in four groups by percentage of failing tests, the lowest group had a life span 4 years shorter than the highest (P&lt;0.01). The four groups did not differ significantly in general practitioner workload, diagnosed problems or causes of death. DISCUSSION Poor cellular immune function was associated with poor survival over lifetime follow up of &gt;30 years. A sensitive, specific and longitudinally consistent measure of T-cell function is required to predict who may be at risk of poorer survival within our practices." }, { "id": "wiki20220301en562_26713", "title": "ELISpot", "score": 0.009523809523809525, "content": "More specifically, the T-cell ELISpot assay is used to characterize T-cell subsets. This is because the assay can detect the production of cytokines IFN-y, IL-2, TNF-alpha, IL-4, IL-5, and IL-13. The first three cytokines are produced by Th1 cells, while the last three are produced by Th2 cells. Measuring T-cell responses through cytokine production also makes it possible to study vaccine efficacy. With T-cell FluoroSpot, you can monitor tumor-infiltrating lymphocytes. You can also analyze the IFN-y cytokine and granzyme B secretion in order to assess cytotoxic T-cell responses. Both of these are used for cancer research. With B-cell FluoroSpot, vaccine efficacy can also be observed by quantifying the secretion of IgG, IgA, and IgM before and after a vaccination. This analysis of multiple immunoglobulins is made possible because of the fluorescence method used in the FluoroSpot. References Biochemistry methods Immunologic tests" }, { "id": "pubmed23n0247_6221", "title": "[Diagnostic significance of immunocomplexes].", "score": 0.009523809523809525, "content": "Immunocomplexes from the blood serum of 129 autopsied males and females from newborn age up to 95 years were examined by means of the PEGIKEM test. In cases of sudden death without inflammatory changes the mean value of immunocomplexes x = 22.794, s = 23.426; in cases of death due to injury without inflammatory changes x = 22.935, s = 21.947. In sudden death with inflammatory changes x = 41.154, s = 50.97; in death due to injury with inflammatory changes x = 54.500, s = 34.757. In inflammatory changes the values of immunocomplexes are increased statisticaly significantly; in sudden death p = 0.0485, in death due to injury p = 0.0193 when compared with controls without inflammatory changes. In sudden death, no statistically significant differences were found between the age groups 0-1 year, 2-15 years and above 16 years. In sudden death and that due to injury, the lowest values of immunocomplexes were found in infants to 1 year of age. Increased values of immunocomplexes may also be found in cases without inflammatory changes and, in contrast to it, may be low in inflammatory changes. Dependence of immunocomplexes upon the duration of the postmortem period was neither proved nor excluded by means of the statistical method. It is suitable to examine immunocomplexes immediately after the withdrawal of blood sample, fluctuation of values may occur in vitro (in cases of drowning and phylonephritis). The examination of immunocomplexes in postmortem blood is possible and in some cases suitably supplements the spectrum of diagnostic methods." }, { "id": "wiki20220301en526_27280", "title": "Lymphocyte-variant hypereosinophilia", "score": 0.009433962264150943, "content": "Following the historical findings cited above, studies identified the cytokine, interleukin 5 (IL5), as the eosinophil growth-stimulating CFU made by T cells from patients suffering the idiopathic hypereosinophilic syndrome. Subsequent studies likewise identified IL5 as a cytokine being overproduced by certain lymphocytes taken from patients with lymphocyte-variant eosinophilia. These and other studies support the view that lymphocyte-variant hypereosinophilia is a unique disease characterized by hypereosinophilia secondary to the pathological production of eosinophil growth factors, particularly IL5 but possibly also IL4; IL13, and GM-CSF by one or more aberrant clones of T cells. The aberrant T cell clone, as defined by immunophenotyping their expression of certain cell surface molecules, the cluster of differentiation (i.e. CD) proteins, varies from patient to patient; furthermore, some of these clones also exhibit clonal rearrangements in their T-cell receptor gene. The most" }, { "id": "pubmed23n0258_13211", "title": "[Use of an apoptosis test in the biological follow up of patients infected with HIV].", "score": 0.009433962264150943, "content": "Among biological parameters, spontaneous apoptosis has been studied in lymphocyte culture of HIV seropositive patients. Apoptosis seems to be related with CD4+ deletion." }, { "id": "wiki20220301en039_79612", "title": "Tuberculosis diagnosis", "score": 0.009345794392523364, "content": "Immunological test ALS Assay Antibodies from Lymphocyte Secretion or Antibody in Lymphocyte Supernatant or ALS Assay is an immunological assay to detect active diseases like tuberculosis, cholera, typhoid etc. Recently, ALS assay nods the scientific community as it is rapidly used for diagnosis of tuberculosis. The principle is based on the secretion of antibody from in vivo activated plasma B cells found in blood circulation for a short period of time in response to TB-antigens during active TB infection rather than latent TB infection. Transdermal Patch A similar approach to the ALS assay. The transdermal patch is a suggested method of detecting active M.tuberculosis circulating within blood vessels of patient. This skin patch contains antibodies recognizing the secreted bacterial protein MPB-64 passing through the blood capillaries of the skin creating an immunological response. If the patch detects this secreted bacterial protein, the surrounding skin will redden." }, { "id": "pubmed23n0415_23549", "title": "Immunology of Early and Late Ontogenesis.", "score": 0.009345794392523364, "content": "Immunological interrelations are one of the most important factors, forming all the periods of ontogenetic body development. At early ontogenesis in the organism of mammals, including humans, the immunological tolerance is induced to own (self) antigens that prevents the development of autoimmune reactions in adult life. The system of immune recognition reaches its fine discriminative capacity in mammals and humans on the background of recognition of self HLA class I (CTL of CD8(+) phenotype) or class II (T helpers of CD4(+) phenotype). The phenomenon of major histocompatibility complex (MHC) restriction reactivity of cytotoxic T lymphocytes (CTL) makes difficult the recognition in changes or mutations in HLA system. Natural killers (NK) control constantly the structure of self MHC class I molecules, and in contrast to CTL may recognize small antigenic changes of MHC molecules, induced by viruses, mutations and transformation. Immune system aging is displayed by both quantitative, and functional changes in lymphocyte subpopulations with prevalence of T helpers type 2 over type 1 cells, responsible for the development of DTH. According to immunological theory of aging, the role of immune system cells should be taken into consideration in relation to the synthesis of activated oxygen forms with bactericidal properties by monocytes and neutrophils. Overproduction of activated oxygen radicals may result in destruction of proteins, lipids, DNA, and in the body aging. Activated oxygen radicals are one of events of lymphocyte apoptosis in aerobic conditions." }, { "id": "pubmed23n0313_17874", "title": "Host defensive, immunological, and microbiological observations of an early-onset periodontitis patient with virus-associated hemophagocytic syndrome.", "score": 0.009259259259259259, "content": "Virus-associated hemophagocytic syndrome (VAHS) is a disorder characterized by benign generalized histiocytic proliferation and marked hemophagocytosis associated with systemic viral infection. An immunodeficiency which includes an extremely decreased leukocyte and platelet count together with abnormalities in the CD4/CD8 ratio are the most common features of VAHS. Here we report an early-onset periodontitis (EOP) patient with VAHS from the standpoint of host-parasite interaction to understand the effect of this systemic disorder which might possibly influence susceptibility to periodontal disease. The patient is a 16-year-old Japanese male clinically diagnosed as having generalized EOP with slight gingival inflammation and moderate bone loss. This patient manifested VAHS at 3 years of age, and then had an unusual 4 recurrences (at 5, 7, 11, and 14 years old). Laboratory tests conducted include: 1) complete blood analyses: 2) peripheral neutrophil functions (chemotaxis, phagocytosis, superoxide production, and adherence); 3) peripheral lymphocyte subpopulations and functions, T-cell proliferative activity and productivity of cytokines (interleukin-2 [IL-2], interferon gamma [IFN-gamma], and tumor necrosis factor alpha [TNF-alpha]); 4) serum cytokine levels (IL-1 beta, IL-2, soluble IL-2 receptor [sIL-2R], IL-4, IL-6, IFN-gamma, and TNF-alpha; 5) serum immunoglobulin G (IgG) antibody titers against periodontopathic bacteria; 6) serological human leukocyte antigen (HLA) typing; and 7) determination of bacterial flora of the periodontal pockets. The results indicated that the patient's neutrophil chemotaxis and random migration were below the normal range. In lymphocyte examinations, T-cell proliferative activity, IL-2, and IFN-gamma productivity were elevated. Serum IFN-gamma level was also significantly higher than normal range. No specific periodontopathic bacteria were predominant in the periodontal pockets, however, the serum IgG titer against Porphyromonas gingivalis was elevated throughout the examination period. It is suggested that VAHS might be a possible risk factor for periodontal disease, and hence may serve as a model in understanding the role of host defense mechanisms in the establishment of inflammatory periodontal disease." }, { "id": "wiki20220301en200_3437", "title": "Dock8", "score": 0.009174311926605505, "content": "This disorder is considered a combined immunodeficiency because it includes both decreased lymphocyte numbers and defective lymphocyte function. It can also be classified as a type of autosomal recessive hyperimmunoglobulinemia E syndrome. Laboratory manifestations include progressive lymphopenia that primarily affects CD4 and CD8 T cell subsets, reduced B cell and/or NK cell counts in some patients, eosinophilia, and immunoglobulin abnormalities. Antibody responses to vaccines are frequently poor. Loss of Dock8 protein expression can be demonstrated by diagnostic intracellular flow cytometry testing." }, { "id": "article-24605_16", "title": "Lymphoproliferative Disorders -- Evaluation", "score": 0.009174311926605505, "content": "The new criteria required for the diagnosis of an autoimmune lymphoproliferative syndrome (ALPS) [6] include chronic non-malignant lymphoproliferation (lymphadenopathy or splenomegaly over six months of evolution) and elevated peripheral blood double-negative T cells (DNTs). The first accessory in diagnosis is a somatic or a germ-line mutation in ALPS causative gene ( FASL , CASP10 , FAS ) and defective in vitro Fas-mediated apoptosis. Secondary diagnostic criteria are elevated biomarkers (plasma sFASL over 200 pg/ml, plasma or serum vitamin B12 greater than 1500 ng/L, plasma IL-10 greater than 20 pg/ml, and plasma IL-18 greater than 500pg/ml) and immunohistochemical findings on biopsy consistent with ALPS. Other diagnostic signs are polyclonal hypergammaglobulinemia, autoimmune cytopenia and a family history of ALPS or non-malignant lymphoproliferation." }, { "id": "pubmed23n0476_2979", "title": "[Anti-HLA antibodies in nephropathic patients].", "score": 0.00909090909090909, "content": "The presence of anti-human leukocyte antigen (HLA) alloantibodies in nephropathic patients is due to immunogenic stimuli such as transfusions, pregnancies, and transplantations. These stimuli can be highlighted using a classic aspecific serologic technique, such as complement-dependent cytotoxicity (CDC) or using more recent and specific techniques, such as cytofluorimetrics or enzyme linked immunoabsorbant assay (ELISA). Because the presence of anti-HLA preformed antibodies is linked to the largest incidence of both acute and chronic rejection, it seems appropriate to re-evaluate that data obtained using aspecific classic serological analysis techniques by using the more specific cytofluorimetric technique. To aid in the possible prevention of ant-HLA antibody formation, it is also appropriate to analyze the influence of immunogenic stimuli on the development of these antibodies. We studied 116 patients (37 women and 79 men). Anti-HLA antibodies were detected using microlymphotoxic technique after separation of B and T lymphocytes. This separation was obtained using magnetic balls. We used a 30-cell panel. We also used a recent cytofluorimetric test (Flow Pra screening; One Lambda Inc., 21001 Kittridge St., Canoga Park, California, U.S.A.) with a panel of micrograins covered with class I and class II purified antigens. Statistical analysis was performed using chi-square analysis or Fischer s exact test. For each test, sensibility, specificity, and positive and negative value were measured. Among 33 patients testing positive using the classic CDC-PRA technique (17 positive for B-lymphocytes and 16 positive for both B and T lymphocytes), using cytometry, 25 were positive for anti-HLA-specific antibodies (10 among the B lymphocyte-positive patients and 15 among the B + T lymphocyte-positive patients). Two patients were shown positive only using the cytofluorimetric method. Of the 27 patients positive at cytometry, 18 were positive for class I and class II, 4 for class I, and 5 for class II. FLOW-PRA screening results were less sensitive and more specific. The results obtained by the two methods are comparable(p&lt;0.0001). The immunogenic stimuli found responsible for immunization were: transfusion in 10 of 25 patients, pregnancies in 3/9 patients, transplant in 4/8 patients, and different immunogenic stimuli in 10/12 patients. The results were not statistically significant (p&gt;0.05). Data show that positivity for B lymphocytes obtained using CDC-PRA is not always linked to the development of anti-HLA antibodies, whereas positivity for B+T lymphocytes, obtained using CDC -PRA, is often linked to specific antibody development. Immune response is more often directed against class I and II antibodies. The specific detection of HLA antibodies using the cytofluorimetric method allows us to identify patients at risk for rejection, and it suggests that red cells should be filtrated to prevent anti-HLA immunization secondary to transfusion in transplantation candidates." }, { "id": "wiki20220301en564_212", "title": "Virological failure", "score": 0.009009009009009009, "content": "The progressive decline in T-CD4 + lymphocyte counts is characterized by immunologic failure. It should be considered, however, that there is a wide biological variability (individual and interindividual) in the counts of these cells, as well as laboratory variability related to the technical reproducibility of the test. There is also circadian variation of CD4 levels and therefore it is recommended that the sample for the test be obtained in the morning. Variability related to the various motifs described above may result in oscillations of up to 25% in absolute CD4 T-lymphocyte counts, with no clinical significance. It is therefore recommended that reductions greater than 25% in T-CD4 + lymphocyte counts are suspected of immunological failure and confirmation is given. References Virology" }, { "id": "pubmed23n0034_1434", "title": "[Demonstration of a granulocyte defect in aged persons correlated with the presence of autoantibodies].", "score": 0.009009009009009009, "content": "Assessment of PMN leukocyte function and search for autoantibodies were performed in 36 aged human subjects (more than 60 years of age) and in 15 younger controls (40 to 60 years of age). Autoantibodies were found in 15 of the 36 aged subjects, and in none of the controls. Leukocyte function defects were therefore correlated to old age and to markers of autoimmunity. Phagocytosis of bacteria was significantly impaired in both groups of old-aged subjects, irrespective to the presence or absence of autoimmunity. Intracellular killing of bacteria was shown to be normal in all the examined subjects. Nitroblue tetrazolium reduction by resting and latex-stimulated leukocytes was significantly impaired only in the group of old-aged subjects with autoimmunity. These leukocyte function defects are similar to those already described in human autoimmune diseases -- particularly S.I.E. -- and confirm the possible association between P.M.N. dysfunction and autoimmunity." }, { "id": "wiki20220301en111_27526", "title": "Pemphigoid", "score": 0.008928571428571428, "content": "Indirect immunofluorescence Indirect immunofluorescence is used to detect circulating antibodies targeting the antigens at the basement membrane zone in patients with pemphigoid. In early studies using routine techniques, only one third of patient with MPP were being tested positive. Circulating IgG and IgA antibodies are found in patient's serum. To increase the likelihood of detecting circulating antibodies, human basement membrane zone-split skin and/or concentrated serum should be used. Antigen-specific serologic testing Autoantibodies directed against a variety of antigens, including BP180, BP230, laminin 332, and type VII collagen may be detected. However, this test could not be used as the only diagnostic tool for testing as ELISA testing has limited sensitivity. Treatment The factors that determine the type of therapy used for mucous membrane pemphigoid are: [1] site(s) of involvement, [2] severity of disease, [3] rate of progression." }, { "id": "pubmed23n0302_16135", "title": "Cytometric analysis of immunosenescence.", "score": 0.008928571428571428, "content": "We have been studying the immune system of healthy centenarians for many years, and they provide the best example of successful aging. They are people who have escaped major age-related diseases and reached the extreme limit of human life in good clinical condition. In most cases, histories of centenarians reveal them to be free of cancer, dementia, diabetes, cardiovascular diseases, and cataracts. Moreover, in order to reach such an advanced age, they should be equipped with well preserved and efficient immuno- and defense mechanisms, and optimal combinations of an appropriate lifestyle and genetic background. Using this approach, several paradoxes emerged as far as the immune system of centenarians is concerned, regarding: i) humoral immunity (increase in plasma immunoglobulins and nonorgan-specific autoantibodies, decrease in B cell number and lack of organ-specific autoantibodies); ii) cellular immunity (well preserved number of \"virgin\" T cells, a relatively intact T cell repertoire despite a thymus involuting since puberty, increased number of cells with markers of NK activity); iii) decreased peripheral blood lymphocyte tendency to programmed cell death, associated with a well preserved mitochondria functionality and intracellular bcl-2 levels. An age-related increase in the levels of adhesion molecule present on lymphocyte plasma-membrane, accompanied by a complex reshaping of the cytokine network, must be added to this scenario. All our data fit the hypothesis that a complex, unpredicted remodeling of the immune system occurs with age. In the present review it is underlined how flow cytometry has been used to study most of the above mentioned aspects of immunosenescence, and to establish new age-related reference values." }, { "id": "wiki20220301en145_11697", "title": "Lactalbumin", "score": 0.008849557522123894, "content": "In an open study, the clinical efficacy of whey protein (Immunocal: cysteine content; 7.6-fold that of casein) isolated from fresh milk and purified without being heated was evaluated based on liver function test, immunological parameters, plasma or lymphocyte GSH concentrations and hepatitis virus markers in 25 patients with chronic hepatitis B or C. Immunocal (12 g as protein) food (mousse) was given twice a day, in the morning and evening, for 12 weeks (test period). Casein (12 g as protein) food (mousse) was given for 2 weeks prior to the start of -supplement with Immunocal food (induction period) and for 4 weeks after the end (follow-up period). The effects of Immunocal food on various clinical parameters were examined at 4-week intervals for 18 weeks to evaluate the efficacy of Immunocal. As a result, serum ALT activity decreased in 6 of 8 patients with chronic hepatitis B 12 weeks after the start of supplement with Immunocal food. Plasma GSH concentrations were increased in 5" }, { "id": "pubmed23n0015_11719", "title": "[Immune complexes in sudden and violent deaths].", "score": 0.008849557522123894, "content": "Immunocomplexes in the blood serum of 115 autopsied subjects chosen at random were examined by means of the Pegikem test. Average values of 34.9 +/- 44.6 were found in a group of 57 suddenly died subjects while those of 51.3 +/- 76.2 were seen in a group of 58 subjects dead due to injury. The possibility of the determination of immunocomplexes for postmortem diagnosis of immune conditions are discussed." }, { "id": "wiki20220301en187_28879", "title": "Cancer immunology", "score": 0.008771929824561403, "content": "monoclonal anti-CTLA4 and anti-PD-1 antibodies are called immune checkpoint inhibitors: CTLA-4 is a receptor upregulated on the membrane of activated T lymphocytes, CTLA-4 CD80/86 interaction leads to switch off of T lymphocytes. By blocking this interaction with monoclonal anti CTLA-4 antibody we can increase the immune response. An example of approved drug is ipilimumab. PD-1 is also an upregulated receptor on the surface of T lymphocytes after activation. Interaction PD-1 with PD-L1 leads to switching off or apoptosis. PD-L1 are molecules which can be produced by tumor cells. The monoclonal anti-PD-1 antibody is blocking this interaction thus leading to improvement of immune response in CD8+ T lymphocytes. An example of approved cancer drug is nivolumab. Chimeric Antigen Receptor T cell This CAR receptors are genetically engineered receptors with extracellular tumor specific binding sites and intracelullar signalling domain that enables the T lymphocyte activation. Cancer vaccine" }, { "id": "pubmed23n0006_584", "title": "[Microlymphocytotoxic test with T lymphocytes: positivity by 3 hrs incubation (author's transl)].", "score": 0.008771929824561403, "content": "Some human anti-HLA-DR and anti-HLA-A,B-sera contain cytotoxins reacting with T lymphocytes in the cytotoxic test by the prolongation of the incubation time to 3 hrs, whereas in the normal cytotoxic test of 1 1/2 hr incubation antibodies are not proved. These results suggest that simultaneous testing of sera with B and T lymphocytes not always give a true image of the actual occurrence of antibodies in the serum. The cause of the phenomen and the problem of the serological character of cytotoxins are discussed." }, { "id": "wiki20220301en546_19539", "title": "Innate immune defect", "score": 0.008695652173913044, "content": "Diagnosis Patients with innate immune defects have generally intact adaptive immune systems with normal antibodies and T-cells. The main symptom is increased level of eosinophils in the blood, but elevated immunoglobulin E (IgE) levels may also be present. The diagnosis is made in suspected patients by measuring cytokine production by white blood cells, after stimulation by bacterial products. Testing of TLR function is becoming available through commercial reference laboratories. By abnormal tests is usually made repeat testing and also genetic testing. Treatment The common treatment for these defects usually involves antibiotic therapy to treat acute infections. Prophylactic antibiotic therapy is also used. Some patients require immunoglobulin treatment. References Immunology" }, { "id": "pubmed23n0398_17998", "title": "Comparison of automated haematology analysers for detection of apoptotic lymphocytes.", "score": 0.008695652173913044, "content": "Automated haematology analysers can rapidly provide accurate blood cell counts and white blood cell differentials. In this study, we evaluated four different haematology analysers for the detection of apoptotic lymphocytes in peripheral blood: MAXM A/L Retic, H*2, Cell-Dyn 3500 and NE-8000. With the MAXM A/L Retic haematology analyser, the apoptotic lymphocyte cluster appeared below the original lymphocyte cluster on the volume/DF1, and to the right under the original lymphocyte cluster on the volume/DF2 scattergrams. With the H*2 haematology analyser, the apoptotic polymorphonuclear lymphocytes produced a higher lobularity index on the BASO channel. With the Cell-Dyn 3500 haematology analyser, the apoptotic lymphocyte cluster appeared to the right side of the original lymphocyte cluster on the 0D/10D scattergram and to the left side of the polymorphonuclear cluster on the 90D/10D scattergram. With the NE-8000 haematology analyser, the apoptotic lymphocyte cluster was not distinguishable. Thus, apoptotic lymphocytes are readily detected on scattergrams generated by selected haematology analysers." }, { "id": "wiki20220301en100_22873", "title": "Timeline of immunology", "score": 0.008620689655172414, "content": "1945 – Coombs test antiglobulin test (AGT) 1946 – Identification of mouse MHC (H2) by George Snell and Peter A. Gorer 1948 – Antibody production in plasma B cells (Astrid Fagraeus) 1949 – Growth of polio virus in tissue culture, neutralization, and demonstration of attenuation of neurovirulence (John Enders) and (Thomas Weller) and (Frederick Robbins) 1951 – A vaccine against yellow fever 1953 – Graft-versus-host disease 1953 – Validation of immunological tolerance hypothesis 1957 – Clonal selection theory (Frank Macfarlane Burnet) 1957 – Discovery of interferon by Alick Isaacs and Jean Lindenmann 1958–1962 – Discovery of human leukocyte antigens (Jean Dausset and others) 1959–1962 – Discovery of antibody structure (independently elucidated by Gerald Edelman and Rodney Porter) 1959 – Discovery of lymphocyte circulation (James Gowans)" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 56, 143 ] ], "word_ranges": [ [ 10, 27 ] ], "text": "By the form of presentation, it is clearly an acute hepatitis, so option 1 is ruled out." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 267, 394 ] ], "word_ranges": [ [ 52, 76 ] ], "text": "When having IgM anti HBc we speak of an acute hepatitis B (3), since there is a window period of negativization of the antigen." }, "4": { "exist": true, "char_ranges": [ [ 186, 265 ] ], "word_ranges": [ [ 36, 52 ] ], "text": "the negative HBs Ag rules out 4 (to have delta virus you need surface antigen B)." }, "5": { "exist": true, "char_ranges": [ [ 145, 180 ] ], "word_ranges": [ [ 27, 35 ] ], "text": "The negative IgM of HAV rules out 5" } }

{ "1": "Chronic hepatitis B.", "2": "Non-viral acute hepatitis.", "3": "Acute hepatitis B.", "4": "D (delta) virus superinfection.", "5": "Acute hepatitis A and B." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0104_13839", "title": "Acute delta superinfection in a previously unrecognised HBsAg carrier with transient loss of HBsAg simulating acute non-A, non-B hepatitis.", "score": 0.01906318082788671, "content": "An 18 yr old previously well male Taiwanese was admitted with malaise, anorexia, and jaundice for two weeks. Results of liver tests were compatible with acute hepatitis. On day 1, he was seronegative for HBsAg, IgM anti-HAV, IgM anti-HBc, IgM anti-CMV, and IgM EBV capsid Ab, but positive for anti-delta in association with anti-HBc and anti-HBs. At follow up on day 5 HBsAg converted to positive with decreasing titre of anti-HBs. On day 19, the titre of HBsAg increased concomitantly with loss of anti-HBs. The results of these serological profiles indicated that this patient was a previously unrecognised HBsAg carrier, who developed acute hepatitis delta virus superinfection with transient loss of HBsAg. This phenomenon should be kept in mind in the serodiagnosis of acute viral hepatitis, especially in areas of high HBV prevalence." }, { "id": "pubmed23n0103_9720", "title": "Fulminant hepatitis in asymptomatic hepatitis B surface antigen carriers in Greece.", "score": 0.018108816781383152, "content": "Eleven male fulminant hepatitis (FH) patients (mean age: 47.7 +/- 16 years) positive for hepatitis B surface antigen (HBsAg) but negative for IgM antibody to hepatitis B core antigen (IgM anti-HBc) were admitted consecutively to the Athens Hospital for Infectious Diseases between May 1981 and November 1983. Because of the absence of IgM anti-HBc, determined by an enzyme immunoassay, these patients were considered to be HBsAg carriers with a superimposed acute hepatitis. Three of the 11 patients received immunosuppressive chemotherapy during the six months before the onset of the acute hepatitis. None of the patients was homosexual or a drug addict. Infection with hepatitis A virus (HAV), hepatitis B virus (HBV), or hepatitis delta virus (HDV) was detected with serologic markers and/or molecular hybridization techniques. Fulminant hepatitis was attributed to spontaneous reactivation of chronic hepatitis B in four patients, chemotherapy-induced reactivation of chronic hepatitis B in three patients, HDV superinfection in one patient and possible superinfection by non-A, non-B agent(s), HDV, or HDV-like agents in three patients. Reactivation of chronic hepatitis B was an important cause of apparent acute hepatitis in heterosexual male HBsAg carriers from an area with a high prevalence of HBV infection." }, { "id": "pubmed23n0126_17819", "title": "Diagnostic usefulness of anti-HBc-IgM and anti-HD antibodies in acute viral hepatitis.", "score": 0.01740314769975787, "content": "To evaluate diagnostic improvement achieved with the determination of antibody to hepatitis core antigen of IgM type (anti-HBc-IgM) and antibody to delta antigen (anti-HD) in acute type B hepatitis, 155 patients (of whom 100 were drug addicts) were studied, using these markers in association with the classical markers of viral hepatitis (anti-HBc, anti-HBs, anti-HAV-IgM and anti-cytomegalovirus antibodies). With classical diagnostic criteria, 121 patients would have been diagnosed as having B hepatitis (HBs Ag and/or anti-HBc antibody positive without anti-HBs antibody), 33 non A non-B hepatitis (all markers negative or anti-HBc and anti-HBs positive) and 3 A hepatitis (anti-HAV-IgM antibody positive). With the current markers, 89 were B hepatitis (anti-HBc-IgM antibody positive), 18 were simultaneous B and D infections (anti-HBc-IgM and anti-HD antibodies positive), 6 were D hepatitis (anti-HBc-IgM antibody negative and anti-HD antibody positive), 39 non-A non-B hepatitis (anti-HBc-IgM, anti-HD, HAV-IgM and anti-cytomegalovirus antibodies negative) and 3 hepatitis A. Of the 121 cases initially diagnosed as B hepatitis, only 79 were actually B hepatitis, 16 were simultaneous B and D infections, 6 D hepatitis, 18 non-A non-B hepatitis and 2 A hepatitis. Of the 33 cases considered to be non A non-B hepatitis, only 21 were really non-A non-B hepatitis; 10 were B hepatitis and 2 B and D hepatitis. When anti-HBc-IgM and anti-HD antibodies were determined, the initial diagnosis was modified in 54 of 155 cases (35 p. 100).(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0538_19109", "title": "Infection with hepatitis A, B, C, and delta viruses among patients with acute hepatitis in Mongolia.", "score": 0.017139090309822018, "content": "One hundred ten consecutive patients (60 males and 50 females; age, mean +/- standard deviation [SD], 22.6 +/- 6.4 years; range 16-48 years) who were clinically diagnosed with sporadic acute hepatitis between December 2004 and January 2005 in Ulaanbaatar, Mongolia, were studied. IgM antibodies to hepatitis A virus were detected in 18 patients (16.4%), IgM antibodies to hepatitis B core (anti-HBc IgM) in 38 patients (34.5%) including two patients with concurrent hepatitis delta virus (HDV) infection, and hepatitis C virus RNA in nine patients (8.2%). There were 30 hepatitis B virus (HBV) carriers who had detectable hepatitis B surface antigen and antibodies to HDV but were negative for anti-HBc IgM, suggesting that they acquired type D acute hepatitis due to superinfection of HDV on a background of chronic HBV infection. None had IgM antibodies to hepatitis E virus (HEV). Consequently, 16.4, 32.7, 6.4, 1.8, and 27.3% of the patients were diagnosed as having acute hepatitis of type A, B, C, type B + D (HBV/HDV coinfection), and type D (superinfection of HDV), respectively. The cause of hepatitis was not known in the remaining 17 patients (15.5%). All 18 HAV isolates were genotyped as IA, all 9 HCV isolates were genotyped as 1b, and all 32 HDV isolates were classified into genotype I. The distribution of HBV genotypes among the 67 HBV isolates was A (1.5%, n = 1) and D (98.5%, n = 66). The present study indicates that de novo infections of HAV, HBV, HCV, and HDV are prevalent among young adults in Mongolia." }, { "id": "pubmed23n0083_6842", "title": "The etiology of acute hepatitis superimposed upon previously unrecognized asymptomatic HBsAg carriers.", "score": 0.01683644595359366, "content": "To study the etiology of acute hepatitis superimposed upon previously unrecognized asymptomatic HBsAg carriers, paired sera were collected in acute and convalescence phases for measurement of HBeAg, anti-HBe, hepatitis B virus DNA and anti-delta from 76 adult patients with acute hepatitis who were HBsAg positive but IgM anti-HBc negative or positive only at low titer. None of them were IgM anti-hepatitis A virus positive on admission. Of the 34 patients who were HBeAg positive initially, two (5.9%) were diagnosed as having delta superinfection, and another two (5.9%) were suspected to have non-A, non-B virus superinfection because of a transient decrease of serum hepatitis B virus DNA. The remaining 30 (88.2%) cases were hepatitis B virus DNA negative with or without anti-HBe seroconversion on follow-up. The episodes of acute hepatitis in these cases may represent \"immune clearance of HBeAg\" or \"immune clearance of hepatitis B virus with delayed anti-HBe seroconversion,\" respectively, in the natural course of chronic hepatitis B virus infection. Of the patients who were anti-HBe positive initially, 23 (54.8%) were diagnosed as having delta superinfection, including eight with de novo seroconversion of anti-delta and 15 with a rising titer of anti-delta; 10 (23.8%) were positive for hepatitis B virus DNA and were considered as reactivation of hepatitis B virus, and the other nine (21.4%) were suspected as having non-A, non-B virus superinfection.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0224_6050", "title": "The role of IgM anti-HBc in the etiologic diagnosis of HBsAg-positive acute and chronic hepatitis.", "score": 0.016693108919086708, "content": "HBsAg, HBeAg, anti-HBc, anti-HBs, IgM anti-HAV, total and IgM anti-delta (RIA) and IgM anti-HBc (ELISA) have been determined on sera of 72 male patients with acute hepatitis (68 HBsAg positive and 4 anti-HBc-positive) at the onset of the disease and at 2, 4 and 6 months thereafter, and of 77 patients with HBsAg-positive chronic active hepatitis. The results indicate that testing for IgM anti-HBc in acute hepatitis is necessary to identify cases of hepatitis B even in the absence of positivity for HBsAg and/or HBeAg. HBsAg-positive cases, negative for IgM anti-HBc, were due to delta superinfection of chronic carriers of HBsAg. Recovery was always associated with negativity of IgM anti-HBc; IgM anti-HBc persistence was not found in all cases evolved to chronicity. In chronic hepatitis cases positivity for IgM anti-HBc was found only in 39% of the anti-delta-negative and only in 5.5% of the anti-delta-positive cases." }, { "id": "pubmed23n0122_760", "title": "Clinical and serological outcome of acute delta infection.", "score": 0.014867022741038488, "content": "To assess the clinical and serological outcome of hepatitis delta virus (HDV) infection, 59 patients with acute delta hepatitis were followed for 6-28 months. Forty-two patients had simultaneous HDV and HBV coinfection (anti-HBc IgM-positive, group I) and 17 were HBsAg carriers with HDV superinfection (anti-HBc IgM-negative, group II). Overall, serum HD-Ag and anti-HD IgM were the most sensitive markers for diagnosis of delta infection during the first 2 weeks after onset of symptoms. The clinical presentation was similar in both groups; 4 patients (1 in group I and 3 in group II) (7%) developed fulminant hepatitis, but none of them died. The majority of patients with HBV-HDV coinfection (group I) eventually recovered, whereas all HBsAg carriers with HDV superinfection (group II) developed chronic liver disease. Liver histology in these patients showed chronic active hepatitis and/or cirrhosis in 90%. The hepatic lesion was probably due to persistent HDV infection, as indicated by the presence of intrahepatic HD-Ag and/or persistence of serum anti-HD IgM in 90% of the patients." }, { "id": "pubmed23n0343_3588", "title": "Etiology of sporadic acute viral hepatitis in Taiwan: the role of hepatitis C virus, hepatitis E virus and GB virus-C/hepatitis G virus in an endemic area of hepatitis A and B.", "score": 0.014426957223567393, "content": "The etiology of sporadic acute hepatitis was studied in 334 consecutive patients from Taiwan (237 men and 97 women, aged 16-81 years), with emphasis on the role of hepatitis C virus (HCV), hepatitis E virus (HEV), and GB virus-C/hepatitis G virus (GBV-C/HGV) in acute non-A, non-B (NANB) hepatitis and in HBsAg carriers with superimposed acute hepatitis. According to the conventional diagnostic criteria, there were 12 cases (3.6%) of acute hepatitis A, 17 cases (5.1%) of acute hepatitis B, 128 cases (38.3%) of acute NANB hepatitis, and 177 cases (53.0%) of acute hepatitis in HBsAg carriers (those who were HBsAg positive but IgM anti-HBc negative). Among 128 cases of acute NANB hepatitis, 70 (54.7%) had acute hepatitis C (HCV RNA positive), 5 (3.9%) had acute hepatitis E (IgM anti-HEV positive), and the other 53 (41.4%) were presumably acute hepatitis non-A-E. The prevalence of acute hepatitis A, B, E, and non-A-E showed no significant sex difference, whereas acute hepatitis C was significantly more prevalent in females. The prevalence of acute hepatitis A and B decreased and that of acute hepatitis C increased significantly with increasing age. In contrast, acute hepatitis E and non-A-E showed no significant age predominance. Of 177 HBsAg carriers with acute hepatitis, 64 (36.1%) demonstrated non-B hepatotropic virus superinfection, with HCV being the most common (60.9%), followed by hepatitis D, E, and A viruses, and the other 55 (31.1%) and 58 (32.8%) were presumed to have acute exacerbation of chronic hepatitis B or superimposed acute hepatitis non-A-E, respectively. Serum GBV-C/HGV RNA was detected in 3-4% of acute hepatitis non-A-E cases, suggesting its limited role in these cases." }, { "id": "pubmed23n0061_11127", "title": "[The etiological structure of acute viral hepatitis in Tadzhikistan in a period of decreased morbidity].", "score": 0.014400073610599928, "content": "In the period of reduced incidence of viral hepatitis in Tajikistan, January-December, 1990, 1562 patients with acute viral hepatitis (AVH) were examined in the first days of the jaundice phase (928 children under 14 years and 634 adults) in Dushanbe. Markers of hepatitis A, B, and D (HBsAg, anti-HA IgM, anti-HBc IgM, anti-delta IgM) were determined by enzyme immunoassay. Hepatitis A occurred in 25.8% of the patients with AVH, mostly children of 1-6 years, HB in 22.8%, HD co- and superinfection) in 9.2%. In 42.1% of the patients who had no HA, HB, or HD markers in the blood, non-A, non-B hepatitis (mostly hepatitis E) was diagnosed, mainly in the age groups of 30-39 years (70.7%) and 15-29 years (59.2%). Thus, in Tajikistan hepatitis E occurs not only during outbreaks of this infection but also sporadically." }, { "id": "pubmed23n0210_20909", "title": "Etiology of fulminant viral hepatitis in Greece.", "score": 0.013946280991735538, "content": "The etiology of fulminant viral hepatitis was determined in 65 consecutive cases among 1,814 (3.58%) adults with acute viral hepatitis who were admitted to the Infectious Diseases Hospital of Athens from May, 1981 to August, 1983. Radioimmunoassays were used to detect hepatitis B virus, hepatitis A virus and delta-agent markers. Enzyme immunoassay was used to detect anti-HBc IgM. Hepatitis B virus was responsible for 48 (73.9%), non-A, non-B for 16 (24.6%) and hepatitis A virus for one case (1.5%). The use of anti-HBc IgM identified 10 cases of fulminant type B hepatitis among HBsAg negative, anti-HBc and anti-HBs positive patients. Fulminant non-A, non-B hepatitis was superimposed on 10 asymptomatic HBsAg carriers; delta-agent co-infection was diagnosed in two fulminant type B hepatitis cases. These data show that hepatitis B virus is the major cause of fulminant hepatitis in Greece. HBsAg carriers are at high risk for fulminant non-A, non-B hepatitis. delta-agent does not seem to be as important as in Italy and other countries." }, { "id": "pubmed23n0226_13907", "title": "Hepatitis A and non-A, non-B viral hepatitis in São Paulo, Brazil: epidemiological, clinical and laboratory comparisons in hospitalized patients.", "score": 0.01345250993138317, "content": "During a 33-month period, 295 patients with acute viral hepatitis were admitted to a state hospital for civil servants and their dependents in São Paulo, Brazil. Seventy-nine per cent (232) were HBsAg negative. To define the contribution of non-A, non-B viral hepatitis to hepatitis morbidity in this population, further serological studies were performed in 147 confirmed HBsAg-negative patients. One hundred and twelve (76%) were serologically classified as hepatitis A based on identification of IgM antibody to hepatitis A virus. Thirty patients (20%) without IgM antibody to hepatitis A virus, HBsAg, or anti-HBc were categorized as the non-A, non-B hepatitis group. The remaining five patients had probable hepatitis B (IgM antibody to hepatitis A virus negative, HBsAg negative, anti-HBs negative but anti-HBc positive). These data suggest that all three etiological forms of viral hepatitis are endemic in São Paulo. Epidemiological, clinical, and laboratory features were compared to the hepatitis A and non-A, non-B hepatitis groups. Patients with non-A, non-B hepatitis were significantly older than patients with hepatitis A (mean age +/- S.D.: 30 +/- 22 years vs. 9 +/- 9 years, p less than 0.001). Contact with hepatitis or jaundice was recognized in 26 (23%) of 112 hepatitis A patients and 3 (10%) of 30 non-A, non-B patients, a difference which was not statistically significant. Parenteral exposures were identified in 13 (43%) of 30 patients with non-A, non-B hepatitis and 23 (21%) of the 112 hepatitis A patients. Blood transfusion in the 2 months preceding onset of illness was reported in 5 (17%) of the 30 non-A, non-B patients and in none of the hepatitis A group (p less than 0.001). Although prodromal symptoms and fever were more common in patients with hepatitis A, neither these nor other clinical features appeared to be distinguishing characteristics. Similarly, mean peak SGPT levels, peak SGPT levels of greater than or equal to 1,000 IU/per liter, and the mean duration of SGPT elevations for each group were not significantly different. Mean peak serum bilirubin levels were slightly higher in the non-A, non-B group than in the hepatitis A group (7.6 +/- 8.0 mg per dl vs. 5.1 +/- 2.7, p less than 0.01) and peak bilirubin levels greater than or equal to 10 mg per dl were found in 27% of the non-A, non-B group and 5% of the hepatitis A group (p less than 0.001). Whether the higher bilirubin levels reflect an agent-related phenomenon or an older population of affected patients is uncertain." }, { "id": "pubmed23n0084_3330", "title": "Fulminant viral hepatitis: Indian experience.", "score": 0.013273558368495076, "content": "Thirty-six patients with fulminant viral hepatitis were studied. Enzyme immunoassay was used to detect the presence of HBsAg, IgM anti-HBc, and IgM anti-HAV. Non-A, non-B virus was the most common aetiological agent (61.1%) followed by hepatitis B virus (HBV; 30.6%) and hepatitis A virus (8.3%). Presence of IgM anti-HBc confirmed the diagnosis of HBV infection in three cases who were negative for HBsAg. Similarly, in one case who was positive for HBsAg, absence of IgM anti-HBc suggested superinfection with some other agent. Survival was significantly higher (P less than 0.01) in the hepatitis A virus (HAV) group (66.6%) compared with non-A, non-B (31.2%) and HBV groups (27.3%). Fever at the onset of illness was seen in all patients with HAV, 54.5% of patients with HBV and 38.88% of patients with non-A, non-B infection (P less than 0.01). The median time interval between the first symptom and the onset of encephalopathy was 16, 13 and 8 days in HAV, HBV and non-A, non-B groups, respectively, but this difference was statistically not significant (P greater than 0.05)." }, { "id": "pubmed23n0346_12063", "title": "Serological diagnosis of jaundice epidemics in India.", "score": 0.012828947368421053, "content": "Enterically transmitted non-A, nonB- hepatitis (ET-NANBH) is a major public health problem in India, where the endemicity of this disease is high and poor public sanitation coupled with compromised quality of drinking water leads to major and minor outbreaks. Sophisticated technics for characterization of hepatitis E virus (HEV) are not easily available/affordable, resulting in continuation of the diagnosis of NANBH for most epidemics. This study attempts to serologically determine the etiology of epidemics of NANBH in India. Eighteen outbreaks of jaundice occurring in various regions of India over a period of twenty months were selected for this laboratory based study. Representative cases of each outbreak were subjected to detailed serological investigation for immunological markers of viral hepatitis. Each serum sample was tested for the immunological markers of acute or recent infection with hepatitis A or B viruses (anti-HAV-IgM, HBsAg and anti-HBc-IgM) by Macro ELISA (Abbott). The sera found to be negative for these three markers ie non-A, non-B hepatitis (NANBH) sera were further tested for anti-HEV by Macro ELISA (anti-HEV EIA, Abbott). A highly significant number of NANBH sera were reactive for anti-HEV in case of almost all the outbreaks. The lowest figure for anti-HEV positivity in NANBH sera of outbreak was compared with anti-HEV positivity in the controls and found to be significantly high. It was concluded that anti-HEV is an important marker revealing probability of the NANBH outbreak being due to HEV." }, { "id": "wiki20220301en023_14705", "title": "Seroconversion", "score": 0.012370125901479036, "content": "On a serological assay, the presence of hepatitis B surface antigen (HBsAg) indicates an individual with a currently active hepatitis B infection, whether acute or chronic. The presence of core antibody (anti-HBc) indicates an individual with an infection in general, whether current or previously resolved. The presence of surface antibody (anti-HBs) indicates an individual with immunity to hepatitis B, whether due to previously resolved infection or due to hepatitis B vaccination. For example, an individual who has never had any exposure to HBV, either by vaccine or by infection, would test negative for the entire serology panel. An individual who has been vaccinated and never had an infection will test seropositive for anti-HBs due to vaccination and negative for markers of infection. An individual with an acute HBV infection would test positive for HBsAg and anti-HBc (total and IgM) while negative for anti-HBs. An individual with a chronic infection would test positive for HBsAg and" }, { "id": "pubmed23n0535_9094", "title": "Active surveillance for acute viral hepatitis in rural villages in the Nile Delta.", "score": 0.012307808831326213, "content": "Acute viral hepatitis is less frequent in Egypt than serum antibody levels suggest. Because acute viral hepatitis has a wide clinical spectrum, we tested the hypothesis that many cases are undetected because of mild illness caused by initial, early-childhood exposure to hepatitis viruses. During active case detection among 20,000 inhabitants of rural villages in Egypt, we screened 1715 symptomatic patients for serum alanine aminotransferase (ALT) levels. Viral hepatitis markers were tested in 47 subjects who had ALT levels that were least twice the normal level. Of the 47 individuals tested, 4 children aged 3-5 years had immunoglobulin M (IgM) antibodies to hepatitis A virus (anti-HAV IgM). One also had a possible false-positive result to a test for IgM antibodies to hepatitis E virus. None had serological evidence of acute hepatitis B virus (HBV) infection or hepatitis C virus (HCV) infection. However, 33 of the remaining 43 had active HCV infection, having both antibodies to HCV (anti-HCV) and HCV RNA. Four others anti-HCV without HCV RNA, and 2 others had seroconversion to anti-HCV during follow-up. Two patients who were positive for hepatitis B surface antigen had chronic HBV infection. Only 3 with elevated ALT levels had no evidence of acute or chronic infections with known hepatitis viruses. Immunoglobulin G antibodies to hepatitis E virus was detected in 40 patients. Active surveillance covering approximately 50,000 person-years detected only 4 cases of acute HAV infection. Almost all persons with mild symptoms and elevated ALT levels had serological evidence of chronic viral hepatitis, most often associated with HCV. Many of these cases were probably \"flare-ups\" of HCV infection or incidental illness in patients with chronic HCV infection, but some could have been caused by difficult-to-confirm initial HCV infections. Although serological evidence for exposures was highly prevalent, hepatitis viruses seldom caused acute viral hepatitis in these communities." }, { "id": "pubmed23n0043_8666", "title": "Non-A, non-B viral hepatitis in Egypt.", "score": 0.012218999274836839, "content": "A study was carried out on 200 patients of ages 20-40 years suffering from acute viral hepatitis. Sera were tested for markers of hepatitis B (HBsAg, and IgM anti-HBc) and hepatitis A (IgM-anti-HAV) by the ELISA technique. Sera negative for the markers of both viruses: Hepatitis A (HAV) and Hepatitis B (HBV) were subsequently tested for IGM Heterophil antibodies against Epstein-Barr virus (EBV) by the Monospot slide test to diagnose acute infectious mononucleosis and tested for anti-CMV (IgM) by ELISA technique for the diagnosis of acute Cytomegalovirus (CMV) infection. Non-A, non-B hepatitis (NANB) was diagnosed by exclusion. The results of the study showed that 133 (66.5%) patients had evidence of HBV infection, while only 9(4.5%) were diagnosed as HAV infection. EBV and CMV were the possible etiological agents of acute viral hepatitis in (3.5%) and 1%) respectively. Accordingly the Non-A, non-B hepatitis in this study amounts to (24.5%) of the acute viral hepatitis." }, { "id": "wiki20220301en349_29113", "title": "Vaccine-induced seropositivity", "score": 0.011990681527498631, "content": "Hepatitis B When a person gets a hepatitis B vaccine then the most common test for hepatitis B will show them to be positive. The usual course of action, in this case, is to give the person a panel of tests for HBsAg, anti-HBc, and anti-HBs (hepatitis B surface antigen, anti-hepatitis B core, and anti-hepatitis B surface). A person who has never been exposed to hepatitis B but has gotten the vaccine will be positive for anti-HBs but negative for the other two tests in the panel. Other combinations of positive and negative in this test can mean other things, such as acute, chronic, or past infection." }, { "id": "wiki20220301en001_273611", "title": "Hepatitis", "score": 0.011959093982420555, "content": "Viral hepatitis Viral hepatitis is primarily diagnosed through blood tests for levels of viral antigens (such as the hepatitis B surface or core antigen), anti-viral antibodies (such as the anti-hepatitis B surface antibody or anti-hepatitis A antibody), or viral DNA/RNA. In early infection (i.e. within 1 week), IgM antibodies are found in the blood. In late infection and after recovery, IgG antibodies are present and remain in the body for up to years. Therefore, when a patient is positive for IgG antibody but negative for IgM antibody, he is considered immune from the virus via either prior infection and recovery or prior vaccination. In the case of hepatitis B, blood tests exist for multiple virus antigens (which are different components of the virion particle) and antibodies. The combination of antigen and antibody positivity can provide information about the stage of infection (acute or chronic), the degree of viral replication, and the infectivity of the virus." }, { "id": "wiki20220301en073_48714", "title": "Needlestick injury", "score": 0.011728939884279688, "content": "Treatment After a needlestick injury, certain procedures can minimize the risk of infection. Lab tests of the recipient should be obtained for baseline studies, including HIV, acute hepatitis panel (HAV IgM, HBsAg, HB core IgM, HCV) and for immunized individuals, HB surface antibody. Unless already known, the infectious status of the source needs to be determined. Unless the source is known to be negative for HBV, HCV, and HIV, post-exposure prophylaxis (PEP) should be initiated, ideally within one hour of the injury. Hepatitis B The risk of hepatitis B (e antigen positive) seroconversion is estimated at 37–62%, significantly more than other blood borne pathogens. After exposure to the hepatitis B virus (HBV), appropriate and timely prophylaxis can prevent infection and subsequent development of chronic infection or liver disease. The mainstay of PEP is the hepatitis B vaccine; in certain circumstances, hepatitis B immunoglobulin is recommended for added protection." }, { "id": "pubmed23n0104_14052", "title": "Delta infection and hepatitis B virus replication in Danish patients with fulminant hepatitis B.", "score": 0.011688575687762569, "content": "The presence of hepatitis B virus and delta agent markers was investigated in 41 patients referred during the years 1970-1985 with fulminant hepatitis classified as type B or non-A non-B and compared to findings in patients with uncomplicated hepatitis B and chronic hepatitis B infection. 13 patients had no markers of hepatitis B and delta infection and were classified as non-A non-B hepatitis. The remaining 28 patients were all HBsAg and IgM anti-HBc positive and 14 (50%) had evidence of delta infection. In contrast, only 13/71 patients (18%) with acute benign hepatitis B had evidence of delta coinfection (p less than 0.005). This corresponds to an odds ratio of 4.5 for development of fulminant hepatitis among patients with hepatitis B and delta coinfection. In 100 chronic HBsAg carriers 29% were positive for delta markers. 12 of the delta infected patients with fulminant hepatitis were positive for total antibody to the delta antigen, and 2 were delta antigen positive. Three were HBeAg positive/anti-HBe negative. None had hepatitis B virus DNA. Among the 14 patients without delta infection, hepatitis B virus DNA was found in 2/4 HBeAg positive/anti-HBe negative patients and in 1/8 patients negative for both markers. The present data indicate that a high proportion of Danish patients with fulminant hepatitis B have hepatitis B and delta agent coinfection. Further, the findings suggest that hepatitis B and delta coinfection may be associated with an increased risk of development of fulminant hepatitis as compared to that of hepatitis B alone." }, { "id": "pubmed23n0304_7174", "title": "Differential diagnosis of acute HBsAg positive hepatitis using IgM anti-HBc by a rapid, fully automated microparticle enzyme immunoassay.", "score": 0.011428571428571429, "content": "We determined the diagnostic significance of IgM anti-HBc by a rapid, fully automated microparticle enzyme immunoassay (IMx CORE-M) in acute HBsAg positive hepatitis. We studied prospectively for at least 6 months 100 patients with acute self-limited hepatitis B (group A) and 40 patients with acute hepatitis superimposed on histologically confirmed chronic hepatitis B (group B). On admission, all patients in group A were positive and those in group B were negative for IgM anti-HBc by a commercially available enzyme immunoassay. Based on the assay criteria, the rates of IMx CORE-M (&gt; 1.2) positive serum samples on admission, 4, 12 and 24 weeks later were: in group A: 100%, 95%, 72%, 44% and in group B: 20%, 27.5%, 17.5%, and 15%, respectively. Misclassification was observed in 20-27.5% of the acute on chronic hepatitis B cases. However, the mean IMx CORE-M index value was found to be significantly higher in group A during the whole follow-up. In particular, on admission the mean IMx CORE-M index value was 2.504 +/- 0.435 (range: 1.508-3.482) in group A and 0.747 +/- 0.346 (range: 0.062-1.384) in group B (p &lt; 0.001). Discriminant function analysis showed that the cutoff level between the two groups for IMxCORE-M index on admission was 1.5. Four to 12 weeks from admission, in the group with acute on chronic hepatitis B cases, 13 patients with HDV and/or HCV superinfection had significantly lower IMx-CORE M index values compared with 27 patients with acute hepatitis due to exacerbation of chronic hepatitis B. IMx CORE-M appears to be an accurate diagnostic test to differentiate acute from acute on chronic HBsAg positive hepatitis, but the cut-off level seems to be higher (1.5 instead of 1.2)." }, { "id": "wiki20220301en037_64388", "title": "Acute liver failure", "score": 0.011333061557276803, "content": "Initial laboratory analysis Prothrombin time/INR Complete blood count Chemistries Liver function test: AST, ALT, alkaline phosphatase, GGT, total bilirubin, albumin Creatinine, urea/blood urea nitrogen, sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphate Glucose Amylase and lipase Arterial blood gas, lactate Blood type and screen Paracetamol (acetaminophen) level, toxicology screen Viral hepatitis serologies: anti-HAV IgM, HBSAg, anti-HBc IgM, anti-HCV Autoimmune markers: ANA, ASMA, LKMA, immunoglobulin levels Ceruloplasmin level (when Wilson's disease suspected) Pregnancy test (females) Ammonia (arterial if possible) HIV status (has implication for transplantation) History taking should include a careful review of possible exposures to viral infection and drugs or other toxins. From history and clinical examination, the possibility of underlying chronic disease should be ruled out as it may require different management." }, { "id": "pubmed23n0127_13857", "title": "[Changes in the response time of anti-HBc IgM in a hepatitis B case load. Diagnostic implications].", "score": 0.011083555310615107, "content": "Anti-HBc IgM were determined in 46 patients whose serum was positive for hepatitis B surface antigen (HBsAg). All sera were tested from 1:4000 up to 1:8128000 dilution with a radioimmunometric assay. Anti-HBc IgM persisted at detectable level for up 15 months from acute infection in more than 50% of the patients. High levels of anti-HBc IgM are seen only in the acute phase but it is difficult to establish a cut-off dilution displaying diagnostic value between current and remote infection. Anti-HBc IgM are always detectable in acute hepatitis B virus (HBV) so that the absence of HBc IgM in acute hepatitis with positive HBsAg allows to discard HBV as the causative agent and to suspect a non-B hepatitis (A, delta, NANB). On the contrary the presence of anti-HBc IgM in detectable amounts in patients with acute hepatitis and negative HBsAg makes possible the diagnosis of acute B virus hepatitis." }, { "id": "wiki20220301en094_18175", "title": "Window period", "score": 0.010711781206171108, "content": "Hepatitis B Two periods may be referred to as window period in hepatitis B infection: (1) the period that elapses during HBsAg to HBsAb seroconversion, i.e. between the disappearance of surface antigen (HBsAg) from serum and the appearance of HBsAb (anti-HBs), and (2) the period between infection and appearance of HBsAg. During the window of HBsAg to HBsAb seroconversion, IgM anti-core (HBc-IgM) is the only detectable antibody. HBV DNA may be positive as well. This window period does not occur in persons who develop chronic hepatitis B, i.e. who continue to have detectable HBV DNA for greater than 6 months (HbsAg remains positive), or in people who develop isolated HBcAb positivity, i.e. who lose HBsAg, but do not develop HBsAb (HBV DNA may or may not remain positive). See also Incubation period, the time between infection and the appearance of symptoms References HIV/AIDS Serology" }, { "id": "wiki20220301en152_1624", "title": "List of hepato-biliary diseases", "score": 0.010686319668355596, "content": "Hepato-biliary diseases include liver diseases and biliary diseases. Their study is known as hepatology. Liver diseases Viral hepatitis Acute hepatitis A Acute hepatitis B Acute hepatitis C Acute hepatitis D – this is a superinfection with the delta-agent in a patient already infected with hepatitis B Acute hepatitis E Chronic viral hepatitis Other viral hepatitis viruses may exist but their relation to the disease is not firmly established like the previous ones (hepatitis F, GB virus C, hepatitis X) Other infectious diseases Hepatitis: cytomegalovirus infection herpesviral: herpes simplex infection Toxoplasmosis Hepatosplenic schistosomiasis Portal hypertension in schistosomiasis Liver disease in syphilis Epstein–Barr virus infection yellow fever virus infection rubella virus infection leptospirosis Echinococcosis Amoebiasis" }, { "id": "InternalMed_Harrison_23540", "title": "InternalMed_Harrison", "score": 0.010675259176239843, "content": "Serologic Tests of Patient’s Serum Note: See text for abbreviations. the absence of HBsAg when IgM anti-HBc is detectable. A diagnosis of acute hepatitis A is based on the presence of IgM anti-HAV. If IgM anti-HAV coexists with HBsAg, a diagnosis of simultaneous HAV and HBV infections can be made; if IgM anti-HBc (with or without HBsAg) is detectable, the patient has simultaneous acute hepatitis A and B, and if IgM anti-HBc is undetectable, the patient has acute hepatitis A superimposed on chronic HBV infection. The presence of anti-HCV supports a diagnosis of acute hepatitis C. Occasionally, testing for HCV RNA or repeat anti-HCV testing later during the illness is necessary to establish the diagnosis. Absence of all serologic markers is consistent with a diagnosis of “non-A, non-B, non-C” hepatitis, if the epidemiologic setting is appropriate." }, { "id": "pubmed23n0078_5991", "title": "Diagnostic significance of IgM antibody to hepatitis delta virus in fulminant hepatitis B.", "score": 0.010504549214226635, "content": "The prevalence of hepatitis delta virus (HDV) infection was studied in 25 adult patients with fulminant hepatitis who were admitted consecutively to our unit from February, 1986, to September, 1988. Enzyme and radioimmunoassays were used for the detection of serological markers of HAV, HBV, and HDV (HDAg, IgM anti-HD, total [IgG] anti-HD) infections. Two hundred twenty-nine serum samples (three to 19 samples/patient) were tested for serological markers of HDV infection. Of the 25 patients, 17 (68%) were HBsAg-positive, and the remaining eight (32%) were HBsAg-negative on admission to the hospital. All patients were seropositive for IgM anti-HBc. Serological markers of HDV infection were detected in 13 (52%) of the 25 patients. In particular, HDV infection was observed in nine (53%) of the 17 HBsAg-positive and in four (50%) of the eight HBsAg-negative patients with type B fulminant hepatitis. Survival was 16.7% for patients with hepatitis B and 57.8% for patients with B and D coinfection. Coinfections were responsible for fulminant hepatitis in 100% of drug addicts and 40% in patients who were not drug addicts. All patients with HBV/HDV coinfections became seropositive for IgM anti-HD. The results show that HDV infection has a significant role (52%) in type B fulminant hepatitis in an area with a moderate prevalence of HBV infections, that it should be tested in cases with early clearance of HBsAg, and that it does not seem to be accompanied by a high fatality rate.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0215_10252", "title": "Absence of circulating HBsAg in acute hepatitis B.", "score": 0.010197759074714721, "content": "We are describing five of a group of 72 cases of acute hepatitis B in which HBsAg was not present when the disease was diagnosed, i.e. two to six days after the appearance of icterus. The role of HBV infection was assessed by demonstrating the absence of anti-HBs during the first few weeks and its appearance at the time of recovery, as well as the presence of anti-HBe, high anti-HBc titers and the IgM class of immunoglobulin. The high levels of transaminases observed in early sera returned to normal values within two to six weeks. Anti-HAV antibodies were absent in all serum samples tested. These case reports should remind us that the absence of HBsAg at the onset of acute viral hepatitis does not exclude the possibility of HBV infection. Therefore, if HBsAg and anti-HAV are not present at the beginning of acute viral hepatitis, serum should also be tested for anti-HBc IgM before the diagnosis of non-A, non-B hepatitis is considered." }, { "id": "article-22788_41", "title": "Hepatitis B -- Evaluation -- Interpretation of Serologic Markers", "score": 0.010114003228410008, "content": "Following serologic markers are often tested: Hepatitis B surface antigen (HBsAg), antibody to Hepatitis B surface antigen (anti-HBs), Hepatitis B core Ab (Anti-HBc) IgM, Hepatitis B core Ab (Anti-HBc) IgG, Hepatitis B e antigen (HBeAg), and Hepatitis B e antibody (anti-HBe). [10] HBsAg: Acute infection (less than 6 months) or chronic infection (more than 6 months). Anti-HBs: Recovery from acute infection or immunity from vaccination. HBeAg: Mostly associated with high viral load. Anti-HBe: Low replicative phase. Anti-HBc IgM: Acute infection, an only marker present in the window period, can be present during exacerbation of chronic infection. Anti-HBc IgG: Exposure to infection, chronic infection (if present along with HBsAg), recovery from acute infection (if present with anti-HBs), if isolated presence, may represent occult infection." }, { "id": "pubmed23n0104_8202", "title": "Acute non-A, non-B hepatitis in Kuwait.", "score": 0.009900990099009901, "content": "In a prospective study of acute hepatitis in Kuwait covering the period February 1983 to January 1984, a total of 1781 cases were diagnosed as having an acute viral hepatitis. 1,384 (77.7%) were found to be due to hepatitis A virus (HAV), 206 (11.5%) hepatitis B virus (HBV), 8 (0.4%) coinfection with HBV and delta virus (HDV), 8 (0.4%) superinfection of HDV on chronic HBsAg carriers and 157 (9%) non-A, non-B virus (NANB). 13 cases of CMV and 5 of EBV infections were also diagnosed. NANB viral hepatitis was a disease of young adults (mean age 29 years) with a male-female ratio of 3:1. A high incidence was noted among males from the Indian subcontinent (29.1/100,000 of population, compared to 5.4/100,000 among local Arabs), the majority of whom gave a history of recent visit to the Indian subcontinent. The clinical features and biochemical findings of acute NANB infection were found to be less severe than those of acute HBV infection and similar to acute HAV infection. Three patients (2.3%) with acute NANB virus infection developed chronic hepatitis (all women), and another 3 patients died because of fulminant hepatitis." }, { "id": "pubmed23n0060_2485", "title": "[Hematological abnormalities in acute viral hepatitis and acute hepatitis in HBsAg carrier].", "score": 0.009708737864077669, "content": "Various kinds of hematological abnormalities have been known to occur in liver diseases. To understand the hematological changes in acute viral hepatitis, 324 adults with acute viral hepatitis were studied. Of them, 3 were acute hepatitis A, 91 acute hepatitis B, 99 acute non-A, non-B hepatitis (NANB) and 181 acute hepatitis on chronic hepatitis B (AH on CH-B). There were 233 males and 91 females; age ranged from 16 to 74 years (mean age 39 years.) The results showed the incidences of thrombocytopenia (platelet less than 120,000/cmm), anemia (Hb less than 12 g% in male and less than 10% in female patients), leukocytosis (WBC greater than 10,000/cmm) and leukopenia (WBC less than 4,000/cmm) were 19.3%, 12.6%, 10.8% and 7.4%, respectively. Patients with AH on CH-B had significantly higher incidence of anemia and thrombocytopenia than those with acute B hepatitis; other than this, there was no significant difference. Patients with anemia, thrombocytopenia or leukocytosis had significantly higher mean levels of serum bilirubin and higher proportions of prolonged prothrombin time, suggesting that these hematological abnormalities were closely related to the severity of hepatocellular damage. In addition, there were 3 cases (0.9%) complicated with aplastic anemia. Two were NANB hepatitis and the other was AH on CH-B which was seronegative for anti-delta, possibly suggesting NANB virus superinfection. Of these 3 cases, 2 died of complications related to aplastic anemia and 1 survived with normal hematological findings 148 days later." }, { "id": "pubmed23n0857_16384", "title": "SEROPREVALENCE OF HAV, HBV, HCV, AND HEV AMONG ACUTE HEPATITIS PATIENTS AT KENYATTA NATIONAL HOSPITAL IN NAIROBI, KENYA.", "score": 0.009523809523809525, "content": "Acute viral hepatitis is most frequently caused by the hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV) and hepatitis E virus (HEV). To determine seroprevalence of HAV, HBV, HCV and HEV among patients with acute hepatitis in Nairobi, Kenya, elucidate various risk factors for hepatitis viral infection and determine the co-infection rates with these viruses in the acute hepatitis patients. Across sectional descriptive study. Kenyatta National Hospital, from November 2007 to April 2008. One hundred patients were recruited by purposive sampling method and comprised of 57 males and 43 females. Among the enrolled patients, twenty three tested positive for one or more markers of acute viral hepatitis, that is, HAV, HBV, HCV and HEV. No markers were detected in 77patients, 2% tested positive for IgM anti-HAV 11% for IgM anti-HBc; 3% for HBsAg; 5% for HCV RNA and 7% for IgM anti-HEV.Various risk factors associated with acute viral hepatitis were identified; poor sanitation, source of water, occupation, place of residence, level of education, household size, drug abuse and sexual behaviours. Co-infection rate with hepatitis Viruses was at 4%, IgM anti-HAV and IgM anti-HEV 1% (n=1); IgM anti-HBc and IgM anti-HEV 1% (n=1); IgM anti-HBc and anti-HCV 2% (n=2). Three patients were positive for HBsAg; among this two were negative for IgM anti-HBc and this accounted for HBV carriage (2%). Hepatitis viruses'infections are commoncause of hepatitis among patients with acute hepatitis at Kenyatta National Hospital. Co-infection with these viruses was also identified among these patients." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 79 ] ], "word_ranges": [ [ 0, 11 ] ], "text": "The most frequent cause of recurrent nerve palsy is bronchopulmonary carcinoma." }, "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": "Pulmonary neoplasia.", "2": "Sarcoidosis.", "3": "Silicosis.", "4": "Tuberculosis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0732_16542", "title": "[Two cases of tuberculous uveitis].", "score": 0.015582808280828083, "content": "Uveitis has many etiologies, but tuberculous uveitis is rare. We herein report 2 cases of uveitis due to tuberculosis infection. The first case was a 28-year-old man who was showed abnormal shadows in the chest radiographic examination performed in search of the etiology of uveitis. Computed tomography (CT) of the chest revealed hilar and mediastinal lymphadenopathy, small nodules, and consolidation, with a small cavity in the right upper lobe. An ulcerated nodule in the truncus intermedius and stenosis of the right middle lobe bronchus were found on bronchoscopy. The biopsy of the nodule in the truncus intermedius showed a small granuloma containing giant cells, consistent with mycobacterial infection. The culture of bronchial washings from the right upper lobe grew Mycobacterium tuberculosis. Diagnosis of pulmonary tuberculosis, tuberculous lymphadenitis, bronchial tuberculosis, and tuberculous uveitis was made. The patient was treated with antituberculosis drugs and his disease, including uveitis, improved. The second case was a 36-year-old man who presented with right hemiparesis, dysarthria, and visual loss of the left eye. He was diagnosed with neuro-Sweet disease causing optic neuritis and visual loss. His chest CT showed a nodule with centrilobular opacities in the left lower lobe that suggested mycobacterial infection. PCR of the bronchial washing from the left lower lobe was positive for M.tuberculosis and the diagnosis of pulmonary tuberculosis was established. Treatment with antituberculosis drugs and corticosteroids was initiated and his pulmonary lesion improved. However, bilateral tuberculous uveitis developed 15 days after initiation of the treatment. The uveitis gradually deteriorated thereafter despite continuation of antituberculosis therapy. Photocoagulation finally halted the disease progression. In both patients with uveitis presented here, chest radiographs and CT scans were important in determining the etiology of the uveitis. It is difficult to find the etiology of uveitis, and general examinations including the lungs are helpful to pinpoint tuberculosis as the etiology of uveitis. As tuberculous uveitis is sometimes asymptomatic and resistant to treatment, ophthalmological examination is recommended for patients with pulmonary tuberculosis." }, { "id": "pubmed23n0284_2430", "title": "[A case of laryngeal and tracheobronchial tuberculosis].", "score": 0.01461530941441001, "content": "The patient was 38-year-old male. His chief complaint was persistent cough. He had been diagnosed at an another clinic as tuberculosis by positive sputum culture. Laboratory findings at the first examination were as follows: ESR was 10 mm/1 hr and CRP was 0.920 mg/dl and other data were within normal limits. Chest X-ray showed infiltrative shadow in the left lower lobe. Bronchoscopic findings before treatment were as follows: there were ulcers on bilateral vocal cords, small white nodules with reddness in trachea and red nodules and white coated ulcers in left main bronchus. He was treated with combination chemotherapy (INH, RFP, EB) and the steroid inhalation was added 1 month later after the initiation of chemotherapy. Bronchoscopic findings at 2 months after starting chemotherapy were as follows: lesions of vocal cords and trachea were improved and lesion of left main bronchus was scarred without stenosis. Bronchial stenosis as sequelae of endobronchial tuberculosis deteriorates the patients' quality of life. Therefore it is important to diagnose endobronchial tuberculosis early and to start treat with chemotherapy as soon as possible, and the follow up by bronchoscopy should be done during treatment." }, { "id": "pubmed23n0975_22510", "title": "Squamous Pulmonary Neoplasia Grafted on Lesions of Pulmonary Tuberculosis Sequelae.", "score": 0.013227513227513227, "content": "Clinical symptoms of hemoptysis, chest pain, dyspnea, night sweats and weight loss seen in a patient known for 14 years with pulmonary tuberculosis with sequelae lesions, will always guide the diagnose to a reactivated pulmonary tuberculosis. Yet, in this case, the latest pulmonary radiography revealed newly emerging bilateral lesions with the appearance of a macronodular opacity of medium intensity, discreetly non-homogeneous, located apical-sub-clavicular on the right side, but also with an apical-sub-clavicular cavity lesion on the left side, well defined, with uniform opaque content, and clear-cut outline. Complementary examinations, computed tomography and biopsy bronchoscopy, confirmed the diagnosis of upper right lobe pulmonary tumor with suspicion of aspergilloma in the upper left lobe." }, { "id": "pubmed23n0848_12471", "title": "Laryngeal tuberculosis without pulmonary involvement.", "score": 0.010991997584176356, "content": "Tuberculosis of the larynx is a rare form of tuberculosis. Patients usually present with hoarseness or dysphagia and other nonspecific constitutional symptoms like fever or localized pain. In this study, we present a case of primary vocal cord lesion with tuberculosis. A 72 year old man presented with hoarseness of voice, low grade fever, and night sweating with in three month duration. Laryncoscopic study showed unilateral thickening of vocal cord and biopsy of the lesion showed granuloma with caseous necrosis. Chest x-ray was normal. The patient was treated with standard regimen of tuberculosis and was cured after 6 months of therapy. Laryngeal tuberculosis should be considered in the differential diagnosis of patients with hoarseness without pulmonary involvement in endemic regions of tuberculosis." }, { "id": "wiki20220301en201_28670", "title": "Maynard v West Midlands Regional HA", "score": 0.010886075949367089, "content": "Maynard v. West Midlands Regional Health Authority [1985] 1 All ER 635 is an English tort law case concerning the Bolam test for professional negligence. The patient presented with symptoms of tuberculosis but both the consultant physician and the consultant surgeon took the view that Hodgkin's disease, carcinoma, and sarcoidosis were also possibilities, the first of which if present would have required remedial steps to be taken in its early stages. Instead of waiting for the results of the sputum tests, the consultants carried out a mediastinoscopy to get a biopsy. The inherent risk of damage was to the left laryngeal recurrent nerve, even if the operation was properly done. In the event, only tuberculosis was confirmed. Unfortunately, the risk became a reality and the patient suffered a paralysis of the left vocal cord. The decision of the physician and the surgeon to proceed was said by their expert peers to be reasonable in all the circumstances. See also Negligence Notes" }, { "id": "Anatomy_Gray_581", "title": "Anatomy_Gray", "score": 0.01067527308838133, "content": "A review of the patient’s history suggested a serious and chronic illness and the patient was admitted to hospital. After admission a bronchoscopy was carried out and sputum was aspirated from the left upper lobe bronchus. This was cultured in the laboratory and also viewed under the microscope and tuberculous bacilli (TB) were identified. A 68-year-old man came to his family physician complaining of discomfort when swallowing (dysphagia). The physician examined the patient and noted since his last visit he had lost approximately 18 lb over 6 months. Routine blood tests revealed the patient was anemic and he was referred to the gastroenterology unit. A diagnosis of esophageal cancer was made and the patient underwent a resection, which involved a chest and abdominal incision. After 4 years the patient remains well though still subject to follow-up." }, { "id": "wiki20220301en060_4876", "title": "Bolam v Friern Hospital Management Committee", "score": 0.010214765443448504, "content": "Maynard v West Midlands Regional Health Authority [1985] 1 All ER 635. The patient presented with symptoms of tuberculosis but both the consultant physician and the consultant surgeon took the view that Hodgkin's disease, carcinoma, and sarcoidosis were also possibilities, the first of which if present would have required remedial steps to be taken in its early stages. Instead of waiting for the results of the sputum tests, the consultants carried out a mediastinoscopy to get a biopsy. The inherent risk of damage was to the left laryngeal recurrent nerve, even if the operation was properly done. In the event, only tuberculosis was confirmed. Unfortunately, the risk became a reality and the patient suffered a paralysis of the left vocal cord. The decision of the physician and the surgeon to proceed was said by their expert peers to be reasonable in all the circumstances." }, { "id": "pubmed23n0730_14309", "title": "Laryngeal tuberculosis presenting as laryngeal carcinoma.", "score": 0.009900990099009901, "content": "Tuberculosis (TB) accounts for the highest number of mortalities among infectious diseases worldwide. Laryngeal TB is an extremely rare presentation of TB. It has many similarities to laryngeal carcinoma, one of the three most common cancers among males in the city, with an age standardized rate of 8.6. The associated risk factors of laryngeal carcinoma i.e. smoking, paan, betel nut usage and alcohol use also tend to be concentrated in the same demographic background as that of TB, creating a diagnostic dilemma. We present a case of granulomatous laryngeal TB, in a 40 year old male, with characteristic presenting features of laryngeal carcinoma i.e. persistent hoarseness and weight loss. He had no associated symptoms of fever, night sweats, cough or dysphagia, nor did he have any history of tobacco or irritant use. There was no history of tuberculosis (TB) contact. He was initially worked up for laryngeal carcinoma; however laryngoscopic biopsy revealed laryngeal TB. We present this case to emphasize the point that although primary laryngeal tuberculosis is a rarity, it must not be overlooked as a possibility when evaluating dysphonia and/or considering laryngeal carcinoma." }, { "id": "pubmed23n0810_3229", "title": "[Synchronous multiple primary lung cancers in a 65-year old heavy smoker. Case report].", "score": 0.00980392156862745, "content": "Here we present a 65-year old ex-smoker with history of recent surgery for vocal cord tumor (histology: moderate grade intraepithelial neoplasia), who reported to the pulmonary outpatient clinic for the nodular lesions in the left lung seen on chest X-ray. Subsequent chest CT scan revealed focal lesion of 18 mm in diameter with spicular margins located in the right upper lobe, another irregular cyst with septa, 62 × 58 mm in the right lower lobe, and calcified nodule in the left lung, no enlarged lymph nodes or pleural effusion was seen. He underwent upper right lobe resection and wedge resection of the lower right lobe. Histological examination revealed adenocarcinoma in the right upper lobe with lymph node metastasis (pT2aN2M0). Examination of the right lower lobe showed squamous cell carcinoma (pT2bN0M0). He was subsequently treated with adjuvant chemotherapy and radiotherapy. During 20 months of the follow-up, he remained in good health with no signs of the disease progression. Patients with synchronous multiple primary lung cancers have significantly less favorable outcome than those with single primary lung malignancies, although it can be considerably improved with radical surgical treatment. Basing on the above case report, we discussed diagnostic and therapeutical scheme in patients with the primary multiple lung cancers, and have analyzed epidemiological data and some aspects of MPM etiology. " }, { "id": "pubmed23n1056_19996", "title": "A Case of Laryngeal Tuberculosis, Endobronchial Tuberculosis and Pulmonary Tuberculosis Coexistent in an Immunocompetent Host.", "score": 0.00980392156862745, "content": "Historically associated with poor prognosis seen in advanced disease, laryngeal tuberculosis (LTB) now represents only 1% of all cases of tuberculosis (TB). The incidence of LTB has decreased drastically with the introduction of anti-tubercular drugs. LTB can be primary or secondary to pulmonary tuberculosis. LTB can mimic laryngeal cancer. We present a case of primary laryngeal TB with descending tracheobronchial spread in an immunocompetent 71-year-old female who developed progressive dysphonia over several months with unintentional weight loss and non-productive cough. Non-contrast enhanced computed tomography (CT) revealed clustering of subcentimeter stellate nodules in the right upper lung field with an enlarging ground-glass opacity in the right lower lung but did not show structural abnormalities within the neck. Positron emission tomography (PET) showed pathologic fluorodeoxyglucose (FDG) uptake within the larynx and trachea with extension into the left mainstream bronchus as well as the proximal left upper and lower lobe bronchi. Diffuse standardized uptake value (SUV) was greatest in the larynx (20.5). Polymerase chain reaction (PCR) on bronchoscope sputum specimen confirmed Mycobacterium tuberculosis. Findings were consistent with primary laryngeal TB with endobronchial extension. She was started on a four-drug regimen comprising of isoniazid, rifampin, ethambutol, and pyrazinamide with a good response. Her close contacts were treated as well. This case highlights the unusual spread of primary laryngeal TB in an immunocompetent host. Early diagnosis can limit adverse complications and unnecessary exposure to healthcare workers. To our knowledge, this is the first case of primary LTB with proximal spread to the tracheobronchial and pulmonary tuberculosis." }, { "id": "pubmed23n0652_14252", "title": "[Tuberculosis or sarcoidosis].", "score": 0.009708737864077669, "content": "Tuberculosis and sarcoidosis are two different diseases with different etiology, clinical features and treatment. Both are granulomatous disease, but tuberculosis has a caseating necrosis granuloma as opposed to sarcoidosis witch present noncaseating epithelioid cell granuloma. If chest radiography shows hilar lymphadenopathy and hystopatological features reveal no caseating necrosis granuloma the differential diagnosis might be difficult. This is a case of abdominal adenopathy in a 39-years-old male, with a past medical history significant for pulmonary tuberculosis. The patient was admitted to the hospital for mild epigastric pain and weight loss (14 kg for the last year). The abdominal ultrasound and CT scan revealed retroperitoneal lymph node enlargement. Chest X-ray revealed bilateral hilar adenopathy and mediastinal adenopathy. After various differential diagnoses were considered, a diagnostic laparoscopy and a lymph node biopsy were performed. The pathology report showed chronic necrotizing granuloma. The case was interpreted as lymph node sarcoidosis and treated with corticosteroids (Prednisone). After one month of treatment the patient complained of dry cough, night sweats, fatigability, decreased appetite and weight loss. Pathological findings of chest radiography and CT scan with iv contrast (left upper lobe infiltrate, right lower lobe ill-defined mass, multiple small nodular opacities scattered throughout both lung fields, bilateral hilar and mediastinal adenopathy, lymph nodes near celiac trunk were enlarged) and positive acid-fast bacilli of sputum smears point to the real diagnosis of pulmonary tuberculosis and abdominal lymph nodes tuberculosis. The patient was started on a daily treatment with Isoniazid, Pyrasinamide, Ethambutol, Streptomycine, Cyprofloxacine, Cicloserine and Protionamide (he was allergic to Rifampin). Five months later the clinical and radiological findings were almost normal and the sputum smear for acid-fast bacili was negative." }, { "id": "pubmed23n0536_9258", "title": "Vocal fold paralysis as a sign of chest diseases: a 15-year retrospective study.", "score": 0.009708737864077669, "content": "Vocal fold paralysis (VFP) is sometimes the only sign of chest diseases. However, some patients with VFP due to chest diseases are not diagnosed correctly at the first examination, which may leave the patients untreated for a long time. Depending on the situation, chest x-ray is not enough for detecting the primary lesion. The objective of this study was to discuss the diagnostic procedure for VFP based on the retrospective analysis of the cases. A total of 42 patients (29 males and 13 females) with VFP due to chest disease examined at the Department of Otolaryngology of Kyoto Prefectural University of Medicine between 1988 and 2002 were reviewed retrospectively. Of the primary chest diseases, lung cancer (15 cases) was the most common, followed by thoracic aortic aneurysm (TAA) (9 cases), metastatic tumor from other regions (6 cases), pulmonary and mediastinal tuberculosis (TB) (5 cases), and esophageal cancer (4 cases). While the primary lesions were easily detected with chest x-ray in most of the cases, some lesions in the aortopulmonary window were difficult to detect. Contrast-enhanced computed tomography (CT) was useful to detect any mass in this region. In the diagnosis of VFP due to chest diseases, chest x-ray was useful but not always enough for detecting the primary lesion. Necessity of further examinations including contrast-enhanced chest CT must be kept in mind for the cases with negative chest radiographs." }, { "id": "wiki20220301en033_17894", "title": "Tuberculosis radiology", "score": 0.009615384615384616, "content": "Radiology (X-rays) is used in the diagnosis of tuberculosis. Abnormalities on chest radiographs may be suggestive of, but are never diagnostic of TB, but can be used to rule out pulmonary TB. Chest X-ray A posterior-anterior (PA) chest X-ray is the standard view used; other views (lateral or lordotic) or CT scans may be necessary. In active pulmonary TB, infiltrates or consolidations and/or cavities are often seen in the upper lungs with or without mediastinal or hilar lymphadenopathy. However, lesions may appear anywhere in the lungs. In HIV and other immunosuppressed persons, any abnormality may indicate TB or the chest X-ray may even appear entirely normal. Old healed tuberculosis usually presents as pulmonary nodules in the hilar area or upper lobes, with or without fibrotic scars and volume loss. Bronchiectasis and pleural scarring may be present." }, { "id": "pubmed23n1068_21031", "title": "Pulmonary sarcoidosis presenting as hoarseness and mass lesion.", "score": 0.009615384615384616, "content": "A 46-year male, ex-smoker presented with cough and hoarseness for 2-3 months. The CECT chest revealed a left upper lobe mass. BAL was negative for AFB, GeneXpert, and malignant cells. The bronchial biopsy showed granuloma with no caseation and infiltration of lymphoid cells. The ultrasound abdomen was normal. The patient was started on prednisolone 0.5 mg/kg. He improved clinic-radiologically. Ex-smoker, middle-aged man with hoarseness and mass lesion on CECT chest is highly suspicious of lung malignancy. Pulmonary sarcoidosis should be kept in the differential diagnosis of unexplained hoarseness and mass lesion as the disease has diverse presentations." }, { "id": "pubmed23n0047_1164", "title": "[A case of sarcoidosis with primary acute pulmonary cavitation].", "score": 0.009523809523809525, "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": "pubmed23n0788_2123", "title": "Laryngeal tuberculosis in the United States of America: a forgotten disease.", "score": 0.009523809523809525, "content": "Laryngeal tuberculosis (TB) was a common manifestation of TB in the early twentieth century, but now represents only 1% of all cases. Most modern case series of laryngeal TB originate outside the USA. We report a case of laryngeal TB from our institution and review other US cases published between 1970 and 2012. One hundred twenty-seven cases were identified. The mean patient age was 49 y and 28% were female. The mean duration of symptoms was 19 weeks. Dysphonia and weight loss were the most common manifestations, seen in 96% and 47% of cases, respectively. These symptoms were usually attributed to malignancy initially. Most cases involved the vocal cords. Eighty-six percent of cases had underlying pulmonary involvement. Mortality was 3%. In the USA, laryngeal TB is rarely suspected and often confused with malignancy. This infection should be considered in patients with unexplained dysphonia and weight loss." }, { "id": "pubmed23n0734_17051", "title": "Bronchiectasis and hoarseness of voice in takayasu arteritis: a rare presentation.", "score": 0.009433962264150943, "content": "Takayasu arteritis is a large vessel vasculitis occurring in young females. We report a rare presentation of Takayasu arteritis in a Sri Lankan woman. She presented with bronchiectasis and left recurrent laryngeal nerve palsy prior to the onset of vascular symptoms. This case illustrates an atypical presentation of this disease and the diagnostic dilemma that the physician may be faced with. A 39-year-old woman presented with chronic cough, haemoptysis and hoarseness of voice. She had left recurrent laryngeal nerve palsy and high inflammatory markers on investigation. CT thorax revealed aortic wall thickening and traction bronchiectasis. 2 D echocardiogram revealed grade 1 aortic regurgitation compatible with aortitis. She did not have weak peripheral pulses or a blood pressure discrepancy and did not meet American College of Rheumatology (ACR) criteria for diagnosis of Takayasu arteritis at this stage. Tuberculosis, syphilis and sarcoidosis was excluded. While awaiting angiography, she developed left arm claudication and a pericardial effusion. Angiography revealed evidence of Takayasu arteritis and absence of flow in the left subclavian artery. Takayasu arteritis was diagnosed at this stage after a period of eight months from the onset of initial symptoms. She is currently on prednisolone, azathioprine and aspirin. Bronchiectasis and recurrent laryngeal nerve palsy is a rare presentation of Takayasu arteritis. Atypical presentations can occur in Takayasu arteritis prior to the onset of vascular symptoms. Elevation of inflammatory markers are an early finding. A high degree of suspicion is needed to identify these patients in the early course of the disease." }, { "id": "pubmed23n0074_377", "title": "[A case report of endobronchial lipoma].", "score": 0.009345794392523364, "content": "Endobronchial lipomas are rare benign tumors of the lung. Nineteen cases have been reported in Japan. We present a case of endobronchial lipoma obstructing the left B4b and chronic saccular bronchiectasis throughout the left upper lobe. A 42-year-old man, 174 cm tall and weighing 47 kg, was referred for investigation of an abnormal chest X-ray film. He had a history of pneumonia and pyothorax in infancy. The chest X-ray film showed linear densities and ill-defined, irregular opacities in the upper-middle lung field. CT scan and tomographic studies showed multiple cystic spaces in the left upper lobe in which the volume was diminished. An angiogram of the left bronchial artery showed peripheral hypervascularity in the left upper lobe and systemic-to-pulmonary artery shunt. Fiberoptic bronchoscopy revealed a smooth, pink mass obstructing B4b. Biopsy specimens were insufficient for histological diagnosis. Preoperatively, an inflammatory polyp in association with chronic saccular bronchiectasis was suspected. Left upper lobectomy was performed on January 13, 1989. Gross examination of the resected specimen showed a pedunculated polypoid mass, 1.5 X 1.2 X 0.6 cm, attached to the bronchial mucosa of B4bii and saccular ectatic changes of bronchi not only in the lingular division but also in upper division. Microscopically, the endobronchial tumor consisted of mature adipose tissue covered with columnar bronchial epithelium. The fat was fairly well localized in the submucosa, but was not encapsulated and did not enclose glands or smooth muscle fibers. The endobronchial lipoma was thought to originate in the bronchus of chronic saccular bronchiectasis." }, { "id": "pubmed23n0237_11088", "title": "[Is annual X-ray examination of the chest still justified in industrial medicine?].", "score": 0.009345794392523364, "content": "Between 1975 and 1979, 137.526 annual X-ray examinations of the chest were performed among the employees of a large Paris administration. Fifty-four cases of tuberculosis, 28 cases of sarcoidosis, 10 cases of bronchial carcinoma and 26 miscellaneous chest diseases were detected. This study confirms the inadequacy of radiological examination for detecting chronic obstructive bronchopulmonary conditions. The small proportion of tuberculosis (0.39 p.1000) and bronchial carcinoma (0.07 p.1000) revealed by this method suggests that it should be reserved to high risk patients." }, { "id": "wiki20220301en576_31549", "title": "Lung cavity", "score": 0.009279147693100781, "content": "Diagnosis of a lung cavity is made with a chest X-ray or CT scan of the chest, which helps to exclude mimics like lung cysts, emphysema, bullae, and cystic bronchiectasis. Once an imaging diagnosis has been made, a person’s symptoms can be used to further narrow the differential diagnosis. For example, recent onset of fever and productive cough suggest an infection, while a chronic cough, fatigue, and unintentional weight loss suggest cancer or tuberculosis. Symptoms of a lung cavity due to infection can include fever, chills, and cough. Knowing how long someone has had symptoms for or how long a cavity has been present on imaging can also help to narrow down the diagnosis. If symptoms or imaging findings have been present for less than three months, the cause is most likely an acute infection; if they have been present for more than three months, the cause is most likely a chronic infection, cancer, or an autoimmune disease." }, { "id": "pubmed23n0975_21190", "title": "[A CASE OF PULMONARY TUBERCULOSIS WITH PANCREATIC LESION].", "score": 0.009259259259259259, "content": "A 52-year-old woman was referred to our hospital presenting with epigastric pain and weight loss. A contrast- enhanced abdominal computed tomography (CT) scan showed a low-density mass in the body of the pancreas, indicative of a malignancy. Endoscopic ultrasound-guided fine needle aspiration of the pancreatic mass was performed three times and showed no specific findings. A distal pancreatectomy was performed, and a pathological examination revealed epitheli- oid cell granulomas and necrosis. Ziehl-Neelsen staining did not reveal acid-fast bacilli in the pancreatic mass. A diagnosis of tuberculosis or sarcoidosis of the pancreas was con- sidered; however, the patient chose to undergo a follow-up examination without therapeutic intervention because the pancreatic mass had been removed completely and she had recovered well. Four months after the operation, the patient was readmitted to our hospital for insulin therapy for pancreatic diabetes. She presented with a fever and a productive cough, and a chest CT scan showed multiple nodules in both upper lobes. A bronchoscopy was performed and bronchoalveolar lavage fluid cultures for Mycobacterium tuberculosis were positive. The patient received antitubercular quadri-therapy and showed symptomatic and radiologic improvement. At the initial examination, we had been unable to establish the correct diagnosis; however, the detection of pulmonary lesions led to the time-delayed diagnosis of pancreatic tuber- culosis. Owing to its rarity, it is difficult to diagnose pancreatic tuberculosis using clinical symptoms and radiological imaging modalities; thus, pathologic and bacteriologic confirmation is essential. To avoid performing an unnecessary laparotomy in patients with pancreatic tuberculosis, increased vigilance and an accurate diagnostic approach are required." }, { "id": "pubmed23n0864_18299", "title": "Factors Associated with Clinical and Topographical Features of Laryngeal Tuberculosis.", "score": 0.009259259259259259, "content": "Laryngeal tuberculosis (LTB) is the most frequent granulomatous disease of the larynx and represents less than 2% of extrapulmonary TB cases. There are no pathognomonic clinical and endoscopic features of this disease and studies on LTB that can assist in its diagnostic characterization are lacking. To identify factors associated with clinical and topographical features of LTB. a retrospective cross-sectional study was conducted from the medical records of 36 patients with confirmed LTB diagnosis. Dysphonia and cough were the main symptoms presented by patients and the true vocal folds the most frequently affected site. The average of the duration of the disease evolution was significantly higher in patients with dysphonia than in patients without this symptom. We observed association between dysphonia and true vocal fold lesions and between odynophagia and lesions in the epiglottis, arytenoids and aryepiglottic folds. Odynophagia was more frequent in individuals with lesions in four or more laryngeal sites. Weight loss equal or above 10% of the body weight was more frequent in patients with odynophagia as first symptom and in patients with ulcerated lesion. Dyspnea on exertion was more frequent in individuals with more extensive laryngeal lesions. The percentage of smokers with lesions in four or more laryngeal sites was greater than that found in non-smokers. Laryngeal tissue fragment bacilloscopy and culture examinations were less positive than sputum ones. Smoking appears to be associated with the development of more extensive LTB lesions, and LTB with dyspnea on exertion and odynophagia with consequent impairment of nutritional status. We emphasize the need for histopathologic confirmation, once positive sputum bacteriological examinations seem not to necessarily reflect laryngeal involvement." }, { "id": "pubmed23n0328_12083", "title": "[Radiological evidence of involvement of dust exposure in pathogenesis of pulmonary alveolar proteinosis].", "score": 0.009174311926605505, "content": "A 52-year-old man was admitted because of increasing dyspnea on exersion and presence of pulmonary infiltrates. The patient had pulmonary tuberculosis at the age of 31, which resulted in volume loss and calcified foci in the upper lobe of his left lung. As a construction worker for more than 20 years, he had been exposed to inorganic dusts. Chest radiographs showed a symmetrical consolidation of infiltrates in both lungs with the exception of the left upper lobe, where no apparent infiltrates were shown. A computed tomographic scan of the chest revealed widely panlobular consolidation with the exception of the left upper lobe. A diagnosis of pulmonary alveolar proteinosis (PAP) was established by analysis of bronchoalveolar lavage fluid. Although the patient underwent segmental bronchoalveolar lavage four times under general anesthesia, he suffered frequent pulmonary infection and died two years after the onset his symptoms. Interestingly, the patient had a markedly narrowed orifice in the left upper lobe, as demonstrated by fiberoptic bronchoscopy. Chest radiographs of this lung field revealed no infiltrative shadows. These results suggest that some inhalative agent was involved in the pathogenesis of PAP in this case. In addition, significantly increased levels of KL-6 detected in both serum and bronchoalveolar lavage fluid were attributable to overproduction of KL-6 by Type II pneumocytes that had been stimulated or damaged by PAP." }, { "id": "pubmed23n1160_1365", "title": "[Isolated laryngeal tuberculosis as an uncommon manifestation of extrapulmonary tuberculosis in adults: a case report].", "score": 0.009174311926605505, "content": "Isolated laryngeal tuberculosis is rare and sometimes difficult to diagnose. It is the most common cause of laryngeal granuloma. We here report the case of a 58-year-old man, with no particular past medical history, hospitalized due to paroxysmal laryngeal dyspnea, dysphagia to solid foods and dysphonia evolving for 6 months without other associated signs. Laryngoscopic examination showed polyploid formation masking the glottic floor. Histological examination revealed epithelioid and gigantocellular granuloma, without caseous necrosis. Direct microscopic examination and culture were negative. The diagnosis of isolated laryngeal tuberculosis was made based on the endemicity in our country and the absence of other arguments in favor of another type of granulomatosis. Anti-tuberculosis therapy, combined with oral corticosteroids, was indicated based on the presence of severe upper airway edema and symptoms were resolved after 40 days of treatment." }, { "id": "pubmed23n0707_6581", "title": "Silicotuberculosis and silicosis as occupational diseases: report of two cases.", "score": 0.00909090909090909, "content": "Silicosis, the most prevalent of the pneumoconioses, is caused by inhalation of crystalline silica particles. Silica-exposed workers are at increased risk for tuberculosis and other mycobacterium-related diseases. The risk of a patient with silicosis developing tuberculosis is higher (2.8 to 39 fold higher, depending on the severity of silicosis) than that found in healthy controls. The first patient was a 52-year-old male who was admitted in 2002 for the second time with dyspnoea, wheezing and fatigue over the last 11 years. He had worked in an iron smelting factory and was exposed to silica dust for 20 years. First hospitalization chest radiography showed bilateral pleural adhesions, diffuse lung fibrosis with signs of a specific lung process. Second hospitalization chest radiography showed bilateral massive irregular, non-homogenous calcified changes in the upper and middle parts of lungs. The patient died due to respiratory failure and chronic pulmonary heart in 2007. The main causes of his death were silicotuberculosis and chronic obstructive pulmonary disease. The second patient was a 50-year-old male who was admitted in 2005 for the second time with chest tightness, dyspnoea, wheezing and fatigue over the last 10 years. He had worked in an iron smelting factory and was exposed to silica dust for 30 years. First hospitalization chest radiography showed diffuse lung fibrosis and small nodular opacities. The patient was diagnosed with silicosis, small opacities sized level p/q, and profusion level 2/3. Second hospitalization chest radiography and CT showed diffuse lung fibrosis and small nodular opacities predominantly in the upper lobes. The patient was recognized as having an occupational disease, and received early retirement due to disability. In low-income countries, new cases of silicosis and associated lung cancer, chronic obstructive pulmonary disease and tuberculosis are likely to be seen for decades because necessary reduction of silica use will take time to be achieved." }, { "id": "pubmed23n0668_22762", "title": "[Laryngeal tuberculosis in the patients of otholaryngology department--case reports].", "score": 0.00909090909090909, "content": "Tubercular infection is still one of the most serious health and social problems. It's been estimated that one-third of the population is infected with Koch's bacillus. More than 90% of overall morbidity of tuberculosis in Poland pose pulmonary tuberculosis, in the worldwide level the percentage reaches 80. The most popular causes that spread the disease are famine, malnutrition, homelessness, limited availability to medical care, alcohol abuse, drug addiction, ageing of the society and more intensive migration. Among the cases of extrapulmonary tuberculosis the most common were certified as tuberculous empyema. Head and neck tuberculosis is diagnosed rarely nowadays. Its symptoms aren't pathognomonic and natural history of the disease is different from those described in medical books. It is essential to enclose laryngeal carcinosis in differential diagnosis. In 2002 two cases of laryngeal tuberculosis were diagnosed in the Department of Otolaryngology Head and Neck Surgery of Medical University of Wroclaw. Both patients had sustained hoarseness. Biopsy confirmed the diagnose of tuberculosis. Both patients underwent the tuberculostatic treatment. Videolaryngoscopic examination showed complete withdrawal of the infiltration in the larynx." }, { "id": "pubmed23n1150_13812", "title": "Concomitant occurrence of advanced fibrocavitary pulmonary sarcoidosis and chronic pulmonary aspergillosis.", "score": 0.009009009009009009, "content": "An African American man in his 30s presented with haemoptysis associated with chronic productive cough, exertional dyspnoea, weight loss and skin lesions. Physical examination was notable for multiple cutaneous plaques over upper extremities and face. CT chest showed bilateral upper lobes cavitations and left upper lobe mass like consolidation. Further workup revealed positive serum aspergillus IgG, respiratory culture grew <iAspergillus fumigatus</i, skin biopsy showed non-caseating granuloma. A final diagnosis of concomitant chronic pulmonary aspergillosis and advanced fibrocavitary pulmonary sarcoidosis with cutaneous involvement was made. The patient was initiated on antifungal therapy without steroids due to the concern of worsening the fungal infection. However, he presented later with worsening haemoptysis requiring bronchial artery embolisation. Surgical intervention was recommended but the patient eventually declined. The patient continued to be followed up closely in the clinic and repeated chest imaging showed stable findings 3 months after initial presentation." }, { "id": "pubmed23n0938_856", "title": "Endobronchial Tuberculosis Simulating Carcinoid Tumor.", "score": 0.009009009009009009, "content": "Diagnosing endobronchial tuberculosis (EBTB) can be difficult due to the lack of specific signs and symptoms that differentiate it from other respiratory diseases, such as lung tumors. We hereby report a case of a very rare presentation of tuberculosis (TB) in a patient who presented with a dry cough and significant weight loss for 3 months. Chest X-ray and CT scan of the chest showed partial atelectasis and a segmental collapse of the right upper lobe and tumor-like arising from its bronchus along with a large right para-tracheal mediastinal lymphadenopathy, mimicking a metastatic (N2) disease. Fiber-optic bronchoscopy revealed a fleshy, highly vascularized mass occluding the right upper lobe bronchus, and thus the initial diagnosis of carcinoid tumor was made. Mediastinoscopy and biopsy of these mediastinal lymph nodes showed caseating chronic granulomatous inflammation consistent with TB, which changed the diagnosis to EBTB. The patient was treated with first-line anti-tuberculous drugs that led to a full resolution in terms of symptoms, radiological findings and complete disappearance of the endobronchial mass by bronchoscopy. To the best of authors' knowledge, there are no other similar cases in presentation and management in the literature." }, { "id": "pubmed23n0541_18283", "title": "Disseminated sporotrichosis mimicking sarcoidosis.", "score": 0.008928571428571428, "content": "A 40-year-old Caucasian man presented to the dermatology clinic at Baylor College of Medicine, Houston, Texas, in February 2003, for the evaluation of three nonhealing ulcers. The patient's past medical history was significant for hypothyroidism and pulmonary sarcoidosis, the diagnosis of which was made in June 2000. In March 2000, the patient had complained of cough and shortness of breath. A purified protein derivative (PPD) (Mantoux text) was negative. Computed tomography (CT) scans of the chest revealed diffuse hilar and mediastinal adenopathy and bilateral interstitial and alveolar infiltrates. Although consistent with sarcoidosis, these findings were insufficient to exclude other etiologies, including disseminated fungal infection. Cultures and stains of subsequent bronchoscopy specimens failed to reveal any organisms, and histopathologic evaluation of the specimens was nondiagnostic. Based on the imaging studies and the negative cultures, a diagnosis of sarcoidosis was made, and the patient was started on therapy with prednisone. Before coming to our clinic, the patient had been on several courses of prednisone. In May 2002, the patient had presented to a private dermatologist with a 1-year history of a nonhealing 2.4 cm x 2.0 cm ulcer on the left medial forearm. Two biopsies were reported as nondiagnostic. The patient's presentation was interpreted as most consistent with Mycobacterium marinum infection, and so he was empirically treated with minocycline. This treatment was continued for almost 3 months without improvement in the ulcer. A few months after the minocycline had been discontinued, the patient was treated empirically for 2 months with ciprofloxacin. This treatment was also unsuccessful in ameliorating the ulcer. In between the two courses of antibiotics, specimens from the lesion were sent for bacterial and fungal cultures, which revealed normal skin flora. In January 2003, the patient returned to his private dermatologist with three ulcerations. In addition to the nonhealing ulcer on his left forearm, which he had acquired several months earlier, he had also developed a 3.0 cm ulcer on his right arm and a 3.0 cm ulcer on his central back. The patient refused biopsies at this visit. Given the patient's previous diagnosis of pulmonary sarcoidosis, it was thought that the skin lesions might represent ulcerative cutaneous sarcoidosis. Pyoderma gangrenosum was also considered to be a likely diagnosis. Therefore, the patient was started on a course of oral prednisone, an effective therapy for both sarcoidosis and pyoderma gangrenosum. Despite 1 month of treatment with 60 mg/day of prednisone, the ulcers increased, and the patient was subsequently referred to our clinic. Physical examination at the time of presentation revealed steroid acne on the trunk and upper extremities and three non-tender ulcers with erythematous, undermined borders (Figs 1-3). On the left arm, there was an adjacent nodule which the patient attributed to a scar from a previously healed ulcer. Histologic examination of biopsy specimens from all three sites showed similar findings. The lesion contained diffuse, suppurative, granulomatous, inflammatory infiltrates with extensive central necrosis. The infiltrates were composed of histiocytes, multinucleated foreign-body-type giant cells, plasma cells, lymphocytes, neutrophils, and neutrophil fragments. No organisms were seen in the initial, routinely stained sections. However, periodic acid-Schiff (PAS) staining demonstrated small fungal spores (Fig. 4) morphologically consistent with sporotrichosis, within the cytoplasm of multinucleated histiocytic giant cells (Fig. 5). Additional stains for bacteria and acid-fast organisms were negative. Cultures of the biopsy specimens from all three sites grew Sporothrix schenckii. Further questioning of the patient failed to reveal an obvious source of the infection. The patient denied any history of traumatic skin inoculation and did not engage in gardening or other outdoor activities that are classically associated with sporotrichosis. The patient did admit to blackberry picking on detailed retrospective questioning. Once the diagnosis of sporotrichosis was made, the patient was given 200 mg/day of itraconazole. After 2 months, the patient's ulcers were almost completely healed. The patient's pulmonary complaints were also much improved." }, { "id": "pubmed23n0292_3059", "title": "[Pulmonary and laryngeal tuberculosis. Study of 26 patients].", "score": 0.008928571428571428, "content": "A description is reported of tuberculosis cases (TBC) with symptomatic laryngeal involvement diagnosed and treated from 1982 to 1994. Twenty-six out of 2,800 (0.9%) patients diagnosed with TBC had laryngeal symptoms. Twelve patients underwent laryngeal biopsy and the disease was diagnosed in 11; the remaining 15 patients were diagnosed on the basis of the typical lesions at laryngoscopy and resolution with specific therapy; in all of them there was a pulmonary TBC associated. The mean time of clinical laryngeal symptoms was five months and the most common symptom was dysphonia. There were factors which increased the risk for TBC in 16 patients (61.5%), alcoholism being the most common symptom in 10 (38%) patients. X-Ray examination revealed bilateral infiltrates or cavitation in 81% of patients. Sputum examination for acid-fast bacilli was positive in 15 (58%) and culture for Mycobacterium tuberculosis was positive in all of them. All patients adhered correctly to the therapeutic regimen and the clinical course was towards healing: no patient had laryngeal carcinoma after one year of follow-up. The incidence of symptomatic laryngeal TBC in our environment is low and usually presents in patients with risk factors, particularly alcoholism, with a long evolution of the disease and associated with extensive pulmonary TBC. The coexistence with laryngeal carcinoma is exceptional; therefore, when the association of laryngeal symptoms and active pulmonary TBC is present it is reasonable to reserve the laryngeal biopsy for those patients with lymph node enlargement, risk factors, or when symptoms persist after a correct therapeutic regime has been instituted." }, { "id": "wiki20220301en434_24242", "title": "Bilateral hilar lymphadenopathy", "score": 0.008853891206832384, "content": "Bilateral hilar lymphadenopathy is a bilateral enlargement of the lymph nodes of pulmonary hila. It is a radiographic term for the enlargement of mediastinal lymph nodes and is most commonly identified by a chest x-ray. Causes The following are causes of BHL: Sarcoidosis Infection Tuberculosis Fungal infection Mycoplasma Intestinal Lipodystrophy (Whipple's disease) Malignancy Lymphoma Carcinoma Mediastinal tumors Inorganic dust disease Silicosis Berylliosis Extrinsic allergic alveolitis Such as bird fancier's lung Less common causes also exist: Eosinophilic granulomatosis with polyangiitis Human immunodeficiency virus Extrinsic allergic alveolitis Adult-onset Still's disease References Medical signs" }, { "id": "pubmed23n0915_19519", "title": "Tetraparesia: an unusual presentation of disseminated tuberculosis.", "score": 0.008849557522123894, "content": "A 48-year-old man with a 4 months history of asthenia, anorexia, 10 kg weight loss and 1 month of hematuria and dysuria was admitted to another hospital for sudden muscular weakness. He was found to have areflexic tetraparesis and was referred to our hospital.On admission, he was bradycardic, tachypneic, with flaccid tetraplegia. Laboratory results showed metabolic acidemia, severe hyperkalemia and hyponatremia, acute renal dysfunction and sterile pyuria. After hyperkalemia correction, the neurological symptoms resolved.On the second day, he became febrile and chest radiograph and CT images showed a pulmonary bilateral reticulomicronodular pattern, left hydronephrosis and diffuse bladder wall thickening. Disseminated tuberculosis was considered as diagnosis by the coexistence of this imagiologic alterations and sterile pyuria. Acid-fast test for <iMycobacteriumtuberculosis</i was negative, but the urine culture became positive after 2 weeks.Antituberculosis treatment was started. One year later, he was asymptomatic and the structural urinary lesions had disappeared." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 176, 261 ] ], "word_ranges": [ [ 24, 37 ] ], "text": "Parkinson's disease cannot be because they do not present apraxia as initial feature," }, "2": { "exist": true, "char_ranges": [ [ 0, 175 ] ], "word_ranges": [ [ 0, 24 ] ], "text": "As it is described as an apraxic phenomenon followed by an asymmetric rigid-akinetic parkinsonism and with superimposed myoclonias, it is typical of corticobasal degeneration." }, "3": { "exist": true, "char_ranges": [ [ 262, 325 ] ], "word_ranges": [ [ 37, 45 ] ], "text": "Alzheimer's disease does not present an asymmetric parkinsonism" }, "4": { "exist": true, "char_ranges": [ [ 330, 448 ] ], "word_ranges": [ [ 46, 68 ] ], "text": "the typical Huntinton's disease is not of so old people and when it debuts with advanced age it behaves like a chorea." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Parkinson's disease.", "2": "Corticobasal degeneration.", "3": "Alzheimer's disease.", "4": "Huntington's disease.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0300_4066", "title": "[Cortico-basal degeneration].", "score": 0.013928147146778092, "content": "Corticobasal degeneration (CBD) is not rare disease, because in our clinic 13 patients were observed for the past 8 years, with ratio to those with Parkinson's disease being 1:18. Our clinical criteria of this disease consist of the combination of 1) limb-kinetic apraxia as cortical sign, 2) akinetic-rigid sign as extrapyramidal sign, 3) their marked asymmetry, and as additional findings, 4) the presence of grasp reflex, alien hand sign, reflex myoclonus, limb dystonia, and others, and 5) neuroimagings (MRI, SPECT) suggestive of asymmetric cortical lesions. There are reports indicating that clinical CBD was diagnosed as Pick's disease, progressive supranuclear palsy and Alzheimer's disease, pathologically. Therefore, more basic investigations, especially from molecular biology are necessary to discriminate these corticobasal complex disorders." }, { "id": "wiki20220301en016_95703", "title": "Foreign accent syndrome", "score": 0.011563724678478778, "content": "The perception of a foreign accent is likely to be a case of pareidolia on the part of the listener. Nick Miller, Professor of Motor Speech Disorders at Newcastle University has explained: \"The notion that sufferers speak in a foreign language is something that is in the ear of the listener, rather than the mouth of the speaker. It is simply that the rhythm and pronunciation of speech has changed.\" Causes and diagnosis Foreign accent syndrome is more commonly pronounced in females than it is in males. In a meta-analysis of 112 patients with FAS, 97% were adults, and 67% were female. The typical age range for this disease is around 25–49 years of age. In cases where handedness was recorded, the majority of patients were right-handed. Only in 12.5% of the cases did the patients have previous exposure to the accent that they later seemed to developed due to FAS." }, { "id": "pubmed23n0798_12650", "title": "Corticobasal degeneration.", "score": 0.01115270427262166, "content": "Among the atypical parkinsonian syndromes, corticobasal degeneration (CBD) is probably the most challenging disorder to diagnose antemortem. It can present with multiple phenotypes, none of them specific enough to lead to an unequivocal diagnosis. Alternatively, multiple other neurodegenerative disorders with a different underlying pathology, such as Alzheimer disease (AD), can mimic its clinical course. The ultimate etiology of CBD is unknown; however, current neuropathological and genetic evidence support a role for microtubule-associated protein tau. The classic clinical presentation is corticobasal syndrome, which typically presents as an asymmetric parkinsonism with a variable combination of ideomotor apraxia, rigidity, myoclonus, and dystonia, often associated with the presence of an alien limb phenomenon. Recently, a new set of diagnostic criteria has been developed, but still definite diagnosis requires autopsy confirmation. At the present time, no disease modifying therapies are available, but extensive research is being conducted. " }, { "id": "pubmed23n0518_6379", "title": "[Clinical features of corticobasal degeneration].", "score": 0.011142322097378277, "content": "Corticobasal degeneration was described in 1968 by Rebeiz, Kolodny and Richardson, who characterized the disease as a syndrome of asymmetric akinesis and rigidity, dystonia of the upper limb, apraxia, myoclonus and dementia. Atrophy of the frontal and parietal lobe, neuronal loss, gliosis and achromatic neurones (and nowadays astrocytic plaques) are the characteristic pathological features of the disease. Corticobasal degeneration is a rare or a rarely recognized disease and it is frequently misdiagnosed as Parkinson's disease. According to the Lang's criteria, corticobasal degeneration can be diagnosed in the presence of rigidity and one cortical symptom (apraxia, cortical sensory loss, alien hand) or in a patient with rigidity, dystonia and focal reflex myoclonus. Exclusion criteria are early dementia (as in primary degenerative dementias), early vertical gaze problems (as in progressive supranuclear palsy), resting tremor and good, sustained therapeutic response to levodopa (as in Parkinson's disease), severe autonomic problems (as in multiple system atrophy) and any pathology on imaging studies which might explain the clinical symptoms. It should be mentioned, that recently early dementia is recognized as an initial symptom of corticobasal degeneration. The authors present a case and review the literature to call attention to this disorder." }, { "id": "wiki20220301en190_31395", "title": "Ideomotor apraxia", "score": 0.009900990099009901, "content": "of lesions are more common in nonapraxic patients. The lesions most associated with ideomotor apraxia are to the left parietal and premotor areas. Patients with lesions to the supplementary motor area have also presented with ideomotor apraxia. Lesions to the corpus callosum can also induce apraxic-like symptoms, with varying effects on the two hands, although this has not been thoroughly studied. In addition to ischemic lesions to the brain, ideomotor apraxia has also been seen in neurodegenerative disorders such as Parkinson's disease, Alzheimer's disease, Huntington's disease, corticobasal degeneration, and progressive supranuclear palsy." }, { "id": "wiki20220301en335_9357", "title": "Bias against left-handed people", "score": 0.009900990099009901, "content": "In Finnish, the word oikea means both \"right\" (okay, correct) and \"right\" (the opposite of left). In Swedish, att göra något med vänsterhanden (literally \"to do something with your left hand\") means \"to do something badly\". In Swedish, vänster means \"left\". The term vänsterprassel means \"infidelity\", \"adultery\" and \"cheating\". From this term the verb vänstra is derived. In Norwegian, the word \"keivhendt\" can be used as a way of saying \"left-handed\", but the word literally translated means \"wrong-handed\". In Hungarian, the word for right is jobb, which also means \"better\". The word for left is bal, which also means \"bad\". In Estonian, the word pahem stands for both \"left\" and \"worse\" and the word parem stands for both \"right\" and \"better\". In Turkish, the word for right is sağ, which means \"alive\". The word for left is sol, which means \"discolor\", \"die\", \"ill\"." }, { "id": "wiki20220301en068_29037", "title": "Corticobasal degeneration", "score": 0.00980392156862745, "content": "The presence of parkinsonism as a clinical symptom of CBD is largely responsible for complications in developing unique diagnostic criteria for the disease. Other such diseases in which parkinsonism forms an integral diagnostic characteristic are Parkinson's disease (PD) and progressive supranuclear palsy (PSP). Parkinsonism in CBD is largely present in an extremity such as the arm, and is always asymmetric. It has been suggested that non-dominant arm is involved more often. Common associated movement dysfunctions that comprise parkinsonism are rigidity, bradykinesia, and gait disorder, with limb rigidity forming the most typical manifestation of parkinsonism in CBD. Despite being relatively indistinct, this rigidity can lead to disturbances in gait and correlated movements. Bradykinesia in CBD occurs when there is notable slowing in the completion of certain movements in the limbs. In an associated study, it was determined that, three years following first diagnosis, 71% of" }, { "id": "wiki20220301en140_47586", "title": "Transitivity (grammar)", "score": 0.00980392156862745, "content": "Languages that express transitivity through morphology The following languages of the below language families (or hypothetical language families) have this feature: In the Uralic language family: Mordvinic languages The three Ugric languages Northern Samoyedic languages In Indo-European (Indo-Aryan) language familyː Hindi-Urdu (Hindustani) Punjabi Gujarati In the Paleosiberian hypothetical language family: Languages of both branches of the Eskimo–Aleut family; for details from the Eskimo branch, see e.g. Sireniki, Kalaallisut Chukotko-Kamchatkan languages Yukaghir The Ket language has a very sophisticated verbal inclination system, referring to the object in many ways (see also polypersonal agreement). All varieties of Melanesian Pidgin use -im or -em as a transitivity marker: laik means 'want', while laikim means 'like (him/her/it)' in Tok Pisin. All varieties of Salish. Form–function mappings" }, { "id": "pubmed23n0489_6074", "title": "Alien hand syndrome.", "score": 0.009708737864077669, "content": "In Stanley Kubrick's movie Dr Strangelove, the main character is described as \"erratic\" and displays a bizarre movement disorder. His right hand seems to be driven by a will of its own, at times clutching his own throat and at other times raising into a Nazi salute. Dr Strangelove must try to restrain this wayward limb with his left hand. Bizarre as this fictional character is, a similar movement disorder can occur in neurologic disease. The complex phenomenon associated with this disorder falls under the rubric of alien hand syndrome. This syndrome is characterized by a limb that seems to perform meaningful acts without being guided by the intention of the patient. Patients find themselves unable to stop the alien limb from reaching and grabbing objects, and they may be unable to release these grasped objects without using their other hand to pry open their fingers. These patients frequently express astonishment and frustration at the errant limb. They experience it as being controlled by an external agent and often refer to it in the third person. This article outlines the origins of the terminology used in describing this syndrome, early observations, and studies regarding its functional neuroanatomy." }, { "id": "wiki20220301en002_194550", "title": "Apraxia", "score": 0.009615384615384616, "content": "Causes Apraxia is most often due to a lesion located in the dominant (usually left) hemisphere of the brain, typically in the frontal and parietal lobes. Lesions may be due to stroke, acquired brain injuries, or neurodegenerative diseases such as Alzheimer's disease or other dementias, Parkinson's disease, or Huntington's disease. It is also possible for apraxia to be caused by lesions in other areas of the brain. Ideomotor apraxia is typically due to a decrease in blood flow to the dominant hemisphere of the brain and particularly the parietal and premotor areas. It is frequently seen in patients with corticobasal degeneration." }, { "id": "wiki20220301en357_5245", "title": "History of Belgian Limburg", "score": 0.009615384615384616, "content": "Whether or not any of the Belgian Germani, or indeed the Aduatuci, spoke a Germanic language is uncertain. The names of their leaders and their tribes for the most part appear to have Celtic origins, which is in fact also true of the neighbouring tribes across the Rhine in \"Germania\" at that time, such the Tencteri and Usipetes. On the other hand, it has been argued by Maurits Gysseling and others that placename analysis shows that a Germanic language was being spoken in this region by the 2nd century BCE, and there are also signs of an older substrate language in the Belgic region. (See Nordwestblock.) So Celtic, while influential culturally, may never have been the main language of the area." }, { "id": "pubmed23n0315_5771", "title": "Natural history and survival of 14 patients with corticobasal degeneration confirmed at postmortem examination.", "score": 0.009523809523809525, "content": "To analyse the natural history and survival of corticobasal degeneration by investigating the clinical features of 14 cases confirmed by postmortem examination. Patients with definite corticobasal degeneration were selected from the research and clinical files of seven tertiary medical centres in Austria, the United Kingdom, and the United States. Clinical features were analysed in detail. The sample consisted of eight female and six male patients; mean age at symptom onset was 63 (SD 7.7) years, and mean disease duration was 7.9 (SD 2.6) years. The most commonly reported symptom at onset included asymmetric limb clumsiness with or without rigidity (50%) or tremor (21%). At the first neurological visit, on average 3.0 (SD 1.9) years after symptom onset, the most often encountered extrapyramidal features included unilateral limb rigidity (79%) or bradykinesia (71%), postural imbalance (45%), and unilateral limb dystonia (43%). Ideomotor apraxia (64%), and to a lesser extent cortical dementia (36%), were the most common cortical signs present at the first visit. During the course of the disease, virtually all patients developed asymmetric or unilateral akinetic rigid parkinsonism and a gait disorder. No patient had a dramatic response to levodopa therapy. Median survival time after onset of symptoms was 7.9 (SD 0.7) (range, 2.5-12.5) years, and, after the first clinic visit, 4.9 (SD 0.7) (range, 0.8-10) years. Early bilateral bradykinesia, frontal syndrome, or two out of tremor, rigidity, and bradykinesia, predicted a shorter survival. The results confirm that unilateral parkinsonism unresponsive to levodopa and limb ideomotor apraxia are the clinical hallmarks of corticobasal degeneration, and only a minority of patients with corticobasal degeneration present with dementia. The study also suggests that a focal cognitive and extrapyramidal motor syndrome is indicative of corticobasal degeneration. Survival in corticobasal degeneration was shortened by the early presence of (more) widespread parkinsonian features or frontal lobe syndrome." }, { "id": "pubmed23n0046_23819", "title": "The alien hand and related signs.", "score": 0.009523809523809525, "content": "Alien limb sign includes failure to recognise ownership of one's limb when visual cues are removed, a feeling that one body part is foreign, personification of the affected body part, and autonomous activity which is perceived as outside voluntary control. Although the hand is most frequently affected, any limb or combination of limbs may fulfil the alien limb criteria. Alien hand sign should be reserved for cases in which the hand feels foreign together with observable involuntary motor activity. To characterise this phenomenon, seven patients with alien hand sign and other motor or behavioural manifestations are described. Aetiologies included multiple infarcts and cortobasal ganglionic degeneration (CBD). In this study, all patients had apraxia in response to verbal commands and problems with bimanual coordination. Most displayed non-goal directed involuntary motor activities, and two had self destructive motor behaviours. Grasp reflex occurred with alien hand due to either aetiology. Cortical reflex myoclonus was frequently seen in CBD patients. The phenomenological spectrum is reviewed, a diagnostic protocol proposed, and possible anatomical bases of alien hand discussed." }, { "id": "pubmed23n0755_21517", "title": "Progressive apraxic agraphia with micrographia presenting as corticobasal syndrome showing extensive Pittsburgh compound B uptake.", "score": 0.009433962264150943, "content": "A 65-year-old woman developed progressive apraxic agraphia, characterized by poorly formed graphemes, a kanji (Japanese morphograms) recall impairment, relatively preserved oral spelling of kanji characters, and incorrect stroke sequences on writing accompanied by micrographia over a 3-year period. She also showed minor degrees of rigidity, limb-kinetic apraxia, and ideomotor apraxia of the left hand. Although asymmetric rigidity and limb-kinetic apraxia strongly suggested corticobasal degeneration, (11)C-Pittsburgh compound B positron emission tomography (PiB-PET) showed the predominantly right-sided accumulation of amyloid β in the cortices and striatum. (18)F-fluoro-deoxy-glucose PET and single photon emission computed tomography with a (99m)Tc-ethylcysteinate dimer (ECD-SPECT) also revealed predominantly right-sided hypometabolism and hypoperfusion in the primary sensorimotor cortex, posterior cingulate gyrus, temporoparietal cortices, frontal cortices, thalamus, and basal ganglia, a pattern characteristic of both corticobasal degeneration and Alzheimer's disease. The findings suggest that progressive apraxic agraphia with micrographia presenting as corticobasal syndrome can show an Alzheimer's disease pathology. It is also suggested that ideomotor apraxia of the left hand can occur without a callosal lesion, and is caused by hypometabolism or hypoperfusion in the right frontal and parietal cortices, as revealed by PET and SPECT." }, { "id": "wiki20220301en389_18134", "title": "Finally Found You", "score": 0.009433962264150943, "content": "Lyrically, \"Finally Found You\" sees Iglesias finding the love of his life at a club and declaring to never her let go, asking his \"object of affection to ignore the advice of her friends and to stick with him till the end\". In the chorus, Enrique sings, \"In this crazy world the choice is ours, only got a few / either you’re coming with me or I’m coming with you / ’cause I finally found, I finally found you,\" with \"heavily processed vocals\", according to \"Idolator\"'s Robbie Daw. Later, Sammy Adams comes in and lets us know that he's \"got his hands full\" from grabbing girls, and informs us that he's \"drunk as fuck.\"" }, { "id": "pubmed23n0260_5609", "title": "[Corticobasal degeneration. The significance of clinical criteria for establishing the diagnosis].", "score": 0.009345794392523364, "content": "Neuropathological studies show that about 20% of all patients suffering from an acinetic-rigid syndrome can not be given the diagnosis of idiopathic Parkinson's disease. Among these non-idiopathic Parkinson-syndromes the corticobasal degeneration (CBD) can be regarded as a separate disease entity. The pathological findings of moderate predominantly frontal and parietal cerebral atrophy, cortical Pick-cells and specific corticobasal inclusion bodies are considered valuable features which support the diagnosis. The clinical Characteristics of CBD are demonstrated in 3 patients including an acinetic-rigid syndrome, limb apraxia and \"alien limb\"-syndrome, as well as reflex myoclonus. Eye movement disorders, dementia and other rare symptoms may also be present. Electrophysiological reflex-testing helps to corroborate diagnosis. These findings and a summary which includes the previously published cases of CBD show that CBD in most cases can be diagnosed intra vitam." }, { "id": "wiki20220301en058_19047", "title": "Sign of the horns", "score": 0.009345794392523364, "content": "Geezer Butler of Black Sabbath can be seen \"raising the horns\" in a photograph taken in 1969. The photograph is included in the CD booklet of the Symptom of the Universe: The Original Black Sabbath 1970–1978 compilation album. This would indicate that there had been some association between the \"horns\" and heavy metal before Dio's popularization of it. When asked if he was the one who introduced the hand gesture to metal subculture, Dio said in a 2001 interview:" }, { "id": "pubmed23n0626_14165", "title": "Corticobasal degeneration.", "score": 0.009259259259259259, "content": "Corticobasal degeneration (CBD) is a neurodegenerative disorder characterized clinically by a combination of cortical and basal ganglia signs. Pathologically, it is classified as a tauopathy. The most distinctive clinical feature is its unilateral or markedly asymmetric presentation; among parkinsonian syndromes, with rare exceptions, only Parkinson's disease presents with such asymmetry. The most common presenting cortical features include apraxia (patients often complain of a \"useless\" limb), aphasia (usually nonfluent), parietal lobe sensory signs (agraphesthesia, extinction, astereognosis), frontal dementia, or myoclonus. Basal ganglia signs include rigidity, akinesia, limb dystonia, and postural instability. The diagnosis is often challenging for three reasons: 1) The full complement of findings are rarely seen at presentation; 2) If CBD is not suspected, subtle but relevant findings (eg, extinction, language impairment, myoclonus, or apraxia) may not be searched for or appreciated; 3) The clinical picture of CBD has substantial overlap with a variety of other parkinsonian and dementing illnesses. The differential diagnosis includes Parkinson's disease, progressive supranuclear palsy, frontotemporal dementia, primary progressive aphasia, and Alzheimer's disease. The clinical diagnosis is not confirmed pathologically in up to half of cases, so the term corticobasal syndrome is often preferred during life, reserving the term corticobasal degeneration for pathologically verified cases. Treatment of CBD is primarily supportive, and most patients die within 10 years of onset. Parkinsonian signs may improve to a modest degree with levodopa, clonazepam can suppress myoclonus, and botulinum toxin can relieve dystonia. Early speech therapy, physical therapy, and occupational therapy, as well as assist devices such as a rolling walker may improve functioning and reduce complications such as aspiration pneumonia and falls. With time, however, most patients lose their independence and mobility. Throughout the course of the illness (particularly when it is advanced), caring for the caregiver is as important as caring for the patient." }, { "id": "wiki20220301en279_20781", "title": "The Fourth Kind", "score": 0.009259259259259259, "content": "After hearing the similarities in their stories, Abbey suspects these patients may have been victims of an alien abduction. There is evidence that she herself may have been abducted, when an assistant gives her a tape recorder which plays the sound of something entering her home and attacking her. The attacker speaks an unknown language, and Abbey has no memory of the incident. Abel Campos (Elias Koteas), a colleague from Anchorage, is suspicious of the claims. Later, Abbey calls upon Dr. Awolowa Odusami (Hakeem Kae-Kazim), a specialist in ancient languages who was a contact of her late husband, to identify the mysterious language on the tape. Odusami identifies it as Sumerian." }, { "id": "wiki20220301en068_29035", "title": "Corticobasal degeneration", "score": 0.009174311926605505, "content": "Motor and associated cortical dysfunctions Some of the most prevalent symptom types in people exhibiting CBD pertain to identifiable movement disorders and problems with cortical processing. These symptoms are initial indicators of the presence of the disease. Each of the associated movement complications typically appears asymmetrically and the symptoms are not observed uniformly throughout the body. For example, a person exhibiting an alien hand syndrome (explained later) in one hand, will not correspondingly display the same symptom in the other hand. Predominant movement disorders and cortical dysfunctions associated with CBD include: Parkinsonism Alien hand syndrome Apraxia (ideomotor apraxia and limb-kinetic apraxia) Aphasia" }, { "id": "wiki20220301en387_9223", "title": "Alexander Potebnja", "score": 0.009174311926605505, "content": "Potebnja viewed the history of a language as the history of its dialects and used the concept of phonetic law, although he often tried to find a psychological basis for the concept. He recognized the existence of a proto-Rus’ language, but located the beginning of its disintegration into dialects back in prehistoric times. He made many discoveries in Ukrainian historical phonetics, such as the primordial dž < dj alteration, the so-called second pleophony, and the conditions for the alternation e:o. He was the first to propose the theory that diphthongs were a transitional stage between Old Ruthenian o, e, and Little Russian (i.e. Modern Ukrainian) language." }, { "id": "pubmed23n0318_3566", "title": "[Corticobasal degeneration].", "score": 0.00909090909090909, "content": "Corticobasal degeneration (CBD) was first reported by Rebeiz et al as corticodentatonigral degeneration with neuronal achromasia in 1967. After Gibb et al described 7 cases including 4 cases from the literature under the term of corticobasal degeneration, CBD has become widely recognized. The disease starts mainly in one's fifties and sixties with the duration of 6 to 7 years. The clinical features include asymmetric parkinsonism, cerebral cortical signs, and others. Typically, patients present with unilateral clumsiness with akinetic-rigid syndrome and limb-kinetic apraxia. Postural instability, gait disturbance and involuntary movements such as dystonia are not uncommon. The parkinsonism is DOPA-resistant. BEsides apraxia, alien limb syndrome, cortical sensory disturbances, frontal lobe-release signs, and dementia are representative cortical signs. Other clinical features include dysarthria, pyramidal tract signs and supranuclear gaze palsy. MRI, SPECT or PET reveals asymmetric atrophy, decrease in blood flow or reduction in metabolism of the frontal parietal region around the central sulcus. Electrophysiological and magnetic stimulation studies demonstrated increase in excitability of the cerebral cortex. Myoclonus in CBD is cortical in origin but without any preceding potential or giant somatosensory evoked potential. Neuropathologically CBD is characterized by involvement of the particular cortices and substantia nigra. Other structures such as the putamen, pallidum, thalamus, subthalamus, cerebellar dentate nucleus and brainstem are affected to various extents. Histological features include achromatic, ballooned neurons as well as tau and Gallyas positive neuronal and glial intracytoplasmic inclusions. Astrocytic plaque is considered to be a form of glial inclusions specific to CBD. Diagnosis of typical cases of CBD appears easy but atypical cases were reported with showed dementia or aphasia as a main feature, or were devoid of the asymmetry of signs and symptoms. CBD, progressive supranuclear palsy and Pick's disease share both clinical and neuropathological features to some extent while they are clearly distinct among typical cases. The etiology and pathomechanism of CBD remain to be elucidated." }, { "id": "wiki20220301en229_33884", "title": "Gothic language", "score": 0.00909090909090909, "content": "Another such clitic is -uh \"and\", appearing as -h after a vowel: ga-h-mēlida \"and he wrote\" from gamēlida \"he wrote\", urreis nim-uh \"arise and take!\" from the imperative form nim \"take\". After iþ or any indefinite besides sums \"some\" and anþar \"another\", -uh cannot be placed; in the latter category, this is only because indefinite determiner phrases cannot move to the front of a clause. Unlike, for example, Latin -que, -uh can only join two or more main clauses. In all other cases, the word jah \"and\" is used, which can also join main clauses. More than one such clitics can occur in one word: diz-uh-þan-sat ijōs \"and then he seized them ()\" from dissat \"he seized\" (notice again the voicing of diz-), ga-u-ƕa-sēƕi \"whether he saw anything\" from gasēƕi \"he saw\"." }, { "id": "wiki20220301en001_264581", "title": "Putamen", "score": 0.009009009009009009, "content": "Parkinson's disease is the slow and steady loss of dopaminergic neurons in substantia nigra pars compacta. In Parkinson's disease the putamen plays a key role because its inputs and outputs are interconnected to the substantia nigra and the globus pallidus. In Parkinson's disease the activity in direct pathways to interior globus pallidus decreases and activity in indirect pathways to external globus pallidus increases. It has also been noted that Parkinson's patients have a difficult time with motor planning. Other diseases and disorders The following diseases and disorders are linked with the putamen: Cognitive decline in Alzheimer's disease Huntington's disease Wilson's disease Dementia with Lewy bodies Corticobasal degeneration Tourette syndrome Schizophrenia Depression Attention deficit hyperactivity disorder Chorea Obsessive-Compulsive Disorder Kernicterus Other anxiety disorders" }, { "id": "wiki20220301en190_31390", "title": "Ideomotor apraxia", "score": 0.009009009009009009, "content": "hand in the plane of his face. This gesture has no meaning attached to it. In contrast, a meaningful gesture is something like saluting or waving goodbye. An important distinction here is that all of the above refer to actions that are consciously and voluntarily initiated. That is to say that a person is specifically asked to either imitate what someone else is doing or is given verbal instructions, such as \"wave goodbye.\" People suffering from ideomotor apraxia will know what they are supposed to do, e.g. they will know to wave goodbye and what their arm and hand should do to accomplish it, but will be unable to execute the motion correctly. This voluntary type of action is distinct from spontaneous actions. Ideomotor apraxia patients may still retain the ability to perform spontaneous motions; if someone they know leaves the room, for instance, they may be able to wave goodbye to that person, despite being unable to do so at request. The ability to perform this sort of spontaneous" }, { "id": "pubmed23n0291_15756", "title": "[Corticobasal degeneration: symptomatological, brain-imaging and electrophysiological studies].", "score": 0.008928571428571428, "content": "Eight cases of clinically diagnosed corticobasal degeneration (CBD) were studied with reference to their symptomatology, brain-imagings and electrophysiological findings. The diagnosis was based on the combination of limb-kinetic apraxia (cortical sign), akinetic-rigid sign (extrapyramidal) and their unilateral predominance. Magnetic resonance imaging (MRI) and 123I-IMP or 99mTc-HMPAO SPECT findings were used to reinforce the diagnosis. The age at onset of 8 cases (4 males, 4 females) was 61 to 80 years (mean 66). Other common symptoms on admission consisted of dysequilibrium (8 cases), dysarthria (8), grasp reflex (6), supranuclear gaze palsy (6), tremor (6), limb dystonia (6) and alien limbs (5). MRI revealed parietal (3 cases) or frontoparietal (3) atrophy. SPECT showed decrease in cerebral blood flow in frontoparietal (3 cases) or frontoparietotemporal lobes (5). SPECT surpassed MRI to detect unilateral predominance of the lesions. With magnetic stimulation of the head and neck central motor conduction time (CMCT) was normal, while motor inhibitory periods (IPs) were significantly shorter in CBD patients compared with those in normal controls and the patients with Parkinson's disease. In 3 patients with reflex myoclonus, giant SEPs were not evoked, though with positive C-reflex, suggesting an elevated excitability of cerebral cortex unrelated to the production of giant SEPs." }, { "id": "wiki20220301en348_34584", "title": "List of common false etymologies of English words", "score": 0.008928571428571428, "content": "Fuck: The word \"fuck\" did not originate as an acronym of \"For Unlawful Carnal Knowledge\", either as a sign posted above adulterers in the stocks, or as a criminal charge against members of the British Armed Forces; nor did it originate during the 15th-century Battle of Agincourt as a corruption of \"pluck yew\" (an idiom falsely attributed to the English for drawing a longbow). The word did not originate in Christianized Anglo-Saxon England as an acronym of \"Fornication Under Consent of King\"; Modern English was not spoken until the 16th century, and words such as \"fornication\" and \"consent\" did not exist in any form in English until the influence of Anglo-Norman in the late 12th century. The earliest recorded use of \"fuck\" in English comes from 1475, in the poem Flen flyys, where it is spelled fuccant (conjugated as if a Latin verb meaning \"they fuck\"). The word derived from Proto-Germanic roots, and has cognates in many other Germanic languages." }, { "id": "pubmed23n0317_17247", "title": "[An 81-year-old woman with progressive motor disturbance, extrapyramidal features, dementia, and oculomotor palsy].", "score": 0.008849557522123894, "content": "We report an 81-year-old woman who presented with motor disturbance in her right hand which was followed by parkinsonism, dementia, and supranuclear gaze palsy. She was well until her age of 73 (1989) when she had an onset of difficulty in using her right hand; she did not have weakness. She also developed small step gait. These symptoms had progressively become worse. She was admitted to our hospital in July of 1992 when she was 75 years old. On admission, she was alert and oriented, but she showed some difficulty in recent memory. She did not have aphasia or ideomotor apraxia, but she showed limb-kinetic apraxia in her right hand, ideational apraxia, dressing apraxia, constructional apraxia, tactile agnosia, and left-right disorientation. Alien-hand syndrome was observed in her right hand. Ocular movement was within normal limit for her age. She had oro-lingual dyskinesia. Otherwise, cranial nerves were intact. She walked in small-steps. She had rigidity and fine myoclonic movements in her right upper extremity. Deep reflexes were within normal limits and symmetric. Superficial and deep sensations were intact. Laboratory findings were unremarkable. She was discharged on August 15, 1992 for outpatient follow-up. Her motor and mental symptoms were progressive. By October of 1992, she developed supranuclear vertical gaze palsy, marked rigidity in the neck, and astereognosis. By June 1993, she became unable to walk without support. MRI taken in May of 1994 revealed atrophy of insular cortices, temporal lobe tips and parietal lobes more on the left side; the third ventricle was slightly dilated. She was admitted to another hospital on June 30, 1994. She had become a bed-ridden state with marked dementia and dysphagia. She developed fever on November 5, 1996 and expired on December 16 of the same year. She was discussed in a neurological CPC and the chief discussant arrived at the conclusion that the patient had corticobasal degeneration. Other diagnoses entertained included progressive supranuclear palsy, pallidonigroluysian atrophy, diffuse Lewy body disease, and Pick's disease. But the most of the participants agreed with the chief discussant's diagnosis. Post-mortem examination revealed aspiration pneumonia in the lungs and liver fibrosis apparently due to viral hepatitis. In the central nervous system, frontal and parietal lobes were atrophic more on the left side. Atrophy was accentuated in the superior frontal gyri, precentral and postcentral gyri, and superior and inferior parietal lobuli. Neuronal loss and astrocytosis were seen in these regions with scattered ballooned neurons. The substantia nigra showed marked neuronal loss and gliosis; neuronal loss was also seen in the pars reticulata. The outer and inner segments of globus pallidus and the periacqueductal gray matter showed gliosis, however, no apparent neuronal loss was seen. Putamen, subthalamic nucleus, and the dentate nucleus were preserved. Pathologic changes were consistent with the diagnosis of corticobasal degeneration. It was interesting to note that anti-tau immunostaining and Gallyas staining revealed neuropil threads and astrocytic plaques in the cortical areas, and intracytoplasmic inclusion bodies in the cortical neurons; these inclusions were not stained by Bodian stain. Tuft-shaped astrocytes which may be seen in progressive supranuclear palsy were not observed in this patient. Although corticobasal degeneration and progressive supranuclear palsy share some neurological features in common, this patient showed typical pathologic changes of corticobasal degeneration." }, { "id": "wiki20220301en012_138219", "title": "Alien hand syndrome", "score": 0.008849557522123894, "content": "The alien limb in the posterior variant of the syndrome may be seen to \"levitate\" upward into the air withdrawing away from contact surfaces through the activation of anti-gravity musculature. Alien hand movement in the posterior variant may show a typical posture, sometimes referred to as a \"parietal hand\" or the \"instinctive avoidance reaction\" (a term introduced by neurologist Derek Denny-Brown as an inverse form of the \"magnetic apraxia\" seen in the frontal variant, as noted above), in which the digits move into a highly extended position with active extension of the interphalangeal joints of the digits and hyper-extension of the metacarpophalangeal joints, and the palmar surface of the hand is actively pulled back away from approaching objects or up and away from supporting surfaces. The \"alien\" movements, however, remain purposeful and goal-directed, a point which clearly differentiates these movements from other disorganized non-purposeful forms of involuntary limb movement" }, { "id": "wiki20220301en550_25210", "title": "Frontal Assessment Battery", "score": 0.008771929824561403, "content": "The Frontal Assessment Battery (FAB), is a short screening test to evaluate executive function (EF). Format FAB is a battery of tests, consisting of six subtests, that takes about 10 minutes and is designed as a short bedside assessment of executive function. Applications FAB is useful in the differential diagnosis of neurological diseases including Parkinson's disease, corticobasal degeneration, frontotemporal dementias, Alzheimer's disease, Huntington's disease, progressive supranuclear palsy, and dementia with Lewy bodies. Development FAB was developed by Dubois et al. in 2000 and became a widely used tool. References Mental disorders diagnostic procedures Neuropsychological tests Medical scoring system Parkinson's disease Cognitive disorders Dementia" }, { "id": "wiki20220301en376_16194", "title": "Ukrainian Sign Language", "score": 0.008771929824561403, "content": "Fingerspelling Ukrainian Sign Language uses a one-handed manual alphabet, or fingerspelling, based on the alphabet used in Old French Sign Language, but adapted to spell out words from the Ukrainian language. Known as the Ukrainian manual alphabet, it consists of 33 signs which make use of the 23 handshapes of USL. Some of these signs thus share handshapes; for example, the signs for Г & Ґ use the same handshape but in one the thumb is still, while in the other it moves up and down. In USL as in other sign languages, fingerspelling serves as a type of borrowing from Ukrainian. It is used for proper nouns, for technical terms with no native USL equivalent, abbreviations of longer Ukrainian words, and some colloquial Ukrainian words. Fingerspelling may also be used instead of a synonymous sign for emphasis. A common misconception is that USL consists only of fingerspelling. Although communication using only fingerspelling has been used, it is not USL." }, { "id": "pubmed23n0751_459", "title": "Evidence of delayed nigrostriatal dysfunction in corticobasal syndrome: a SPECT follow-up study.", "score": 0.008695652173913044, "content": "To demonstrate that degeneration of substantia nigra neurons may occur at later stages of disease in some patients with corticobasal syndrome (CBS) who evidenced preserved nigrostriatal pathway at a baseline FP-CIT SPECT study. Current pathological criteria for the definite diagnosis of corticobasal degeneration consider substantia nigra cell loss as a mandatory finding. However, dopamine transporter SPECT imaging performed in a large cohort of CBS patients showed about 10% of normal scans. We describe 4 patients with clinical diagnosis of CBS and normal FP-CIT SPECT at baseline whose tracer uptake resulted pathological at 1-year follow-up scan. Clinical assessment has been performed at the time of SPECT scan. A semi-quantitative approach was performed for striatal FP-CIT binding values. Baseline SPECT scans have been performed after 2.3 ± 1.5 years from onset. All CBS patients presented asymmetric rigid-akinetic parkinsonism (mean Hoehn-Yahr stage 2.5; UPDRS motor score 18) with poor levodopa response and ideo-motor limb apraxia. At follow-up, neurological examination revealed some additional features, including limb dystonia, language impairment, postural instability, ocular gaze impairment, alien limb. All patients showed pathological FP-CIT uptake at the SPECT performed 10-15 months apart from the baseline scan. Our longitudinal FP-CIT SPECT findings support in vivo the hypothesis that substantia nigra neuronal loss may occur at later stages in some patients with CBS, despite early extrapyramidal symptoms." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 25, 88 ] ], "word_ranges": [ [ 5, 17 ] ], "text": "The normal range of stool output in young infants is very wide." }, "5": { "exist": true, "char_ranges": [ [ 89, 277 ] ], "word_ranges": [ [ 17, 45 ] ], "text": "To suspect aganglionic megacolon there is usually a delay in the evacuation of meconium and often other associated symptoms such as abdominal distension, difficulty in gaining weight, etc." } }

{ "1": "Start laxative treatment.", "2": "Supplement breastfeeding with anti-constipation formula.", "3": "Start daily rectal stimulation.", "4": "It is considered normal intestinal rhythm.", "5": "Refer to Pediatric Digestive to rule out aganglionic megacolon." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0276_17528", "title": "Management of chronic constipation in infants and toddlers.", "score": 0.015898050596176896, "content": "Infants and toddlers with constipation usually have a history of infrequent, hard and painful bowel movements, often accompanied by screaming and stool-holding maneuvers. Encopresis, the intermittent and involuntary passage of formed-to-liquid feces, is common. Although constipation most often has a functional cause, the history and physical examination should rule out anatomic, endocrinologic, metabolic or neurologic causes. Hirschsprung's disease--aganglionic megacolon--is a congenital cause of severe constipation that occurs in one of every 5,000 births. Treatment consists of fecal disimpaction, laxatives to prevent future impaction, promotion of regular bowel habits and, finally, toilet training. Parents should be reassured that although this disorder is not life-threatening, several months to years of supportive intervention may be required for effective treatment." }, { "id": "pubmed23n0923_5158", "title": "Safety of a New Synbiotic Starter Formula.", "score": 0.015560966918097049, "content": "Breastfeeding is the best way to feed all infants, but not all infants can be (exclusively) breastfed. Cow's milk based infant formula is the second choice infant feeding. The safety of a new synbiotic infant formula, supplemented with <iBifidobacterium lactis</i and fructo-oligosaccharides, with lactose and a whey/casein 60/40 protein ratio was tested in 280 infants during 3 months. The median age of the infants at inclusion was 0.89 months. Weight evolution was in accordance with the World Health Organization growth charts for exclusive breastfed infants. The evolution of all anthropometric parameters (weight-for-length z score and body mass index-for-age z score) was within the normal range. The incidence of functional constipation (3.2%), daily regurgitation (10.9%), infantile crying and colic (10.5%) were all significantly lower than the reported median prevalence for a similar age according to literature (median value of 7.8% for functional constipation, 26.7% for regurgitation, 17.7% for infantile colic). The new synbiotic infant starter formula was safe, resulted in normal growth and was well tolerated. Functional gastro-intestinal manifestations (functional constipation, regurgitation and colic) were significantly lower than reported in literature. Synbiotics (<iBifidobacterium lactis</i and fructo-oligosaccharides) in cow's milk based infant formula bring the second choice infant feeding, formula, closer to the golden standard, exclusive breastfeeding." }, { "id": "pubmed23n0828_2312", "title": "Defecation patterns of the infants mainly breastfed from birth till the 12th month: Prospective cohort study.", "score": 0.015463620102706134, "content": "Studies about defecation patterns have been mostly conducted on infants who were breastfed in a short term but were fed predominantly with formula. In this study, defecation patterns of 125 infants, most of them being breastfed during 12th month were evaluated. Frequency, consistency and color of the stool were analyzed in relation to the feeding pattern at the 15th day and at the 1st, 2nd, 3rd, 4th, 5th, 6th and 12th months. Frequency of defecation was highest in 15th day with a median of 6/day. It decreased with age (p=0.0001), being 4/day and 3/day in 1st and 2nd months respectively, and 2/day between 3rd-12th months. During first 5 months, the stool frequency was higher in infants who were exclusively breastfed compared to those being fed with breastfed and formula (p&lt;0.05). The effect of the feeding pattern on stool frequency disappeared in the following months (p&gt;0.05). Stool frequency decreased by half at the 2nd month when the rate of less than once/day attained its highest value (24.8%). In those who had a rate of less than once/day, stool frequency stayed low until the 6th month and exclusively breastfed rate was also found lower (p&lt;0.05). Besides the age, exclusive breastfeeding was also effective on stool frequency. It points out that infants who are fed with formula in addition to breastfeeding may defecate less than once per day hence should not be diagnosed as having constipation depending solely on defecation frequency and should not receive unneccesary treatments." }, { "id": "wiki20220301en077_29367", "title": "Bristol stool scale", "score": 0.014999442399910783, "content": "Types 1 and 2 indicate constipation, with 3 and 4 being the ideal stools as they are easy to defecate while not containing excess liquid, 5 indicating lack of dietary fiber, and 6 and 7 indicate diarrhoea. In the initial study, in the population examined in this scale, the type 1 and 2 stools were more prevalent in females, while the type 5 and 6 stools were more prevalent in males; furthermore, 80% of subjects who reported rectal tenesmus (sensation of incomplete defecation) had type 7. These and other data have allowed the scale to be validated. The Bristol stool scale is also very sensitive to changes in intestinal transit time caused by medications, such as antidiarrhoeal loperamide, senna, or anthraquinone with laxative effect. Uses Diagnosis of irritable bowel syndrome" }, { "id": "wiki20220301en009_97060", "title": "Laxative", "score": 0.013401043870785724, "content": "Laxatives, purgatives, or aperients are substances that loosen stools and increase bowel movements. They are used to treat and prevent constipation. Laxatives vary as to how they work and the side effects they may have. Certain stimulant, lubricant and saline laxatives are used to evacuate the colon for rectal and bowel examinations, and may be supplemented by enemas under certain circumstances. Sufficiently high doses of laxatives may cause diarrhea. Some laxatives combine more than one active ingredient. Laxatives may be administered orally or rectally. Types Bulk-forming agents Bulk-forming laxatives, also known as roughage, are substances, such as fiber in food and hydrophilic agents in over-the-counter drugs, that add bulk and water to stools so that they can pass more easily through the intestines (lower part of the digestive tract)." }, { "id": "wiki20220301en531_26054", "title": "Constipation in children", "score": 0.01232741617357002, "content": "Constipation in children refers to the medical condition of constipation in children. It is a functional gastrointestinal disorder. Presentation Children have different bowel movement patterns than adults. In addition, there is a wide spectrum of normalcy when considering children’s bowel habits. On average, infants have 3-4 bowel movements/day, and toddlers have 2-3 bowel movements per day. At around age 4, children develop an adult-like pattern of bowel movements (1-2 stools/day). Children benefit from scheduled toilet breaks, once early in the morning and 30 minutes after meals. The Rome III Criteria for constipation in children helps to define constipation for various age groups. Causes" }, { "id": "article-19913_40", "title": "Constipation -- Treatment / Management", "score": 0.011974557522123893, "content": "Laxatives represent first-line treatment for childhood constipation; if an adequate regimen is implemented, they often have a symptomatic improvement. Consensus guidelines recommend daily polyethylene glycol (PEG) of 1 to 1.5 g/kg per day for 3 to 6 days for initial fecal disimpaction, followed by a daily maintenance dose of 0.4 g/kg per day for at least 2 months to prevent reaccumulation. A stimulant laxative should be added if PEG alone does not cause disimpaction after 2 weeks of treatment. Other pharmacological agents used for treating constipation include the following: Bulk-forming agents (fiber) Emollient stool softeners Rapidly acting lubricants Prokinetics Laxatives Prosecretory drugs Osmotic agents" }, { "id": "wiki20220301en009_97043", "title": "Constipation", "score": 0.011511072090527753, "content": "The pelvic floor muscles play an important role in helping pass a bowel movement. Injury to those muscles by some of the above risk factors (examples- delivering a large child, lengthy second stage of labor, forceps delivery) can result in constipation. Enemas may be administered during labor and these can also alter bowel movements in the days after giving birth. However, there is insufficient evidence to make conclusions about the effectiveness and safety of laxatives in this group of people. See also Obstructed defecation Rectal tenesmus References External links Constipation - Introduction (UK NHS site) Constipation Guideline - the World Gastroenterology Organisation (WGO) Conditions diagnosed by stool test Digestive disease symptoms Diseases of intestines Nursing diagnoses Waterborne diseases Wikipedia medicine articles ready to translate Wikipedia emergency medicine articles ready to translate" }, { "id": "Pediatrics_Nelson_296", "title": "Pediatrics_Nelson", "score": 0.010590858416945374, "content": "When disimpaction is achieved, the child begins the maintenance phase of treatment. This phase promotes regular stool production and prevents reimpaction. It involves attention to diet, medications to promote stool regularity, and behavioral training. Increasing dietary fiber and fluid are recommended. For children with chronic constipation, the recommended daily dose of fiber is calculated as 10 grams plus the child’s age in years (e.g., a 10-year-old should take 20 grams of fiber per day). At least 2 oz of nondairy fluid intake per gram of fiber intake is recommended. Sorbitol-based juices, including prune, pear, and apple juice, increase the water content of bowel movements. Lubricants or osmotic laxatives are used to promote regular soft bowel movements. Maintenance medications, including side effects, are listed in Table 14-3. Polyethylene glycol powder is well tolerated because the taste and texture are palatable. Some children may require the use of a lubricant in addition to" }, { "id": "InternalMed_Harrison_3170", "title": "InternalMed_Harrison", "score": 0.010569105691056912, "content": "After the cause of constipation is characterized, a treatment decision can be made. Slow-transit constipation requires aggressive medical or surgical treatment; anismus or pelvic floor dysfunction usually responds to biofeedback management (Fig. 40-4). The remaining ∼60% of patients with constipation has normal colonic transit and can be treated symptomatically. Patients with spinal cord injuries or other neurologic disorders require a dedicated bowel regimen that often includes rectal stimulation, enema therapy, and carefully timed laxative therapy. Patients with constipation are treated with bulk, osmotic, pro- kinetic, secretory, and stimulant laxatives including fiber, psyllium, milk of magnesia, lactulose, polyethylene glycol (colonic lavage" }, { "id": "article-19913_51", "title": "Constipation -- Pearls and Other Issues", "score": 0.010517498138495904, "content": "Pediatric Rome IV criteria are met when at least 2 of the following are present for at least 1 month in infants and children up to 4 years. For children older than 4 years of age, symptoms should last for at least 2 months: Fewer than 3 spontaneous bowel movements per week At least 1 episode of fecal incontinence per week after the child has acquired complete bowel control History of extensive fecal retention or withholding behavior by the child Hard and painful stools Large fecal mass on digital rectal examination Large diameter of stools causing rectal outlet obstruction or that obstruct the toilet [39]" }, { "id": "pubmed23n0831_7699", "title": "CON-COUR study: Interferential therapy in the treatment of chronic constipation in adults: study protocol for a randomized controlled trial.", "score": 0.010173748142073703, "content": "The prevalence of chronic constipation is about 15 % in Western countries with a significant impact on quality of life and health care costs. The first-line therapy, based on medical treatment combined with laxatives and dietary rules, is often disappointing. Interferential therapy is a new treatment that has demonstrated its efficiency in the treatment of chronic constipation in children and encouraging results in adults. The primary objective of this study is to assess the efficacy of interferential therapy during 8 weeks in adult patients. The secondary objectives are to assess this new and noninvasive therapy in terms of persistence of the clinical efficacy, colonic transit time, ano-rectal manometry, patient satisfaction and quality of life (QoL), and tolerance. multicenter, prospective, randomized, placebo-controlled, double blind, two-parallel groups study. nine French adult gastroenterology centers. adult patients with a history of chronic constipation refractory to medical treatment for at least 3 months. Treatment groups: (1) interferential-experimental group (effective stimulation); (2) placebo-control group (sham stimulation). 1:1 allocation ratio. Evaluation times: inclusion (T0, randomization), baseline assessment (T1), start of stimulation (T2), intermediary assessment (T3, 4 weeks), end of stimulation (T4, 8 weeks), follow-up (T5 and T6, 1- and 6-month). (1) primary: short-term efficacy at T4 (treatment response defined as three or more spontaneous, complete bowel movements per week); (2) secondary: efficacy at T5 and T6, symptoms (Patient Assessment of Constipation Symptoms questionnaire), colonic transit time, anorectal manometry, patient satisfaction (analogical visual scale), patient QoL (Patient Assessment of Constipation Quality of Life Questionnaire), side/unexpected effects. 200 individuals to obtain 80 % power to detect a 20 % difference in treatment response at T4 between the two groups (15 % of lost to follow-up patients expected). The randomized, double-blind, placebo-controlled design is the most appropriate to demonstrate the efficacy of a new experimental therapeutic (Evidence-Based Medicine Working Group classification). National and international recommendations could be updated based on the findings of this study. Current controlled trials NCT02381665 (registration date: February 13, 2015)." }, { "id": "wiki20220301en009_97032", "title": "Constipation", "score": 0.009950859950859951, "content": "Criteria The Rome III Criteria for functional constipation must include two or more of the following and present for the past three months, with symptoms starting for at least 6 months prior to diagnosis. Straining during defecation for at least 25% of bowel movements Lumpy or hard stools in at least 25% of defecations Sensation of incomplete evacuation for at least 25% of defecations Sensation of anorectal obstruction/blockage for at least 25% of defecations Manual maneuvers to facilitate at least 25% of defecations Fewer than 3 defecations per week Loose stools are rarely present without the use of laxatives There are insufficient criteria for irritable bowel syndrome Prevention Constipation is usually easier to prevent than to treat. Following the relief of constipation, maintenance with adequate exercise, fluid intake, and high-fiber diet is recommended. Treatment A limited number of cases require urgent medical intervention or will result in severe consequences." }, { "id": "pubmed23n0684_15377", "title": "Successful relactation--a case history.", "score": 0.009900990099009901, "content": "A healthy, term male infant was weaned at 10 days postpartum because of his mother's illness. The baby was breastfed by his mother's sister, but mostly he was fed with his aunt's expressed milk and with formula by bottle. At 9 weeks postpartum relactation began. Techniques used were a supplemental nursing support system device; frequent suckle at the breast, supplemented by formula given by bottle; breast pumping; domperidone; and support from an International Board Certified Lactation Consultant and family. Problems that appeared during relactation were that at 12 postpartum weeks the baby refused the supplemental nursing system device, and at 12 weeks and 3 days he refused the breast; after 3 weeks of relactation, the milk supply was still low, needing supplementation; and in the first week of exclusive breastfeeding, the baby stopped growing, then he gained weight slowly, and his gain fell down to the 15(th) percentile. Solutions and interventions used to solve the problems were usage of an artificial nipple during breast strike for 3 days and cessation of supplementary formula and frequent suckling at the breast. Four days after relactation started, colostrum appeared (for 2 weeks), and within 1 month from the beginning of relactation the baby was fully breastfed. He was exclusively breastfed until 7 months, and he was continually breastfed until 2 years. His growth was good and was around the 50th percentile on the weight/length curve. Thus relactation is possible at 9 weeks postpartum, if the mother's motivation to breastfeed is strong. The best technique to increase milk supply is frequent, short breastfeedings." }, { "id": "pubmed23n0094_5582", "title": "[Constipation--a new approach].", "score": 0.009900990099009901, "content": "Chronic idiopathic constipation is defined as the emission of less than 3 stools per week. Beside signs evoking a severe form (Hirschsprung's disease, idiopathic megacolon), a treatment with bran, at a dose of 20 grams per day, is instituted right away, which cures almost 60% of the patients (constipation secondary to dietetic errors). If this is not the case, the study of the colonic transit time of markers, anorectal manometry, defecation radiographs, enables to recognize various etiological forms (colonic inertia, irritable colon, anism, descending perineum, etc...) which require a specific treatment." }, { "id": "pubmed23n0960_15945", "title": "PROPOSALS TO APPROXIMATE THE PEDIATRIC ROME CONSTIPATION CRITERIA TO EVERYDAY PRACTICE.", "score": 0.00980392156862745, "content": "Acceptance of the prevailing pediatric Rome constipation criteria, by primary care physician, is still low. Even for research purposes they have not been universally adopted. Thus, it has been indicated that some re-evaluation of these criteria would be welcome. The authors aimed to look at the timing of diagnosis and the dietary treatment recommendations in the criteria, to make proposals trying to approximate them to everyday practice. The literature cited in the Rome criteria was reviewed and the publications pertinent to the subject, searched by Medline up to January 2018, were included. An early diagnosis is fundamental to avoid evolution to bothersome complications and possibly to 'intractable' constipation, but the inclusion of two items of the criteria might hamper it. Thus, one constipation sign/symptom should suffice, usually the easily observable 'painful or hard bowel movements'. Details about dietary fiber recommendations are missing in the criteria, although its increase is usually the first approach in primary care, and overall the data about dietary fiber supplements point to beneficial effects. For diagnosis and treatment of pediatric constipation in primary care, one constipation sign/symptom should suffice. The recommended daily dietary fiber intake, according to the American Health Foundation, should be detailed as a treatment measure, and also for prevention, from weaning on." }, { "id": "wiki20220301en009_97041", "title": "Constipation", "score": 0.009750208933048565, "content": "Since the 1700s in the West there has been some popular thought that people with constipation have some moral failing with gluttony or laziness. Special populations Children Approximately 3% of children have constipation, with girls and boys being equally affected. With constipation accounting for approximately 5% of general pediatrician visits and 25% of pediatric gastroenterologist visits, the symptom carries a significant financial impact upon the healthcare system. While it is difficult to assess an exact age at which constipation most commonly arises, children frequently suffer from constipation in conjunction with life-changes. Examples include: toilet training, starting or transferring to a new school, and changes in diet. Especially in infants, changes in formula or transitioning from breast milk to formula can cause constipation. The majority of constipation cases are not tied to a medical disease, and treatment can be focused on simply relieving the symptoms." }, { "id": "pubmed23n0512_3787", "title": "Outbreak of life-threatening thiamine deficiency in infants in Israel caused by a defective soy-based formula.", "score": 0.009708737864077669, "content": "Between October and November 2003, several infants with encephalopathy were hospitalized in pediatric intensive care units in Israel. Two died of cardiomyopathy. Analysis of the accumulated data showed that all had been fed the same brand of soy-based formula (Remedia Super Soya 1), specifically manufactured for the Israeli market. The source was identified on November 6, 2003, when a 5.5-month-old infant was admitted to Sourasky Medical Center with upbeat nystagmus, ophthalmoplegia, and vomiting. Wernicke's encephalopathy was suspected, and treatment with supplementary thiamine was started. His condition improved within hours. Detailed history revealed that the infant was being fed the same formula, raising suspicions that it was deficient in thiamine. The formula was tested by the Israeli public health authorities, and the thiamine level was found to be undetectable (&lt;0.5 microg/g). The product was pulled from the shelves, and the public was alerted. Thiamine deficiency in infants is very rare in developed countries. The aim of this study was to report the epidemiology of the outbreak and to describe the diagnosis, clinical course, and outcome of 9 affected infants in our care. After the index case, an additional 8 infants were identified in our centers by medical history, physical examination, and laboratory testing. The group consisted of 6 male and 3 female infants aged 2 to 12 months. All were assessed with the erythrocyte transketolase activity assay, wherein the extent of thiamine deficiency is expressed in percentage stimulation compared with baseline (thiamine pyrophosphate effect [TPPE]). Normal values range from 0% to 15%; a value of 15% to 25% indicates thiamine deficiency, and &gt;25% indicates severe deficiency. Blood lactate levels (normal: 0.5-2 mmol/L) were measured in 6 infants, cerebrospinal fluid lactate in 2 (normal: 0.5-2 mmol/L), and blood pyruvate in 4 (normal: 0.03-0.08 mmol/L). The diagnostic criteria for thiamine deficiency were abnormal transketolase activity and/or unexplained lactic acidosis. Treatment consisted of intramuscular thiamine 50 mg/day for 14 days combined with a switch to another infant formula. Early symptoms were nonspecific and included mainly vomiting (n = 8), lethargy (n = 7), irritability (n = 5), abdominal distension (n = 4), diarrhea (n = 4), respiratory symptoms (n = 4), developmental delay (n = 3), and failure to thrive (n = 2). Infection was found in all cases. Six infants were admitted with fever. One patient had clinical dysentery and group C Salmonella sepsis; the others had mild infection: acute gastroenteritis (n = 2); upper respiratory infection (n = 2); and bronchopneumonia, acute bronchitis, and viral infection (n = 1 each). Two infants were treated with antibiotics. Three infants had neurologic symptoms of ophthalmoplegia with bilateral abduction deficit with or without upbeat nystagmus. All 3 had blood lactic acidosis, and 2 had high cerebrospinal fluid lactate levels. Patient 1, our index case, was hospitalized for upbeat nystagmus and ophthalmoplegia, in addition to daily vomiting episodes since 4 months of age and weight loss of 0.5 kg. Findings on brain computed tomography were normal. Blood lactate levels were high, and TPPE was 37.8%. Brain magnetic resonance imaging (MRI) revealed no abnormalities. Patient 2, who presented at 5 months with lethargy, vomiting, grunting, and abdominal tenderness, was found to have intussusception on abdominal ultrasound and underwent 2 attempts at reduction with air enema several hours apart. However, the lethargy failed to resolve and ophthalmoplegia appeared the next day, leading to suspicions of Wernicke's encephalopathy. Laboratory tests showed severe thiamine deficiency (TPPE 31.2%). In patients 1 and 2, treatment led to complete resolution of symptoms. The third infant, a 5-month-old girl, was admitted on October 10, 2003, well before the outbreak was recognized, with vomiting, fever, and ophthalmoplegia. Her condition deteriorated to seizures, apnea, and coma. Brain MRI showed a bilateral symmetrical hyperintense signal in the basal ganglia, mamillary bodies, and periaqueductal gray matter. Suspecting a metabolic disease, vitamins were added to the intravenous solution, including thiamine 250 mg twice a day. Clinical improvement was noted 1 day later. TPPE assay performed after treatment with thiamine was started was still abnormal (17.6%). Her formula was substituted after 4 weeks, after the announcement about the thiamine deficiency. Although the MRI findings improved 5 weeks later, the infant had sequelae of ophthalmoplegia and motor abnormalities and is currently receiving physiotherapy. All 3 patients with neurologic manifestations were fed exclusively with the soy-based formula for 2 to 3.5 months, whereas the others had received solid food supplements. Longer administration of the formula (ie, chronic thiamine deficiency) was associated with failure to thrive. For example, one 12-month-old girl who received the defective formula for 8 months presented with refusal to eat, vomiting, failure to thrive (75th to &lt;5th percentile), hypotonia, weakness, and motor delay. Extensive workup was negative for malabsorption and immunodeficiency. On admission, the patient had Salmonella gastroenteritis and sepsis and was treated with antibiotics. After thiamine deficiency was diagnosed, she received large doses of thiamine (50 mg/day) for 2 weeks. Like the other 5 infants without neurologic involvement, her clinical signs and symptoms disappeared completely within 2 to 3 weeks of treatment, and TPPE levels normalized within 1 to 7 days. There were no side effects. As part of its investigation, the Israel Ministry of Health screened 156 infants who were fed the soy-based formula for thiamine deficiency. However, by that time, most were already being fed alternative formulas and had begun oral thiamine treatment. Abnormal TPPE results (&gt;15%) were noted in 8 infants, 3 male and 5 female, all &gt;1 year old, who were receiving solid food supplements. Although their parents failed to notice any symptoms, irritability, lethargy, vomiting, anorexia, failure to thrive, and developmental delay were documented by the examining physicians. None had signs of neurologic involvement. Treatment consisted of oral thiamine supplements for 2 weeks. Clinician awareness of the possibility of thiamine deficiency even in well-nourished infants is important for early recognition and prevention of irreversible brain damage. Therapy with large doses of thiamine should be initiated at the earliest suspicion of vitamin depletion, even before laboratory evidence is available and before neurologic or cardiologic symptoms appear." }, { "id": "pubmed23n0857_25045", "title": "[Treatment of Chronic Functional Constipation during Pregnancy and Lactation].", "score": 0.009708737864077669, "content": "Natural fibres (bulk-forming agents), docusate sodium (stool-softener), mineral oils (lubricant laxatives), macrogol (polyethylene glycol, PEG), sugars and sugar alcohols (osmotic laxatives) and anthraquinones and diphenolic laxatives (stimulant laxatives) seem to be safe medicaments regarding teratogenicity and lactation. The US Food and Drug Administration (FDA) risk categories for these substances taken during pregnancy and lactation are often the result of the lack of studies than of evidence-based information. So risk categories do not help in the decision-making for the right laxative. Alternative solutions such as proposals of the American College of Gastroenterology's Committee on FDA related matters, (ACG-FDA) and the Motherisk Programme try to improve decision-making. For newer compounds such as chloride-channel-activators and procinetics no data regarding safe use in pregnancy and during breast-feeding are available as yet. We suggest the use of macrogol and lactulose as the first-line therapy in treating chronic constipation during pregnancy. Macrogol shows some advantages, such as faster onset of bowel action and fewer flatulences. If this treatment does not work or starts but then stops working, we recommend in the second and third trimenon a second-line treatment with diphenolic laxatives such as bisacodyl and and sodium picosulfate. During pregnancy the decision on the application of these laxatives is largely determined by the side-effects of tenesmus associated with preterm births. During lactation we recommend macrogol (preferable to lactulose due to the lack of data), lactulose, bisacodyl and sodium picosulfate, according to the nature of the conditions." }, { "id": "wiki20220301en009_97065", "title": "Laxative", "score": 0.009654191891396074, "content": "Properties Site of action: small and large intestines Onset of action: 0.5–3 hours (oral), 2–15 minutes (rectal) Examples: sodium phosphate (and variants), magnesium citrate, magnesium hydroxide (milk of magnesia), and magnesium sulfate (Epsom salt) Stimulant agents Stimulant laxatives are substances that act on the intestinal mucosa or nerve plexus, altering water and electrolyte secretion. They also stimulate peristaltic action and can be dangerous under certain circumstances. Properties Site of action: colon Onset of action: 6–10 hours Examples: senna, bisacodyl Prolonged use of stimulant laxatives can create drug dependence by damaging the colon's haustral folds, making a user less able to move feces through the colon on their own. A study of patients with chronic constipation found that 28% of chronic stimulant laxative users lost haustral folds over the course of one year, while none of the control group did." }, { "id": "pubmed23n1144_21942", "title": "Breastfeeding and Infant Nutrition Knowledge, Attitude, and Practices of Parents.", "score": 0.009615384615384616, "content": "This study aimed to evaluate the knowledge, attitude, and practices of parents about breastfeeding, complementary food, and infant nutrition who have healthy infants born at term and under 2 years of age. This is a cross-sectional study conducted among the parents of infants who came for well-child visits to pediatric clinics of 4 hospitals. Healthy infants under 2 years of age and who had been born at term were interviewed. The questionnaire included 35 questions to evaluate parents' knowledge, attitude, and practices about breastfeeding and infant nutri- tion in addition to sociodemographic data. Data were obtained via questionnaire and were analyzed using Statistical Package for the Social Sciences 20.0 package program. The study group consisted of 679 infants and their parents. The median durations of exclusive breastfeeding and total breastfeeding time were found to be 4 months and 10 months. Although 75% of the participants stated that infants must be exclusively breastfed for 6 months, the rate of exclusive breastfeeding for the first 6 months was 44%. The 393 (58%) participants used formula for infant nutrition and 47 (12%) of those started with complementary feeding. 90% of the participants stated that formula advertisements did not affect their decision on starting formula but the rate of thinking that other people may be affected by the advertisements was 80%. The knowledge of parents on human milk is not insufficient but they need to be supported especially to continue exclusive breastfeeding during the first 6 months and appro- priate complementary food during the weaning period." }, { "id": "Gynecology_Novak_4985", "title": "Gynecology_Novak", "score": 0.009615384615384616, "content": "Patients with slow-transit constipation tend to respond poorly to fiber supplementation, although most have already tried an empiric trial of fiber before testing to confirm the diagnosis (160). Some patients may benefit from regular toileting, either in the morning or after meals when there is increased colonic motor activity. Biofeedback may have modest short-term benefits, but the long-term effect is questionable (168). Enemas and suppositories can be used in conjunction with bowel regimens. It is also reasonable to attempt a trial of any of the laxatives listed in Table 28.10. Stimulant laxatives are commonly used, but questions remain about the development Table 28.10 Laxatives for the Treatment of Disordered Defecation PO, by mouth; PR, per rectum. From Wald A. Approach to the patient with constipation. In: Yamada T, ed. Textbook of gastroenterology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 1999:921, with permission." }, { "id": "pubmed23n0623_20895", "title": "Bowel habits and toilet training in a diverse population of children.", "score": 0.009523809523809525, "content": "To gather data concerning bowel habits and toilet training of developmentally normal children ages 5 to 8 years. A questionnaire containing information on age, race, and sex was completed anonymously by a parent in 9 pediatric practices. Recall information was elicited about onset and completion of toilet training, frequency and quality of stooling, size of bowel movements, and behavioral components of defecation. Questionnaires were completed for 1142 children. When all of the children were considered together, toilet training started at a mean of 27.2 months and was completed at a mean of 32.5 months. It began and was completed nearly 3 months earlier for girls than for boys (P&lt;0.001). African American children started and completed toilet training at least 6 months earlier than white children (P&lt;0.001). Of the children, 95% defecated either daily or every other day. Straining at defecation and infrequent stooling were reported significantly more often for girls, whereas staining of underclothes and passage of large bowel movements were reported more often in boys. Approximately 10% of children fulfilled criteria for functional constipation. Most of the children between 5 and 8 years of age have a medium-size bowel movement daily or every other day without straining or withholding. Although African American children toilet train at an earlier age than do white children, bowel habits appear to be similar. A sizeable subgroup of children presenting to primary care providers have a history that is consistent with constipation." }, { "id": "pubmed23n0849_16428", "title": "[Management of the most frequent functional gastrointestinal dis orders in healthy infants].", "score": 0.009523809523809525, "content": "Healthy infants during the first year of life often have multiple functional gastrointestinal symptoms such as colic, regurgitation and constipation. The usual fuzziness and/or crying at this stage of life is interpreted as digestive discomfort or pain, and the corresponding concerns result in unsuitable behaviors as overeating, interruption of breastfeeding, multiple changes of formulas, innumerable queries and unnecessary medications. The aim of this paper is to update knowledge on the pathophysiology of the most common functional gastrointestinal dis orders, in order to avoid over diagnosis and select the most appropriate therapeutic approach and convenient nutritional interventions. " }, { "id": "wiki20220301en235_43972", "title": "Breastfeeding", "score": 0.009433962264150943, "content": "Growth The average breastfed baby doubles its birth weight in 5–6 months. By one year, a typical breastfed baby weighs about times its birth weight. At one year, breastfed babies tend to be leaner than formula-fed babies, which improves long-run health. The Davis Area Research on Lactation, Infant Nutrition and Growth (DARLING) study reported that breastfed and formula-fed groups had similar weight gain during the first 3 months, but the breastfed babies began to drop below the median beginning at 6 to 8 months and were significantly lower weight than the formula-fed group between 6 and 18 months. Length gain and head circumference values were similar between groups, suggesting that the breastfed babies were leaner. Infections Breast milk contains several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections) and lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria)." }, { "id": "pubmed23n0274_10457", "title": "Clinical management of constipation.", "score": 0.009433962264150943, "content": "First, it is important to find out whether the patient is complaining of infrequent defaecation, excessive straining at defaecation, abdominal pain or bloating, a general sense of malaise attributed to constipation, soiling, or a combination of more than one symptom. Second, one must decide if there is a definable abnormality as a cause of the symptom(s). Is the colon apparently normal or is its lumen widened (megacolon)? Is the upper gut normal or is there evidence of neuropathy or myopathy? Is the ano-rectum normal or is there evidence of a weak pelvic floor, mucosal prolapse, major rectocele, an internal intussusception or solitary rectal ulcer? Is there any systemic component such as hypothyroidism, hypercalcaemia, neurological or psychiatric disorder or relevant drug therapy? Choice of treatment will depend on this clinical evaluation. The range of treatments available is: Reassurance and stop current treatment: Patients with a bowel obsession may take laxatives or rectal preparations regularly without need. Increase dietary fibre: Most cases of 'simple' constipation respond to increased dietary fibre, possibly with an added supplement of natural bran. Toilet training and altered routine of life: Young people particularly may need to recognise the call to stool and alter their daily routine to permit and encourage regular defaecation. Medicinal bulking agent: Ispaghula, methyl cellulose, concentrated wheat germ or bran, and similar preparations are useful when patients with a normal colon find it difficult to take adequate dietary fibre. These preparations increase the bulk of stool and soften its consistency. They may be useful for those patients with the constipated form of irritable bowel syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en003_54870", "title": "Infant formula", "score": 0.009345794392523364, "content": "Uses, risks and controversies The use and marketing of infant formula has come under scrutiny. Breastfeeding, including exclusive breastfeeding for the first 6 months of life, is widely advocated as \"ideal\" for babies and infants, both by health authorities — and accordingly in ethical advertising of infant formula manufacturers. Despite the recommendation that babies be exclusively breastfed for the first 6 months, less than 40% of infants below this age are exclusively breastfed worldwide. The overwhelming majority of American babies are not exclusively breastfed for this period – in 2005 under 12% of babies were breastfed exclusively for the first 6 months, with over 60% of babies of 2 months of age being fed formula, and approximately one in four breastfed infants having infant formula feeding within two days of birth." }, { "id": "pubmed23n0622_23401", "title": "[Value of a new thickened formula in infants with regurgitations].", "score": 0.009345794392523364, "content": "The purpose of this open multicenter study was to evaluate the value of a new starch-thickened formula in infants with regurgitations in ambulatory pediatric practice. The study population comprised full-term infants with an age at inclusion of 1-90 days, who were bottle-fed and presented regurgitations. The formula tested was an infant formula-thickened with starch (2g/100mL). The primary endpoint was the frequency of bottles regurgitated, expressed in percentage of meals per day after 15 days of feeding with the preparation studied. Secondary endpoints were the assessment of regurgitations using the Vandenplas' score, as well as the daily increase in weight, height, and cranial circumference, overall and gastrointestinal tolerance, and formula acceptability. Sixty-four infants presenting regurgitation were included. The frequency of bottles regurgitated estimated at 80.3% at inclusion significantly decreased at D3, D15, and D30 to 40.1, 40.2 and 37.2% (P&lt;0.0001), respectively. Thirty percent of infants did not present regurgitations at all at D30. Similarly, a significant decrease in the Vandenplas' score was observed from 1.9 at D0 to 0.9 at D30 (P&lt;0.0001). Infant growth was similar to the French and European growth curves. The results showed rapid and lasting improvement in decreasing the frequency of feeding-bottles regurgitated by 50% from the first 3 days of using this new starch-thickened formula (2g/100mL). These satisfying results encourage the use of the tested formula in cases of infant regurgitation, in line with the European Society of Gastroenterology, Hepatology and Nutrition (ESPGHAN) recommendations." }, { "id": "pubmed23n0644_6750", "title": "Early and late outcomes of primary laparoscopic endorectal colon pull-through leaving a short rectal seromuscular sleeve for Hirschsprung disease.", "score": 0.009259259259259259, "content": "To report early and late outcomes of laparoscopic colon pull-through leaving a short rectal sleeve for Hirschsprung disease. Laparoscopic endorectal colon pull-through was performed using 4 ports. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies obtained laparoscopically. The rest of the procedure was carried out according to Georgeson's technique. However, we left a short rectal seromuscular sleeve of 1.5 to 2 cm above the dentate line. From January 2001 to December 2007, 200 patients were operated upon by the same surgeon. Ages ranged from 14 days to 36 months old. The aganglionic segment was located in the rectum in 112 patients, in the sigmoid colon in 80 children, and in the left colon in 8 patients. The median operating time was 152 minutes. There were no perioperative deaths. Conversion to open surgery was required in four patients. There was minimal blood loss during the surgery. Oral intakes of clear fluid were started 12 hours after surgery and advanced to formula on the second day. In 1 patient, a small intestinal perforation occurred 3 days after surgery, requiring a diverting ileostomy. The mean hospital stay was 6.6 days (range, 4-12 days). Follow-up ranging from 5 to 85 months was obtained in 157 patients; 124 patients (79%) had 1 to 4 defecations a day, 17 (11%) had 5 to 6, and 8 had more than 6. Fecal incontinence occurred in 3 patients (2.0%), constipation in 5 patients (3.0%), and enterocolitis in 15 patients (9.5%). Anastomotic fistula occurred in 2 patients. Laparoscopic endorectal pull-through leaving a short rectal seromuscular sleeve is a safe and effective procedure for Hirschsprung disease." }, { "id": "Pediatrics_Nelson_735", "title": "Pediatrics_Nelson", "score": 0.009259259259259259, "content": "When rehydration is complete, maintenance therapy should be started, using 100 mL of ORS/kg in 24 hours until the diarrhea stops. Breastfeeding or formula feeding should be maintained and not delayed for more than 24 hours. Patients with more severe diarrhea require continued supervision. The volume of ORS ingested should equal the volume of stool losses. If stool volume cannot be measured, an intake of 10 to 15 mL of ORS/kg/hr is appropriate. Parenteral nutrition (PN) is necessary when enteral feeding is inadequate to meet the nutritional needs of a patient. Enteral nutrition is always preferred because it is more physiologic, less expensive, and associated with fewer complications. Fewer complications are expected if at least some nutrition can be provided enterally." }, { "id": "pubmed23n0990_25267", "title": "The Magnesium-Rich Formula for Functional Constipation in Infants: a Randomized Comparator-Controlled Study.", "score": 0.009174311926605505, "content": "To compare the effectiveness of the magnesium (Mg)-enriched formula vs. control formula in constipated infants. An open-label, interventional, and the comparator-controlled study was conducted to evaluate the effectiveness of the Mg-enriched formula in formula-fed infants ≤6 months old presenting with functional constipation according to modified Rome IV criteria. Infants were randomized 1:1 to intervention or control formula for 30 days. Parents recorded stool consistency (hard, normal, or watery) and frequency on days 1-7 and 23-29. Physicians recorded patient baseline characteristics and performed the clinical examination at the time of three patient visits (baseline, day 8, and 30). Of the 286 recruited infants, 143 received the Mg-rich formula and 142 received the control formula. After 7 days, significantly more infants had stools with normal consistency with the Mg-rich formula compared to the infants fed with the control formula (81.8% vs. 41.1%; <ip</i&lt;0.001). The number of infants passing one or more stools per day was increased at day 7 in the Mg-rich formula group (86.7% vs. 68.2%; <ip</i&lt;0.001). At days 7 and 29, &gt;25% of infants responded completely to the Mg-rich formula compared to &lt;5% of infants fed with the control formula (<ip</i&lt;0.001). Parents of infants in the Mg-rich formula group were very satisfied with the treatment (80.8% vs. 10.2%), with the majority willing to continue treatment after 30 days (97.9% vs. 52.6%; <ip</i&lt;0.001). The Mg-rich formula significantly improved stool consistency and frequency compared to the control formula in constipated infants." }, { "id": "article-21993_29", "title": "Pediatric Functional Constipation -- Prognosis", "score": 0.0091530809615916, "content": "The frequency of mandatory toilet visits and the use of laxatives can be reduced after the child develops regular bowel habits (and uses the toilet on their own). The laxative dose is gradually reduced to prevent fecal incontinence and maintain 1 to 2 daily bowel movements. [17]" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 403, 586 ] ], "word_ranges": [ [ 61, 85 ] ], "text": "Postinfectious glomerulonephritis is more typical of children and adults older than 60 years, and usually manifests with hematuria after streptococcal infections (option 1 incorrect)." }, "2": { "exist": true, "char_ranges": [ [ 285, 402 ] ], "word_ranges": [ [ 44, 61 ] ], "text": "Direct nephrotoxicity is very rare and is characterized by crystallization in the renal tubules (incorrect option 2)." }, "3": { "exist": true, "char_ranges": [ [ 587, 692 ] ], "word_ranges": [ [ 85, 101 ] ], "text": "Acute pyelonephritis would have been presented with high fever and renal fossa pain (option 3 incorrect)." }, "4": { "exist": true, "char_ranges": [ [ 0, 185 ] ], "word_ranges": [ [ 0, 28 ] ], "text": "General malaise, arthralgias, skin rash, acute renal failure and active sediment with sterile leukocyturia following the intake of a drug is highly suggestive of AIN (option 4 correct)." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Postinfectious glomerulonephritis.", "2": "Ciprofloxacin nephrotoxicity.", "3": "Acute pyelonephritis.", "4": "Acute interstitial nephritis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0882_9723", "title": "Is ciprofloxacin safe in patients with solitary kidney and upper urinary tract infection?", "score": 0.01597082494969819, "content": "The solitary kidney (SK) undergoes adaptive phenomena of hyperfunction and hyperfiltration. These secondary adaptive phenomena can make it more vulnerable to potentially nephrotoxic therapies. Adverse reactions of the kidneys to ciprofloxacin are rare, but sometimes severe. Therefore, our study sought to assess the reactions to ciprofloxacin of patients with solitary kidney (SK) and urinary tract infection (UTI) by means of urinary biomarkers. We studied 19 patients with SK and urinary tract infection (UTI) who had been administered a 7-day treatment with intravenous ciprofloxacin. Urinary N-acetyl-beta-d-glucosaminidase, alpha 1-microglobulin, and estimated glomerular filtration rate (eGFR) of these patients were measured at the initiation and at the end of treatment. In 47.37% patients NAG diminished under ciprofloxacin treatment. This observation has the significance of favourable evolution of the tubulointerstitial lesions caused by UTI and lack of nephrotoxic effects; 52.63% cases presented an increase of urinary NAG, a fact that suggests a nephrotoxic effect of ciprofloxacin. The evolution of urinary alpha 1-microglobulin was similar to that one of urinary NAG. Only one of three cases with chronic kidney disease (CKD) stage 5 presented acute kidney injury, associated with increase in the tubular markers. In spite of the high variability of the urinary biomarkers, UTI evolved favourably in these cases; eGFR increased in 16 out of 19 patients, a fact which is indicative of a good outcome of renal function, even in patients with elevated levels of the tubular damage biomarkers. This observation supports the hypothesis that eGFR may be dissociated from the biomarkers which assess tubular injury. In SK patients the occurrence of AKI is not frequent, although the urinary biomarkers rise in some patients treated with ciprofloxacin. This is related not only to the nephrotoxic effect of the drug, but probably to the association of other factors (allergy, individual susceptibility). In SK patients, renal tubular biomarkers, especially NAG, allow monitoring of tubular injury and impose caution in prescribing ciprofloxacin treatment, mainly to patients at risk. Ciprofloxacin is relatively safe regarding its nephrotoxicity, while caution is required in vulnerable patients." }, { "id": "pubmed23n0616_19427", "title": "[Unexpected cause of acute renal failure in an 85-year-old woman].", "score": 0.014675697865353037, "content": "Acute postinfectious glomerulonephritis (APIGN) is usually diagnosed in young people, while in elderly people rapidly progressive forms appear to be the most important glomerular disease causing acute renal failure. We report on a 85-year-old woman with acute renal failure due to APIGN. An 85-year-old woman with a history of hypertension and cerebrovascular disease was hospitalized because of diarrhea and syncope associated with atrial fibrillation. She was found to have left lower lobe pneumonia. Serum creatinine was over 2 mg/dL. Fluids were given, without improvement in renal function but leading to volume overload instead. Within a few days serum creatinine reached a level of 5.4 mg/dL with reduction of urine output despite administration of diuretics. The patient developed hematuria and purpura of the feet. Serum IgA was high and the urine sediment showed casts. Methylprednisolone 125 mg i.v. was given for three days followed by prednisone 50 mg daily. The patient's clinical condition gradually improved and serum creatinine decreased to 1.9 mg/dL. Renal biopsy showed APIGN. During hospitalization, three major complications occurred: hemodynamic instability due to atrial fibrillation, Clostridium difficile colitis and urinary tract infections due to Enterococcus faecalis and Candida tropicans, all successfully treated. APIGN should be taken into account as a cause of acute renal failure in hospitalized elderly patients with many comorbidities." }, { "id": "pubmed23n0828_8681", "title": "Kidney function and the use of nitrofurantoin to treat urinary tract infections in older women.", "score": 0.013445809960176424, "content": "The antibiotic nitrofurantoin is commonly used to treat uncomplicated urinary tract infections. However, when this drug is used by patients with reduced kidney function, its urine concentration may be subtherapeutic. We conducted a population-based study of older women (mean age 79 years) in Ontario, Canada, whose estimated glomerular filtration rate was relatively low (median 38 mL/min per 1.73 m(2)) and for whom 1 of 4 antibiotics had been prescribed for urinary tract infection: nitrofurantoin, ciprofloxacin, norfloxacin or trimethoprim-sulfamethoxazole. We assessed 2 measures of treatment failure in the subsequent 14 days: receipt of a second antibiotic indicated for urinary tract infection and hospital encounter (emergency department visit or hospital admission) with a urinary tract infection. We repeated the analysis for older women with relatively high estimated glomerular filtration rate (median 69 mL/min per 1.73 m(2)). The baseline characteristics of the 4 antibiotic groups were similar. Relative to nitrofurantoin, the other antibiotics (including ciprofloxacin) were associated with a lower rate of treatment failure among women with relatively low estimated glomerular filtration rate (for ciprofloxacin v. nitrofurantoin: second antibiotic prescription, 130/1989 [6.5%] v. 516/3739 [13.8%], odds ratio [OR] 0.44, 95% confidence interval [CI] 0.36-0.53; hospital encounter, 21/1989 [1.1%] v. 95/3739 [2.5%], OR 0.41, 95% CI 0.25-0.66). However, a similar risk of treatment failure with nitrofurantoin was also observed among women with relatively high estimated glomerular filtration rate. The results were consistent in multiple additional analyses. In this study, the presence of mild or moderate reductions in estimated glomerular filtration rate did not justify avoidance of nitrofurantoin." }, { "id": "pubmed23n1151_13279", "title": "Ten Cases of Biopsy-Proven Acute Tubulointerstitial Nephritis: Report from a Single Center in a Rural Area from 2008 to 2021.", "score": 0.012677798392084105, "content": "Acute tubulointerstitial nephritis (ATIN) can be caused by any number of factors, and it accounts for several percent of renal biopsy cases. In Japan, case reports exist, but there are few single-center series of ATIN cases. <iCase 1</i. A teenage male patient developed fever and cough on day X-61 and was found to have normal renal function and positive C-reactive protein (CRP) by his primary care physician. On day X-20, he presented with cough and nasal discharge in addition to low-grade fever, and his doctor noted renal dysfunction with serum creatinine of 2.12 mg/dL, negative urine occult blood, and positive urine glucose. Renal biopsy results showed diffuse interstitial nephritis with scarce glomerular involvement. There was no concurrent uveitis. Renal function normalized after 4 months of treatment with moderate-dose prednisolone. <iCases 2-10</i. Of the 422 cases for which renal biopsies were performed at our institution from 2008 to 2021, acute tubulointerstitial nephritis was confirmed clinically and pathologically in 9 cases in addition to case 1, accounting for 2.4% of all biopsy cases. In the analysis of the 10 patients, the median age was 40 years old, eGFR at diagnosis was 19.4 (3.2-49.1) mL/min/1.73 m<sup2</sup, and 2 of them underwent hemodialysis, but both were weaned from dialysis, and the eGFR after treatment was 53.6 (20.8-110.0) mL/min/1.73 m<sup2</sup; all patients showed improvement (<iP</i &lt; 0.001). Treatment consisted of steroids in 8 patients and no steroids in 2 patients, the latter being treated by discontinuation of the suspect drugs and treatment of infection; 7 of the 10 patients were examined for ocular uveitis, and uveitis was diagnosed in 5 patients. The causes and clinical course of ATIN are diverse, but it is treated according to individual judgment in addition to standard treatment, and it generally has a good renal prognosis." }, { "id": "wiki20220301en100_5658", "title": "List of MeSH codes (C12)", "score": 0.012163433537923929, "content": "– anti-glomerular basement membrane disease – goodpasture syndrome – glomerulonephritis, iga – glomerulonephritis, membranoproliferative – glomerulonephritis, membranous – glomerulosclerosis, focal – lupus nephritis – nephritis, hereditary – nephritis, interstitial – balkan nephropathy – pyelonephritis – pyelonephritis, xanthogranulomatous – nephrocalcinosis – nephrosclerosis – nephrosis – nephrosis, lipoid – nephrotic syndrome – perinephritis – pyelitis – pyelonephritis – pyelonephritis, xanthogranulomatous – renal artery obstruction – renal insufficiency – kidney failure – kidney failure, acute – kidney tubular necrosis, acute – kidney failure, chronic – renal insufficiency, acute – kidney failure, acute – kidney tubular necrosis, acute – renal insufficiency, chronic – kidney failure, chronic – renal osteodystrophy – renal tubular transport, inborn errors – acidosis, renal tubular – aminoaciduria, renal" }, { "id": "wiki20220301en001_192901", "title": "Urinary tract infection", "score": 0.01156737998843262, "content": "Pyelonephritis Pyelonephritis is treated more aggressively than a simple bladder infection using either a longer course of oral antibiotics or intravenous antibiotics. Seven days of the oral fluoroquinolone ciprofloxacin is typically used in areas where the resistance rate is less than 10%. If the local resistance rates are greater than 10%, a dose of intravenous ceftriaxone is often prescribed. Trimethoprim/sulfamethoxazole or amoxicillin/clavulanate orally for 14 days is another reasonable option. In those who exhibit more severe symptoms, admission to a hospital for ongoing antibiotics may be needed. Complications such as ureteral obstruction from a kidney stone may be considered if symptoms do not improve following two or three days of treatment. Prognosis With treatment, symptoms generally improve within 36hours. Up to 42% of uncomplicated infections may resolve on their own within a few days or weeks." }, { "id": "pubmed23n0696_21547", "title": "[Chronic renal failure: unexpected late sequela of pulmonary tuberculosis after 30 years].", "score": 0.010999220763651622, "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": "pubmed23n0609_5694", "title": "[Postinfectious acute glomerulonephritis].", "score": 0.010481663929939792, "content": "Postinfectious acute glomerulonephritis mostly happens in children aged two to 10 years old. Typically, it follows group A beta-hemolytic streptococcus skin or upper respiratory tract infection. There is a latent period of one to three weeks before nephritic syndrome appears. Microscopic or macroscopic hematuria is always present. Proteinuria and decreased glomerular filtration rate are usually mild. By contrast, salt and water retention can be severe and complicated with hypertension, congestive heart failure or pulmonary edema. Fluid overload must be urgently treated by loop diuretics or renal replacement therapy in the most severe cases." }, { "id": "wiki20220301en019_111573", "title": "Glomerular filtration rate", "score": 0.010445387062566279, "content": "Normal ranges The normal range of GFR, adjusted for body surface area, is 100–130 average 125 mL/min/1.73m2 in men and 90–120 ml/min/1.73m2 in women younger than the age of 40. In children, GFR measured by inulin clearance is 110 mL/min/1.73 m2 until 2 years of age in both sexes, and then it progressively decreases. After age 40, GFR decreases progressively with age, by 0.4–1.2 mL/min per year. Decreased GFR A decreased renal function can be caused by many types of kidney disease. Upon presentation of decreased renal function, it is recommended to perform a history and physical examination, as well as performing a renal ultrasound and a urinalysis. The most relevant items in the history are medications, edema, nocturia, gross hematuria, family history of kidney disease, diabetes and polyuria. The most important items in a physical examination are signs of vasculitis, lupus erythematosus, diabetes, endocarditis and hypertension." }, { "id": "pubmed23n0089_4493", "title": "Acute renal failure secondary to oral ciprofloxacin therapy: a presentation of three cases and a review of the literature.", "score": 0.009900990099009901, "content": "The fluoroquinolones represent a new class of antimicrobial agents with a broad spectrum of activity. We report three cases of acute renal failure following ciprofloxacin in patients without a previous history of renal insufficiency. The average baseline creatinine was 1.1 mg/dl and rose to an average of 4.0 mg/dl during therapy. The length of antecedent ciprofloxacin therapy ranged from several days to several weeks. Other causes of acute renal failure and postobstructive uropathy were excluded. Kidney size was normal-to-increased. Gallium scans were positive in one of two patients studied. Peripheral eosinophilia developed in one case, suggesting an acute hypersensitivity reaction to the drug. The acute renal failure in all cases was non-oliguric and was completely reversed after discontinuation of ciprofloxacin. In two of the three reported cases there was an increased creatinine to BUN ratio, but increased production of creatinine (i.e., rhabdomyolysis) was unlikely with a normal serum creatinine phosphokinase (CPK). In addition, we performed in vitro studies which eliminated the possibility of methodological artifact. The nephrotoxicity of the quinolones has been linked to the development of crystalluria in experimental animals. However, in humans, crystalluria is unlikely and renal damage has not been noted. There have been only two previous case reports of acute renal failure due to oral ciprofloxacin therapy. In one, biopsy showed acute interstitial nephritis. We conclude that oral ciprofloxacin therapy may lead to acute renal failure secondary to tubulointerstitial nephritis characterized by an increased creatinine to BUN ratio. Patients placed on ciprofloxacin therapy need to be followed closely." }, { "id": "pubmed23n1103_23217", "title": "Methimazole-Induced ANCA Vasculitis: A Case Report.", "score": 0.00980392156862745, "content": "Rapidly progressive glomerulonephritis (RPGN) is a syndrome which presents rapid loss of renal function. Vasculitis represents one of the major causes, often related to anti-neutrophil cytoplasmic antibodies (ANCA). Herein, we report a case of methimazole-induced ANCA-associated vasculitis. A 35-year-old woman complained of weight loss and fatigue for 2 weeks and attended the emergency room with alveolar hemorrhage. She had been diagnosed with Graves' disease and had been taking methimazole in the past 6 months. Her physical examination showed pulmonary wheezing, hypertension and signs of respiratory failure. Laboratory tests revealed urea 72 mg/dL, creatinine 2.65 mg/dL (eGFR CKD-EPI: 20 mL/min/1.73 m<sup2</sup), urine analysis with &gt;100 red blood cells per high-power field, 24 h-proteinuria: 1.3 g, hemoglobin 6.6 g/dL, white-cell count 7700/mm<sup3</sup, platelets 238,000/mm<sup3</sup, complement within the normal range, negative viral serological tests and ANCA positive 1:80 myeloperoxidase pattern. Chest tomography showed bilateral and diffuse ground-glass opacities, and bronchial washing confirming alveolar hemorrhage. A renal biopsy using light microscopy identified 27 glomeruli (11 with cellular crescentic lesions), focal disruption in glomerular basement membrane and fibrinoid necrosis areas, tubulitis and mild interstitial fibrosis. Immunofluorescence microscopy showed IgG +2/+3, C3 +3/+3 and Fibrinogen +3/+3 in fibrinoid necrosis sites. She was subsequently diagnosed with crescentic pauci-immune glomerulonephritis, mixed class, in the setting of a methimazole-induced ANCA vasculitis. The patient was treated with methimazole withdrawal and immunosuppressed with steroids and cyclophosphamide. Four years after the initial diagnosis, she is currently being treated with azathioprine, and her exams show creatinine 1.30 mg/dL (eGFR CKD-EPI: 52 mL/min/1.73 m<sup2</sup) and negative p-ANCA." }, { "id": "pubmed23n0729_18451", "title": "Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial.", "score": 0.00980392156862745, "content": "Acute pyelonephritis is a common infection in adult women, but there is a paucity of controlled trials of its treatment and the optimum duration of antibiotic treatment has not been properly defined. We compared the efficacy of ciprofloxacin for 7 days and 14 days in women with community-acquired acute pyelonephritis. In a prospective, non-inferiority trial undertaken at 21 centres of infectious diseases in Sweden, women (aged ≥18 years) who were not pregnant and had a presumptive diagnosis of acute pyelonephritis were randomly assigned to oral treatment with ciprofloxacin 500 mg twice daily for 7 days or 14 days. The first week was open label. A computer-generated randomisation list in block sizes of two was used for treatment allocation in a 1:1 ratio. The study was double-blind and placebo-controlled during the second week of treatment, which was either continuation of ciprofloxacin 500 mg or placebo tablets twice daily according to the randomisation code. Patients, carers, site investigators, and trial coordinating centre staff were masked to group assignment. The primary endpoint was the clinical and bacteriological outcome 10-14 days after completion of treatment with active drug. Analysis was by per protocol. This trial is registered with EudraCT, number 2005-004992-39, and ClinicalTrials.gov, number ISRCTN73338924. 126 of 248 patients were randomly assigned to 7 days and 122 to 14 days of ciprofloxacin. 73 and 83 patients, respectively, were analysed. Short-term clinical cure occurred in 71 (97%) patients treated with ciprofloxacin for 7 days and 80 (96%) treated for 14 days (difference -0·9%; 90% CI -6·5 to 4·8; p=0·004; non-inferiority test). Cumulative efficacy at long-term follow-up was 93% in each group (68 of 73 vs 78 of 84; -0·3%; -7·4 to 7·2; p=0·015). Both regimens were well tolerated. Two patients discontinued ciprofloxacin because of myalgia with 7 days of treatment and itching exanthema with 14 days. Four (5%) of 86 patients assigned to 7 days of treatment who complied with study criteria and six (6%) of 93 assigned to 14 days reported an adverse event after the first week of treatment that was possibly or probably related to the study drug. In those assigned to 7 days, no patient had mucosal candida infection after the first week versus five treated for 14 days (p=0·036). Our results show that acute pyelonephritis in women, including older women and those with a more severe infection, can be treated successfully and safely with oral ciprofloxacin for 7 days. Short courses of antibiotics should be favoured in an era of increasing resistance. Swedish Strategic Programme against Antibiotic Resistance (Strama)." }, { "id": "wiki20220301en085_59102", "title": "Contrast-induced nephropathy", "score": 0.009708737864077669, "content": "Decreased kidney function European guidelines classify a pre-existing decreased kidney function to be a risk factor of contrast-induced nephropathy in the following cases: Estimated glomerular filtration rate (eGFR) < 45 ml/min/1.73 m2 of body surface area before intra-arterial administration with first-pass renal exposure (not passing lungs or peripheral circulation before kidneys), or in the intensive care unit eGFR < 30 ml/min/1.73 m2 before intravenous administration or intra-arterial administration with second-pass renal exposure Known or suspected acute kidney injury To calculate estimated GFR from creatinine, European guidelines use the CKD-EPI formula in adults ≥ 18 years, and the revised Schwartz formula in children. Swedish guidelines recommends no specific formula in children because of lack of evidence, but on the other hand recommends GFR based on cystatin C rather than creatinine in those with abnormal muscle mass or liver failure or cirrhosis." }, { "id": "pubmed23n0289_9158", "title": "Chronic granulomatous interstitial nephritis: unusual complication of acute pyelonephritis.", "score": 0.009708737864077669, "content": "We describe an unusual complication of acute pyelonephritis in a 45-year-old diabetic female. She was admitted to our hospital due to fever and flank pain which had developed 10 days earlier. Urinalysis showed many WBC and urine culture revealed Escherichia coli. After adequate antibiotic treatment, clinical symptoms abated but renal failure and leukocyturia persisted. Abdominal CT showed bilateral focal bacterial nephritis and renal biopsy disclosed chronic granulomatous interstitial nephritis. On the 80th hospital day she was discharged with a serum creatinine of 299 mumol/l. In the outpatient clinic, renal dysfunction and leukocyturia persisted up to 1 year. In conclusion, this case raises the possibility of a chronic interstitial process of acute pyelonephritis." }, { "id": "pubmed23n0510_13943", "title": "[Acute tubulointerstitial nephritis in children].", "score": 0.009615384615384616, "content": "Acute tubulointerstitial nephritis (ATIN) is a rare renal disorder in children. Patients usually present non-specific symptoms and signs so that the diagnosis of ATIN is often delayed. The disease may be infection- or drug-induced or it may occur without a known cause. Early recognition and appropriated therapy usually lead to an excellent prognosis. The aim of the study was to describe clinical and laboratory findings and the course of ATIN in 21 patients, that are typical enough to enable early recognition of the disease as it is potentially reversible. Between 1986 and 1997 we observed 21 patients, aged 7-16 years (mean, 12.8), with acute tubulointerstitial nephritis, including eight with tubulointerstitial nephritis and uveitis (TINU syndrome). Laboratory studies included urinalysis, complete blood count, erytrocyte sedimentation rate (ESR), plasma creatinine, glomerular filtration rate (GFR), electrolytes, proteins, IgG, C3, C4 antinuclear-antibodies (ANA), antistreptolysin-O and antibodies to hantaviruses. Renal ultrasound was done in all patients. Renal biopsy was performed in 5 children. All children had previously been healthy. The symptoms of ATIN developed within a few days (Table 1). The most common initial symptoms were fatigue, fever, gastrointestinal disturbances, anorexia and weight loss. Less common complaints included headache, arthralgias and maculopapular rash. On addmition no patient had hypertension, oedema or evidence of acute infection. ESR, plasma urea and creatinine concentrations were increased in all, plasma proteins and IgG levels in the majority of patients. ANA were negative in 15 pts in whom this analysis was performed; C3 and C4 levels were normal. In two children recent strepococcal and in the other 6 hantavirus infection was serologicaly proved. All patients had non-oliguric acute renal failure (ARF): GFR was 21.7 +/- 8 9 in 14 pts and 67 +/- 9.7 in 7 pts. Low urine specific gravity (1003-1014), mild proteinuria (0.3-0.4 g/24 h), leukocyturia and/or haematuria were found in all patients; glycosuria, aminoaciduria and decreased tubular reaposrption of phosphate (TRP) were found in 12/21, 9/21 and 9/14 patients, respectively. Urine cultures were negative in all children. Renal US demonstrated enlarged hyperechoic kidneys in 11 pts, in remaining 10 pts no abnormalities were found. Renal biopsy, performed in 5 children, confirmed the diagnosis of ATIN. Eight patients subsequently developed anterior uveitis as part of TINU syndrome. Treatment included supportive therapy in all and six patients received prednisolone for 4-8 weeks (40-60 mg/m2/24 h for 10-14 days with subsequent reduction of dose over several weeks). Anterior uveitis was successfully treated with topical steroids. Renal function completely recovered in all patients: GFR (109 +/- 22.6 ml/min) within a mean interval of 47 +/- 33 days, concentration ability within 2-12 (mean 4.5) months. Common clinical features of ATIN are non-oliguric acute renal failure of various degrees, signs of tubular dysfunction, proteinuria, haematuria, leukocyturia and absence of hypertension. All our patients had normal blood pressure, non-oliguric renal failure, proteinuria, hypostenuria and abnormal urinary sediment; about half of them had glycosuria and/or other signs of proximal tubular dysfunction. The most important causes of ATIN in children reported in literature are systemic infections and drugs. However, the cause of ATIN in our patients was assessed as being related to infection only in 8 patients and to diclofenac in one. No infection, drug, toxin or other cause could be identified in 4, as well as in 8 pts with TINU syndrome. The prognosis of ATIN in children is considered to be favourable, but some patients may develop chronic renal failure. Renal function completely recovered in all our patients; that is consistent with outcome data from the most reports. Acute tubulointerstitial nephritis is an important cause of ARF in children, its aetiology may be different and it carries an excellent prognosis. ATIN should be suspected in a child who presents typical, although non-specific symptoms and signs, associated with lukocyturia and/or microhaematuria, signs of tubular dysfunction and unexplained renal failure. The diagnosis can be verified at renal biopsy. Early recognition of the disease is important to remove possible aetiologic agents and to treat them before chronic lesions are present to avoid long-term renal damage." }, { "id": "pubmed23n0052_12403", "title": "[Acute interstitial nephritis in childhood].", "score": 0.009615384615384616, "content": "Acute tubulointerstitial nephritis (TIN) was diagnosed during a 10-year period in 6 previously healthy children (4 boys) with a mean age of 10 years (range 2.5-14 years). All presented with a non-specific history. First laboratory findings were nearly identical, with a raised erythrocyte sedimentation rate and non-oliguric renal failure; the urine contained protein, glucose, and leucocytes, but no bacteria. A serologically proven infection (streptococcal infection 2x; mononucleosis 1x) or drug-related TIN (penicillin) was present in 4 children; in one, both conditions could have been responsible. One girl suffered from idiopathic TIN with uveitis. Rapid progression of renal failure occurred in 3 children, but the response to steroid therapy was satisfactory. No dialysis was necessary and all patients showed a complete recovery. We think that acute TIN occurs more frequently than suggested previously. Many episodes are probably mild or subclinical and the rate of spontaneous remission is high. The results of initial laboratory evaluation in conjunction with acute renal failure and predominantly proximal tubular dysfunction, are sufficiently typical to arouse suspicion of acute TIN at an early stage, although they do not permit any conclusion as to the aetiology." }, { "id": "pubmed23n0361_2988", "title": "[Tubulo-interstitial nephritis and uveitis syndrome--TINU syndrome].", "score": 0.009523809523809525, "content": "Acute tubulo-interstitial nephritis and uveitis (TINU syndrome) in a 53-year-old woman is reported. This rare syndrome was described 27 years ago by Dobrin et al. Since then about 50 cases have been described. The syndrome can appear at any age but most patients are under 20 years; about 75% are females. Clinical characteristics include fatigue, general malaise, weight loss, fever, night sweats, anorexia, nausea and vomiting, pallor, nocturia, polyuria, arthralgia and skin rash. Ocular involvement usually includes anterior uveitis but is sometimes posterior; in most cases the uveitis is bilateral. The characteristic laboratory findings are anemia, rapid sedimentation rate, decreased glomerular filtration rate with increased serum creatinine and urea. Total protein is increased because of polyclonal gammopathy and elevated beta 2-microglobulin. Urinalysis characteristically reveals proteinuria and beta 2-microglobulinuria. The histopathologic features on renal biopsy are characteristic of tubulo-interstitial nephritis. Uveitis can precede, accompany or follow onset of the nephropathy. The pathogenesis and etiology of the syndrome are as yet unknown. Treatment consists of large doses of corticosteroids, but the necessity for treatment is unclear, since there is evidence of spontaneous improvement. Although the prognosis of the nephropathy is favorable and most cases are reversible, the uveitis tends to recur." }, { "id": "pubmed23n0927_12100", "title": "Clinical Manifestations and Outcomes of Fluoroquinolone-Related Acute Interstitial Nephritis.", "score": 0.009523809523809525, "content": "To describe the clinical presentation, diagnosis, and outcomes of patients with biopsy-proven acute interstitial nephritis (AIN) related to fluoroquinolone (FQ) therapy. We conducted a retrospective review of biopsy-proven AIN attributed to FQ use at Mayo Clinic's campus in Rochester, Minnesota, from January 1, 1993, through December 31, 2016. Cases were reviewed by a renal pathologist and attributed to FQ use by an expert nephrologist. We also reviewed and summarized all published case reports of biopsy-proven AIN that were attributed to FQ use. We identified 24 patients with FQ-related biopsy-proven AIN at our institution. The most commonly prescribed FQ was ciprofloxacin in 17 patients (71%), and the median antibiotic treatment duration was 7 days (interquartile range [IQR], 5-12 days). The median time from the initiation of FQ to the diagnosis of AIN was 8.5 days (IQR, 3.75-20.75 days). Common clinical manifestations included fever (12; 50%), skin rash (5; 21%), and flank pain (2; 8%), and 9 (38%) had peripheral eosinophilia. However, 4 (17%) of the patients were asymptomatic at the time of diagnosis and AIN was suspected on the basis of routine laboratory monitoring. Most patients (17; 71%) recovered after the discontinuation of antibiotic therapy, and renal function returned to baseline at a median of 20.5 days (IQR, 11.75-27.25 days). Six patients (25%) required temporary hemodialysis, and 14 patients (58%) received corticosteroid therapy. The onset of FQ-related AIN can be delayed, and a high index of suspicion is needed by physicians evaluating these patients. Overall outcomes are favorable, with recovery to baseline renal function within 3 weeks of discontinuing the offending drug." }, { "id": "wiki20220301en000_98838", "title": "Ciprofloxacin", "score": 0.009433962264150943, "content": "Ciprofloxacin occupies an important role in treatment guidelines issued by major medical societies for the treatment of serious infections, especially those likely to be caused by Gram-negative bacteria, including Pseudomonas aeruginosa. For example, ciprofloxacin in combination with metronidazole is one of several first-line antibiotic regimens recommended by the Infectious Diseases Society of America for the treatment of community-acquired abdominal infections in adults. It also features prominently in treatment guidelines for acute pyelonephritis, complicated or hospital-acquired urinary tract infection, acute or chronic prostatitis, certain types of endocarditis, certain skin infections, and prosthetic joint infections." }, { "id": "pubmed23n0074_5289", "title": "Acute renal failure due to ciprofloxacin.", "score": 0.009433962264150943, "content": "Acute renal failure developed in three patients within a few days of starting ciprofloxacin hydrochloride therapy. An allergic interstitial nephritis was suggested by fever and eosinophiluria in one patient and by erythema multiforme in another. A kidney biopsy specimen confirmed this diagnosis in one patient. Renal function improved shortly after withdrawal of the drug in all three patients. Literature survey revealed an additional three patients with a similar complication. Allergic manifestations, such as fever or rash, were a feature in most reported cases. In view of this potential complication, renal function should be closely monitored in patients receiving ciprofloxacin therapy, especially if other potentially nephrotoxic drugs are prescribed concomitantly." }, { "id": "pubmed23n1142_17389", "title": "Targeted Cancer Therapies Causing Elevations in Serum Creatinine Through Tubular Secretion Inhibition: A Case Report and Review of the Literature.", "score": 0.009345794392523364, "content": "Targeted cancer therapies have revolutionized the field of oncology by selecting for specific molecular pathways, thus improving overall clinical prognosis. However, many of these targeted treatments have been reported to have adverse kidney effects, including acute kidney injury, interstitial nephritis, and glomerular disease. Furthermore, some of these targeted therapies have also been found to cause an asymptomatic rise in serum creatinine levels through inhibition of active tubular secretion. A 79-year-old woman was being followed for stage 4 A2 chronic kidney disease secondary to type 2 diabetes and longstanding hypertension. She was diagnosed with invasive mammary carcinoma and was initiated on letrozole, an aromatase inhibitor, and palbociclib, a selective cyclin-dependent kinase inhibitor, was subsequently added. Prior to the initiation of her treatments, her baseline estimated glomerular filtration rate (eGFR) fluctuated between 25 and 28 mL/min/1.73 m<sup2</sup over the previous year. After initiating palbociclib, her serum creatinine progressively increased, despite having well-controlled blood pressure and diabetes. In addition, there was no history of pre-renal events nor any sonographic evidence of obstruction. Within 7 months, her eGFR based on serum creatinine had decreased down to 12 mL/min/1.73 m<sup2</sup. Given that there were no clinical or other biochemical changes suggestive of worsening renal function, a serum cystatin C was measured using an immunoturbidimetric assay, which was 1.71 mg/L and correlated with an eGFR of 33 mL/min/1.73 m<sup2</sup based on the chronic kidney disease epidemiology collaboration (CKD-EPI) cystatin C equation (2012). This value was consistent with her previous baseline. Based on these findings, the significant decrease in eGFR measured by serum creatinine was attributed to the inhibitory effects of palbociclib on tubular creatinine secretion, rather than representing true kidney damage. Thus, a kidney biopsy was not performed in this context. Seven months later, a repeat serum cystatin C was repeated to assess for any worsening of the patient's kidney function and revealed an eGFR of 35 mL/min/1.73 m<sup2</sup based on the CKD-EPI cystatin C equation (2012), thus revealing stable kidney function and reinforcing the inhibitory effects of palbociclib on tubular creatinine secretion through its direct effects on kidney transporters. This case report and literature review acknowledges the importance of using alternative methods of assessing kidney function when patients are undergoing targeted cancer therapies known to affect tubular creatinine secretion, which include cyclin-dependent kinase 4/6 inhibitors, poly(adenosine diphosphate-ribose) polymerase inhibitors, tyrosine kinase inhibitors, and mesenchymal-epithelial transition inhibitors. The use of non-creatinine-based markers of glomerular filtration rate (GFR), such as cystatin C and nuclear renal scans, will allow for more accurate estimation of kidney function in the appropriate setting, thus avoiding invasive diagnostic tests and unnecessary adjustments of treatment plans. However, certain targeted cancer therapies have also been proven to cause true kidney injury; therefore, physicians must still maintain a high degree of suspicion and consider invasive investigations and/or cessation or reduction of treatments when alternative measurements of kidney function do not suggest an underestimation of GFR via serum creatinine." }, { "id": "pubmed23n0012_4227", "title": "Late sequelae of adult-onset acute bacterial nephritis.", "score": 0.009345794392523364, "content": "The late manifestations of adult-onset acute bacterial nephritis were studied in four patients from 4 months to 5.6 years following initial infection. An unusual combination of generalized (global) wasting of the kidney and focal calyceal clubbing developed within a few weeks of the acute infection. The pattern of calyceal deformity strongly suggests papillary necrosis; it may develop during the acute phase, but go unrecognized during excretory urography at that time because of impaired contrast material excretion. The combination of a small, smooth kidney and papillary necrosis previously has been associated only with the more severe forms of analgesic nephropathy. Observations in these patients indicate that the same urographic findings may also occur as a result of a single earlier episode of acute bacterial infection of the kidney." }, { "id": "pubmed23n0397_21529", "title": "Drug-induced acute tubulointerstitial nephritis: a case with elevated urinary cadmium.", "score": 0.009259259259259259, "content": "Acute tubulointerstitial nephritis (ATIN) has many different causes, but is most frequently caused by drugs. We report a 13-year-old vegetarian girl with drug-induced ATIN, confirmed by renal biopsy, and simultaneous occurrence of elevated urinary cadmium. Four weeks prior to admission she had been treated with antibiotics and acetaminophen for respiratory infection, and remaining febrile, was treated with different \"home-made\" herbal mixtures. She presented with acute non-oliguric renal failure, tubular dysfunction, and sterile pyuria, but without skin rash or edema. Laboratory data showed a raised erythrocyte sedimentation rate, normal white blood count with eosinophilia, and a serum creatinine of 245 micromol/l. Urinalysis was remarkable for glycosuria, tubular proteinuria, and elevated beta(2)-microglobulin and N-acetyl-beta-D-glucosaminidase excretion. Immunoserological tests characteristic of acute glomerulonephritis and systemic diseases were negative. She was treated with steroids and her renal function improved. Follow-up analyses disclosed normal urinary cadmium and enzyme excretion within 6 months. Heavy metal analysis of herbal preparations that she had taken confirmed the presence of cadmium, but within approved concentrations. In conclusion, elevated urinary cadmium in the case of drug-induced ATIN may be assumed to be an accidental finding. However, consumption of different herbs containing cadmium and cadmium-induced nephro-toxicity could be the reason for such serious renal damage." }, { "id": "pubmed23n0549_11097", "title": "[Fluoroquinolone induced acute renal failure. General review about a case report with crystalluria due to ciprofloxacin].", "score": 0.009259259259259259, "content": "A 58 year-old woman developed an acute renal failure very quickly after ingestion of two 500 mg tablets of ciprofloxacin, without any other identifiable risk factor. Renal biopsy was performed. No sign of acute interstitial nephritis was observed but tubular lesions were found, accompanied by deposits of a brown-yellowish substance identified by infrared microscopy as a ciprofloxacin salt. The outcome was favourable. This observation gives the opportunity to remind the different forms of quinolone-induced renal injury and to discuss the possible ways for preventing renal side-effects related to the quinolone use." }, { "id": "pubmed23n0534_4422", "title": "[A case of microscopic polyangitis with sepsis due to pyelonephritis].", "score": 0.009174311926605505, "content": "A 69-year-old woman, who had been diagnosed with interstitial pneumonia at 66 years of age, was admitted to our hospital because of high fever, purpura occurring on her arms and legs, and renal dysfunction. At the time of admission, her renal function had severely deteriorated (sCr 8.2 mg/dl, 24 h Ccr 6 ml/min), she had a severe high fever (BT 39.5 degrees C), back pain, a white blood cell count of 19,540/,microl, and a CRP level of 26.7 mg/dl. Blood and urine cultures yielded identical strains of E. coli. We diagnosed sepsis caused by pyelonephritis, and started intravenous meropenem trihydrate(MEPM) at 0.5 g/day. Her renal dysfunction was severe, so we started hemodialysis therapy. Immunological examination revealed the presence of ANCA-associated glomerulonephritis. Renal biopsy before steroid therapy confirmed the diagnosis of pauci-immune-type crescentic glomerulonephritis. Based on purpura and interstitial pneumonia, along with rapidly MPO-ANCA-positive progressive glomerulonephritis (RPGN) with acute renal failure, we diagnosed microscopic polyangitis (MPA). To treat sepsis and severe pyelonephritis, we started intravenous immunoglobulin 5 g (100 mg/kg)/day for 5 days before starting immunosuppressive steroid therapy (m-PSL 1 g/day, PSL 20 mg/day) for 3 days. These treatments improved her general condition and immediately improved her renal function. It is important to prevent infection during treatment using conventional immunosuppressive therapy. These findings suggest immunoglobulin therapy to be a safe immuno-suppressive treatment that is efficacious against ANCA-associated glomerulonephritis." }, { "id": "pubmed23n0258_8339", "title": "[Long-term monitoring of female acute uncomplicated cystitis cases after lomefloxacin single-dose therapy].", "score": 0.009174311926605505, "content": "Female acute uncomplicated cystitis responds relatively well to antimicrobial chemotherapy, but this is also a disease which shows a high frequency of recurrence. However, there have been no published reports regarding long-term monitoring of the course of this disease after therapy has been administered. Accordingly, using primarily a questionnaire, the authors carried out long-term monitoring (for a mean of 242 days) of the natural course of cases of female acute uncomplicated cystitis after single-dose therapy with lomefloxacin (LFLX), a new quinolone antimicrobial agent. The subjects of this study were female patients diagnosed as having acute uncomplicated cystitis with pain upon urination, pyuria (&gt; or = 10 WBCs/hpf) and bacteriuria (&gt; or = 10(4) cfu/ml). LFLX was orally administered as a single dose of 100 mg or 300 mg, and the therapeutic efficacy was evaluated on the 3rd and 7th days thereafter. In principle, the evaluation of cure was performed on the 7th day after LFLX administration, and monitoring was conducted to detect early recurrence during the next 7 days (i.e., through the 14th day after treatment). Then the subjects were monitored for late recurrence during a mean follow-up period of 242 days by means of a questionnaire. Confirmation of recurrence was carried out to the greatest extent possible. It was possible to carry out long-term monitoring of the natural course of 101 cases of female acute uncomplicated cystitis in which the clinical efficacy on the 3rd day after LFLX treatment had been evaluated as good or excellent.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en013_55983", "title": "Kidney failure", "score": 0.00909090909090909, "content": "Acute kidney failure Acute kidney injury (AKI), previously called acute renal failure (ARF), is a rapidly progressive loss of renal function, generally characterized by oliguria (decreased urine production, quantified as less than 400 mL per day in adults, less than 0.5 mL/kg/h in children or less than 1 mL/kg/h in infants); and fluid and electrolyte imbalance. AKI can result from a variety of causes, generally classified as prerenal, intrinsic, and postrenal. Many people diagnosed with paraquat intoxication experience AKI, sometimes requiring hemodialysis. The underlying cause must be identified and treated to arrest the progress, and dialysis may be necessary to bridge the time gap required for treating these fundamental causes. Chronic kidney failure Chronic kidney disease (CKD) can also develop slowly and, initially, show few symptoms. CKD can be the long term consequence of irreversible acute disease or part of a disease progression." }, { "id": "pubmed23n0296_5889", "title": "Management of acute renal failure in the elderly. Treatment options.", "score": 0.00909090909090909, "content": "Renal changes that occur with aging mainly consist of impairment in the ability to concentrate urine and to conserve sodium and water. These physiological changes increase the risk of volume depletion and the prerenal type of acute renal failure (ARF) in elderly people. Bladder outlet obstruction caused by benign prostatic hypertrophy is a common cause of ARF in elderly men. Another frequent cause of ARF in the elderly is drug-induced nephropathy. Nonsteroidal anti-inflammatory drugs (NSAIDs) and antibiotics are most often implicated in the development of ARF in the elderly. However, considering the high usage of these drugs, the incidence of drug-induced nephropathy is relatively small. NSAIDs are more likely to cause ARF in patients with congestive heart failure, chronic renal disease (including diabetic nephropathy) or chronic liver disease than in otherwise healthy individuals. NSAID-induced ARF is often of the prerenal type, but may be caused by acute interstitial nephritis (AIN). The presence of heavy proteinuria or nephrotic syndrome differentiates NSAID-induced AIN from AIN caused by other drugs. Antibiotics, especially semisynthetic penicillins, more commonly give rise to AIN associated with peripheral blood eosinophilia and eosinophiluria than NSAIDs. Ciprofloxacin is increasingly reported to cause AIN. Fever commonly accompanies AIN, especially when induced by antibiotics. Aminoglycosides produce ARF by inducing acute tubular necrosis (ATN), which results from the excessive accumulation of myeloid bodies in the tubules. In all cases of ARF it is essential to obtain a good history, to perform a through physical examination, with particular attention to skin turgor, and to measure blood pressure, pulse rate (supine and upright), urinary electrolyte and creatinine levels. Fractional excretion of sodium and the urine:plasma creatinine ratio are reliable indices that distinguish prerenal ARF from ATN. A prompt response to fluid challenge, with an increase in urine output and urinary sodium excretion, and a rapid decrease in blood urea nitrogen, constitutes strong evidence for prerenal ARF. However, these indices are unreliable when prerenal ARF has progressed to ATN or when ARF has an obstructive pattern to begin with. In all cases of ARF, especially in elderly men, urinary tract obstruction should be suspected unless the history is otherwise clear cut. Ultrasound of the kidneys and bladder is a simple, non-invasive and meaningful test that can be used to rule out obstructive causes of ARF. If obstruction is the cause of ARF, ultrasound will be positive; in contrast, urinary obstruction is very unlikely if ultrasound findings are normal in a patient who has been oliguric or anuric for 48 hours or more. Similarly, acute glomerulonephritis, including rapidly progressive glomerulonephritis, should be suspected when ARF is associated with heavy proteinuria. In such instances, percutaneous renal biopsy is essential to document the diagnosis. It is of utmost importance to establish whether ARF is of prerenal or postrenal type, both of which are potentially fully reversible. In contrast, patients with ATN or rapidly progressive glomerulonephritis may not recover, or may only partially recover, their renal function. Haemodialysis and nutritional support are common measures for patients with severe ATN and a highly catabolic state. Corticosteroids and immunosuppressive therapy should be instituted for rapidly progressive glomerulonephritis, in addition to haemodialysis. haemodiafiltration instead of haemodialysis is recommended for patients who are haemodynamically unstable [i.e., with a persistently low blood pressure (systolic &lt; or = 100 mm Hg)]. Haemodiafiltration has been shown to improve acid-base balance and uraemia better than standard haemodialysis. However, despite dialysis, mortality in patients with ARF associated with ischaemic ATN remains high." }, { "id": "pubmed23n0811_18248", "title": "Drug-induced tubulointerstitial nephritis and uveitis syndrome with posterior uveitis resembling acute posterior multifocal placoid pigment epitheliopathy.", "score": 0.009009009009009009, "content": "To report the occurrence of acute posterior multifocal placoid pigment epitheliopathy (APMPPE)-like posterior uveitis as part of the ocular manifestation of tubulointerstitial nephritis and uveitis (TINU) syndrome. A 54-year-old previously healthy woman received oral ibuprofen and dipirone because of high fever and malaise. Three days after being started on this treatment, she developed bilateral posterior uveitis resembling APMPPE accompanied by anterior segment inflammation in the context of acute renal nephritis and maculopapular skin rash probably related to drug exposure. The patient was hospitalized because of acute renal failure and received support therapy and topical steroids in both eyes. A renal biopsy was not performed (based on good clinical response), but she fulfilled the clinical criteria of acute interstitial nephritis and TINU. Although her renal and ocular functions improved in the first week, she needed to be readmitted days later because of fever and generalized edema and received steroid pulse therapy. Fluorescein angiography was consistent with an APMPPE-like pattern and optical coherence tomography showed neither macular edema nor subretinal fluid. The ocular picture improved during the following weeks with fundus changes resembling those of APMPPE. Although anterior uveitis is considered the typical ocular component of TINU syndrome, posterior uveitis resembling APMPPE may also be its ocular manifestation." }, { "id": "pubmed23n0289_7631", "title": "[Acute renal failure as a complication of cholera].", "score": 0.009009009009009009, "content": "We present a 72-year-old man who had episodes of severe, acute renal failure during severe attacks of diarrhea caused by Vibrio cholerae. Patterns of acute tubular necrosis and tubulointerstitial nephritis developed following hypotension and decrease in renal blood flow, causing secondary renal ischemia. There was severe dehydration with profound hypovolemia and infection. The clinical picture included fever, weakness, arthralgia, pedal edema, mild bilateral pleural effusions, anemia, leukocytosis, azotemia with a maximum of 330 mg/dl of urea, creatine to a maximum of 9.8 mg/dl, hypoproteinemia, severe metabolic acidosis, marked increase in lactate dehydrogenase (LDH) and creatine phosphokinase (CPK), microscopic hematuria, sterile leukocyturia, normoglycemic glucosuria and phosphaturia with diminished tubular reabsorption of phosphorus. A short oliguric phase was followed by a polyuric phase lasting about 10 days, and glomerular and tubular function became normal after about 3 weeks. Treatment was by intensive infusions of fluids, electrolytes, sodium bicarbonate, salt-free albumin and antibiotics. To the best of our knowledge, this renal complication of cholera has not yet been described in Israel." }, { "id": "wiki20220301en000_98837", "title": "Ciprofloxacin", "score": 0.008849557522123894, "content": "Ciprofloxacin was patented in 1980 and introduced in 1987. It is on the World Health Organization's List of Essential Medicines. The World Health Organization classifies ciprofloxacin as critically important for human medicine. It is available as a generic medication. In 2019, it was the 113th most commonly prescribed medication in the United States, with more than 5million prescriptions. Medical uses Ciprofloxacin is used to treat a wide variety of infections, including infections of bones and joints, endocarditis, gastroenteritis, malignant otitis externa, respiratory tract infections, cellulitis, urinary tract infections, prostatitis, anthrax, and chancroid. Ciprofloxacin only treats bacterial infections; it does not treat viral infections such as the common cold. For certain uses including acute sinusitis, lower respiratory tract infections and uncomplicated gonorrhea, ciprofloxacin is not considered a first-line agent." }, { "id": "pubmed23n0591_13498", "title": "A double-blind, randomized comparison of levofloxacin 750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for the treatment of complicated urinary tract infections and acute pyelonephritis.", "score": 0.008849557522123894, "content": "A clinical study was conducted to compare the efficacy and safety of levofloxacin 750 mg once daily for 5 days to ciprofloxacin twice daily for 10 days for the treatment of complicated urinary tract infections (cUTI) or acute pyelonephritis (AP). A multicenter, double-blind, randomized, noninferiority study enrolled subjects with AP or cUTI. Subjects received either levofloxacin 750 mg intravenously or orally once daily for 5 days or ciprofloxacin 400 mg intravenously and/or ciprofloxacin 500 mg orally twice daily for 10 days and were evaluated at end of therapy, posttherapy, and poststudy for microbiologic eradication and clinical outcome. A total of 1109 subjects were enrolled; 619 with confirmed diagnosis of AP or cUTI and a study entry uropathogen with a colony count 10(5) CFU/mL or greater and were included in the modified intent-to-treat population. Five hundred six subjects met all criteria for inclusion and were included in the microbiologically evaluable population. At end of therapy, eradication rates in the modified intent-to-treat population were 79.8% for levofloxacin and 77.5% for ciprofloxacin-treated subjects (95% CI, -8.8% to 4.1%). In the microbiologically evaluable population, eradication rates were 88.3% for levofloxacin and 86.7% for ciprofloxacin-treated subjects (95% CI, -7.4% to 4.2%). Outcomes were comparable for the 2 treatments at posttherapy and poststudy. This study demonstrates that both drug regimens are safe and effective and that a 5-day course of therapy with levofloxacin, administered at a dose of 750 mg once daily, is noninferior to a 10-day course of therapy with ciprofloxacin for the treatment of AP and cUTI." } ] } } }

{ "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": [ [ 202, 622 ] ], "word_ranges": [ [ 32, 96 ] ], "text": "conjunctival jaundice, splenomegaly and family history of biliary lithiasis at an early age. He has reached 30 years of age without suffering a hemolytic crisis, without suffering any symptoms. There was no mention of microcytosis or macrocytosis to suggest thalassemia minor or B12 and/or folic acid deficiency. Nor of hemolytic crisis associated with the consumption of drugs, infections or ingestion of beans or peas." } }

{ "1": "Glucose 6-phosphate dehydrogenase deficiency.", "2": "Thalassemia minor.", "3": "Vitamin Bl2 and/or folic acid deficiency.", "4": "Familial pyruvate kinase deficiency.", "5": "Hereditary spherocytosis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0814_18982", "title": "Misdiagnosis of two cases of hereditary spherocytosis in a family and review of published reports.", "score": 0.016420147260050824, "content": "Hereditary spherocytosis is usually diagnosed based on a combination of clinical and family histories, physical examination, and laboratory data. Milder or atypical cases can be difficult to diagnose. We report one case each of mild and moderate hereditary spherocytosis whose diagnoses were made by the First Affiliated Hospital, Guangxi Medical University in China. In case 1, laboratory test results were as follows: hemoglobin 81.40 g/l, mean corpuscular hemoglobin concentration 339.00 g/l, mean corpuscular volume 82.88 fl, reticulocyte count 19%, mean sphered corpuscular volume 71.66 fl, total bilirubin 57.60 μmol/l, and blood smears showed increased spherocytosis. In case 2, laboratory test results were as follows: hemoglobin 133.10 g/l, mean corpuscular hemoglobin concentration 358.60 g/l, mean corpuscular volume 96.75 fl, reticulocyte count 17%, mean sphered corpuscular volume 77.78 fl, total bilirubin 62.50 μmol/l, and blood smears showed increased spherocytosis. Mild and moderate hereditary spherocytosis can be easily misdiagnosed. Assessment of total, direct, and indirect serum bilirubin, erythrocyte morphology and red cell characteristics (particularly mean corpuscular volume and mean sphered corpuscular volume) clearly distinguishes hereditary spherocytosis from autoimmune hemolytic anemia, glucose-6-phosphate dehydrogenase deficiency, thalassemia, and autoimmune hepatitis." }, { "id": "pubmed23n1105_16680", "title": "Confounding factors in the diagnosis and clinical course of rare congenital hemolytic anemias.", "score": 0.015867066466766618, "content": "Congenital hemolytic anemias (CHAs) comprise defects of the erythrocyte membrane proteins and of red blood cell enzymes metabolism, along with alterations of erythropoiesis. These rare and heterogeneous conditions may generate several difficulties from the diagnostic point of view. Membrane defects include hereditary spherocytosis and elliptocytosis, and the group of hereditary stomatocytosis; glucose-6-phosphate dehydrogenase and pyruvate kinase, are the most common enzyme deficiencies. Among ultra-rare forms, it is worth reminding other enzyme defects (glucosephosphate isomerase, phosphofructokinase, adenylate kinase, triosephosphate isomerase, phosphoglycerate kinase, hexokinase, and pyrimidine 5'-nucleotidase), and congenital dyserythropoietic anemias. Family history, clinical findings (anemia, hemolysis, splenomegaly, gallstones, and iron overload), red cells morphology, and biochemical tests are well recognized diagnostic tools. Molecular findings are increasingly used, particularly in recessive and de novo cases, and may be fundamental in unraveling the diagnosis. Notably, several confounders may further challenge the diagnostic workup, including concomitant blood loss, nutrients deficiency, alterations of hemolytic markers due to other causes (alloimmunization, infectious agents, rare metabolic disorders), coexistence of other hemolytic disorders (autoimmune hemolytic anemia, paroxysmal nocturnal hemoglobinuria, etc.). Additional factors to be considered are the possible association with bone marrow, renal or hepatic diseases, other causes of iron overload (hereditary hemochromatosis, hemoglobinopathies, metabolic diseases), and the presence of extra-hematological signs/symptoms. In this review we provide some instructive clinical vignettes that highlight the difficulties and confounders encountered in the diagnosis and clinical management of CHAs." }, { "id": "InternalMed_Harrison_3242", "title": "InternalMed_Harrison", "score": 0.015826564739608216, "content": "Hemolytic disorders that cause excessive heme production may be either inherited or acquired. Inherited disorders include spherocytosis, sickle cell anemia, thalassemia, and deficiency of red cell enzymes such as pyruvate kinase and glucose-6-phosphate dehydrogenase. In these conditions, the serum bilirubin level rarely exceeds 86 μmol/L (5 mg/dL). Higher levels may occur when there is coexistent renal or hepatocellular dysfunction or in acute hemolysis, such as a sickle cell crisis. In evaluating jaundice in patients with chronic hemolysis, it is important to remember the high incidence of pigmented (calcium bilirubinate) gallstones found in these CAuSES of iSoLATED HyPERBiLiRuBinEMiA PART 2 Cardinal Manifestations and Presentation of Diseases I. Indirect hyperbilirubinemia A. Hemolytic disorders 1. Inherited a. Spherocytosis, elliptocytosis, glucose-6-phosphate dehydrogenase and pyruvate kinase deficiencies b. 2. Acquired a. b. c. d. e. B. 1." }, { "id": "pubmed23n0049_16255", "title": "Homozygosity for dominant form of hereditary spherocytosis.", "score": 0.015617433414043584, "content": "A 6-month-old male infant with hereditary spherocytosis (HS) who was the first child of a cousin marriage is presented. The patient had splenomegaly and severe anaemia. Examination of the peripheral blood smear revealed spherocytes and the osmotic fragility of red blood cells was greatly increased. Physical examination of the parents revealed that both parents had mild anaemia, jaundice and splenomegaly. Their peripheral blood smears showed spherocytes and a few acanthocytes. Osmotic fragility of red blood cells of both parents were increased. Red cell membrane electrophoresis indicated a deficiency of ankyrin in the propositus; mild deficiency was also detected in both parents. Electrophoretic patterns of red cell membrane proteins suggested that the child was homozygous for the dominant form of HS associated with ankyrin deficiency, while both parents had the simple dominant form of the disease. Red blood cell transfusions were given to the patient starting at the age of 1 month until splenectomy was performed at the age of 1 year that resulted in complete haematological response. This observation indicates that homozygosity for dominant type of HS associated with ankyrin deficiency is life compatible and splenectomy may cure the anaemia." }, { "id": "pubmed23n1088_11994", "title": "Glucose 6 phosphate dehydrogenase deficiency: A single-center experience.", "score": 0.015546218487394958, "content": "This study aims to evaluate the demographic information, clinical and laboratory findings of patients with glucose 6 phosphate dehydrogenase deficiency. We collected data by reviewing files and electronic records of 65 patients with glucose 6 phosphate dehydrogenase deficiency under the age of 18 years who were followed up in our clinic between 2007 and 2019. Demographic, clinical, and laboratory features, family history, complications of the disease, and history of splenectomy and cholecystectomy were evaluated. Mean, standard deviation, and median values were used when descriptive analyses were presented. The age of diagnosis ranged between 1-192 months and the median age of diagnosis was two months. Fifty-nine patients (90.7%) were boys and six (9.2%) were girls. The mean value of glucose 6 phosphate dehydrogenase enzyme on admission was 1,9±1,4 U/g of hemoglobin (Hb). Family history was pesent in 40% of patients in whom information was avaliable. The most common presentation was prolonged jaundice and the most common physical finding was jaundice. Splenomegaly was detected in none of the patients. Cholelithiasis was present in one of 21 patients who were evaluated with ultrasonography. None of the patients required splenectomy, cholecystectomy, and regular erythrocyte transfusion during follow-up. As G6PD variants with chronic hemolysis are not usually seen in Turkey, patients who required splenectomy, cholecystectomy, and regular erythrocyte transfusion were not detected. Although glucose 6 phosphate dehydrogenase deficiency is more common in males, it can also be seen in girls. In Turkey, glucose 6 phosphate dehydrogenase deficiency should be considered in patients presenting with prolonged jaundice." }, { "id": "pubmed23n0320_5086", "title": "Pyruvate kinase deficiency in an alpha-thalassemia family: first case report in Thailand.", "score": 0.01538021726700972, "content": "In Thailand, the most common cause of chronic hemolytic anemia is thalassemia hemoglobinopathy. We report here a 10-year-old girl with pyruvate kinase (PK) deficiency who was initially diagnosed to have Hb H disease, like her sister. The patient had a history of neonatal jaundice which required blood exchange transfusion twice and phototherapy. She became anemic and regular blood transfusion was required since the age of 2 1/2 months. She was very anemic compared to her sister and was transfusion dependent. Besides, she never had red cell inclusion bodies, thus re-evaluation was performed. The diagnosis of red cell pyruvate kinase deficiency and the exclusion of Hb H disease was achieved after cessation of blood transfusion for 3 months. The family study also confirmed the diagnosis. The patient is now on high transfusion and iron chelation. She is doing well with mild splenomegaly." }, { "id": "pubmed23n0267_13390", "title": "[Megaloblastic anemia due to folate deficiency associated with hereditary spherocytosis].", "score": 0.015219907407407408, "content": "A 19 years old male admitted to our hospital with fever, abdominal pain in May 1991. Physical examination revealed anemia, jaundice and marked splenomegaly. Severe pancytopenia with macrocytic hyperchronic anemia was noted along with elevated LDH and reduced serum folate. Blood smear showed nucleated RBCs, but only few microspherocytes. Bone marrow showed erythroid hyperplasia with remarkable megaloblastic changes. Megaloblasts were negative for PAS stain. Chromosome analysis revealed normal karyotype. Erythroleukemia was suspected initially, but his general condition as well as hematological data improved following 10 units of RBC transfusion. Following brief folic acid supplements, numerous microspherocytes became evident, typical osmotic fragility test revealed a pattern for hereditary spherocytosis. These observations led us to the diagnosis of hereditary spherocytosis complicated by megaloblastic anemia due to folate deficiency. As he developed folate deficiency again 10 months later, splenectomy were performed. The anemia improved after splenectomy." }, { "id": "pubmed23n0865_16607", "title": "Disease-modifying influences of coexistent G6PD-deficiency, Gilbert syndrome and deletional alpha thalassemia in hereditary spherocytosis: A report of three cases.", "score": 0.01509627435342372, "content": "Hereditary spherocytosis (HS) is a common inherited hemolytic anemia characterized by heterogeneous clinical presentations with variable degrees of anemia, jaundice, splenomegaly and gallstones. Although the underlying genetic defects in red cell membrane proteins may explain many phenotypic variations, a proportion of variability may be due to other co-inherited factors like enzymopathies, thalassemias and Gilbert syndrome. Associations of HS with glucose-6-phosphate dehydrogenase (G6PD) deficiency and Gilbert syndrome in isolation have been reported previously. We describe 3 adult cases of HS with concomitant Gilbert syndrome and G6PD-Mediterranean mutations (2 hemizygous males, aged 15 and 35y and 1 heterozygous 25-y female). Two patients required multiple transfusions that required splenectomy for management. One patient (15y male) also carried the single gene alpha 4.2 deletion and was less symptomatic. These cases illustrate the importance of clinico-pathological correlation and judicious extended testing for various contributing factors that may modify the clinical course of HS patients. G6PD deficiency is also a common enzymopathy in India and can contribute to the phenotypic heterogeneity. Its recognition is important for advising avoidance of oxidizing drug exposure." }, { "id": "pubmed23n0638_16908", "title": "Hereditary spherocytosis in a 27-year-old woman: case report.", "score": 0.013264462809917357, "content": "Hereditary spherocytosis (HS) is a familial hemolytic disorder with marked heterogeneity of clinical features, ranging from an asymptomatic condition to a fulminant hemolytic anemia. Although a positive family history of spherocytosis increases the risk for this disorder, it may be sporadic in some cases. In severe cases the disorder may be detected in early childhood, but in mild cases it may go unnoticed until later in adult life. A 27-year-old Nigerian woman presented with mild anemia, jaundice, splenomegaly and a history of multiple blood transfusion. Blood film showed about 70% spherocytes, reticulocytosis of 6.5%, increased osmotic fragility test and a negative direct antiglobulin test. She was managed conservatively on nutritional supplements and a significant regression of symptoms after 6 months was achieved." }, { "id": "pubmed23n0054_18706", "title": "Hereditary spherocytosis: experience of 145 cases.", "score": 0.013168963955219052, "content": "145 patients were diagnosed to have hereditary spherocytosis (HS) over a period of 25 years. Jaundice (66.9%), fever (65.5%), weakness (44.8%), and abdominal pain (35.8%) were the commonest complaints. 94.5% had splenomegaly (JP-17 cm) and 71.7% had hepatomegaly (JP-6 cm). Spherocytes were detected in the peripheral smears of all patients at presentation on careful examination. 67 patients had been investigated elsewhere and spherocytes missed in 86.6%. Gall stones were seen in 20 of the 54 patients investigated. Family history suggestive of HS was available in only 16.6% of cases, whereas examination and investigations revealed HS in almost all families. Splenectomy was done in all symptomatic patients. In the 39 patients followed up for 1-9 years after splenectomy." }, { "id": "wiki20220301en003_62153", "title": "Jaundice", "score": 0.01291918636613524, "content": "Prehepatic causes Prehepatic jaundice is most commonly caused by a pathological increased rate of red blood cell (erythrocyte) hemolysis. The increased breakdown of erythrocytes → increased unconjugated serum bilirubin → increased deposition of unconjugated bilirubin into mucosal tissue. These diseases may cause jaundice due to increased erythrocyte hemolysis: Sickle-cell anemia Spherocytosis Thalassemia Pyruvate kinase deficiency Glucose-6-phosphate dehydrogenase deficiency Microangiopathic hemolytic anemia Hemolytic-uremic syndrome Severe malaria (in endemic countries) Hepatic causes" }, { "id": "wiki20220301en003_62176", "title": "Jaundice", "score": 0.012877180575200377, "content": "Causes The most common cause of jaundice in infants is normal physiologic jaundice. Pathologic causes of neonatal jaundice include: Breastmilk jaundice Formula jaundice Hereditary spherocytosis Glucose-6-phosphate dehydrogenase deficiency Pyruvate kinase deficiency ABO/Rh blood type autoantibodies Alpha 1-antitrypsin deficiency Alagille syndrome (genetic defect resulting in hypoplastic intrahepatic bile ducts) Progressive familial intrahepatic cholestasis Pyknocytosis (due to vitamin deficiency) Cretinism (congenital hypothyroidism) Sepsis or other infectious causes Pathophysiology Transient neonatal jaundice is one of the most common conditions occurring in newborns (children under 28 days of age) with more than eighty percent affected during their first week of life. Jaundice in infants, like adults, is characterized by increased bilirubin levels (total serum bilirubin greater than 5 mg/dL)." }, { "id": "pubmed23n1086_19962", "title": "Clinical Features and Outcome of Children With Hereditary Spherocytosis.", "score": 0.012658713414400245, "content": "The aim of this study was to evaluate the demographics, clinical, and laboratory findings and treatment responses of patients with hereditary spherocytosis (HS). Data of children with HS were examined. Diagnosis was based on clinical history, physical examination, family history, presence of spherocytes on peripheral blood smear, and osmotic fragility test. A total of 101 patients were included. The median (range) age at diagnosis was 38.0 (1 to 188) months. Mild, moderate, and severe forms of HS were present in 29 (28.7%), 15 (14.9%), and 57 (56.4%) patients, respectively. Family history was available in 73 patients and 56 of these (76.7%) had a positive family history for HS. Forty-five (44.5%) patients needed regular transfusions and all of these had severe disease. Although most patients did not require transfusion postsplenectomy, 2 of 45 (4.4%) patients continued to require transfusion. Transfusion dependence was significantly (P&lt;0.001) higher in patients with severe spherocytosis. In HS, splenomegaly, pallor, and jaundice are the most common clinical features. Splenectomy dramatically reduces hemolysis in most cases and virtually abolishes further requirement for transfusion." }, { "id": "article-29287_9", "title": "Hereditary Spherocytosis -- History and Physical", "score": 0.012031454783748362, "content": "Most patients with hereditary spherocytosis have a positive family history. [8] This disease should be suspected in any child presenting with splenomegaly, anemia, and hyperbilirubinemia. Patients may also present with asymptomatic cholelithiasis of undetermined etiology, commonly with a positive family history. [7]" }, { "id": "pubmed23n0973_10151", "title": "Hemolytic jaundice induced by pharmacological dose ascorbic acid in glucose-6-phosphate dehydrogenase deficiency: A case report.", "score": 0.011977520196698278, "content": "Hemolysis induced by high dose ascorbic acid (AA) in patients with G6PD deficiency has been reported, but is rare. To our knowledge, this is the first reported case of a male with G6PD deficiency, coexpressed with cholecystolithiasis and cholecystitis, who developed extreme hemolysis and hyperbilirubinemia after receiving pharmacological doses ascorbic acid infusion. A 27-year-old man history with glucose-6-phosphate dehydrogenase deficiency was admitted to our hospital because of cholecystolithiasis and cholecystitis. He appeared with scleral jaundice and very deep colored urine after receiving pharmacological doses ascorbic acid infusion. Clinical findings when combined with his medical history and various laboratory results confirmed the diagnosis as hemolysis and hyperbilirubinemia induced by ascorbic acid. The patient was treated with steroids, hepatoprotective drugs, and folic acid in addition avoidance of agents with known hemolysis risk (such as vitamin C). As a result, the patient's symptoms from hemolytic jaundice improved, hemoglobin remained stable, and the patient was discharged 11 days later. Clinicians should bear in mind the possibility that vitamin C exposure may result in hemolysis in patients with G6PD deficiency, especially in those with known severe disease." }, { "id": "InternalMed_Harrison_3243", "title": "InternalMed_Harrison", "score": 0.011964822319631682, "content": "A. Hemolytic disorders 1. Inherited a. Spherocytosis, elliptocytosis, glucose-6-phosphate dehydrogenase and pyruvate kinase deficiencies b. 2. Acquired a. b. c. d. e. B. 1. Cobalamin, folate, and severe iron deficiencies 2. C. Increased bilirubin production 1. 2. Resorption of hematoma D. Drugs 1. 2. 3. E. Inherited conditions 1. 2. II. A. B. patients, which increases the likelihood of choledocholithiasis as an alternative explanation for hyperbilirubinemia. lytic anemia (e.g., hemolytic-uremic syndrome), paroxysmal noc turnal hemoglobinuria, spur cell anemia, immune hemolysis, and parasitic infections (e.g., malaria and babesiosis). Ineffective erythro poiesis occurs in cobalamin, folate, and iron deficiencies. Resorption increased hemoglobin release and overproduction of bilirubin. In the absence of hemolysis, the physician should consider a problem with the hepatic uptake or conjugation of bilirubin." }, { "id": "wiki20220301en218_13340", "title": "Hematologic disease", "score": 0.01193590935628257, "content": "Myeloid Hemoglobinopathies (congenital abnormality of the hemoglobin molecule or of the rate of hemoglobin synthesis) Sickle cell disease Thalassemia Methemoglobinemia Anemias (lack of red blood cells or hemoglobin) Iron-deficiency anemia Megaloblastic anemia Vitamin B12 deficiency Pernicious anemia Folate deficiency Hemolytic anemias (destruction of red blood cells) Genetic disorders of RBC membrane Hereditary spherocytosis Hereditary elliptocytosis Congenital dyserythropoietic anemia Genetic disorders of RBC metabolism Glucose-6-phosphate dehydrogenase deficiency (G6PD) Pyruvate kinase deficiency Immune mediated hemolytic anemia (direct Coombs test is positive) Autoimmune hemolytic anemia Warm antibody autoimmune hemolytic anemia Idiopathic Systemic lupus erythematosus (SLE) Evans syndrome (antiplatelet antibodies and hemolytic antibodies) Cold autoimmune hemolytic anemia Cold agglutinin disease Paroxysmal cold hemoglobinuria (rare)" }, { "id": "wiki20220301en003_200643", "title": "Anemia", "score": 0.01153588195841717, "content": "Anemias of increased red blood cell destruction are generally classified as hemolytic anemias. These types generally feature jaundice, and elevated levels of lactate dehydrogenase. Intrinsic (intracorpuscular) abnormalities cause premature destruction. All of these, except paroxysmal nocturnal hemoglobinuria, are hereditary genetic disorders. Hereditary spherocytosis is a hereditary defect that results in defects in the RBC cell membrane, causing the erythrocytes to be sequestered and destroyed by the spleen. Hereditary elliptocytosis is another defect in membrane skeleton proteins. Abetalipoproteinemia, causing defects in membrane lipids Enzyme deficiencies Pyruvate kinase and hexokinase deficiencies, causing defect glycolysis Glucose-6-phosphate dehydrogenase deficiency and glutathione synthetase deficiency, causing increased oxidative stress Hemoglobinopathies Sickle cell anemia Hemoglobinopathies causing unstable hemoglobins Paroxysmal nocturnal hemoglobinuria" }, { "id": "First_Aid_Step2_389", "title": "First_Aid_Step2", "score": 0.011473429951690822, "content": "Erythrocytosis (an abnormal elevation of hematocrit) may be either 1° (due to ↑ RBC production) or 2° (due to ↓ plasma volume and hemoconcentration). T AB LE 2.7 -5. Differential Diagnosis of Thalassemias β-thalassemia major 0/2 β Patients develop severe microcytic anemia in the frst year of life and need chronic transfusions or marrow transplant to survive. β-thalassemia minor 1/2 β Patients are asymptomatic, but their cells are microcytic and hypochromic on peripheral smear. Hydrops fetalis 0/4 α Patients die in utero. Hemoglobin H disease 1/4 α Patients have severe hypochromic, microcytic anemia with chronic hemolysis, splenomegaly, jaundice, and cholelithiasis. The reticulocyte count elevates to compensate, and one-third of patients have skeletal changes due to expanded erythropoiesis. α-thalassemia trait 2/4 α Patients have low MCV but are usually asymptomatic. Silent carrier 3/4 α Patients have no signs or symptoms of disease." }, { "id": "article-29287_10", "title": "Hereditary Spherocytosis -- History and Physical", "score": 0.01146246044205228, "content": "The classic triad of jaundice, anemia, and splenomegaly is rare in neonates. The most common finding in this population is jaundice. Thus hereditary spherocytosis should be considered in neonates with hyperbilirubinemia of unknown cause. Additionally, spherocytes are seen less often in newborns along with several markers of the hemolysis that are typically present in older infants or adults. [9] Most neonates with hereditary spherocytosis have a positive family history; this should increase suspicion and aid in the diagnostic workup of patients with an unknown cause of jaundice. [9]" }, { "id": "pubmed23n0257_4573", "title": "[Hereditary spherocytosis: clinical characteristics and treatment with splenectomy].", "score": 0.011445444319460067, "content": "To analyse the clinico-biological characteristics at diagnosis, the clinical course, and the response to splenectomy of a series of patients with hereditary spherocytosis (HS). The clinical records of 61 patients diagnosed of HS along 30 years were reviewed. The diagnosis was based upon the existence of family history, physical findings, blood cell examination, reticulocyte count, peripheral blood spherocytes, red-cell osmotic fragility, auto-haemolysis, serum haptoglobin, LDH, non-conjugated bilirubin and direct anti-human globulin test. Data regarding the time of diagnosis and clinical course were taken into account in every case. Within the sub-group of 29 patients undergoing splenectomy, the changes in haemoglobin rates and reticulocyte and platelet counts after surgery were evaluated. Of the 61 patients, 35 were men and 26 women; the median age at diagnosis was 13 years (range: 0-64 years). Family history was positive in only 40% of the cases. The mean haemoglobin rate was 112 g/L (range: 46-151 g/L), over 60% of the patients having anaemia. The mean reticulocyte count was 282 x 10(9)/L (range: 31-583 x 10(9)/L), this being above 100 x 10(9)/L in 91% of the cases. Red-cell osmotic fragility with fresh blood was increased in 86% of the cases, and in 97% after blood incubation. Serum haptoglobins were decreased, whereas LDH was increased in 58% of the patients and non-conjugated bilirubin in 72%. Splenomegaly appeared in the clinical course in 87% of the patients; cholelithiasis was present in 31.5% of them. Haemoiytic crises were seen in 45% of patients, aplastic phases in 7%, and transfusion was needed by 16% of the patients to variable extents. Splenectomy was performed in 50% of the instances before 14 years of age (range: 4-64 years), and it increased haemoglobin rates in 40 g/L, anaemia being corrected in all cases; the mean reticulocyte count returned to normal, but thrombocytosis developed after surgery, it being present in 82% of the cases 2-3 months later. (1) Wide clinical variability is seen in HS, from severe forms requiring frequent transfusion to asymptomatic cases. (2) Highly frequent findings in HS are reticulocytosis and splenomegaly; relatively frequent were anaemia, haemolytic crisis and cholelithiasis, in this order. (3) Anaemia was always corrected after splenectomy, which also rose the haemoglobin rate even in the cases without anaemia, and returned the reticulocyte count to normal values." }, { "id": "InternalMed_Harrison_8087", "title": "InternalMed_Harrison", "score": 0.010095579450418161, "content": "The diagnosis of β-thalassemia major is readily made during childhood on the basis of severe anemia accompanied by the characteristic signs of massive ineffective erythropoiesis: hepatosplenomegaly, profound microcytosis, a characteristic blood smear (Fig. 127-5), and elevated levels of HbF, HbA2, or both. Many patients require chronic hypertransfusion therapy designed to maintain a hematocrit of at least 27–30% so that erythropoiesis is suppressed. Splenectomy is required if the annual transfusion requirement (volume of RBCs per kilogram of body weight per year) increases by >50%. Folic acid supplements may be useful. Vaccination with Pneumovax in anticipation of eventual splenectomy is advised, as is close monitoring for infection, leg ulcers, and biliary tract disease. Many patients develop endocrine deficiencies as a result of iron overload. Early endocrine evaluation is required for glucose intolerance, thyroid dysfunction, and delayed onset of puberty or secondary sexual" }, { "id": "wiki20220301en100_5529", "title": "List of MeSH codes (C18)", "score": 0.010024190608741757, "content": "– lactose intolerance – mannosidase deficiency diseases – alpha-mannosidosis – beta-mannosidosis – mucolipidoses – mucopolysaccharidoses – mucopolysaccharidosis I – mucopolysaccharidosis II – mucopolysaccharidosis III – mucopolysaccharidosis IV – mucopolysaccharidosis VI – mucopolysaccharidosis VII – multiple carboxylase deficiency – biotinidase deficiency – holocarboxylase synthetase deficiency – pyruvate metabolism, inborn errors – Leigh disease – pyruvate carboxylase deficiency disease – pyruvate dehydrogenase complex deficiency disease – cytochrome-c oxidase deficiency – glucosephosphate dehydrogenase deficiency – hyperbilirubinemia, hereditary – Crigler–Najjar syndrome – gilbert disease – jaundice, chronic idiopathic – lipid metabolism, inborn errors – hypercholesterolemia, familial – hyperlipidemia, familial combined – hypercholesterolemia, familial – hyperlipoproteinemia type IV – hyperlipoproteinemia type III" }, { "id": "pubmed23n0792_7564", "title": "[Clinical and experimental studies of adult hereditary spherocytosis].", "score": 0.00980392156862745, "content": "To explore the clinical characteristic of adult hereditary spherocytosis (HS) and the efficacies of splenectomy. Six cases with adult HS were collected from July 2006 to July 2012. And their clinical features, laboratory profile and treatment were retrospectively analyzed. There were 2 males and 4 females with a diagnostic age of 21-67 years. Their chief complaints were symptoms of upper gastrointestinal tract. The characteristic tetralogy was anemia, hemolysis, splenomegaly and gallstone.Familial inheritance pattern was found in 2 patients. The laboratory examination results demonstrated anemia, reticulocyte and elevated indirect bilirubin in 6 patients. Three patients had positive urobilinogen. The osmotic fragility (OF) test were 2 positive and 4 negative ones. And 2 negatives turned positive after incubation. The acidified glycerol lysis test (AGLT50) was positive in all. Ultrasonography showed splenomegaly and gallstone. There were 3 abnormal types red cells in peripheral blood, densely-dyed red cells (35%-89%) , microspherocytes (14%-20%) and irregular-shaped red cells.Scanning electron microscope showed single or many acanthocytes or spikes in red cell surface.Red cell body was irregular dish or flower-shaped. Biconcave disc shape disappearance. Three patients had short bands 3, 4.1 or 4.2. The age of onset was late and clinical symptoms was lighter.Spectrin-ankyrin was deficient for another 2 patients. The age of onset was early and clinical sign serious.Splenectomy and cholecystectomy were performed in 3 patients. Their postoperative hemoglobin was normal during follow-ups. Clinical relief was achieved. Combined experiments can enhance the diagnostic rate of adult HS so as to avoid misdiagnosis. And the efficacies of splenectomy are definite." }, { "id": "article-23157_11", "title": "Unconjugated Hyperbilirubinemia -- History and Physical", "score": 0.009621347364464907, "content": "Patients with unconjugated hyperbilirubinemia may present with jaundice or other signs, or the condition may be noticed in the asymptomatic patient by the finding of high levels of bilirubin in the serum during routine blood testing. As far as the differential diagnosis of unconjugated hyperbilirubinemia is involved, it requires a detailed history and physical examination of patients for the evaluation. The assessment of the patient’s clinical history includes; age at the disease manifestation, ethnic origin/race, hereditary disorder, family history of anemia or jaundice, recently used medications, diet history, and history of liver disease." }, { "id": "wiki20220301en059_49921", "title": "Neonatal jaundice", "score": 0.009615384615384616, "content": "Unconjugated Hemolytic Intrinsic causes of hemolysis Membrane conditions Spherocytosis Hereditary elliptocytosis Enzyme conditions Glucose-6-phosphate dehydrogenase deficiency (also called G6PD deficiency) Pyruvate kinase deficiency Globin synthesis defect sickle cell disease Alpha-thalassemia, e.g. HbH disease Extrinsic causes of hemolysis Systemic conditions Sepsis Arteriovenous malformation Alloimmunity (The neonatal or cord blood gives a positive direct Coombs test and the maternal blood gives a positive indirect Coombs test) Hemolytic disease of the newborn (ABO) Rh disease Hemolytic disease of the newborn (anti-Kell) Hemolytic disease of the newborn (anti-Rhc) Other blood type mismatches causing hemolytic disease of the newborn" }, { "id": "pubmed23n0976_19909", "title": "[Clinical and genetic features of children with hereditary spherocytosis: an analysis of 4 cases].", "score": 0.009523809523809525, "content": "Four children (two boys and two girls), aged from 3 years and 7 months to 5 years, had mild or moderate anemia, mild hepatosplenomegaly, jaundice (mainly an increase in indirect bilirubin), an increase in the percentages of reticulocytes and spherical erythrocytes in peripheral blood smear and an increase in erythrocyte osmotic brittleness. High-throughput sequencing found two novel mutations in the SLC4A1 gene, c.37G&gt;A and c.340T&gt;C, in case 1 and case 2 respectively, and these two mutations were predicted to be pathogenic by Mutation Taster. The Polyphen2 scores of these two mutations were 0.87 and 0.83 respectively, which suggested that these mutations were probably damaging. The SIFT scores of these two mutations were 0.008 and 0.09 respectively, suggesting that these mutations were probably damaging. No abnormality in this gene was found in their parents. Two reported heterozygous mutations in the ANK1 gene, c.830A&gt;G and c.985G&gt;C, were found in case 3 and case 4 respectively. Gene detection was not performed for the parents of case 3. The mother of case 4 was diagnosed with hereditary spherocytosis and had a heterozygous mutation of c.985G&gt;C in the ANK1 gene. All four children were diagnosed with hereditary spherocytosis. Case 3 had a hemoglobin level of &lt;80 g/L and underwent splenectomy at the age of 5 years and 6 months, and regular postoperative reexamination showed a hemoglobin level of &gt;105 g/L. Hereditary spherocytosis is a hereditary hemolytic disease caused by abnormality in erythrocyte membrane protein, and gene detection helps to make a confirmed diagnosis." }, { "id": "InternalMed_Harrison_23373", "title": "InternalMed_Harrison", "score": 0.009465434083601287, "content": "dispute this assertion. Moreover, on theoretical grounds, the results of such studies should provide no more information than simple measurements of the baseline serum bilirubin concentration. Family studies indicate that GS and hereditary hemolytic anemias such as hereditary spherocytosis, glucose-6-phosphate dehydrogenase deficiency, and β-thalassemia trait sort independently. Reports of hemolysis in up to 50% of GS patients are believed to reflect better case finding, since patients with both GS and hemolysis have higher bilirubin concentrations, and are more likely to be jaundiced, than patients with either defect alone." }, { "id": "wiki20220301en254_1491", "title": "Congenital hemolytic anemia", "score": 0.009433962264150943, "content": "Congenital hemolytic anemia refers to hemolytic anemia which is primarily due to congenital disorders. Types Basically classified by causative mechanism, types of congenital hemolytic anemia include: Genetic conditions of RBC Membrane Hereditary spherocytosis Hereditary elliptocytosis Genetic conditions of RBC metabolism (enzyme defects). This group is sometimes called congenital nonspherocytic (hemolytic) anemia, which is a term for a congenital hemolytic anemia without spherocytosis, and usually excluding hemoglobin abnormalities as well, but rather encompassing defects of glycolysis in the erythrocyte. Glucose-6-phosphate dehydrogenase deficiency (G6PD or favism) Pyruvate kinase deficiency Aldolase A deficiency Hemoglobinopathies/genetic conditions of hemoglobin Sickle cell anemia Congenital dyserythropoietic anemia Thalassemia See also Hematopoietic ulcer List of circulatory system conditions References External links Hereditary hemolytic anemias" }, { "id": "pubmed23n0630_12789", "title": "Clinico-hematological profile of hereditary spherocytosis: experience from a tertiary care center in North India.", "score": 0.009433962264150943, "content": "Hereditary spherocytosis (HS) is an inherited membranopathy characterized by phenotypic and genotypic heterogeneity. This study describes the clinico-hematological profile of 70 HS patients diagnosed at a tertiary care center in North India over a period of five years. Patients commonly presented with intermittent jaundice (82.9%), pallor (80%) and dark colored urine (11.4%). The common signs were splenomegaly (92.9%), hepatomegaly (50%), cholelithiasis or choledocholithiasis (36.8%) and hemolytic facies (10%). Family history was contributory in 28.6% patients. Blood transfusion (BT) requirement was present in 35.7% patients. Unconjugated and conjugated hyperbilirubinemia was seen in 89.1 and 10.9% patients respectively. At presentation, the hemoglobin ranged from 3-14 g/dl with a mean of 9.37 g/dl (SD2.43). Spherocytes were seen in 88.6% and incubated Osmotic fragility test (OFT) was positive in 88.2% patients. The Eosin-5-maleimide (EMA) flow cytometric test was done in 28 patients. Mean fluorescence intensity (MFI) for normal subjects was 11861.5 (SD-883.51) and for confirmed HS patients was 7949.3 (SD1304.1). Taking the MFI range of 5341.1-10 557.5 for HS, eight cases of suspected HS/undiagnosed hemolytic anemia with a negative (n=5) or equivocal (n=3) incubated OFT were diagnosed as HS. An increase in HbF level was seen in 10 cases ranging from 2.1 to 17.7% with a mean of 5.66%, three of these had associated beta thalassaemia trait. Twelve patients (17%) underwent splenectomy and 91% of them did not require any BT post-splenectomy. Among the patients treated conservatively 49% had persisting pallor and 16.3% had transfusion requirement." }, { "id": "wiki20220301en003_103400", "title": "Hemolysis", "score": 0.009345794392523364, "content": "Toxic agent ingestion or poisoning Paxillus Involutus ingestion can cause hemolysis. Intrinsic causes Hemolysis may result from intrinsic defects in the red blood cell itself: Defects of red blood cell membrane production (as in hereditary spherocytosis and hereditary elliptocytosis) Defects in hemoglobin production (as in thalassemia, sickle-cell disease and congenital dyserythropoietic anemia) Defective red cell metabolism (as in glucose-6-phosphate dehydrogenase deficiency and pyruvate kinase deficiency) Paroxysmal nocturnal hemoglobinuria (PNH), sometimes referred to as Marchiafava-Micheli syndrome, is a rare, acquired, potentially life-threatening disease of the blood characterized by complement-induced intravascular hemolytic anemia. Extrinsic causes" }, { "id": "pubmed23n0652_17689", "title": "Hereditary spherocytosis.", "score": 0.009345794392523364, "content": "A 12-year-old girl was brought to the Dhaka Hospital of ICDDR,B with diarrhoea. Incidentally, the parents provided a history of repeated episodes of pallor and jaundice since she was two and half years old. Three of her family members had similar problems. History, clinical examination, and laboratory findings of the girl and her family members suggested a case of hereditary spherocytosis. To our knowledge, this is the first report of such a case in Bangladesh." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 641, 912 ] ], "word_ranges": [ [ 106, 150 ] ], "text": "In this case, the water deficit is: ([[tel:155-140/140|155-140/140]])x60x0.4 = 2.57 liters. There are only two answers that come close to this figure, but 2 seems more correct, as it is the only one that completely covers the water deficit and uses a hyposodium solution." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": true, "char_ranges": [ [ 641, 912 ] ], "word_ranges": [ [ 106, 150 ] ], "text": "In this case, the water deficit is: ([[tel:155-140/140|155-140/140]])x60x0.4 = 2.57 liters. There are only two answers that come close to this figure, but 2 seems more correct, as it is the only one that completely covers the water deficit and uses a hyposodium solution." } }

{ "1": "Hypertonic saline (3%), 500 ml + 500 ml of 5% glucose.", "2": "Hyposaline saline (0.45%), 3000 ml.", "3": "Serum glucose 5% 1000 ml.", "4": "Oral hydration with 1 liter of water.", "5": "Isotonic saline (0.9%), 2000 ml." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en086_257", "title": "Hyperosmolar hyperglycemic state", "score": 0.015152384778740743, "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": "pubmed23n0599_16576", "title": "Gastric distension attenuates the hypotensive effect of intraduodenal glucose in healthy older subjects.", "score": 0.013606071825249907, "content": "Postprandial hypotension occurs frequently, and current management is suboptimal. Recent studies suggest that the magnitude of the fall in postprandial blood pressure (BP) may be attenuated by gastric distension. The aim of this study was to determine the effect of gastric distension on the hypotensive response to intraduodenal (ID) glucose. Eight healthy subjects (5 males, 3 females, aged 65-76 years) received an ID infusion of either 1) 50 g glucose in 300 ml saline (ID glucose) over 60 min (t=0-60 min), 2) 50 g glucose in 300 ml saline over 60 min and intragastric (4) infusion of 500 ml water between t=7-10 min (IG water and ID glucose), or 3) ID saline (0.9%) infusion over 60 min and IG infusion of 500 ml water (IG water and ID saline) all followed by ID saline infusion for another 60 min (t=60-120 min) on three separate days. BP and heart rate (HR) were measured. Gastric emptying (GE) of the IG water was quantified by two-dimensional ultrasonography. Between t=0-60 min, systolic and diastolic BP was greater (P&lt;0.05 for both) with IG water and ID saline compared with IG water and ID glucose, and less (P&lt;0.05 for both) with ID glucose compared with IG water and ID glucose. These effects were evident at relatively low IG volumes (approximately 300 ml). GE was faster with IG water and ID saline when compared with IG water and ID glucose. We conclude that, in healthy older subjects, IG administration of water markedly attenuates the hypotensive response to ID glucose, presumably as a result of gastric distension." }, { "id": "pubmed23n0418_9681", "title": "The effect of an oral glucose load on sodium and water excretion after rapid intravenous infusion of 0.9% (w/v) saline.", "score": 0.013540155488598741, "content": "Previous studies have suggested that oral or intravenous glucose enhances salt and water retention following a saline load. To test this, we studied the effects of an oral glucose load on urinary sodium and water excretion and serum biochemistry in response to a 2l intravenous infusion of 0.9% saline in normal subjects. A crossover study was conducted on six male volunteers. On one occasion, they received 2l 0.9% saline intravenously over 1h. A week later, they were given 100ml 50% dextrose orally prior to the same infusion. Subjects passed urine before start of the infusion. Body weight, haematocrit and serum biochemistry were recorded preinfusion and hourly for 6h. Urine was collected for 6h postinfusion and analysed for sodium, potassium and osmolality. The six subjects had a mean (SE) age of 20.9 (0.4) years and BMI of 22.7 (0.2). Median (IQR) water balance over 6h was 1462 (1005-1650)ml after saline and 1203 (989-1735)ml after glucose and saline (NS). Urinary sodium and potassium excretion on the two occasions over 6h were 76 (69-111) vs 74 (92-174)mmol and 31 (29-40) vs 30 (20-36)mmol, respectively (NS). Using repeated measures testing, there was no significant difference in body weight, haematocrit, serum albumin, sodium, potassium, chloride, osmolality and blood glucose measured at hourly intervals on the two occasions. In contrast to previous literature, in normal subjects, an additional oral glucose load does not appear to have an effect on urinary sodium excretion or serum biochemistry after a rapid 2l infusion of 0.9% saline. This does not preclude an effect under conditions of prior starvation or injury." }, { "id": "wiki20220301en010_64094", "title": "Hyponatremia", "score": 0.013325647633256476, "content": "Total body water = kilograms of body weight x 0.6 Fluids Options include: Mild and asymptomatic hyponatremia is treated with adequate solute intake (including salt and protein) and fluid restriction starting at 500 millilitres per day (mL/d) of water with adjustments based on serum sodium levels. Long-term fluid restriction of 1,200–1,800 mL/d may maintain the person in a symptom-free state. Moderate and/or symptomatic hyponatremia is treated by raising the serum sodium level by 0.5 to 1 mmol per liter per hour for a total of 8 mmol per liter during the first day with the use of furosemide and replacing sodium and potassium losses with 0.9% saline. Severe hyponatremia or severe symptoms (confusion, convulsions, or coma): consider hypertonic saline (3%) 1–2 mL/kg IV in 3–4 h. Hypertonic saline may lead to a rapid dilute diuresis and fall in the serum sodium. It should not be used in those with an expanded extracellular fluid volume." }, { "id": "wiki20220301en322_22294", "title": "Intravenous sugar solution", "score": 0.01330542151575362, "content": "Concentrated dextrose solutions should not be administered subcutaneously or intramuscularly as they can cause cell death via dehydration and subsequent necrosis. Types Types of glucose/dextrose include: D5W (5% dextrose in water), which consists of 278 mmol/L dextrose D5NS (5% dextrose in normal saline), which, in addition, contains normal saline (0.9% w/v of NaCl). D5 1/2NS 5% dextrose in half amount of normal saline (0.45% w/v of NaCl). D5LR (5% dextrose in lactated Ringer solution) D50 – 50% dextrose in water The percentage is a mass percentage (or more precisely, a mass-volume percentage), so a 5% glucose/dextrose solution contains 50 g/L of glucose/dextrose (5g/100ml). Glucose provides energy 4 kcal/gram, so a 5% glucose solution provides 0.2 kcal/ml. If prepared from dextrose monohydrate, which provides 3.4 kcal/gram, a 5% solution provides 0.17 kcal/ml. References External links" }, { "id": "wiki20220301en057_29614", "title": "Crush syndrome", "score": 0.01280358060019077, "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": "InternalMed_Harrison_27969", "title": "InternalMed_Harrison", "score": 0.012637436310002682, "content": "Fluid replacement should initially stabilize the hemodynamic status of the patient (1–3 L of 0.9% normal saline over the first 2–3 h). Because the fluid deficit in HHS is accumulated over a period of days to weeks, the rapidity of reversal of the hyperosmolar state must balance the need for free water repletion with the risk that too rapid a reversal may worsen neurologic function. If the serum sodium is >150 mmol/L (150 meq/L), 0.45% saline should be used. After hemodynamic stability is achieved, the IV fluid administration is directed at reversing the free water deficit using hypotonic fluids (0.45% saline initially, then 5% dextrose in water [D5W]). The calculated free water deficit (which averages 9–10 L) should be reversed over the next 1–2 days (infusion rates of 200–300 mL/h of hypotonic solution). Potassium repletion is usually necessary and should be dictated by repeated measurements of the serum potassium. In patients taking diuretics, the potassium deficit can be quite" }, { "id": "article-25982_9", "title": "Normal Saline -- Administration", "score": 0.012481146304675717, "content": "Normal saline solution can be administered only via intravenous access. [2] When deciding dosage, the provider must take into account various patient factors (e.g., weight, age, clinical presentation, laboratory findings). Therefore, monitoring should focus on laboratory results and clinical evaluation (see ‘Monitoring’ section). Naturally, there are two methods of administration for normal saline: 1) Fluid bolus This route is normally used in the acute care setting when a rapid infusion of fluids is necessary (e.g., hypovolemia). Delivery of fluid should be administered through large-bore peripheral lines or via central-line access. [3] 2) Maintenance The calculation of daily fluid requirements is achievable in various ways. Common practices utilize the formulas created by Drs. Holliday and Segar which indicate that one can use the \"100-50-25\" or \"4-2-1\" rules. [4] Examples: For a 50 kg patient First 10 kg weight = 1000 mL (100 mL/kg x 10) Second 10 kg weight = 500 mL (50 mL/kg x 10)" }, { "id": "wiki20220301en040_16506", "title": "Saline (medicine)", "score": 0.012361402457296973, "content": "Normal saline (NSS, NS or N/S) is the commonly used phrase for a solution of 0.90% w/v of NaCl, 308 mOsm/L or 9.0 g per liter. Less commonly, this solution is referred to as physiological saline or isotonic saline (because it is approximately isotonic to blood serum, which makes it a physiologically normal solution). Although neither of those names is technically accurate because normal saline is not exactly like blood serum, they convey the practical effect usually seen: good fluid balance with minimal hypotonicity or hypertonicity. NS is used frequently in intravenous drips (IVs) for people who cannot take fluids orally and have developed or are in danger of developing dehydration or hypovolemia. NS is also used for aseptic purpose. NS is typically the first fluid used when hypovolemia is severe enough to threaten the adequacy of blood circulation, and has long been believed to be the safest fluid to give quickly in large volumes. However, it is now known that rapid infusion of NS" }, { "id": "wiki20220301en040_16508", "title": "Saline (medicine)", "score": 0.012278353964536635, "content": "The solution is 9 grams of sodium chloride (NaCl) dissolved in water, to a total volume of 1000 ml (weight per unit volume). The mass of 1 millilitre of normal saline is 1.0046 grams at 22 °C. The molecular weight of sodium chloride is approximately 58.4 grams per mole, so 58.4 grams of sodium chloride equals 1 mole. Since normal saline contains 9 grams of NaCl, the concentration is 9 grams per litre divided by 58.4 grams per mole, or 0.154 mole per litre. Since NaCl dissociates into two ions – sodium and chloride – 1 molar NaCl is 2 osmolar. Thus, NS contains 154 mEq/L of Na+ and the same amount of Cl−. This points to an osmolarity of 154 + 154 = 308, which is higher (i.e. more solute per litre) than that of blood (approximately 285). However, if the osmotic coefficient (a correction for non-ideal solutions) is taken into account, then the saline solution is much closer to isotonic. The osmotic coefficient of NaCl is about 0.93, which yields an osmolarity of 0.154 × 1000 × 2 × 0.93 =" }, { "id": "wiki20220301en002_195789", "title": "Diabetic ketoacidosis", "score": 0.012266337999237022, "content": "Fluid replacement The amount of fluid replaced depends on the estimated degree of dehydration. If dehydration is so severe as to cause shock (severely decreased blood pressure with insufficient blood supply to the body's organs), or a depressed level of consciousness, rapid infusion of saline (1 liter for adults, 10 ml/kg in repeated doses for children) is recommended to restore circulating volume. Slower rehydration based on calculated water and sodium shortage may be possible if the dehydration is moderate, and again saline is the recommended fluid. Very mild ketoacidosis with no associated vomiting and mild dehydration may be treated with oral rehydration and subcutaneous rather than intravenous insulin under observation for signs of deterioration. Normal saline (0.9% saline) has generally been the fluid of choice. There have been a few small trials looking at balanced fluids with few differences." }, { "id": "InternalMed_Harrison_27954", "title": "InternalMed_Harrison", "score": 0.012146914840702636, "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": "InternalMed_Harrison_12823", "title": "InternalMed_Harrison", "score": 0.012040133779264214, "content": "Moderatec,d <4 months (<5 kg) 200–400 mL of ORS 4–11 months (5–<8 kg) 400–600 mL of ORS 12–23 months (8–<11 kg) 600–800 mL of ORS 2–4 years (11–<16 kg) 800–1200 mL of ORS 5–14 years (16–<30 kg) 1200–2200 mL of ORS ≥15 years (≥30 kg) 2200–4000 mL of ORS All ages and weights Undertake IV fluid replacement with Ringer’s lactate (or, if not available, normal saline). Give 100 mL/kg in the first 3-h period (or the first 6-h period for children <12 months old); start rapidly, then slow down. Give a total of 200 mL/ kg in the first 24 h. Continue until the patient is awake, can ingest ORS, and no longer has a weak pulse. aAdapted from World Health Organization: First steps for managing an outbreak of acute diarrhoea. Global Task Force on Cholera Control, 2009 (www.who.int/topics/cholera). bContinue normal feeding during treatment. cReassess regularly; monitor stool and vomit output. dVolumes of ORS listed should be given within the first 4 h. Abbreviation: ORS, oral rehydration solution." }, { "id": "pubmed23n0414_18875", "title": "[Anesthesia for cesarean section in a patient with transient diabetes insipidus].", "score": 0.012030346820809248, "content": "A 32-year-old pregnant female was admitted to our hospital at 32 week gestation and was scheduled for emergent cesarean section because of fetal distress. She had been suffering hydrodipsia and dry mouth, and had lost 4 kg in 2 weeks. Hypernatremia, hyperchloremia, and lower urinary specific gravity were preoperatively noted. Her electrolyte imbalance was partially corrected by the infusion of 1400 ml of 5% glucose solution and 500 ml of acetated Ringer's solution, but unexpected hyperglycemia; 440 mg.dl-1, appeared before surgery. Cesarean section was successfully performed with spinal anesthesia. A 1566 g male infant was delivered with 1 and 5 min Apgar scores of 2 and 1. Hyperglycemia and secondary hypoglycemia occurred in the infant in the neonatal ICU. The mother's fluid loss, including blood and amniotic fluid, was estimated at 784 ml. Five hundred milliliters of acetated Ringer's solution and 1000 ml of half saline solution with 2.5% glucose were infused before delivery, followed by the glucose solution containing a low concentration of sodium after delivery. After surgery, high serum osmotic pressure and paradoxically low urinary osmotic pressure were found. The plasma antidiuretic hormone level was normal against the high serum osmotic pressure. The electrolyte imbalance and urinary osmotic pressure were improved by using I-deamino-8-d-arginine vasopressin, and DI was finally diagnosed. Hormonal therapy was discontinued on day 20, and the patient was discharged on day 21. Some pregnancies are complicated by transient DI. Anesthesiologists have to consider DI when a pregnant female has symptoms of dehydration and a significant electrolyte imbalance." }, { "id": "pubmed23n0415_3568", "title": "Effects of high-dose furosemide and small-volume hypertonic saline solution infusion in comparison with a high dose of furosemide as bolus in refractory congestive heart failure: long-term effects.", "score": 0.011525086934923, "content": "Diuretics have been accepted as first-line treatment in refractory congestive heart failure (CHF), but a lack of response to them is a frequent event. A randomized, 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 New York Heart Association (NYHA) class IV CHF and a normosodic diet during follow-up. Materials and Methods One hundred seven patients (39 women and 68 men, age range 65-90 years) with refractory CHF (NYHA class IV) of different etiologies, who were unresponsive to high oral doses of furosemide, angiotensin-converting enzyme inhibitors, digitalis, and nitrates, were enrolled. Inclusion criteria included an ejection fraction (EF) &lt;35%, serum creatinine level &lt;2 mg/dL, blood urea nitrogen level &lt; or =60 mg/dL, reduced urinary volume, and low natriuresis. The patients were randomized in 2 groups (single-blind). Patients in group 1 (20 women and 33 men) received an intravenous (IV) infusion of furosemide (500-1000 mg) plus HSS (150 mL of 1.4%-4.6% NACl) twice a day in 30 minutes. Patients in group 2 (19 women and 35 men) received an IV bolus of furosemide (500-1000 mg) twice a day, without HSS, during a period lasting 6 to 12 days. Both groups received IV KCl (20-40 mEq) to prevent hypokalemia. At study entry, all patients underwent a physical examination and measurement of body weight (BW), blood pressure (BP), and heart rate (HR), an evaluation of signs of CHF, and measurement of control levels of serum Na, K, Cl, bicarbonate, albumin, uric acid, creatinine, urea, and glycemia daily during hospitalization, and measurements of the daily output of urine for Na, K, and Cl. A chest radiograph, electrocardiogram, and echocardiogram were obtained at study entry, during hospitalization, and at the time of discharge from the hospital. During the treatment and after discharge, the daily dietary Na intake was 120 mmol in group 1 versus 80 mmol in group 2, with a fluid intake of 1000 mL daily in both groups. An assessment of BW and 24-hour urinary volume, serum, and urinary laboratory parameters were performed daily until patients reached a compensated state, when IV furosemide was replaced with oral administration (250-500 mg/d). After discharge from the hospital, patients were observed as outpatients weekly for the first 3 months and, subsequently, once a month. The groups were similar in age, sex, EF, risk factors, treatment, and etiology of CHF. All patients showed a clinical improvement. Ten patients in both groups had hyponatremia at entry. A significant increase in daily diuresis and natriuresis was observed in both groups, but it was more significant in the group receiving HSS (P &lt;.05). The serum Na level increased in group 1 and decreased in group 2 (P &lt;.05). The serum K level was decreased in both groups (P &lt;.05). BW was reduced in both groups (P &lt;.05). Group 2 had an increase in serum creatinine level. Serum uric acid levels increased in both groups. BP values decreased and HR was corrected to normal values in both groups. In the follow-up period (31 +/- 14 months), 25 patients from group 1 were readmitted to the hospital for heart failure. In group 2, 43 patients were readmitted to the hospital at a higher class than at discharge. Twenty-four patients in group 1 died during follow-up, versus 47 patients in group 2 (P &lt;.001). This treatment is effective and well tolerated, improves the quality of life through the relief of signs and symptoms of congestion, and may delay more aggressive treatments. The effects were also beneficial in a long period for mortality reduction (55% vs 13% survival rate) and for clinical improvement." }, { "id": "pubmed23n0130_4218", "title": "Evaluation of an oral rehydration solution with Na+ 60 mmol/l in infants hospitalized for acute diarrhoea or treated as outpatients.", "score": 0.01144678221846444, "content": "An oral rehydration solution (ORS) containing 60 mmol/l of Na+ (ORS60) was compared in a randomized trial with the ORS of WHO formula (Na+ 90 mmol/l = ORS90) for the treatment of diarrhoeal dehydration in 66 hospitalized infants aged 3 to 34 months. The infants had a 5 +/- 3% dehydration, and received within 6-10 hours 76 +/- 32 ml/kg of ORS60 or 74 +/- 41 ml/kg of ORS90 corresponding to a sodium input of 4.6 +/- 1.9 mmol/kg and 6.6 +/- 3.7 mmol/kg, respectively. Both treatments were found adequate and equally effective for the correction of dehydration and sodium deficit. The same ORS60 was also compared to a commercial low sodium glucose-electrolyte solution (sodium 35 mmol/l, glucose 3.5 milligrams) for ambulatory treatment of acute diarrhoea in infants. Satisfactory rehydration was achieved within 6 hours in 19 of 23 infants receiving ORS60 as opposed to 6 of 18 infants receiving the commercial solution (p less than 0.001); the poor result with the latter was in most cases attributed to a refusal by the infant to consume the sweetish solution. It is concluded that ORS60 is suitable for the treatment of isotonic diarrhoeal dehydration in hospitalized children as well as outpatients." }, { "id": "pubmed23n0351_68", "title": "Hypertonic saline.", "score": 0.01118798304662179, "content": "A key feature in the successful resuscitation of dehydrated or endotoxemic ruminants is the total amount of sodium administered. Administration of small volumes of HS and HSD offer major advantages over large volumes of isotonic saline because HS and HSD do not require intravenous catheterization or periodic monitoring, and are therefore suitable for use in the field. Hypertonic saline and HSD exert their beneficial effect by rapidly increasing preload and transiently decreasing afterload. Contrary to early reports, HS and HSD decrease cardiac contractility and do not activate a pulmonary reflex. The osmolality of HS and HSD should be 2400 mOsm/L (7.2% NaCl solution, 8 times normal plasma osmolality). Use of HS and HSD solutions of different osmolality to 2400 mOsm/L should be avoided at all costs, as too low a tonicity removes the main advantages of HS (low cost, decreased infusion time), whereas too high a tonicity may cause rapid vasodilation and decreased cardiac contractility, resulting in death. Rapid administration (&gt; 1 mL/kg-1/min-1) of HS (2400 mOsm/L) should be avoided, as the induced hypotension may be fatal when coupled with a transient decrease in cardiac contractility. For treating dehydrated adult ruminants, HS (2400 mOsm/L, 4-5 mL/kg i.v. over 4-5 minutes) should be administered through the jugular vein and the cow allowed to drink water. This means that 2 L of HS should be administered to adult cattle. HSD should be administered in conjunction with isotonic oral electrolyte solutions to all calves 8% or more dehydrated (eyes recessed &gt; or = 4 mm into the orbit, cervical skin tent duration &gt; 6 seconds) or calves with reduced cardiac output (fetlock temperature &lt; 29 degrees C when housed at 10-24 degrees C). For treating dehydrated calves, HSD (2400 mOsm/L NaCl in 6% dextran-70, 4-5 mL/kg i.v. over 4-5 minutes) should be administered through the jugular vein and the calf allowed to suckle an isotonic oral electrolyte solution. This means that 120-200 mL of HSD of HSD should be administered to a calf. HSD should be routinely administered to severely depressed or comatose calves, as HSD provides the fastest method of resuscitation while rapidly reversing the effects of hyperkalemia." }, { "id": "article-19180_28", "title": "Cerebral Contusion -- Treatment / Management", "score": 0.010868365883261613, "content": "If using a parenchymal ICP device, change to an EVD. Hyperosmolar therapy (mannitol or hypertonic saline), given intermittently. Mannitol administered in intermittent boluses (0.25 to 1 gm/ kg body weight). Check frequently the serum sodium and osmolality; additional doses held if serum osmolality exceeds 320 mOsm/L. Hypertonic saline 3% sodium chloride solution administered in intermittent boluses of 250 ml over 0.5 hours (2-5 mL/kg over 10-20 minutes). Serum sodium and osmolality checked every 6 hours. Additional doses held if serum sodium exceeds 160 mEq/L. A bolus of up to 23.4% sodium chloride solution can be given for refractory increased ICP. CPP no less than 50 mm Hg. (Goal between 60 and 70 mm Hg). PaCO2 goal of 30 to 35 mmHg should be maintained. Repeat head CT imaging if no improvement. Neuromuscular paralysis bolus test dose. If ICP remains ≥ 20 to 25 mmHg, proceed to Tier 3. Tier 3" }, { "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": 0.010814195053928683, "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": "wiki20220301en408_9374", "title": "Evans formula", "score": 0.010442773600668337, "content": "The Evans formula was the first burn resuscitation formula based on body surface area damage and body weight, described in 1952. It was the standard burn care formula for years. Formula Evans formula: normal saline at 1 ml/kg/% TBSA burn \" colloid at 1 ml/kg/% TBSA burn. For second 24 hours, give half of the first 24-hour requirements \" D5W (dextrose 5% in water) 2000 ml. References Emergency medical procedures" }, { "id": "InternalMed_Harrison_26613", "title": "InternalMed_Harrison", "score": 0.010260650592900232, "content": "from as little as 15 min after injection to 60 min after oral administration. When given in a dose that normalizes 24-h urinary osmolarity (400–800 mosmol/L) and volume (15–30 mL/kg body weight), DDAVP produces a slight (1–3%) increase in total body water and a decrease in plasma osmolarity/sodium that rapidly eliminates thirst and polydipsia (Fig. 404-5). Consequently, water balance is maintained within the normal range. Hyponatremia does not develop unless urine volume is reduced too far (to less than 10 mL/kg per day) or fluid intake is excessive due to an associated" }, { "id": "article-21836_33", "title": "Fluid Management -- Preparation", "score": 0.01021978021978022, "content": "Another commonly used formula predicts fluid requirements over 24 hours. The following example shows an application of this formula: First 10 kg: 100 mL/kg/d Next 10 to 20 kg: Additional 50 mL/kg/d Any remaining weight more than 20 kg: Additional 20 mL/kg/d For example, the maintenance fluid requirements of an adult man whose body weight is 70 kg man are calculated as follows: First 10 kg: 100 mL/kg/d x 10 kg = 1000 mL/d Next 10 to 20 kg: 50 mL/kg/d x 10 kg = 500 mL/d Remaining 50 kg: 20 mL/kg/d x 50 kg = 1000 mL/d Total fluids per day: 1000 + 500 + 1000 = 2500 mL/d Hourly fluid rate: 2500/24 = 104 mL/h" }, { "id": "pubmed23n0262_1451", "title": "[Hyponatremia and hypernatremia in the elderly].", "score": 0.009900990099009901, "content": "The study aimed at evaluating an incidence of hypo- and hypernatremia in the elderly and the results of therapy. Hyponatremia. The studies involved 18 patients aged 69.8 +/- 5.9 years with hyponatremia of 126.8 +/- 2.7 mmol/L. The main causes of hyponatremia were: diuretics, diarrhoea, and vomiting. Sodium deficit was calculated prior to the treatment in all patients. An analysis of hyponatremia incidence indicates that hyponatremia was diagnosed in 1.39% of patients over 60 years, hospitalized within 1989-1990. Sodium deficit in this group was 495.5 +/- 167.7 mmol. Sodium chloride solution was given intravenously to 12 patients, according to the \"free correction\" principle (a mean increase in serum sodium level was 0.17 +/- 0.07 mmol/L per hour). Mortality in such treated patients was 33%. Sodium chloride was not given to 6 out of examined patients. In 12 patients (66.6%) hyponatremia developed prior to hospitalization, in 6 patients (33.3%) during hospitalization. Mortality rate was 16.6% and 50%, respectively. This confirms higher mortality rate of the rapidly developing hyponatremia in the hospitalized elderly patients. In some cases hyponatremia may constitute iatrogenic complication, especially in the elderly given diuretics in an uncontrollable way. Own experience suggests that elderly patients with a risk of hyponatremia require close monitoring and early compensation of the electrolyte disorders. Hypernatremia. The studies involved 20 patients aged 71.4 +/- 7.7 years with hypernatremia of 155.6 +/- 8.4 mmol/L. A total water deficit (DH20) was calculated in this group. An analysis of hypernatremia incidence showed that this state was diagnosed in 1.55% of patients treated at the Department of Arterial Blood Hypertension within 1989-1990. Total water deficit was 3.9 +/- 1.9 L. A 5% glucose was given intravenously to 15 patients whereas oral fluid therapy was carried out in 5 patients. A mean corrected DH2O in the first day was 46.0 +/- 21.0%. Mortality rate in this group was 65%. It is worth mentioning that 37% of patients with chronic hypernatremia which developed prior to hospitalization died while in case of the acute hypernatremia developed in the hospital mortality rate was 83%. A significant effect on the results of therapy plays an early correction of hypernatremia. Mortality rate in case of DH2o supplementation below 30% during the first 24 hours is about 66%., if DH2o supplementation is 31-60%, a mortality rate is 63%, and in DH2o supplementation over 60% mortality rate is 100%. The obtained results suggest that hypernatremia in the elderly is related to the high mortality rate (65%). An early decrease of water deficit increases mortality rate in patients with hypernatremia." }, { "id": "wiki20220301en032_83062", "title": "Syndrome of inappropriate antidiuretic hormone secretion", "score": 0.00980392156862745, "content": "Treatment How to manage SIADH depends on whether symptoms are present, the severity of the hyponatremia, and the duration. Management of SIADH includes: Removing the underlying cause when possible. Mild and asymptomatic hyponatremia is treated with adequate solute intake (including salt and protein) and fluid restriction starting at 500 ml per day of water with adjustments based on serum sodium levels. Long-term fluid restriction of 1,200–1,800 mL/day may maintain the person in a symptom free state. Moderate and symptomatic hyponatremia is treated by raising the serum sodium level by 0.5 to 1 mmol per liter per hour for a total of 8 mmol per liter during the first day with the use of furosemide and replacing sodium and potassium losses with 0.9% saline. For people with severe symptoms (severe confusion, convulsions, or coma) hypertonic saline (3%) 1–2 ml/kg IV in 3–4 h should be given. Drugs" }, { "id": "pubmed23n0321_10715", "title": "Effect of 50 milliliters of 50% dextrose in water administration on the blood sugar of euglycemic volunteers.", "score": 0.00980392156862745, "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": "wiki20220301en178_38961", "title": "Ranson criteria", "score": 0.009708737864077669, "content": "Acute pancreatitis not secondary to gallstones At admission: Blood glucose > 11.11 mmol/L (> 200 mg/dL) Age > 55 years Serum LDH > 350 IU/L Serum AST > 250 IU/L WBC count > 16000 cells/mm3 Within 48 hours: Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit decreased by > 10% Oxygen (hypoxemia with PaO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration Base deficit (negative base excess) > 4 mEq/L Sequestration of fluids > 6 L Acute pancreatitis secondary to gallstones At admission: Glucose > 220 mg/dl Age > 70 years LDH > 400 IU/L AST > 250 IU/ 100 ml WBC count > 18000 cells/mm3 Within 48 hours: Serum calcium < 8 mg/dL Hematocrit decreased by > 10% Base deficit > 4 mEq/L BUN increased by > 2 mg/dL Sequestered fluid > 6L" }, { "id": "pubmed23n0106_5793", "title": "Hypernatremic diarrheal dehydration treated with oral glucose-electrolyte solution containing 90 or 75 mEq/L of sodium.", "score": 0.009615384615384616, "content": "Of 33 infants with hypernatremic dehydration (serum Na+ of greater than or equal to 150 mEq/L) 7 were excluded, 6 because severe alteration of the level of consciousness or shock precluded oral rehydration and 1 because he was given glucose-electrolyte solution plus water. We studied the remaining 27 infants. Twenty (group A) were treated with the World Health Organization-recommended oral rehydration solution (90 mEq/L Na+) and seven (group B) were treated with Pedialyte-RS (Abbott Laboratories Ltd.; 75 mEq/L Na+). The rehydrating solutions were administered in a volume equivalent to twice the clinically estimated fluid deficit. Initial serum sodium was 156.7 +/- 0.9 mEq/L for group A and 155.8 +/- 1.8 mEq/L for group B (mean +/- SEM). The mean time to achieve rehydration was 14.3 and 16.6 h for groups A and B, respectively. Twenty-four hours after commencing oral rehydration, serum Na+ had decreased to 144.8 +/- 1.8 mEq/L for group A and 144.5 +/- 0.9 mEq/L for group B. In two patients in group A, the serum Na+, which, had not decreased to less than 150 mEq/L at 24 h, did so at 48 h. Only in one case (group A) did the serum Na+ increase. This patient had high stool output and failed to become rehydrated after 24 h of unsuccessful oral rehydration. None of the patients had seizures or persistent CNS dysfunction. We conclude that the slow administration of oral rehydration solutions containing either 90 or 75 mEq/L Na+ is a safe and effective treatment of hypernatremic dehydration." }, { "id": "wiki20220301en008_58118", "title": "Shock (circulatory)", "score": 0.009523809523809525, "content": "Fluids Aggressive intravenous fluids are recommended in most types of shock (e.g. 1–2 liter normal saline bolus over 10 minutes or 20 ml/kg in a child) which is usually instituted as the person is being further evaluated. Colloids and crystalloids appear to be similar with respect to outcomes., Balanced crystalloids and normal saline also appear to be similar in critically ill patients. If the person remains in shock after initial resuscitation, packed red blood cells should be administered to keep the hemoglobin greater than 100 g/l. For those with hemorrhagic shock, the current evidence supports limiting the use of fluids for penetrating thorax and abdominal injuries allowing mild hypotension to persist (known as permissive hypotension). Targets include a mean arterial pressure of 60 mmHg, a systolic blood pressure of 70–90 mmHg, or until their adequate mentation and peripheral pulses. Hypertonic fluid may also be an option in this group. Medications" }, { "id": "pubmed23n0285_432", "title": "A double-blind clinical trial comparing World Health Organization oral rehydration solution with a reduced osmolarity solution containing equal amounts of sodium and glucose.", "score": 0.009523809523809525, "content": "To compare the safety and efficacy of an oral rehydration solution (ORS) containing 75 mmol/L of sodium and glucose each with the standard World Health Organization (WHO) ORS among Egyptian children with acute diarrhea. One hundred ninety boys, aged 1 to 24 months, who were admitted to the hospital with acute diarrhea and signs of dehydration were randomly assigned to receive either standard ORS (311 mmol/L) or a reduced osmolarity ORS (245 mmol/L). Intake and output were measured every 3 hours. In the group treated with reduced osmolarity ORS, the mean stool output during the rehydration phase was 36% lower (95% confidence interval, 1%, 100%) than in those treated with WHO ORS. The relative risk of vomiting during the rehydration phase was significantly lower in children treated with reduced osmolarity ORS (relative risk, 2.4; 95% confidence interval, 1.2, 4.8). During the maintenance phase, stool output, mean intake of food and ORS, duration of diarrhea, and weight gain were similar in the treatment groups. The relative risk of treatment failure (need for unscheduled administration of intravenous fluids) was significantly increased in children receiving standard WHO ORS (relative risk, 7.9; 95% confidence interval, 1.1, 60.9). The mean serum sodium concentration at 24 hours was significantly lower in children receiving the reduced osmolarity ORS solution (134 +/- 6 mEq/L) than in children receiving the standard WHO ORS (138 +/- 7 mEq/L) (p &lt; 0.001). The relative risk of the development or worsening of hyponatremia was not increased in children given the reduced osmolarity ORS, and urine output was similar in the treatment groups. The reduced osmolarity ORS has beneficial effects on the clinical course of acute diarrhea in children by reducing stool output, and the proportion of children with vomiting during the rehydration phase, and by reducing the need for supplemental intravenous therapy. These results provide support for the use of a reduced osmolarity ORS in children with acute noncholera diarrhea." }, { "id": "First_Aid_Step2_1101", "title": "First_Aid_Step2", "score": 0.009480531052303306, "content": "Assess volume status by conducting a clinical exam and measuring urine volume and osmolality. Hypertonic Na+ gain: Due to hypertonic saline/tube feeds or ↑aldosterone (suppresses ADH). Pure water loss: Due to central or nephrogenic diabetes insipidus; characterized by large volumes of dilute urine. Do not neglect dermal and respiratory insensible losses. Hypotonic f uid loss: Due to ↓ intake, diuretics, intrinsic renal disease, GI losses (diarrhea), burns, and osmotic diuresis (mannitol, glucose in DKA, urea with high protein feeds). A minimal volume (approximately 500 ml/day) of maximally concentrated urine (> 800 mOsm/kg) suggests adequate renal response without adequate free-water replacement. Treat the underlying causes and replace free-water deficit with hypotonic saline, D5W, or oral water, depending on volume status." }, { "id": "article-25982_10", "title": "Normal Saline -- Administration", "score": 0.009467495493674299, "content": "Remaining 30 kg weight = 750 mL (25 mL/kg x 30) Total = 2250 mL/day or 94 mL/hr First 10 kg weight = 4 mL/kg/hr x 10 = 40 mL/hr Second 10 kg weight = 2 mL/kg/hr x 10 = 20 mL/hr Remaining 30 kg weight = 1 mL/kg/hr x 30 = 30 mL/hr Total = 90 mL/hr" }, { "id": "InternalMed_Harrison_3447", "title": "InternalMed_Harrison", "score": 0.00944822373393802, "content": "The therapeutic goals in hypovolemia are to restore normovolemia and replace ongoing fluid losses. Mild hypovolemia can usually be treated with oral hydration and resumption of a normal maintenance diet. More severe hypovolemia requires intravenous hydration, tailoring the choice of solution to the underlying pathophysiology. Isotonic, “normal” saline (0.9% NaCl, 154 mM Na+) is the most appropriate resuscitation fluid for normonatremic or hyponatremic patients with severe hypovolemia; colloid solutions such as intravenous albumin are not demonstrably superior for this purpose. Hypernatremic patients should receive a hypotonic solution, 5% dextrose if there has only been water loss (as in diabetes insipidus), or hypotonic saline (1/2 or 1/4 normal saline) if there has been water and Na+-Cl– loss. Patients with bicarbonate loss and metabolic acidosis, as occur frequently in diarrhea, should receive intravenous bicar bonate, either an isotonic solution (150 meq of Na+-HCO3 in 5%" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 823, 909 ] ], "word_ranges": [ [ 127, 140 ] ], "text": "acute cholangitis is characterized by the triad of jaundice, abdominal pain and fever;" }, "2": { "exist": true, "char_ranges": [ [ 631, 793 ] ], "word_ranges": [ [ 96, 123 ] ], "text": "It is true that the acute course and the absence of constitutional syndrome may make us think against this option and tip the balance towards ibuprofen hepatitis." }, "3": { "exist": true, "char_ranges": [ [ 631, 793 ] ], "word_ranges": [ [ 96, 123 ] ], "text": "It is true that the acute course and the absence of constitutional syndrome may make us think against this option and tip the balance towards ibuprofen hepatitis." }, "4": { "exist": true, "char_ranges": [ [ 910, 988 ] ], "word_ranges": [ [ 140, 152 ] ], "text": "Gilbert's syndrome is an increase in bilirubin at the expense of indirectness." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Acute cholangitis due to biliary mud.", "2": "Toxic hepatitis due to ibuprofen.", "3": "Cholangiocarcinoma.", "4": "Gilbert's syndrome.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "article-18277_24", "title": "Biliary Obstruction -- History and Physical -- History and Presentation", "score": 0.010990017400860886, "content": "A careful history of symptom duration, if gradual or acute onset, accompanying symptoms like weight loss, loss of appetite, nausea/vomiting is important. Similarly, any right-sided abdominal pain, along with severity and radiation, is important to know. History of diarrhea, hematochezia, and upper GI bleeding symptoms is also relevant to diagnosing the underlying process. It is imperative to know any pertinent personal and family history like bile duct or pancreatic malignancy, inflammatory bowel disease, or primary liver disease. A careful review of social history related to current and former smoking, alcohol use, and drug abuse is important. Similarly, travel history to parasitic endemic regions is of value in determining the etiology of biliary obstruction. A careful review of medication history can sometimes be of great significance in determining intrahepatic cholestasis vs. extrahepatic biliary obstruction." }, { "id": "pubmed23n0618_3539", "title": "Hydralazine-induced cholestatic hepatitis.", "score": 0.009900990099009901, "content": "Hydralazine has been widely used for treating hypertension, particularly in patients with renal failure. We report a case on a patient in whom we believe the drug was implicated in an otherwise unexplained disturbance of liver function. A 63-year-old African-American female with medical history of hypertension and end-stage renal disease (on hemodialysis) was admitted to the hospital with epigastric pain and jaundice. The symptoms started about 1 week ago. Initial laboratory tests showed abnormal liver enzymes with elevated conjugated bilirubin and alkaline phosphatase suggestive of cholestatic jaundice. Amylase and lipase were normal. Abdominal ultrasound showed normal caliber common bile duct without evidence of obstruction. Abdominal CT scan does not show any evidence of intra- or extrahepatic biliary ductal dilatation, and no mass lesions were seen in the pancreas. Further blood chemistry showed worsening of liver enzymes and increased bilirubin over the next 2-3 days. Magnetic resonance cholangiopancreatography failed to show any evidence of intra- or extrahepatic biliary ductal dilatation. No other laboratory evidence of cholestatic jaundice was found. Before proceeding for invasive diagnostic procedure, that is, endoscopic retrograde cholangiopancreatography, the patient's drug history was reviewed. She was on hydralazine 75 mg 3 times per day, started 5 months ago. At that time, her liver function tests were normal. As we could not find any other cause of cholestatic jaundice, we attributed this as a side effect of hydralazine. A trial was given by stopping the hydralazine. It was seen that there was significant improvement in the liver function enzymes over the next week. Complete clinical and biochemical recovery occurred over the next 4 weeks. Liver injury after long-term therapy with hydralazine and after short-term therapy with hydralazine (2-10 days) has been described. Hydralazine-induced hepatotoxicity may manifest as hypersensitivity-type injury, mixed hepatocellular injury, acute hepatitis, cholestatic jaundice, or centrilobular necrosis. The Hydralazine-induced cholestatic liver injury seems to be fully reversible. Complete clinical and biochemical recovery occurs after discontinuation of the drug. Also, the differential diagnosis of any patient with hepatocellular injury should include medications. This will prevent unnecessary diagnostic tests." }, { "id": "pubmed23n0221_6711", "title": "Diagnosing alcoholism.", "score": 0.009900990099009901, "content": "Although the average physician can generally expect to see at least one alcoholic everyday, alcoholism is one of the most poorly diagnosed of the common illnesses. Alcoholism has supplanted syphilis as the great imitator of other diseases and produces measurable damage in every bodily system. The clues that the body presents, while not diagnostic in themselves, should alert physicians to the possibility of the alcoholism diagnosis. The author discusses some of the stereotypes and definitions that have added to the problem of reaching an alcoholism diagnosis, the importance of distinguishing between primary and secondary alcoholism, and the clues that may present both during a physician's history-taking session and in an examination. He concludes by discussing how to present the diagnosis to the patient." }, { "id": "wiki20220301en031_59174", "title": "Cholangiocarcinoma", "score": 0.00980392156862745, "content": "Cholangiocarcinoma, also known as bile duct cancer, is a type of cancer that forms in the bile ducts. Symptoms of cholangiocarcinoma may include abdominal pain, yellowish skin, weight loss, generalized itching, and fever. Light colored stool or dark urine may also occur. Other biliary tract cancers include gallbladder cancer and cancer of the ampulla of Vater. Risk factors for cholangiocarcinoma include primary sclerosing cholangitis (an inflammatory disease of the bile ducts), ulcerative colitis, cirrhosis, hepatitis C, hepatitis B, infection with certain liver flukes, and some congenital liver malformations. However, most people have no identifiable risk factors. The diagnosis is suspected based on a combination of blood tests, medical imaging, endoscopy, and sometimes surgical exploration. The disease is confirmed by examination of cells from the tumor under a microscope. It is typically an adenocarcinoma (a cancer that forms glands or secretes mucin)." }, { "id": "article-17340_17", "title": "Alcoholic Liver Disease -- History and Physical -- Physical Examination", "score": 0.00980392156862745, "content": "The clinical definition of alcoholic hepatitis is a syndrome of liver failure where jaundice is a characteristic feature; fever and tender hepatomegaly are often present. The typical presentation age is between 40 and 50 yrs, and it occurs in the setting of heavy alcohol use. Patients often report a history of intake of at least 30 to 50 g alcohol/day though over 100 g/day is common. Patients may be abstinent for weeks before admission. The cardinal sign is the rapid onset of jaundice. Other signs and symptoms include fever, ascites (SAAG greater than 1.1), and proximal muscle loss. Patients presenting with severe alcoholic hepatitis may have encephalopathy. Typically, the liver is enlarged and tender." }, { "id": "wiki20220301en024_87837", "title": "Clonorchis sinensis", "score": 0.009708737864077669, "content": "Unusual cases of liver abscesses due to clonorchiasis have been reported. Liver abscesses may be seen even without dilatation of intrahepatic bile ducts. Symptoms While normally asymptomatic, most pathological manifestations result from inflammation and intermittent obstruction of the biliary ducts. The acute phase consists of abdominal pain with associated nausea and diarrhea. Long-standing infections consist of fatigue, abdominal discomfort, anorexia, weight loss, diarrhea, and jaundice. The pathology of long-standing infections consist of bile stasis, obstruction, bacterial infections, inflammation, periductal fibrosis, and hyperplasia. Development of cholangiocarcinoma is progressive." }, { "id": "article-23802_24", "title": "Jaundice -- History and Physical -- History", "score": 0.009708737864077669, "content": "Patients usually present with varying symptoms apart from yellowish discoloration of skin along with pruritus, thus providing clues to narrow down the etiology or can also be asymptomatic. A thorough questioning regarding the use of drugs, alcohol or other toxic substances, risk factors for hepatitis (travel, unsafe sexual practices), HIV status, personal or family history of any inherited disorders or hemolytic disorders is vital. Other important points include the duration of jaundice; and the presence of any coexisting signs and symptoms, like a joint ache, rash, myalgia, changes in urine and stool. [22] A history of arthralgias and myalgias before yellowing indicates hepatitis, either due to drugs or viral infections." }, { "id": "pubmed23n0757_728", "title": "Secondary Sclerosing Cholangitis due to Gallbladder Adenocarcinoma.", "score": 0.009615384615384616, "content": "Sclerosing cholangitis is a chronic cholestatic liver disease defined by both inflammatory and fibrotic changes of the biliary tract leading to diffuse stricture formation. This entity exists in both a primary and secondary form. Here we present a rare case of secondary sclerosing cholangitis due to direct metastasis from a gallbladder adenocarcinoma. A 55-year-old morbidly obese male presented electively with a 2-week history of low back pain and scleral icterus for 2 days. He also described severe epigastric pain that worsened postprandially and a 13 kg weight loss over the previous month. The patient denied any personal or familial history of malignancy or prior liver disease. Laboratory evaluation revealed mild elevation of transaminases with moderately elevated alkaline phosphatase and total bilirubin. Imaging included ultrasound and contrast-enhanced computed tomography of the abdomen and pelvis showing multiple large gallstones and a large tissue density mass within the fundus of the gallbladder. Subsequent endoscopic ultrasound was performed revealing celiac and portal lymphadenopathy with fine needle aspirations demonstrating adenocarcinoma. Over the next 15 days, bilirubin progressively increased. Magnetic resonance cholangiopancreatography was unremarkable. Liver biopsy, performed to exclude other etiologies of liver failure, demonstrated biliary cholestasis. Endoscopic retrograde cholangiopancreatography was then performed and an occlusion cholangiogram revealed diffuse multifocal stricturing of the intrahepatic bile ducts and moderate stenosis of the common bile duct without proximal ductal dilatation. Thus secondary sclerosing cholangitis due to gallbladder adenocarcinoma was diagnosed." }, { "id": "wiki20220301en179_18761", "title": "The Natural History of Alcoholism Revisited", "score": 0.009615384615384616, "content": "Footnotes References" }, { "id": "pubmed23n1164_2588", "title": "Epstein-Barr Virus Hepatitis Masquerading as Painless Jaundice.", "score": 0.009523809523809525, "content": "Epstein-Barr virus (EBV) infection typically presents with pharyngeal symptoms and subclinical transaminitis. We present a case of a 27-year-old woman with no known past medical history who presented with painless jaundice and dark-colored urine for three days. Her review of systems was negative for fever, sore throat, nausea, vomiting, pruritus, or rash. Her last sexual contact was six months ago with a male partner, and she only drank alcohol socially. Family and surgical history were non-significant. Physical examination revealed 3+ bilateral conjunctival icterus without abdominal tenderness or organomegaly. She had elevated transaminases: alanine transaminase (ALT) of 1287U/L and aspartate aminotransferase of (AST) 1057U/L but her alkaline phosphatase (ALP) was only slightly above normal at 109U/L (normal range 35-104U/L), with a direct hyperbilirubinemia - total bilirubin 9.5mg/dl, direct bilirubin 6.8mg/dl; the abdominal ultrasound revealed non-dilated bile ducts. Hepatitis A, B, and C serology was negative, but her EBV serology showed an infection. She had incidental thalassemia minor without splenomegaly or asterixis. She was managed conservatively, and her liver enzymes trended down with supportive management. Although EBV is an uncommon cause of painless jaundice, this diagnosis should be considered, especially when other more common causes of jaundice have been ruled out. A high index of suspicion should be maintained to detect EBV hepatitis as it can easily be diagnosed through serological testing." }, { "id": "pubmed23n0004_9525", "title": "[How Johannes Brahms died].", "score": 0.009523809523809525, "content": "In 1896, when he was 63 years old, Johannes Brahms, who had always been demonstrably in good health, developed an icterus of increasing intensity together with a considerable enlargement of the liver and loss of weight. Since infectious hepatitis could scarcely come into the question, from the medical point of view a neoplasm in the region of the liver as well as cirrhosis of the liver were considered. While hepatic carcinoma is a relatively rare disease in Europe even today and Brahms, on the other hand, had consumed copious quantities of concentrated alcoholic drinks during his lifetime, cirrhosis of the liver is the most probable diagnosis, especially as at the end hemorrhages from esophageal varices and the lower intestinal segments occurred." }, { "id": "pubmed23n0412_18897", "title": "Cases from the Osler Medical Service at Johns Hopkins University.", "score": 0.009433962264150943, "content": "A 37-year-old woman presented with increasing abdominal pain and jaundice. Six weeks before admission, she developed persistent diarrhea and jaundice of the skin. She also bruised easily, and her gums bled. In the subsequent weeks, her appetite decreased, she was fatigued, and she had nausea, vomiting, and abdominal distension. She had a history of drinking 1 quart of vodka every day for 20 years, with brief periods of abstinence; she stopped consuming alcohol 11 days before admission because it no longer provided symptomatic relief. Her past medical history was also notable for depression, including a suicide attempt 4 years earlier. She did not smoke, use illicit drugs, or have unprotected sexual intercourse. She had received no blood transfusions and had not traveled recently. She took no medications, except for occasional ibuprofen. On physical examination, she was thin and deeply jaundiced, and she trembled and responded slowly to questions. She was afebrile but tachypneic, and she had orthostatic hypotension. Her HEENT examination was notable for scleral and sublingual icterus, as well as crusted blood on her gums and teeth. The jugular veins were flat. The cardiac examination revealed tachycardia (heart rate, 103 beats per minute) without murmurs, rubs, or gallops. The abdomen was nontender and protuberant, with hypoactive bowel sounds; the spleen was not palpable, and there was no fluid wave or caput medusae. The liver percussed to 18 cm, with a smooth edge extending 10 cm below the costal margin. She had cutaneous telangiectases on her chest and bilateral palmar erythema. There was no peripheral edema. The neurologic examination was notable for asterixis. Her stool was guaiac positive. Laboratory studies revealed the following values: hematocrit, 21.2%; white blood cells, 17,310/mm(3); ammonia, 42 micromol/L; serum creatinine, 3.9 mg/dL; serum urea nitrogen, 70 mg/dL; albumin, 2.1 g/dL; total bilirubin, 26.8 mg/dL; alanine aminotransferase, 14 U/L; aspartate aminotransferase, 77 U/L; alkaline phosphatase, 138 U/L; prothrombin time, 103 seconds (international normalized ratio, 10.6); and urinary sodium, &lt;5 mg/dL. Urinalysis revealed an elevated specific gravity and numerous muddy granular casts. Hepatitis A, B, and C serologies were negative. On abdominal ultrasound examination, there was no ascites, and the liver was echogenic. The portal and hepatic veins were patent, and the hepatic arteries were normal. The spleen measured 14 cm. What is the diagnosis?" }, { "id": "wiki20220301en179_18737", "title": "The Natural History of Alcoholism Revisited", "score": 0.009433962264150943, "content": "if the alcoholic's spouse ever complained of his drinking before they split. Interviews and questionnaires should always be backed up with interviews with the subject's family, with consultation of medical records, and with searches in public records for evidence of legal problems associated with drinking." }, { "id": "pubmed23n0844_9084", "title": "Diagnosis of ganglionar tuberculosis by endoscopic ultrasonography.", "score": 0.009345794392523364, "content": "The endoscopic ultrasonography (EUS) is an endoscopic technique of proven clinical validity today, having a significant impact on the diagnosis and evaluation of several diseases with a low complication rate. The EUS-fine-needle aspiration (FNA) allows the evaluation of subepithelial lesions, extra-luminal lymph nodes or the gastrointestinal tract that are difficult to access by other methods with safe and high diagnostic accuracy. In the case reported, the EUS-FNA was useful for the differential diagnosis with residual biliary microlithiasis and the diagnosis of non-oncologic pathology. Male, white, 35-year-old, human immunodeficiency virus and tuberculosis treatment for about 5 months presented with jaundice. No fever, weight loss or abdominal pain. Choluria and hipocholia. History of cholecystectomy for about 1 year due to cholelithiasis. Laboratory tests showed cholestatic jaundice (direct hyperbilirrubinemia). Abdominal ultrasound showed liver without particularities, without biliary dilatation or filling defects. Initially suspected hepatitis due tuberculosis drugs so, the treatment was suspended. After a week with no drugs, no improvement in jaundice was observed. In contrast, a progressive increase indirect bilirubin. EUS performed with identification of mass along the distal common bile duct near the duodenal papilla. FNA performed with the presence of lymphocytes and tuberculosis bacile positive. After, endoscopic retrograde cholangiopancreatography was performed with sphincterotomy and placement of endoprosthesis for biliary drainage. The tuberculosis drugs were restarted with the plan to complete. The jaundice was resoluted. The patient completed 9 months of treatment and abdominal tomography has not identified a mass in that place. The EUS-FNA was proven to be a useful tool for diagnosis of non-oncologic pathologies like tuberculosis." }, { "id": "wiki20220301en439_31283", "title": "Eddi McKee", "score": 0.009345794392523364, "content": "During her time in the show, it was hinted that Eddi liked to drink. Potts pointed out that drinking did appear to be the only way Eddi could deal with her many issues. Potts hoped the storyline would explored further, especially as Eddi's mother was an alcoholic. She also thought it would be fun to see Eddi lose her grip. Potts added that studies had shown people with alcoholics in their families became predisposed to it themselves." }, { "id": "pubmed23n1045_12217", "title": "Caroli Disease: A Presentation of Acute Pancreatitis and Cholangitis.", "score": 0.009259259259259259, "content": "Caroli disease is a rare congenital disorder resulting from the dilation of large intrahepatic bile ducts. Patients affected with Caroli disease are at increased risk of complications resulting from bile stasis and stone formation. We report the case of a 37-year-old woman with a past surgical history of cholecystectomy who presented to the emergency room with a chief complaint of abdominal pain and nausea. The pain was characteristic of acute pancreatitis but she was hemodynamically stable. Total bilirubin was 4.1 mg/dL with a direct fraction of 3.1 mg/dL, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were 850 IU/L and 1025 IU/L, respectively. Serum amylase and lipase were elevated at 581 IU/L and 1328 IU/L, respectively. CT scan of abdomen/pelvis without contrast showed common bile duct (CBD) measuring 1.6 cm with intrahepatic biliary system dilation and mild peripancreatic fat stranding. She was diagnosed with acute pancreatitis. On the second day, she developed a temperature of 99.6°F. Hepatitis immunity panel was negative for acute hepatitis. The patient was started on antibiotics (IV ciprofloxacin and metronidazole) for suspicion of acute cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) was done which showed mild dilated intrahepatic ducts and CBD dilation of 1.6 cm, and a choledochal cyst at CBD. Sphincterotomy was done and good bile drainage was reported. She was later discharged in a stable condition. Caroli disease affects males and females equally and most are diagnosed before the age of 30 years correlated with the onset of symptoms. By far, the most commonly reported symptom is acute cholangitis but pancreatitis occurs rarely. Recurrent bouts of infection lead to portal hypertension, fibrosis of the liver and ultimately end up with an orthotopic liver transplant (OLT). Regular follow-ups are important for disease surveillance and monitoring." }, { "id": "article-26578_31", "title": "Acute Pancreatitis -- History and Physical", "score": 0.009259259259259259, "content": "The patient commonly describes moderate to severe abdominal pain in the epigastrium associated with nausea and anorexia. The nature of the pain can vary, depending on whether the etiology is a biliary obstruction or a metabolic/toxicologic cause. Biliary etiology is often described as a sharper pain that radiates to the back with a more acute onset. In contrast, metabolic and toxicologic causes like alcohol often have a more sluggish start with dull and generalized pain in the epigastrium. A detailed history regarding alcohol use and medications should be inquired about, keeping in mind that it takes over five years of heavy alcohol use to induce alcohol-related pancreatitis. Smoking history is also a significant risk factor for acute pancreatitis." }, { "id": "pubmed23n0273_19769", "title": "[Cancer of the middle third of the choledochus: an infrequent diagnosis].", "score": 0.009174311926605505, "content": "We report the case of an 80-year-old woman with a previous history of HBP, hysterectomy due to cancer of the uterus and cholelithiasis, who was admitted in our hospital because of diffuse abdominal pain, marked jaundice, choluria and acholia during one week, together with anorexia and loss of weight. Blood chemistry results disclosed a total bilirubin of 11 mg/dl, a direct bilirubin of 8 mg/dl, GGTP 826 U/I, alkaline phosphatase 287 U/I, AST 285 U/I, ALT 837 U/I and LDH 242 U/I. The CA 19-9 marker was higher than 500 U/ml. The abdominal ultrasound examination did not show any space-occupying lesions; the extra and intrahepatic bile ducts were very dilated and the gall bladder showed multiple stones within its contents. The endoscopic retrograde cholangiopancreatography (ERCP) showed a homogeneous filiform defect at the middle third of the common bile duct of approximately 1 cm in length and with a marked dilatation of the bile ducts. A percutaneous drainage of the bile tree was performed, but the patient died." }, { "id": "pubmed23n0550_8946", "title": "[Medical aid in urgent alcohol-associated conditions].", "score": 0.009174311926605505, "content": "The facts that the clinical manifestations of alcohol-associated urgent conditions are polymorphic, and that terms traditionally used by doctors to characterize these conditions are diverse, determine objective difficulties in rendering medical aid in such situations. However, the number of urgent alcohol-associated conditions grows every year. Analysis of diagnostic errors demonstrates that 30% of doctor's errors are subjective. Mistaken diagnosis is followed by casual treatment, independently on its cost and length. Treatment of alcohol-associated pathology is prerogative of general practitioners, which makes knowledge of clinical picture, terminology, legal aspects of rendering medical aid, expertise of the ability to work, and therapeutic tactics in urgent alcohol-associated conditions, important to doctors of all specialties." }, { "id": "wiki20220301en003_84271", "title": "Bilirubin", "score": 0.00909090909090909, "content": "Very high levels of bilirubin may be caused by: Neonatal hyperbilirubinemia, where the newborn's liver is not able to properly process the bilirubin causing jaundice Unusually large bile duct obstruction, e.g. stone in common bile duct, tumour obstructing common bile duct etc. Severe liver failure with cirrhosis (e.g. primary biliary cirrhosis) Crigler–Najjar syndrome Dubin–Johnson syndrome Choledocholithiasis (chronic or acute). Cirrhosis may cause normal, moderately high or high levels of bilirubin, depending on exact features of the cirrhosis. To further elucidate the causes of jaundice or increased bilirubin, it is usually simpler to look at other liver function tests (especially the enzymes alanine transaminase, aspartate transaminase, gamma-glutamyl transpeptidase, alkaline phosphatase), blood film examination (hemolysis, etc.) or evidence of infective hepatitis (e.g., hepatitis A, B, C, delta, E, etc.). Jaundice" }, { "id": "InternalMed_Harrison_23981", "title": "InternalMed_Harrison", "score": 0.00909090909090909, "content": "Clinical Features The diagnosis of alcoholic liver disease requires an accurate history regarding both amount and duration of alcohol consumption. Patients with alcoholic liver disease can present with nonspecific symptoms such as vague right upper quadrant abdominal pain, fever, nausea and vomiting, diarrhea, anorexia, and malaise. Alternatively, they may present with more specific complications of chronic liver disease, including ascites, edema, or upper gastrointestinal (GI) hemorrhage. Many cases present incidentally at the time of autopsy or elective surgery. Other clinical manifestations include the development of jaundice or encephalopathy. The abrupt onset of any of these complications may be the first event prompting the patient to seek medical attention. Other patients may be identified in the course of an evaluation of routine laboratory studies that are found to be abnormal. On physical examination, the liver and spleen may be enlarged, with the liver edge being firm and" }, { "id": "InternalMed_Harrison_23559", "title": "InternalMed_Harrison", "score": 0.009017971758664955, "content": "agents can produce a picture of either acute hepatitis or cholestasis (Chap. 361). Equally important is a past history of unexplained “repeated episodes” of acute hepatitis. This history should alert the physician to the possibility that the underlying disorder is chronic hepatitis. Alcoholic hepatitis must also be considered, but usually the serum aminotransferase levels are not as markedly elevated, and other stigmata of alcoholism may be present. The finding on liver biopsy of fatty infiltration, a neutrophilic inflammatory reaction, and “alcoholic hyaline” would be consistent with alcohol-induced rather than viral liver injury. Because acute hepatitis may present with right upper quadrant abdominal pain, nausea and vomiting, fever, and icterus, it is often confused with acute cholecystitis, common duct stone, or ascending cholangitis. Patients with acute viral hepatitis may tolerate surgery poorly; therefore, it is important to exclude this diagnosis, and in confusing cases, a" }, { "id": "pubmed23n0269_6918", "title": "Cholestatic jaundice due to ackee fruit poisoning.", "score": 0.009009009009009009, "content": "A 27-yr-old Jamaican male presented with a 2-month history of jaundice, pruritus, intermittent diarrhea, and right upper quadrant abdominal pain. Over the next month, his abdominal pain and diarrhea improved, but his jaundice and pruritus worsened. He was afebrile and profoundly jaundice, with a benign abdominal examination. Medical workup included a normal abdominal ultrasound, iron studies, ceruloplasm, and serum electrophoresis. Negative viral (Epstein-Barr virus, cytomegalovirus, mononucleosis, hepatitis A, B, C) studies, ANA, AMA, ASMA, RPR were noted. He denied any alcohol, drug, or toxin exposure. Liver tests revealed total bilirubin of 25.6 mg/dl, direct bilirubin of 13.9 mg/dl, alkaline phosphatase 278 IU/L, AST 45 IU/L, and ALT 71 IU/L. Liver biopsy demonstrated centrilobular zonal necrosis and cholestasis most consistent with a toxic reaction. The patient was again interviewed regarding potential toxins, and he admitted to the ingestion of ackee fruit, a native Jamaican fruit that is illegal in the United States. Shortly after he had ceased intake of the fruit, his symptoms resolved and his liver function tests returned to normal. We present a case of chronic ackee fruit ingestion that led to cholestatic jaundice, vomiting, and abdominal pain." }, { "id": "wiki20220301en000_38848", "title": "Alcoholism", "score": 0.009009009009009009, "content": "Historically the name \"dipsomania\" was coined by German physician C.W. Hufeland in 1819 before it was superseded by \"alcoholism\". That term now has a more specific meaning. The term \"alcoholism\" was first used in 1849 by the Swedish physician Magnus Huss to describe the systematic adverse effects of alcohol." }, { "id": "wiki20220301en190_11398", "title": "Choluria", "score": 0.008928571428571428, "content": "Choluria is the presence of bile in urine. Choluria is a common symptom of liver diseases, such as hepatitis and cirrhosis. It can be described as dark or brown urine, often referred to as the color of Coca-Cola. Choluria is usually manifested when serum bilirubin is higher than 1.5 mg/dL. The presence of choluria is a useful symptom to distinguish if somebody presenting with jaundice has liver disease (direct hyperbilirubinemia) or hemolysis (indirect hyperbilirubinemia). In the first case, patients have choluria due to excess conjugated (\"direct\") bilirubin in blood, which is eliminated by kidneys. Hemolysis, on the contrary, is characterized by unconjugated (\"indirect\") bilirubin which is bound to albumin and thus not eliminated in urine. See too Acholia References External links Urinary bladder disorders" }, { "id": "article-26577_13", "title": "Pancreatitis -- History and Physical", "score": 0.008928571428571428, "content": "In regards to medical history, healthcare providers should ask the patient specifically about the previous history of gallbladder disease, history of hyperlipidemia, and previous episodes of pancreatitis. A detailed social history should be obtained including a history of alcohol use. Clinicians should ask patients about recent procedures such as ERCP, and they should obtain a list of medications that the patient is currently taking. Patients should also be asked about a family history of pancreatic disorders." }, { "id": "wiki20220301en024_81121", "title": "Autoimmune hepatitis", "score": 0.008849557522123894, "content": "Signs and symptoms Autoimmune hepatitis may present completely asymptomatic (12–35% of the cases), with signs of chronic liver disease, or acute or even fulminant hepatic failure. People usually present with one or more nonspecific, long-lasting symptoms such as fatigue, general ill health, lethargy, weight loss, mild right upper quadrant abdominal pain, malaise, anorexia, itching, nausea, jaundice or joint pain especially affecting the small joints. Rarely, rash or unexplained fever may appear. In women, the absence of menstruation (amenorrhoea) is a frequent feature. Physical examination may be normal, but it may also reveal signs and symptoms of chronic liver disease. Many people have only laboratory abnormalities as their initial presentation, as unexplained increase in transaminases and are diagnosed during an evaluation for other reasons. Others have already developed cirrhosis at diagnosis. Of note, alkaline phosphatase and bilirubin are usually normal." }, { "id": "article-17343_39", "title": "Alcohol Use Disorder -- History and Physical", "score": 0.008849557522123894, "content": "Patients may be asymptomatic or present with hypertension or insomnia in the early stages. In the later stages, as the condition progresses, patients may report additional symptoms such as nausea or vomiting, hematemesis, abdominal distension, epigastric pain, weight loss, jaundice, or other signs of liver dysfunction. To screen for AUDs, the US Preventive Services Task Force recommends the following tools: The 10-Question AUDIT (AUDs Identification Test) The 3-Question AUDIT (AUDIT-C) Single-Question Screening Test" }, { "id": "pubmed23n1000_9583", "title": "Late cholestatic syndrome due to previous perforating trauma: Case report.", "score": 0.008771929824561403, "content": "The presence of a foreign body obstructing the bile duct may appear through a typical picture of cholangitis, usually caused by the presence of gallstones. Male patient, 31 years old, involved an in accident with gunshot in 2006, injured in the abdominal region. Evolved to a picture of intense pain in the right hypochondrium, mainly after fat meals, without irradiation 12 years after being injured. Presented jaundice episode associated to fecal acholia, choluria, pruritus and sporadic fever. It was diagnosed cholangitis due to the foreign body like a bullet, located in the hepatic duct after tomography performed for investigation. The conduction of the case is described next. Cholestatic syndrome caused by gun bullet in a prior event to the symptoms is a rare event in the literature. Total, there are 8 case reports of bullets found in bile ducts with distinct evolution time among themselves. The first exam will not necessarily identify the bullet, but it simplifies the visualization of the bile ducts dilation, characterizing obstruction. The presence of a foreign body in the bile ducts is well reported in literature, and it is directly dependent on previous history. We should always avoid using cholangioresonance in dubious cases. To keep the ERCP as initial treatment is recommended due to the advances on the procedure quality, but in more severe cases or lack of resources, the surgical exploration is still indicated." }, { "id": "InternalMed_Harrison_31817", "title": "InternalMed_Harrison", "score": 0.008771929824561403, "content": "The diagnosis of an alcohol use disorder ultimately rests on the documentation of a pattern of repeated difficulties associated with alcohol (Table 467-2). Thus, in screening, it is important to probe for marital or job problems, legal difficulties, histories of accidents, medical problems, evidence of tolerance, and so on, and then attempt to tie in use 5-Point Scale Item (Least to Most) 1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day? 3. How often do you have six or more drinks on one occasion? 4. How often during the last year have you found that you were not able to stop drinking once you had started? 5. How often during the last year have you failed to do what was normally expected from you because of drinking? 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7." }, { "id": "wiki20220301en031_59177", "title": "Cholangiocarcinoma", "score": 0.008695652173913044, "content": "Signs and symptoms The most common physical indications of cholangiocarcinoma are abnormal liver function tests, jaundice (yellowing of the eyes and skin occurring when bile ducts are blocked by tumor), abdominal pain (30–50%), generalized itching (66%), weight loss (30–50%), fever (up to 20%), and changes in the color of stool or urine. To some extent, the symptoms depend upon the location of the tumor: people with cholangiocarcinoma in the extrahepatic bile ducts (outside the liver) are more likely to have jaundice, while those with tumors of the bile ducts within the liver more often have pain without jaundice." }, { "id": "wiki20220301en075_29629", "title": "Phillip Crosby", "score": 0.008695652173913044, "content": "In his later years, Phillip's health was not good and he had problems with his back and knees following a motorcycle accident. In the 1980s, he was arrested several times for drunk driving and, despite 18 months of Alcoholics Anonymous, he told People, \"I don't drink any more -- but I don't drink any less.\"" } ] } } }

{ "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, 244 ] ], "word_ranges": [ [ 0, 41 ] ], "text": "It is a lymphocytic exudate whose main diagnoses are tumor and tuberculous pleuritis. They do not give the value of glucose which should be lowered, but if the cytology shows absence of malignant cells so we are left with tuberculous pleuritis." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Pleural empyema.", "2": "Pleural effusion due to heart failure (transudate).", "3": "Pleural mesothelioma.", "4": "Tuberculous pleural effusion.", "5": "Effusion secondary to pulmonary infarction." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0052_13531", "title": "Pleural diseases.", "score": 0.016122816032887975, "content": "In the United States, approximately one million patients each year develop a pleural effusion. Pleural effusions have classically been divided into transudative and exudative pleural effusions. A transudative pleural effusion occurs when the systemic factors influencing pleural fluid formation and reabsorption are altered so that pleural fluid accumulates; an exudative pleural effusion occurs when the local factors influencing pleural fluid formation and reabsorption are altered, allowing accumulation of pleural fluid. The leading causes of transudative pleural effusions are left ventricular failure and cirrhosis with ascites. The leading causes of exudative pleural effusions are pneumonia, malignancy, and pulmonary embolization. Transudative pleural effusions can be differentiated from exudative pleural effusions by measurement of the pleural fluid protein and lactic dehydrogenase (LDH) levels. The ratio of the pleural fluid protein to the serum protein is less than 0.5, the ratio of the pleural fluid LDH to the serum LDH is less than 0.6, and the absolute value of the pleural fluid LDH level is less than two thirds of the upper normal limit for serum with transudative pleural effusions while at least one of these criteria is not met with exudative effusions. Most patients who have a pleural effusion with congestive heart failure have left ventricular failure. It is believed that the transudation of the pulmonary interstitial fluid across the visceral pleura overwhelms the capacity of the lymphatics to remove the fluid. Most patients with cirrhosis who have a pleural effusion also have ascites. It is also believed that the pleural effusions form when fluid moves directly from the peritoneal cavity into the pleural cavity through pores in the diaphragm. Approximately 40% of patients with pneumonia will have a pleural effusion. If these patients have a significant amount of pleural fluid, a diagnostic thoracentesis should be performed. Chest tubes should be inserted if the pleural fluid is gross pus, if the Gram stain of the pleural fluid is positive, if the pleural fluid glucose level is below 40 mg/dl, or if the pleural fluid pH level is less than 7.00. If drainage with the chest tubes is unsatisfactory, either streptokinase or urokinase should be injected intrapleurally. If drainage is still unsatisfactory, a decortication should be considered. The three leading malignancies that have an associated pleural effusion are breast carcinoma, lung carcinoma, lymphomas and leukemias. The diagnosis of pleural malignancy is made most commonly with pleural fluid cytology; in recent years immunohistochemical tests have proved invaluable in differentiating benign from malignant pleural effusions.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0813_1687", "title": "[Contribution of pleural fluid analysis to the diagnosis of pleural effusion].", "score": 0.015998551074619657, "content": "Analysis of pleural fluid can have, on its own, a high diagnostic value. In addition to thoracocentesis, a diagnostic hypothesis based on medical history, physical examination, blood analysis and imaging tests, the diagnostic effectiveness will significantly increase in order to establish a definite or high probable diagnosis in a substantial number of patients. Differentiating transudates from exudates by the classical Light's criteria helps knowing the pathogenic mechanism resulting in pleural effusion, and it is also useful for differential diagnosis purposes. An increased N-terminal pro-brain natriuretic peptide, both in the fluid and in blood, in a due clinical context, is highly suggestive of heart failure. The presence of an increased inflammatory marker, such as C-reactive protein, together with the presence of over 50% of neutrophils is highly suggestive of parapneumonic pleural effusion. If, in these cases, the pH is&lt;7.20, then the likelihood of complicated pleural effusion is high. There remains to be demonstrated the usefulness of other markers to differentiate complicated from uncomplicated effusions. An adenosine deaminase &gt; 45 U/L and&gt;50% lymphocytes is suggestive of tuberculosis. If a malignant effusion is suspected but the cytological result is negative, increased concentrations of some markers in the pleural fluid can yield high specificity values. Increased levels of mesothelin and fibruline-3 are suggestive of mesothelioma. Immunohistochemical studies can be useful to differentiate reactive mesothelial cells, mesothelioma and metastatic adenocarcinoma. An inadequate use of the information provided by the analysis of pleural fluid would results in a high rate of undiagnosed effusions, which is unacceptable in current clinical practice." }, { "id": "pubmed23n0300_18714", "title": "[Differential diagnosis between exudate and transudate in pleural effusion].", "score": 0.015914786967418545, "content": "The objective was 1) to determine the usefulness of different criteria in the differential diagnosis between exudate and transudate in pleural effusion, 2) to evaluate albumin gradient changes in pleural effusion fluids characterized as transudates in patients who do and do not receive diuretic therapy, 3) to define the specificity of pleural effusions of neoplastic etiology. All patients with pleural effusion admitted to the hospital between January 15 and August 15 1994 were evaluated consecutively. Serum and pleural effusion, total protein, LDH, albumin and cholesterol levels were measured and the etiologic diagnosis of the pleural effusion (gold standard) was established. Out of the total of 112 evaluated patients, 7 were excluded because it was impossible to reach a final diagnosis. Based on the etiologic diagnosis, 47 patients (44.8%), average age of 69.6 +/- 12.07, had pleural effusions defined as transudate and 58 patients (55.2%), average age of 66.5 +/- 14.26, had pleural effusions defined as exudate. Sixty-six percent of the transudates were secondary to heart failure, while 40% of the exudates were of neoplastic origin. Using the criteria of Light et al, we obtained a diagnostic accuracy (DA) of 82.7% (CI 95% 73.1-90.0)%. However, when the cut-off point was modified according to Valdez and the value of cholesterol in pleural effusion and its relation to serum cholesterol was added, the DA rose to 90.2 (83.2-96.0)% (p &lt; 0.05). The effusion-serum cholesterol ratio demonstrated 100 (85.1-100)% sensitivity for neoplastic effusions, whereas for non-neoplastic exudative effusions the sensitivity was 89 (73.2-96.8)%. The tests, however, showed only 17.4 (6.56-33.6)% specificity. The albumin gradient (the difference between serum and pleural effusion albumin) did no vary in patients with transudates who received diuretics, allowing a correct diagnosis of transudate in 93 (82.4-97.8)% of the cases. However, in patients who were taking diuretics, the classic criteria of protein index defined correctly only 66 (53.4-82.1)% of the cases (p &lt; 0.05). It can be concluded that the variation of cut-off points originally established by Light et al. and the addition of cholesterol determination in pleural effusion and its relation to the serum cholesterol level allowed us to increase the DA. This appears to be the best way to differentiate a transudate from an exudate. The relation between pleural effusion and serum cholesterol levels showed a very low specificity for the differentiation of neoplastic and non-neoplastic exudative pleural effusions. Unlike the pleural effusion-serum total protein ratio, the albumin gradient allowed us to establish the correct diagnosis of transudate even in patients taking diuretics." }, { "id": "wiki20220301en015_101883", "title": "Pleural effusion", "score": 0.015463337831758885, "content": "The ratio of pleural fluid protein to serum protein is greater than 0.5 The ratio of pleural fluid LDH and serum LDH is greater than 0.6 Pleural fluid LDH is greater than 0.6 or times the normal upper limit for serum. Different laboratories have different values for the upper limit of serum LDH, but examples include 200 and 300 IU/l." }, { "id": "pubmed23n0750_19696", "title": "Frequency and characteristics of pleural effusions in pulmonary embolism.", "score": 0.014839367669556349, "content": "Pulmonary embolism (PE) is the fourth cause of pleural effusions, after pneumonia, neoinfiltrates and tuberculosis. Several questions are yet unanswered: are the pleural effusions in PE exudates or transudates, what is their size, are they unilateral or bilateral, are they only haemorrhagic, etc. The aim of this study is to determine the frequency, side, size, biochemical and cytological characteristics of pleural effusions in PE. In this study, 100 patients with suspicion of PE were examined and treated and in all the diagnosis of PE was establish. 31 of them had pleural effusions. Of 31 patients with PE and pleural effusions, six (9.84%), had bilateral pleural effusions, 14 (22.95%) patients had right-sided pleural effusion, and 11 (18.03%) had pleural effusion on the left side. 22 (36.07%) had small pleural effusions, 8 (13.11%) had medium and 1 (1.64%) had a large pleural effusion.18 (29.51%) had yellowish colored pleural effusions, 12 (19.67%) had haemorrhagic pleural effusions and 1 (1.64%) had transparent pleural effusion. Values of the total protein in pleural effusions varied in the interval 45.70±7.25 gr/l., 30 patients had LDH an effusion/sera ratio bigger than 0.6, and 1 patient had an LDH p/s ratio&lt;0.6. 15 patients (24.59) had neutrophil cells, 10 (16.39%) had lymphocytes, and eosinophil cells dominated in 5 (8.20%). One patient (1.64%) had a negative cytological finding. We can conclude that pleural effusions secondary to PE can be found in around one third of all cases with PE. They are small, mostly unilateral, often but not always haemorrhagic. They are always exudates with a predomination of neutrofil cells." }, { "id": "wiki20220301en010_91068", "title": "Pleural cavity", "score": 0.014588610563842763, "content": "If malignant cells are present, a pathologist may perform additional studies including immunohistochemistry to determine the etiology of the malignancy. Chemical analysis Chemistry studies may be performed including pH, pleural fluid:serum protein ratio, LDH ratio, specific gravity, cholesterol and bilirubin levels. These studies may help clarify the etiology of a pleural effusion (exudative vs transudative). Amylase may be elevated in pleural effusions related to gastric/esophageal perforations, pancreatitis or malignancy. Pleural effusions are classified as exudative (high protein) or transudative (low protein)." }, { "id": "pubmed23n0377_18952", "title": "Influence of diuretics on the concentration of proteins and other components of pleural transudates in patients with heart failure.", "score": 0.014541622760800843, "content": "Diuretic therapy increases the total protein and lactate dehydrogenase concentrations in pleural fluid in patients with transudates due to heart failure, but the effect of diuresis on other substances in pleural fluid constituents is not known. Twenty-one patients with transudative pleural effusions due to congestive heart failure were prospectively studied. Repeated diagnostic thoracentesis (mean +/- SD = 3 +/- 1; range, 2 to 6) was performed until the effusions were radiographically unapparent (5 +/- 2 days). Thirty-one patients with congestive heart failure who underwent only a single thoracentesis after diuretic therapy served as controls. We measured the concentrations of various components of pleural effusions in the serum and in the pleural fluid, and determined the serum-pleural fluid gradient (serum concentration minus pleural fluid concentration) and ratio (serum concentration divided by pleural fluid concentration). The pleural concentrations of most components increased significantly (P &lt;0.001) from the initial specimen to the final specimen: total protein, from 23 +/- 7 g/L to 33 +/- 9 g/L; albumin, from 13 +/- 4 g/L to 18 +/- 6 g/L; lactate dehydrogenase, from 177 +/- 62 U/L to 288 +/- 90 U/L; cholesterol, from 31 +/- 16 mg/dL to 52 +/- 22 mg/dL; and cholinesterase, from 1,304 +/- 616 U/L to 1,884 +/- 674 U/L. Expressed as percentage change, the increases in the serum-pleural fluid gradients for albumin (12% +/- 22%) and total protein (11% +/- 12%) were significantly less than the increases in their concentrations in pleural fluid (albumin, 47% +/- 49%; total protein, 48% +/- 40%) or in their pleural fluid/serum ratios (albumin, 27% +/- 29%; total protein, 38% +/- 34%). The concentrations of the biochemical components commonly measured in pleural fluid increase progressively during diuretic therapy. Calculation of the serum-pleural fluid gradients for protein and albumin may be the most useful way to distinguish transudates from exudates in patients with congestive heart failure who have undergone diuresis." }, { "id": "pubmed23n0492_372", "title": "[Cuttoff values of biochemical tests on pleural fluid: their usefulness in differential diagnosis of 1,040 patients with pleural effusion].", "score": 0.014412216499503028, "content": "The aim of biochemical pleural fluid testing is to reach an etiological diagnosis of the pleural effusion. We assessed the utility of considering cuttoff points for the wide range of analytes used to investigate pleural fluid. Among 1,040 patients with pleural effusion, we sought the etiologies of those fluids which showed any of the following characteristics: red blood cell count = 10 x 109/L, leukocytes = 10 x 109/L, percentage of neutrophils or lymphocytes &gt;50%, protein = 50 g/L, glucose = 60 mg/dL, pH = 7.2, lactate dehydrogenase = 1,000 U/L, adenosine deaminase = 40 U/L, amylase = 100 U/L or cholesterol = 60 mg/dL. Some of the more prominent findings were: a) a sixth of transudates were blood-tinged or contained predominantly neutrophils; b) a groosly bloody fluid suggests malignant disease, trauma, or pulmonary embolization; c) nearly 90% of fluids containing = 10 x 10(9) leukocytes/L were parapneumonics; d) 73% of tuberculous pleural fluids had protein &gt; or = 50 g/L, e) tuberculosis and parapneumonics explained more than 90% of fluids with high adenosine deaminase content; f) one third of amylase-rich pleural effusions were malignant; g) a low pleural glucose or pH levels indicate that patient probably has a parapneumonic, tuberculous or malignant etiology; y h) the diagnostic yield of pleural fluid cytology in malignant effusions was 57%, a percentage which raised to 94% in those with low glucose fluid level. Cuttof values of biochemical pleural fluid tests may greatly support particular causes of pleural effusions." }, { "id": "wiki20220301en063_55700", "title": "Thoracentesis", "score": 0.013858115457438664, "content": "Transudate Congestive heart failure Nephrotic syndrome Hypoalbuminemia Cirrhosis Atelectasis trapped lung Peritoneal dialysis Superior vena cava obstruction Amylase A high amylase level (twice the serum level or the absolute value is greater than 160 Somogy units) in the pleural fluid is indicative of either acute or chronic pancreatitis, pancreatic pseudocyst that has dissected or ruptured into the pleural space, cancer or esophageal rupture. Glucose This is considered low if pleural fluid value is less than 50% of normal serum value. The differential diagnosis for this is: rheumatoid effusion. The levels are characteristically low (<15 mg/dL). lupus effusion bacterial empyema malignancy tuberculosis esophageal rupture (Boerhaave syndrome) pH Normal pleural fluid pH is approximately 7.60. A pleural fluid pH below 7.30 with normal arterial blood pH has the same differential diagnosis as low pleural fluid glucose." }, { "id": "wiki20220301en058_47998", "title": "Chylothorax", "score": 0.013689281413087114, "content": "The fluid of a chylothorax may appear milky, serous or serosanguineous. If the appearance of the fluid is not milky, that does not exclude a chylothorax from consideration. Since chyle is rich in triglycerides, a pleural effusion that is rich in triglycerides (>110 mg/dL) confirms the presence of a chylothorax; a pleural effusion that is low in triglyceride content (<50 mg/dL) virtually excludes the diagnosis. If a pleural effusion contains triglycerides between 50–110 mg/dL, analysis of the lipoprotein content of the pleural effusion to evaluate for chylomicrons is recommended. If that procedure detects chylomicrons in the fluid, that confirms a chylothorax. Chylothoraces are typically exudative and often contain a high number of lymphocytes and have low levels of the enzyme lactate dehydrogenase (LDH). However, atypical chylothoraces can occur and are transudative in 14% of cases. A milky appearance of pleural fluid is insufficient to confirm the diagnosis of chylothorax as" }, { "id": "pubmed23n0897_979", "title": "Behaviour of nucleated cells in various types of pleural effusion.", "score": 0.013573700954400848, "content": "To know the behavior of cellular components of pleural fluid can help focus the differential diagnosis of a pleural effusion. Our objective was to assess their composition in different types of pleural effusions and assess whether it provides relevant clinical information. Observational, cross-sectional and retrospective study in which the cellular components of pleural effusions of different etiology were analyzed. Pleural effusions were classified as neutrophilic, lymphocytic (≥50% of each one of them), eosinophilic (≥10%) or mesothelial (&gt;5%) and were grouped into six diagnostic categories RESULTS: 1.467 patients were studied (354 heart failure; 59 other transudates; 349 paraneumonic; 133 tuberculous; 397 malignant and 175 other exudates). The predominance cell was lymphocytic in heart failure (44,4%), uncomplicated parapneumonic (29,2%), tuberculosis (88%) and malignant (49,6%); neutrophilic in parapneumonic (57%) and malignant (9,6%); eosinophilic in malignant (6,3%) and mesotelial in tuberculosis (12%). The most frequent etiologies with lymphocyte count ≥80% were tuberculosis (35,1%) and malignant (23,3%). Parameters with higher discriminating accuracy were: leukocytes (transudates: AUC 0,835) and percentage of neutrophils (empyemas: AUC 0,906 and complicated parapneumonic+empyemas: AUC 0,907). Nucleated cell counts will help focus the etiology of pleural effusions, since each etiology often have a characteristic cell predominance. The percentage of nucleated cells in pleural fluid not ruled out tuberculosis if there is a high count of mesothelial cells, nor a parapneumonic effusion with lymphocytic predominance, or malignancy with ≥80% lymphocytes." }, { "id": "wiki20220301en063_55699", "title": "Thoracentesis", "score": 0.013337670787247884, "content": "A transudate is defined as pleural fluid to serum total protein ratio of less than 0.5, pleural fluid to serum LDH ratio > 0.6, and absolute pleural fluid LDH > 200 IU or > 2/3 of the normal. An exudate is defined as pleural fluid that filters from the circulatory system into lesions or areas of inflammation. Its composition varies but generally includes water and the dissolved solutes of the main circulatory fluid such as blood. In the case of blood it will contain some or all plasma proteins, white blood cells, platelets and (in the case of local vascular damage) red blood cells. Exudate hemorrhage Infection Inflammation Malignancy Iatrogenic Connective tissue disease Endocrine disorders Lymphatic disorders vs Constrictive pericarditis Transudate Congestive heart failure Nephrotic syndrome Hypoalbuminemia Cirrhosis Atelectasis trapped lung Peritoneal dialysis Superior vena cava obstruction" }, { "id": "pubmed23n0128_5351", "title": "Transudative pleural effusions.", "score": 0.0132213608957795, "content": "A transudative pleural effusion develops when the systemic factors influencing the formation or absorption of the pleural fluid are altered. The pleural surfaces are not involved by the primary pathologic process. The diagnosis of transudative effusion is simple to establish by examining the characteristics of the pleural fluid. Transudates have all of the following three characteristics: The ratio of the pleural fluid to the serum protein is less than 0.5. The ratio of the pleural fluid to the serum LDH is less than 0.6. The pleural fluid LDH is less than two thirds the upper limit of normal for the serum LDH. Among the conditions that produce transudative pleural effusion, congestive heart failure is by far the most common. Pulmonary embolism, cirrhosis of the liver with ascites, and the nephrotic syndrome are the other common causes. Management of transudative pleural effusions involves managing the primary disease. Refractory, massive effusions can be controlled by tetracycline pleurodesis." }, { "id": "wiki20220301en015_101884", "title": "Pleural effusion", "score": 0.012893190459730383, "content": "The sensitivity and specificity of Light's criteria for detection of exudates have been measured in many studies and are usually reported to be around 98% and 80%, respectively. This means that although Light's criteria are relatively accurate, twenty percent of patients that are identified by Light's criteria as having exudative pleural effusions actually have transudative pleural effusions. Therefore, if a patient identified by Light's criteria as having an exudative pleural effusion appears clinically to have a condition that usually produces transudative effusions, additional testing is needed. In such cases, albumin levels in blood and pleural fluid are measured. If the difference between the albumin level in the blood and the pleural fluid is greater than 1.2 g/dL (12 g/L), this suggests that the patient has a transudative pleural effusion. However, pleural fluid testing is not perfect, and the final decision about whether a fluid is a transudate or an exudate is based not on" }, { "id": "pubmed23n0362_11326", "title": "Management of pleural effusions.", "score": 0.012861604207758053, "content": "This review summarizes current strategies in the treatment of patients with pleural effusion. To determine whether a patient has a transudative or exudative pleural effusion, Light's criteria should be applied to measure the concentrations of protein and lactate dehydrogenase (LDH) in the pleural fluid and serum. If the effusion is transudative, therapy should be directed toward the underlying congestive heart failure, cirrhosis, or nephrosis. Consideration should be given to pleurodesis with a sclerosant if patients with recurrent transudative effusion have severe dyspnea due to their effusion. If the effusion is exudative, attempts should be made to define the etiology. The diagnosis of pleural malignancy is most easily established via pleural fluid cytology. If this is negative and the patient is suspected of having pleural malignancy, thoracoscopy is indicated. The concentrations of adenosine deaminase and gamma-interferon in pleural fluid are useful in the diagnosis of pleural tuberculosis. Patients with pneumonia and pleural effusion should undergo therapeutic thoracentesis; the pleural fluid should be Gram-stained and cultured, and the differential cell count, glucose and LDH concentration, and pH should be determined. Indicators of a poor prognosis include the presence of frank pus, a positive Gram-stain, a pleural glucose concentration of less than 2.2 mmol/L, a pH less than 7.00, the presence of pleural loculations, and an LDH concentration greater than three times the upper limit of normal in serum. If the pleural fluid cannot be completely evacuated because of loculations, intrapleural thrombolytic therapy should be considered. If thrombolytics are ineffective, thoracoscopy or thoracotomy with decortication should be performed. Dyspneic patients with malignant pleural effusions whose dyspnea is relieved with therapeutic thoracentesis should be considered for pleurodesis using a tetracycline derivative. Talc is not recommended because it induces acute respiratory distress syndrome in about 5% of patients, with an overall mortality of 1%." }, { "id": "wiki20220301en015_101869", "title": "Pleural effusion", "score": 0.012695652173913044, "content": "When a pleural effusion has been determined to be exudative, additional evaluation is needed to determine its cause, and amylase, glucose, pH and cell counts should be measured. Red blood cell counts are elevated in cases of bloody effusions (for example after heart surgery or hemothorax from incomplete evacuation of blood). Amylase levels are elevated in cases of esophageal rupture, pancreatic pleural effusion, or cancer. Glucose is decreased with cancer, bacterial infections, or rheumatoid pleuritis. pH is low in empyema (<7.2) and maybe low in cancer. If cancer is suspected, the pleural fluid is sent for cytology. If cytology is negative, and cancer is still suspected, either a thoracoscopy, or needle biopsy of the pleura may be performed. Gram staining and culture should also be done." }, { "id": "wiki20220301en063_55701", "title": "Thoracentesis", "score": 0.012589403006860313, "content": "pH Normal pleural fluid pH is approximately 7.60. A pleural fluid pH below 7.30 with normal arterial blood pH has the same differential diagnosis as low pleural fluid glucose. Triglyceride and cholesterol Chylothorax (fluid from lymph vessels leaking into the pleural cavity) may be identified by determining triglyceride and cholesterol levels, which are relatively high in lymph. A triglyceride level over 110 mg/dl and the presence of chylomicrons indicate a chylous effusion. The appearance is generally milky but can be serous. The main cause for chylothorax is rupture of the thoracic duct, most frequently as a result of trauma or malignancy (such as lymphoma). Cell count and differential The number of white blood cells can give an indication of infection. The specific subtypes can also give clues as to the type on infection. The amount of red blood cells are an obvious sign of bleeding." }, { "id": "wiki20220301en015_101867", "title": "Pleural effusion", "score": 0.0124855702047512, "content": "By pathophysiology: Transudative pleural effusion Exudative pleural effusion By the underlying cause (see next section). Causes Transudative The most common causes of transudative pleural effusion in the United States are heart failure and cirrhosis. Nephrotic syndrome, leading to the loss of large amounts of albumin in urine and resultant low albumin levels in the blood and reduced colloid osmotic pressure, is another less common cause of pleural effusion. Pulmonary emboli were once thought to cause transudative effusions, but have been recently shown to be exudative. The mechanism for the exudative pleural effusion in pulmonary thromboembolism is probably related to increased permeability of the capillaries in the lung, which results from the release of cytokines or inflammatory mediators (e.g. vascular endothelial growth factor) from the platelet-rich blood clots. The excessive interstitial lung fluid traverses the visceral pleura and accumulates in the pleural space." }, { "id": "wiki20220301en010_91064", "title": "Pleural cavity", "score": 0.012443972635055436, "content": "Absorption occurs into lymphatic vessels at the level of the diaphragmatic pleura. Clinical significance Pleural effusion A pathologic collection of pleural fluid is called a pleural effusion. Mechanisms: Lymphatic obstruction Increased capillary permeability Decreased plasma colloid osmotic pressure Increased capillary venous pressure Increased negative intrapleural pressure Pleural effusions are classified as exudative (high protein) or transudative (low protein). Exudative pleural effusions are generally caused by infections such as pneumonia (parapneumonic pleural effusion), malignancy, granulomatous disease such as tuberculosis or coccidioidomycosis, collagen vascular diseases, and other inflammatory states. Transudative pleural effusions occur in congestive heart failure (CHF), cirrhosis or nephrotic syndrome." }, { "id": "pubmed23n0419_23878", "title": "Role of pleural fluid cholesterol in differentiating transudative from exudative pleural effusion.", "score": 0.012429846698557385, "content": "Pleural fluid cholesterol has been reported to be useful in distinguishing between transudative and exudative pleural effusion. However, the difference in lipid profile between tubercular and non-tubercular pleural effusion has not been studied. The lipid profile of pleural fluid in 50 patients with exudative (25 tubercular and 25 non-tubercular) and 25 with transudative effusion was studied. The diagnosis was based on clinical criteria and/or a positive diagnosis from another site. The criteria that best identified an exudative pleural effusion were pleural fluid cholesterol &gt; or = 60 mg/dl, pleural fluid to serum cholesterol ratio &gt; or = 0.4, pleural fluid triglyceride &gt; or = 40 mg/dl and pleural fluid to serum triglyceride ratio &gt; or = 0.3. Pleural fluid cholesterol had a sensitivity of 88% and a specificity of 100% for exudates with an accuracy of 92%. Pleural fluid to serum cholesterol ratio had a sensitivity of 98% and a specificity of 84%. These results were superior to the criteria proposed by Light et al. (sensitivity 98% and specificity 80%). Pleural fluid cholesterol estimation is an effective and cost-efficient method of differentiating exudative from transudative pleural effusion. The lipid profile does not help in diagnosing tubercular effusion." }, { "id": "pubmed23n0088_3725", "title": "[Clinical evaluation and tissue distribution of CA125 in patients with pleural effusion].", "score": 0.012340600575894693, "content": "CA125 in serum and pleural effusion was measured in 51 patients with malignant effusion and 38 patients with benign effusion, and the tissue distribution of CA125 was investigated by immunohistochemical technique. The 51 malignant effusions were secondary to primary lung cancer. The 38 benign effusions were taken from 23 patients with tuberculous pleurisy, 9 patients with empyema, 5 patients with congestive heart failure and one patient with nephrosis. In the mean level and the positive rate of serum CA125, no significant difference was shown between primary lung cancer and tuberculosis or the other benign diseases. The mean level of CA125 in pleural effusion of primary lung cancer was significantly higher than that in pleural effusion of tuberculosis (p less than 0.01), and showed a tendency to increase compared to that in pleural effusion of the other benign diseases (p less than 0.1). The mean level of CA125 in pleural effusion of tuberculosis was significantly lower than that in the other benign diseases (p less than 0.02). The positive rate of CA125 in malignant effusion was 43.1% and the diagnostic specificity of it was 86.7%. CA125 was detected in carcinoma cells and activated mesothelial cells in pleural effusion and mesothelial cells of normal pleural tissue by immunohistochemical staining. These results suggest that the measurement of CA125 in pleural effusion is useful for differential diagnosis of the malignant effusion from the benign effusion and that CA125 in pleural effusion of pleuritis carcinomatosa is produced by not only carcinoma cells but also activated mesothelial cells." }, { "id": "wiki20220301en167_881", "title": "Parapneumonic effusion", "score": 0.012287624943878635, "content": "A parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis. There are three types of parapneumonic effusions: uncomplicated effusions, complicated effusions, and empyema. Uncomplicated effusions generally respond well to appropriate antibiotic treatment. Diagnosis The criteria for a complicated parapneumonic effusion include Gram stain–positive or culture-positive pleural fluid, pleural fluid pH <7.20, and pleural fluid LDH that is greater than three times the upper limit of normal of serum LDH. Diagnostic techniques available include plain film chest x-ray, computed tomography (CT), and ultrasound. Ultrasound can be useful in differentiating between empyema and other transudative and exudative effusions due in part to relative echogenicity of different organs such as the liver (often isoechogenic with empyema)." }, { "id": "InternalMed_Harrison_20549", "title": "InternalMed_Harrison", "score": 0.012255762255762255, "content": "Perform diagnostic thoracentesis Measure pleural fluid protein and LDH Exudate Further diagnostic procedures Transudate Treat CHF, cirrhosis, nephrosis Measure PF glucose Obtain PF cytology Obtain differential cell count Culture, stain PF PF marker for TB Consider:Malignancy Bacterial infections Rheumatoid pleuritis Glucose < 60 mg/dL No diagnosis Consider pulmonary embolus (spiral CT or lung scan) Treat for PE Treat for TB PF marker for TB Observe Consider thoracoscopy or image-guided pleural biopsy Any of following met? PF/serum protein > 0.5 PF/serum LDH > 0.6 PF LDH > 2/3 upper normal serum limit Pleural effusion Yes No Yes Yes Yes No No No SYMPTOMS IMPROVING FIGURE 316-1 Approach to the diagnosis of pleural effusions. CHF, congestive heart failure; CT, computed tomography; LDH, lactate dehydrogenase; PE, pulmonary embolism; PF, pleural fluid; TB, tuberculosis." }, { "id": "wiki20220301en063_55698", "title": "Thoracentesis", "score": 0.012092731829573935, "content": "The use of ultrasound for needle guidance can minimize the complication rate. Follow-up imaging While chest X-ray has traditionally been performed to assess for pneumothorax following the procedure, it may no longer be necessary to do so in asymptomatic, non-ventilated persons given the widespread use of ultrasound to guide this procedure. Interpretation of pleural fluid analysis Several diagnostic tools are available to determine the etiology of pleural fluid. Transudate versus exudate First the fluid is either transudate or exudate. A transudate is defined as pleural fluid to serum total protein ratio of less than 0.5, pleural fluid to serum LDH ratio > 0.6, and absolute pleural fluid LDH > 200 IU or > 2/3 of the normal." }, { "id": "wiki20220301en191_9135", "title": "Malignant pleural effusion", "score": 0.01204978813559322, "content": "Malignant pleural effusion is a condition in which cancer causes an abnormal amount of fluid to collect between the thin layers of tissue (pleura) lining the outside of the lung and the wall of the chest cavity. Lung cancer and breast cancer account for about 50-65% of malignant pleural effusions. Other common causes include pleural mesothelioma and lymphoma. Diagnosis Clinical evaluation Clinical factors predicting the diagnosis of malignant pleural effusions are symptoms lasting more than 1 month and the absence of fever." }, { "id": "pubmed23n0284_20812", "title": "The etiology of pleural effusions in an area with high incidence of tuberculosis.", "score": 0.011956521739130435, "content": "To investigate the etiology of pleural effusions in our region, we undertook a prospective study of patients with this condition in our centers. During a 5-year period, we studied 642 pleural effusion patients aged 57.1 +/- 21.1 years, of whom 401 were men aged 56.5 +/- 21 years and 241 were women aged 57.8 +/- 21.4 years; the male/female ratio was 1.6:1. The most frequent cause of pleural effusion was tuberculosis (25%), followed by neoplasia (22.9%) and congestive heart failure (17.9%). The etiology of 48 cases (7.5%) remained uncertain. In the neoplastic effusion group, the most frequent locations of the primary tumor were lung (32.6%), breast (11.5%), lymphoma (10.8%), and ovary (7.5%); in 21 cases (14.3% of the neoplastic group), it was not possible to identify the primary tumor. The 111 patients aged younger than 40 years with tuberculous effusions made up 69.4% of tuberculous effusion cases and the same percentage of patients younger than 40 years; the proportion of effusions that were tuberculous peaked in the 11- to 30-year-old age group and declined steadily thereafter. Of the patients with neoplastic effusions, 83% were older than 50 years; the proportion of effusions that were neoplastic rose steadily from zero in the 0- to 30-year-old age group to a peak among 60- to 70-year-olds. The age-wise distribution of effusions secondary to congestive heart failure was similar to that of neoplastic effusions. Of the effusions secondary to congestive heart failure, 86% (99/115) affected the right pleura or both, and 83% of effusions secondary to pulmonary thromboembolism (15/18) affected the right side. Neoplastic, tuberculous, parapneumonic, empyematous, and other exudative effusions showed no preference for either side. Of the 97 bilateral effusions, 77 (79.4%) were secondary to heart failure (59, 60.8%) or neoplasia (18, 18.6%). We conclude that in our region, the most frequent cause of pleural effusion is tuberculosis, followed by neoplasia and congestive heart failure. We suggest that all those interested in pleural disease should determine the etiologic pattern of pleural effusion in their region with a view to the adoption of regionally optimized diagnostic and therapeutic attitudes." }, { "id": "InternalMed_Harrison_20548", "title": "InternalMed_Harrison", "score": 0.011915767847971237, "content": "If a patient has an exudative pleural effusion, the following tests on the pleural fluid should be obtained: description of the appearance of the fluid, glucose level, differential cell count, microbiologic studies, and cytology. Effusion Due to Heart Failure The most common cause of pleural effusion is left ventricular failure. The effusion occurs because the increased amounts of fluid in the lung interstitial spaces exit in part across the visceral pleura; this overwhelms the capacity of the lymphatics in the parietal pleura to remove fluid. In patients with heart failure," }, { "id": "wiki20220301en191_9136", "title": "Malignant pleural effusion", "score": 0.011900425015179114, "content": "Diagnosis Clinical evaluation Clinical factors predicting the diagnosis of malignant pleural effusions are symptoms lasting more than 1 month and the absence of fever. Imaging This is needed to confirm the presence of a pleural effusion. Chest radiograph is usually performed first and may demonstrate an underlying lung cancer as well as the pleural effusion. Ultrasound has a sensitivity of 73% and specificity of 100% at distinguishing malignant pleural effusions from other causes of pleural effusion, based on the presence of visible pleural metastases, pleural thickening greater than 1 cm, pleural nodularity, diaphragmatic thickening measuring greater than 7mm and an echogenic swirling pattern visible in the pleural fluid. Biochemical analysis Malignant pleural effusions are exudates. A low pleural fluid pH is associated with poorer survival and reduced pleurodesis efficacy." }, { "id": "wiki20220301en015_101882", "title": "Pleural effusion", "score": 0.011678981937602629, "content": "Transudative pleural effusions are defined as effusions that are caused by systemic factors that alter the pleural equilibrium, or Starling forces. The components of the Starling forces – hydrostatic pressure, permeability, and oncotic pressure (effective pressure due to the composition of the pleural fluid and blood) – are altered in many diseases, e.g., left ventricular failure, kidney failure, liver failure, and cirrhosis. Exudative pleural effusions, by contrast, are caused by alterations in local factors that influence the formation and absorption of pleural fluid (e.g., bacterial pneumonia, cancer, pulmonary embolism, and viral infection). An accurate diagnosis of the cause of the effusion, transudate versus exudate, relies on a comparison of the chemistries in the pleural fluid to those in the blood, using Light's criteria. According to Light's criteria (Light, et al. 1972), a pleural effusion is likely exudative if at least one of the following exists:" }, { "id": "wiki20220301en015_101871", "title": "Pleural effusion", "score": 0.01157435316245087, "content": "The most common causes of exudative pleural effusions are bacterial pneumonia, cancer (with lung cancer, breast cancer, and lymphoma causing approximately 75% of all malignant pleural effusions), viral infection, and pulmonary embolism. Another common cause is after heart surgery when incompletely drained blood can lead to an inflammatory response that causes exudative pleural fluid. Conditions associated with exudative pleural effusions: Parapneumonic effusion due to pneumonia Malignancy (either lung cancer or metastases to the pleura from elsewhere) Infection (empyema due to bacterial pneumonia) Trauma Pulmonary infarction Pulmonary embolism Autoimmune disorders Pancreatitis Ruptured esophagus (Boerhaave's syndrome) Rheumatoid pleurisy Drug-induced lupus" }, { "id": "article-20929_15", "title": "Pleural Effusion -- Evaluation", "score": 0.011500708764609912, "content": "Commonly performed tests on the pleural fluid to determine etiology are a measurement of fluid pH, fluid protein, albumin and LDH, fluid glucose, fluid triglyceride, fluid cell count differential, fluid gram stain and culture, and fluid cytology. Exudates are characterized by elevated protein, elevated LDH, and decreased glucose. Pleural fluid LDH greater than 1000 U/L may be seen in tuberculosis, lymphoma, and empyema. Low pH (pH less than 7.2) indicates complex pleural effusion in the setting of pneumonia and almost always requires chest tube insertion for drainage. Other causes of low pH may be an esophageal rupture and rheumatoid arthritis." }, { "id": "wiki20220301en015_101891", "title": "Pleural effusion", "score": 0.01149725633655605, "content": "See also Pleural disease Empyema Heart failure Pulmonary embolism Subpulmonic effusion Thoracentesis References External links Pleural Effusion Images from MedPix Disorders of fascia Diseases of pleura Articles containing video clips" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 171 ] ], "word_ranges": [ [ 0, 32 ] ], "text": "Let's see, if that subject was not in any risk group, the positive is in the 15mm, therefore both tests are negative, and as only one answer refers to negative, that's it." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "The first reaction is a false positive.", "2": "The second reaction is a true positive.", "3": "The first reaction is a true negative.", "4": "The second reaction is a false positive.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0470_302", "title": "TUBERCULIN reaction size on five consecutive days.", "score": 0.018524871355060035, "content": "The present paper gives the results of a study on tuberculin reaction size-erythema and induration-at different intervals after intradermal testing with 1 TU.In the course of tuberculin-testing some 18,000 textile workers in Mehalla el Kobra, Egypt, the tuberculin reactions of 417 men were read daily for five days after the tests had been given. The successive readings were made by the same observer without reference to his previous readings.No difference of any practical significance was found between the results of readings made on the second through the fifth day. Almost all the reactions of over 6 mm of induration on any one day (except the first) remained above 6 mm on the subsequent days, and those measuring 0-6 mm did not exceed 6 mm on the later days. Thus, whether the reactions had been read on the second, third, fourth, or fifth day, essentially the same persons would have been classified as positive and negative according to the induration-reaction size.Erythema could have served as well as induration for separating the study population into the same two groups, had 0-8 mm of erythema been defined as negative and erythema of 9 mm or more as positive for reactions read on the second through the fifth day.In tuberculin surveys of the population under study there would thus have been no need to adhere to a fixed reading interval.The material included in the present paper illustrates how the results of a relatively small and inexpensive preliminary study may serve to simplify and rationalize subsequent large-scale work." }, { "id": "pubmed23n0058_1160", "title": "Four-stage tuberculin testing in elderly subjects induces age-dependent progressive boosting.", "score": 0.018521679754182313, "content": "We administered four sequential tuberculin skin tests (5 TU, PPD) with intervals of one week to 223 subjects older than 65 years of age to evaluate whether elderly subjects demonstrated progressive boosting. Indurations of at least 10 mm with increases of at least 6 mm (over the previous test) were considered significant reactions, and these were found in 29 percent of the subjects after test 1, in 43 percent after test 2, in 53 percent after test 3, and in 57 percent after test 4 (p less than 0.05), ie, only about 50 percent of all the positives were detected after the first test. The percentage of positive reactors was inversely related to age (p less than 0.001), yet this age-dependent difference decreased with increasing number of tests. For the 65- to 74-year-old age group, 44 percent reacted positively after the first test and after three tests almost a plateau of 65 to 70 percent positive reactors was reached, suggesting that a minority only of about 30 to 35 percent of these geriatric patients might have outlived their bacilli or were never infected. For the 75- to 84-year-old age group, 24 percent reacted after the first test and 55 percent reacted after the fourth one. For the older than 85-year-old age group, 19 percent positive reactors were found after the first test and 46 percent were found after the fourth test, without clear-cut leveling off toward a plateau value, suggesting that additional tests would induce further boosting. Mean diameters of positive reactions were 15 to 24 mm, and were mostly at least 12 mm larger than in the previous tests. These data support the hypothesis that the negative tuberculin reaction, which is often found in elderly subjects, is mainly due to the failing immune response to tuberculin antigen that can be restored progressively by repeated administrations. These findings, furthermore, emphasize that especially in elderly, care should be taken not to interpret a boosting reaction as a conversion and especially that neither a two-step testing as recommended by the ATS and CDC (Am Rev Respir Dis 1990; 142:723-35) nor even a four-step testing may suffice to detect all positives in this type of population." }, { "id": "pubmed23n0265_14273", "title": "Two-stage tuberculin skin testing in an HIV-infected population: a preliminary report.", "score": 0.017820370663709804, "content": "To identify differences in purified protein derivative (PPD) tuberculin positivity rates and to assess the utility of sequential PPD testing among persons with HIV infection, we performed two sequential administrations of 5 tuberculin units of PPD in a group of persons with HIV infection. Eligible patients were skin-tested with the tuberculin using the Mantoux method. Patients who tested &lt; 5 mm of induration were skin-tested seven days later along with Candida and mumps antigens. Of 37 tested patients, only 18 (49%) returned to have the first test read. Using a &gt; or = 5 mm cutoff, 5 (28%) tested positive. Positivity varied markedly between patients with CD4+ cell counts under and at or over 400 cells/mm3 (0% vs. 56%). Among patients who had a reaction to the first test, the reaction was smaller in patients with CD4+ cell counts under 400 than in those with counts at or over 400 cells/mm3 (mean induration: 2.8 vs. 30.4 mm). Positivity was also less frequent in intravenous drug users than in nonusers (9% vs. 57%); these two groups did not differ with respect to CD4+ cell counts. Of the 13 patients who tested &lt; 5 mm, only 8 (62%) kept their appointments to have the second test placed and read. Only 1 of these, a drug user with a CD4+ count of 6 cells/mm3, had a positive reaction with boosting from 4 mm on the first test to 10 mm on the second. These data indicate that PPD testing may be unreliable in screening for tuberculosis infection in persons with CD4+ counts &lt; 400 cell/mm3.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0365_647", "title": "[Two-step tuberculin skin testing in our hospital employees].", "score": 0.017577673271143318, "content": "To evaluate the baseline values of tuberculin reaction, two-step tuberculin skin testing was carried out in 365 employees of our hospital. We defined strongly response group when the size of erythema showed more than 30 mm or who showed strongly positive reaction. Two-step tuberculin skin testing was carried out in 165 hospital employees excluding those who were defined as the strongly response group in the first testing. 80 hospital employees (48.5%) became strongly response group by the second tuberculin skin testing. Altogether, 76.7% of all employees were strongly response group either by the first time or the second tuberculin skin testing. The size of erythema and that of induration showed 13.2 +/- 12.6 mm (mean +/- SD), 6.9 +/- 9.2 mm increase, respectively, in the two-step tuberculin skin testing, so-called Booster phenomenon. We could not know the true tuberculin reaction status by the single tuberculin skin testing. Therefore, two-step tuberculin skin testing is important as one of an infection prevention countermeasures in the hospital workers." }, { "id": "pubmed23n0063_6143", "title": "Stability of positive tuberculin tests: are boosted reactions valid?", "score": 0.017170228445099484, "content": "To determine the stability and presumed significance of tuberculin skin tests, we followed a cohort of 380 tuberculin-positive patients living in chronic care facilities. Each patient had a positive reaction (greater than or equal to 10 mm induration to 5 tuberculin units of purified protein derivative) to one of three sequential baseline tuberculin tests. One year after the initial series, each patient had a single repeat skin test. Reversion to a negative test occurred in 98 (26%) of the 380 patients. Decreases in induration of 6 mm or more occurred in 88 (90%) of the reverters. Initially positive tests were more likely (p less than 0.001) to remain stable than tests that were \"boosted\" to positive reactions on the second or third initial administration. Stable responses were found in 96% of those whose tests had greater than or equal to 15 mm induration compared with 61% of those with reactions of 10 to 14 mm induration. Increasing age also was associated with a high rate of reversion. The instability of boosted tuberculin reactions brings into question the clinical significance of these tests. We propose limiting tuberculin testing to two sequential tests." }, { "id": "pubmed23n0077_16566", "title": "Choosing an appropriate criterion for true or false conversion in serial tuberculin testing.", "score": 0.01713418160786582, "content": "This study evaluates five different criteria of true conversion in relation to the annual tuberculosis infection rate or risk of infection. It also examines prospective results of a general population, 16 to 69 yr of age, who had less than 6 mm of induration at first PPD test. This population received a second PPD test between 1976 and 1986. In about 95% of cases, the interval was 1 to 5 yr. In 1,355 bacillus Calmette-Guerin (BCG)-vaccinated subjects, none of the criteria is acceptable for true conversion. Among 1,834 nonvaccinated BCG, only the criterion of a change from less than 10 to 18 mm or more with an increase of 12 mm or more, or the criterion of change from less than 10 to 18 mm or more with an increase of 18 mm or more, is compatible with true conversion and with the correspondent annual risk of infection. But we must accept that with smaller increases, recently infected persons may escape diagnosis of infection. A third test was performed in 81 subjects with two negative test results. In all cases except one, the annual conversion rate observed was much higher than the annual risk of infection. These data reveal shortcomings of the current criterion for conversion. They show that the tuberculin conversion at retesting is not epidemiologically related to new infection and that none of the criteria assures the discovery of true converters. Other factors must be taken into account." }, { "id": "pubmed23n0564_5512", "title": "The presence of a booster phenomenon among contacts of active pulmonary tuberculosis cases: a retrospective cohort.", "score": 0.0167013167013167, "content": "Assuming a higher risk of latent tuberculosis (TB) infection in the population of Rio de Janeiro, Brazil, in October of 1998 the TB Control Program of Clementino Fraga Filho Hospital (CFFH) routinely started to recommend a two-step tuberculin skin test (TST) in contacts of pulmonary TB cases in order to distinguish a boosting reaction due to a recall of delayed hypersensitivity previously established by infection with Mycobacterium tuberculosis (M.tb) or BCG vaccination from a tuberculin conversion. The aim of this study was to assess the prevalence of boosted tuberculin skin tests among contacts of individuals with active pulmonary tuberculosis (TB). Retrospective cohort of TB contacts &gt; or = 12 years old who were evaluated between October 1st, 1998 and October 31st 2001. Contacts with an initial TST &lt; or = 4 mm were considered negative and had a second TST applied after 7-14 days. Boosting reaction was defined as a second TST &gt; or = 10 mm with an increase in induration &gt; or = 6 mm related to the first TST. All contacts with either a positive initial or repeat TST had a chest x-ray to rule out active TB disease, and initially positive contacts were offered isoniazid preventive therapy. Contacts that boosted did not receive treatment for latent TB infection and were followed for 24 months to monitor the development of TB. Statistical analysis of dichotomous variables was performed using Chi-square test. Differences were considered significant at a p &lt; 0.05. Fifty four percent (572/1060) of contacts had an initial negative TST and 79% of them (455/572) had a second TST. Boosting was identified in 6% (28/455). The mean age of contacts with a boosting reaction was 42.3 +/- 21.1 and with no boosting was 28.7 +/- 21.7 (p = 0.01). Fifty percent (14/28) of individuals whose test boosted met criteria for TST conversion on the second TST (increase in induration &gt; or = 10 mm). None of the 28 contacts whose reaction boosted developed TB disease within two years following the TST. The low number of contacts with boosting and the difficulty in distinguishing boosting from TST conversion in the second TST suggests that the strategy of two-step TST testing among contacts of active TB cases may not be useful. However, this conclusion must be taken with caution because of the small number of subjects followed." }, { "id": "wiki20220301en002_179063", "title": "Mantoux test", "score": 0.016453503863575806, "content": "Use of two-step testing is recommended for initial skin testing of adults who will be retested periodically (e.g., health care workers). This ensures any future positive tests can be interpreted as being caused by a new infection, rather than simply a reaction to an old infection. The first test is read 48–72 hours after injection. If the first test is positive, consider the person infected. If the first test is negative, give a second test one to three weeks after the first injection. The second test is read 48–72 hours after injection. If the second test is positive, consider the person infected in the distant past If the second test is negative, consider the person uninfected. A person who is diagnosed as \"infected in the distant past\" on two-step testing is called a \"tuberculin reactor\". The US recommendation that prior BCG vaccination be ignored results in almost universal false diagnosis of tuberculosis infection in people who have had BCG (mostly foreign nationals)." }, { "id": "pubmed23n0242_8950", "title": "[Tuberculin screening tests. Open comparative trial of Tine-Test and Monotest versus Mantoux 1:1000 (10 TU) in 119 outpatients].", "score": 0.01630151278038602, "content": "The two percutaneous tuberculin tests Tine test (TT) (old tuberculin) and Monotest (MT) (PPD-tuberculin) were compared simultaneously with the standard intradermal reaction (Mantoux [MX] 1:1000 = 10 EPPD-RT23-tuberculin) in 119 unselected 16-81 year old outpatients (general medicine) in an open trial. The tests were read after 48 and/or 72 h. Indurations of greater than or equal to 10 mm (MX), greater than or equal to 2 mm (MT) and greater than or equal to 5 mm of one papule or confluescent papules (TT) were considered to be positive. 6-9 mm for MX and 2-4 mm for TT were considered doubtful. The overall agreement with MX (69.7% positive, 27.7% negative reactions) was 92.4% for MT and 68.1% for TT. Regarding sensitivity (false negative reactions), MT provided far better results than TT (8.4% vs. 44.6%). TT performed equally well when the doubtful reactions were reclassified as positive (8.4% false negative). It is recommended that the limit for a positive TT be lowered to greater than or equal to 2 mm, as other authors have suggested. MT always produced easily palpable and measurable indurations, whereas the borderline TT reactions (2-4 mm) were difficult to read and the size of the four papules varied considerably in most instances. Only MT showed significantly more positive readings after 72 h compared to 48 h. MT was better tolerated subjectively than TT with regard to application and skin reaction. The Monotest can be recommended as tuberculin screening test for general practice." }, { "id": "pubmed23n0103_18213", "title": "Sensitivity to avian sensitin of tuberculin reactors in Belgium.", "score": 0.01626123744050767, "content": "It was proposed that a study should be made on the specificity of the reactions of 1068 subjects reacting \"weakly to moderately\" to an intradermal test with 2 units of PPD RT23; 43% were classified as \"positives\" (greater than or equal to 10 mm) and Palmer type IV indurations or merely erythema were seen in 81%. Three months later, the same people were retested, this time with 2 units of PPD RT23 and, simultaneously, with 0.1 mcg of avian sensitin: 23% of all reactors (13% of all \"positives\", but none with a Palmer type I of II induration) had completely lost their sensitivity to RT23. Of the 1068 original reactors, 87% reacted to avian sensitin and 69% did so with a reaction greater than or equal to to human RT23. According to the results of this double test, and depending on the strictness of the comparative criterion, 69% to 84% of the original reactors (65% to 78% of the \"positives\") would be classified as non-specifically infected. There was a high degree of agreement between an induration greater than or equal to 10 mm to PPD RT23 in the second test and classification as specific infection, based on a comparative criterion." }, { "id": "pubmed23n0318_17960", "title": "Underreading of the tuberculin skin test reaction.", "score": 0.01554001554001554, "content": "The tuberculin skin test is the best diagnostic method to detect tuberculous infection. How accurate is interpretation of the test? Observational study. Both general hospital and university hospital. One hundred seven health-care professionals, including 52 practicing pediatricians, 33 pediatric house officers, 10 pediatric academicians, 11 registered nurses, and 1 pediatric nurse practitioner. A tuberculin skin test (Mantoux) was applied to the arm of a known tuberculin converter. As participants entered/left the room, they were guided to the tuberculin converter. At no time did a participant observe readings other than his/her own. Mantoux tuberculin reaction measuring 15 mm induration was read individually by a group of 52 practicing pediatricians, 33 pediatric house officers, 10 pediatric academicians, 11 registered nurses, and one pediatric nurse practitioner. The median induration recorded by this group of 107 health-care professionals was 10 mm, and 17 (33%) practicing pediatricians read the reaction as &lt;10 mm induration. Using the &gt; or = 15-mm induration indicator to identify a positive reaction, 93% of those in the study (99/107 participants) would have identified our known converter as tuberculin negative. This study confirms a general inaccuracy in interpretation of the tuberculin skin test reaction. It raises two questions. (1) Is there a general tendency toward underreading? (2) Does this general tendency to underread tuberculin skin test reactions raise some question as to the American Academy of Pediatrics, American Thoracic Society, and Centers for Disease Control and Prevention move in raising the amount of induration considered tuberculin positive to 15 mm in low-risk individuals?" }, { "id": "pubmed23n0067_11194", "title": "A 19-year follow-up of tuberculin reactors. Assessment of skin test reactivity and in vitro lymphocyte responses.", "score": 0.015182648401826484, "content": "Tuberculin skin test reactivity decreases with time such that repeat PPD skin testing may result in reactions of less than 10 mm. This reactivity may be boosted in some individuals with a second tuberculin skin test. The immunologic basis of these observations remains unclear. We studied the relationship between skin-test reactivity and in vitro blastogenic response to PPD in a cohort of 22 individuals (aged 28 to 81 years) known to be tuberculin reactors (induration greater than or equal to 10 mm) in 1970. In 1989, 18 subjects remained reactive to PPD on the first skin test and responded to PPD in vitro (mean incorporation of 3H-thymidine by peripheral blood mononuclear cells, 22,650 cpm). Three subjects reverted (induration in response to PPD less than 10 mm) and lost in vitro reactivity to PPD (mean incorporation of 3H-thymidine, 2,205 cpm). One subject boosted (increase of induration of at least 6 mm to greater than or equal to 15 mm) on the second skin test and showed a concomitant in vitro boost in the blastogenic response to PPD (from 1,008 cpm to 47,837 cpm). In this cohort, interpretation of the two-step tuberculin skin test correlated closely with in vitro proliferative responses. Over a 19-year period, the majority of individuals maintained skin test reactivity and strong in vitro responses to PPD despite a lack of ongoing exogenous exposure to Mycobacterium tuberculosis. The immunologic basis for reversion appears to depend in part on a loss of lymphocyte blastogenic capacity. In the one individual who exhibited the booster phenomenon, repeat antigen stimulation resulted in a dramatic increase in the in vitro blastogenic responses." }, { "id": "pubmed23n0234_8006", "title": "Multiple-puncture tuberculin testing: reason for variable response to tine test.", "score": 0.015106569984618765, "content": "1040 'Tine Test' (TT) discs from 3 production batches were examined under a dissecting microscope. The dried tuberculin coatings of the 4 metal tines of the test discs were found to vary from being thin and smooth to being thick with droplet formation. Variations in coating were identified in the following proportions: 47% thin, 37% medium, and 16% thick (N = 4160 tines), these proportions varying significantly between the 3 batches (p much less than 0.001). Pairs of thin and thick coated TT discs were selected and applied to 103 tuberculin positive volunteers. When thickly coated TT were applied the sum of the diameters of induration was substantially smaller (p less than 0.001) than when thinly coated TT were used. At a greater than or equal to 2 mm limit for a positive reaction the thick TT failed to detect 16% of subjects positive to a 'Monotest' (MT) or a Mantoux (MX) 10 IU and the thin TT failed to detect 5% (p less than 0.05); at a greater than or equal to 5 mm limit the figures were 77% and 59% (p less than 0.01) respectively. In moderately sensitized populations, thick coated TT could lead to an excess of false negative results. The TT is of limited value as a screening test unless thin and uniform coating of tuberculin can be guaranteed." }, { "id": "pubmed23n0104_5590", "title": "Evaluation of a third sequential tuberculin skin test in a chronic care population.", "score": 0.014448074356968665, "content": "To evaluate factors that might influence the accuracy of tuberculin tests in identifying elderly persons recently infected with Mycobacterium tuberculosis, we performed as many as 3 sequential administrations of 5 tuberculin units of purified protein derivative in 1,726 persons residing in chronic care facilities. Significant reactions (greater than or equal to 10 mm of induration) to 1 of 3 tests were found in 702 (40.7%) persons. Of these, 68% were found with Test 1, 22.5% with Test 2, and 9.5% with Test 3. Of 1,146 persons with nonsignificant reactions to Test 1, 13.8% had significant reactions on Test 2, and of 769 persons with nonsignificant reactions to Tests 1 and 2, 8.7% had significant reactions on Test 3. Males, nonwhites, and persons between 50 and 79 yr of age had a greater proportion of significant reactions for each of the first 2 tests but not for the third test. These data indicate that continued boosting of the tuberculin reaction occurs in a substantial number of persons who receive a third sequential test. Marked increases in the size of reactions caused by boosting may explain high apparent conversion rates found in facilities where the third test is delayed for one year." }, { "id": "wiki20220301en029_96904", "title": "Heaf test", "score": 0.014286955011290603, "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": "pubmed23n0348_3483", "title": "[The booster phenomenon in two-step tuberculin testing of employees in a community hospital].", "score": 0.01427569625325586, "content": "A study was made to clarify to what degree the booster phenomenon was present when the employees in a community hospital in Japan received two-step tuberculin testing (PPD). Of the seventy-five employees, most of all BCG-vaccinated subjects, twenty-three showed strongly positive of more than 30 mm of induration at the first test (PPD/T1), and the remaining fifty-two subjects received a second (PPD/T2) after 2 weeks. The second PPD showed a marked increase in reactivity, sixteen subjects newly became strongly positive and six of eight who were initially PPD negative (&lt; 10 mm) were converted positive, and the mean reaction size changed from 14.7 +/- 5.6 mm (PPD/T1) to 31.5 +/- 15.5 mm (PPD/T2). The degree of boosting, measured by the change in millimeters induration size between PPD/T1 and PPD/T2 (PPD/T2-PPD/T1), was correlated with neither the size of PPD/T1 nor the age of the study participants, and was not associated with the difference of the position in the hospital. Thus, we could not explain the factor why such a marked boosting was observed in this study. However, these results indicated that the two-step tuberculin testing is an essential means of distinguishing new tuberculous infection from booster phenomenon. We agree with the current recommendation for routine two-step testing of new employees in the hospital." }, { "id": "pubmed23n0286_10115", "title": "Investigation into typical and atypical tuberculin sensitivity in the Royal Netherlands Army, resulting in a more rational indication for isoniazid prophylaxis.", "score": 0.013406593406593406, "content": "The Department of Military Health Services (DMGZ) vaccination clinic, Utrecht, The Netherlands. To improve upon PPD skin testing procedure by introducing a double Mantoux test. During the first part of the study, from 1986-1988, army recruits were double-tested simultaneously with PPD and Mycobacterium scrofulacaeum sensitin. During the second part of the study, from 1989 to 1993, recruits reacting to PPD, with an induration in the range of 10-15 mm, underwent a second skin test with M. scrofulaceum sensitin. The total study population consisted of 237,692 non-BCG-vaccinated recruits. From 1986-1993 and average of 0.45% persons reacted with indurations &gt; or = 10 mm to PPD. An average of 7.76% if army recruits reacted with indurations &gt; or = 10 mm to M. scrofulaceum sensitin during the first part of the study. Using a modified ITSC (International Tuberculosis Surveillance Centre) model, 48% of the persons reacting to PPD with indurations in the range 10 mm and 15 mm were classified as false-positive. A total of 16% with indurations &gt; or = 10 mm to PPD were classified as false positive. False-positive persons were then excluded from INH chemoprophlaxis. In areas with a high prevalence of non-tuberculous mycobacteria infection the use of double skin testing might be useful in differentiating between indurations due to tubercle bacilli and those due to infection with non-tuberculous mycobacteria." }, { "id": "wiki20220301en002_179056", "title": "Mantoux test", "score": 0.013158375671625425, "content": "A tuberculin test conversion is defined as an increase of 10 mm or more within a two-year period, regardless of age. Alternative criteria include increases of 6, 12, 15 or 18 mm. False positive result TST (tuberculin skin test) positive is measured by size of induration. The size of the induration considered to be a positive result depends on risk factors. For example, a low-risk patient must have a larger induration for a positive result than a high-risk patient. High-risk groups include recent contacts, those with HIV, those with chest radiograph with fibrotic changes, organ transplant recipients, and those with immunosuppression." }, { "id": "wiki20220301en041_28736", "title": "Lepromin", "score": 0.01295191295191295, "content": "By contrast, two forms of positive reactions are seen when tuberculoid or borderline cases of HD are assessed by the lepromin test. (There are three borderline diagnoses possible as well as the tuberculoid and lepromatous diagnoses in the Ridley-Jopling classification system. The severity of disease and thus assignment to one of the five diagnoses is related to the strength of the cell mediated immune response.) The Fernandez (early) reaction appears within two days and is roughly equivalent in nature and underlying mechanism to the response seen in tuberculosis patients reacting positively to the tuberculin test. Induration of 5mm or more with erythema (redness), or 10mm without, 48 hours post-injection are positive Fernandez reactions. Unlike the tuberculin test, however, another reaction occurs in lepromatous patients at the injection site 21 days post-injection, also appearing as induration and possible ulceration. This late positive reaction is known as the Mitsuda reaction." }, { "id": "pubmed23n0382_16673", "title": "[Two-step tuberculin testing and BCG vaccination in the personnel of a medical and pharmaceutical university].", "score": 0.012948987587116994, "content": "In an attempt to cope with recent nosocomial spread of tuberculosis, the tuberculin test with a 0.05 microgram of 0.1 ml intradermal dose of purified protein derivative was performed by a two-step procedure on the personnel of a medical and pharmaceutical university, followed by BCG vaccination for non-reactors in the second test. The second test was repeated after two weeks in all but those with erythema of 10 mm or more in diameter associated with double erythema, vesicle formation, and/or necrosis on the initial testing. The first test was done in a total of 935 participants (73% of all personnel) with a median age of 37 (range, 21-67) years. The rate of participation, by occupation, in the hospital personnel ranged from 63% (183/289) for doctors to 98% (351/358) for nurses. The size of erythema showed a unimodal distribution with a peak in the range of 10-19 mm, with a median of 20 mm (range, 0-102). Reactions below 9 mm, which are interpreted as negative, were found in 16% of all participants, and those above 30 mm in 35%. Among participants aged 20-49 years, especially among nurses, reactions tended to be larger with increasing age. Among 539 participants undergoing repeated testing, reactions between the first and second tests correlated well, showing a median increase in size of 10 mm (range, -43-(+)70) on retesting. Reactions above 30 mm associated with an increase in size larger than 20 mm, among those initially below 29 mm in diameter, were observed in 28% of those retested. Adverse reactions such as vesicle formation with or without hemorrhage, or lymphangitis occurred in 2.5% of all participants on the initial testing and in 1.5% on the retesting, with the highest frequency seen in those aged 30-39 years. BCG was administered to 26 of the 49 participants with a negative reaction on the second test. All vaccinees with a median age of 30 (range, 21-46) years showed tuberculin conversion after two months without developing Koch's phenomenon soon after the vaccination. Incidentally, it is desirable that two-step tuberculin testing such as that in the present study should also be performed using the diameter of induration, particularly that measured transversely, since erythema is not used in any other country than Japan." }, { "id": "pubmed23n0389_6179", "title": "[Results of two-step tuberculin skin test against medical and nursing school students and treatment according to the results of the test].", "score": 0.012654690618762475, "content": "To assess the risk of tuberculosis infection in medical and nursing school students, tuberculin skin tests were carried out in the two-step manner. The second tuberculin skin test was repeated two weeks later excluding those who were strongly positive in the first test. BCG vaccination was done with the consent of students who showed negative reaction twice. Medical interview and revaluation of prior routine chest radiogram were made on students who were strongly positive. Prophylactic INH medication was considered to those who are at high risk of tuberculosis. Eight hundred thirty eight students underwent the two-step tuberculin skin test, and among them, 771 students showed the positive reaction on the first test (92.0%) which included 58 weakly positive (6.9%), 347 intermediately positive (41.4%) and 366 strongly positive (43.7%) and 2 not-measurable (0.2%), and 65 students were negative (7.8%). The average size of the erythema was 30.9 +/- 18.8 mm on the first test and 37.9 +/- 20.6 mm on the second test. Twenty one students were negative on the second tuberculin skin test, and among them, 15 received BCG vaccination. Out of eight students who were vaccinated with BCG in 1999 and were followed up in the next year, 6 (75.0%) converted to positive. Strongly positive reaction was seen in 28 students (3.3%) and one of them underwent prophylactic medication of INH according to her family history of exposure to tuberculosis." }, { "id": "pubmed23n0245_10183", "title": "A comparative study of the old tuberculin tine test and the PPD-tine test.", "score": 0.012447013487475915, "content": "Forty-one children suspected of having tuberculosis were simultaneously given an intermediate strength Mantoux test, an old tuberculin tine test (OT), and a purified protein derivative (PPD) tine test. Each test was read at 48 hours, and the largest diameter of induration was recorded. Twenty-nine patients had a positive reaction to the Mantoux test, 20 patients had a positive reaction to the OT tine test, and 16 patients had a positive reaction to the PPD-tine test. There were seven instances of a doubtful reaction to the OT tine test and nine to the PPD-tine test. Two children with positive Mantoux tests had negative OT tine tests, and four with positive Mantoux tests had negative PPD-tine test reactions. There was a significant difference between the number of positive reactors to the Mantoux test and both tine tests. If all tine test reactions of 2 mm or more were considered positive (doubtful plus positive reactors), there was no significant difference between any of the tuberculin tests. All suggestively positive tine reactors should, therefore, be retested with a Mantoux test to avoid false-negative interpretation of the tines." }, { "id": "wiki20220301en002_179053", "title": "Mantoux test", "score": 0.01240079365079365, "content": "the bacteria is expected to mount an immune response in the skin containing the bacterial proteins. The response is a classical example of delayed-type hypersensitivity reaction (DTH), a type IV of hypersensitivities. T cells and myeloid cells are attracted to the site of reaction in the timeframe of 1–3 days and generate local inflammation. The reaction is read by measuring the diameter of induration (palpable raised, hardened area) across the forearm (perpendicular to the long axis) in millimeters. If there is no induration, the result should be recorded as \"0 mm\". Erythema (redness) should not be measured. In the Pirquet version of the test tuberculin is applied to the skin via scarification." }, { "id": "pubmed23n0619_20535", "title": "Interpretation of a serial Mantoux test taking into account the annual risk of tuberculous infection.", "score": 0.012398412398412398, "content": "Interpretation of tuberculin tests (TSTs) can be difficult. However, it is even more difficult to classify an individual as infected or non-infected if he or she has undergone a prior TST, as the difference between the booster effect and true conversion is not always clear. To determine the size of the induration that is indicative of true infection after a second Mantoux test, based on the fact that the annual risk of tuberculous infection (ARTI) is equivalent, regardless of whether it is calculated directly or indirectly. We performed two TSTs in the same population (aged 6 years at the first examination) with a 1-year interval. We calculated the prevalence of infection the first year (1.16%, 95%CI 0.67-1.65) and the ARTI using the indirect method (0.18%, 95%CI 0.00-0.37). For the second year, we considered different induration sizes and finally accepted a diameter of &gt;10 mm as the criterion according to which the ARTI, calculated directly, corresponded to the value of the previous year (0.18%). Although they served as an aid in the interpretation of the TST, calculations of this type will probably be unnecessary in the future, when in vitro diagnostic tests for tuberculosis are made available in every health centre, thus enabling the classification of those individuals with indurations of intermediate size in the TST." }, { "id": "pubmed23n0615_20545", "title": "Two-step tuberculin skin test and booster phenomenon prevalence among Brazilian medical students.", "score": 0.01232420429311621, "content": "Five medical schools in three cities in Rio de Janeiro State, Brazil, with different tuberculosis (TB) incidence rates. To evaluate the prevalence of the booster phenomenon and its associated factors in a young universally BCG-vaccinated TB-exposed population. A two-step tuberculin skin test (TST) was performed among undergraduate medical students. Boosting was defined as an induration &gt; or =10 mm in the second TST (TST2), with an increase of at least 6 mm over the first TST (TST1). The association of boosting with independent variables was evaluated using multivariate analysis. Of the 764 participants (mean age 21.9 +/- 2.7 years), 672 (87.9%) had a BCG scar. The overall booster phenomenon prevalence was 8.4% (95%CI 6.5-10.6). Boosting was associated with TST1 reactions of 1-9 mm (aOR 2.5, 95%CI 1.04-5.9) and with BCG vaccination, mostly after infancy, i.e., after age two years (aOR 9.1, 95%CI 1.2-70.7). The prevalence of the booster phenomenon was high. A two-step TST in young BCG-vaccinated populations, especially in those with TST1 reactions of 1-9 mm, can avoid misdiagnosis as a false conversion and potentially reduce unnecessary treatment for latent TB infection." }, { "id": "pubmed23n0542_12218", "title": "High rate of negative results of tuberculin and QuantiFERON tests among individuals with a history of positive skin test results.", "score": 0.01219692489651094, "content": "To evaluate individuals at high risk for tuberculosis exposure who had a history of a positive tuberculin skin test (TST) result in order to determine the prevalence of unsuspected negative TST results. To confirm these findings with the QuantiFERON-TB test (QFT), an in vitro whole-blood assay that measures tuberculin-induced secretion of interferon-gamma. This survey was conducted from November 2001 through December 2003 at 3 sites where TST screening is regularly done. Detailed histories and reviews of medical records were performed. TSTs were placed and read by 2 experienced healthcare workers, and blood was drawn for QFT. Any subject with a negative result of an initial TST during the study (induration diameter, &lt;10 mm) underwent a second TST and a second QFT. The TST-negative group comprised individuals for whom both TSTs had an induration diameter of &lt;10 mm. The confirmed-negative group comprised individuals for whom both TSTs yielded no detectable induration and results of both QFTs were negative. A total of 67 immunocompetent subjects with positive results of a previous TST were enrolled in the study. Of 56 subjects who completed the TST protocol, 25 (44.6%; 95% confidence interval [CI], 31.6%-57.6%) were TST negative (P&lt;.001). Of 31 subjects who completed the TST protocol and the QFT protocol, 8 (25.8%; 95% CI, 10.4%-41.2%) were confirmed negative (P&lt;.005). A significant proportion of subjects with positive results of a previous TST were TST negative in this study, and a subset of these were confirmed negative. These individuals' TST status may have reverted or may never have been positive. It will be important in future studies to determine whether such individuals lack immunity to tuberculosis and whether they should be considered for reentry into tuberculosis screening programs." }, { "id": "pubmed23n0240_11731", "title": "The use of repeat skin tests to eliminate the booster phenomenon in serial tuberculin testing.", "score": 0.012085584927705565, "content": "During the early years of our annual tuberculosis skin testing program for hospital employees, we experienced conversion rates that were inordinately high. In an effort to eliminate the booster phenomenon in serial tuberculin testing as a contributing factor, a program of repeat skin testing performed within 7 to 28 days in new employees with less than 10-mm induration on initial skin testing was begun in 1978. Employees demonstrating a 6-mm increase in reaction size to a total induration of 10 mm or greater on repeat testing were classified as boosters. The booster rate for 1978 was 8.3%, and elimination of these employees from subsequent annual testing resulted in a decrease in the conversion rate from 8.7% in 1978 to 2.9% in 1979 (p less than 0.01). The rate of conversion was age-dependent in 1978, but this effect was absent in 1979 when the boosters were eliminated. On the basis of the results for the first 2 yr of our program, we concluded that repeat tuberculin skin testing is a practical approach to reduce falsely elevated conversion rates and can potentially reduce the number of persons exposed to the risk of isoniazid toxicity." }, { "id": "pubmed23n0354_18882", "title": "[Two-step tuberculin skin test in nurse students and hospital employees].", "score": 0.011761914446478205, "content": "Booster phenomenon (recall effect) of tuberculin skin test, which disturbs diagnosis of tuberculous infection, is prevalent among BCG vaccinated population. We retested 34 nurse students whose initial tuberculin reaction was smaller than 30 mm by erythema (Group A) and 53 hospital employees whose initial reaction was smaller than 20 mm by erythema (Group B). Among the people whose diameter of erythema was less than 10 mm by the first test, 88 percent (8/9) of group A and 43% (6/14) of group B showed reaction 10 mm &lt; or = by erythema and among those whose induration was &lt; 10 mm, 54% (6/11) of group A and 48% (12/25) of group B showed reaction 10 mm &lt; or = in the second testing. Mean and standard deviation of [the difference between the diameter of the 2nd and the 1st testing] was +7.3 +/- 11.8 mm in group A, +9.8 +/- 11.1 mm in group B by erythema and +2.6 +/- 5.9 mm in group A, +2.9 +/- 5.1 mm in group B by induration. These results indicate that booster phenomenon is highly prevalent among the tested group and there can be no appropriate criteria to distinguish new infection and booster phenomenon. Though two-step tuberculin skin test is recommended to get rid of booster phenomenon. Only a little is known about the value of this test to diagnose new infection in Japanese population, majority of whom being BCG vaccinated. Further investigations are required to apply two-step tuberculin skin test for diagnosis of new infection among hospital employees and health care workers in Japan." }, { "id": "wiki20220301en002_179066", "title": "Mantoux test", "score": 0.011652598609120348, "content": "T-SPOT.TB is another IGRA; it uses the ELISPOT method. Heaf test The Heaf tuberculin skin test was used in the United Kingdom, but discontinued in 2005. The equivalent Mantoux test positive levels done with 10 TU (0.1 ml at 100 TU/ml, 1:1000) are <5 mm induration (Heaf 0–1) 5–15 mm induration (Heaf 2) >15 mm induration (Heaf 3–4) See also Tuberculosis Latent tuberculosis QuantiFERON Tine test References Immunologic tests Tuberculosis Dermatologic procedures" }, { "id": "wiki20220301en002_179054", "title": "Mantoux test", "score": 0.01142044781424002, "content": "Classification of tuberculin reaction The results of this test must be interpreted carefully. The person's medical risk factors determine at which increment (5 mm, 10 mm, or 15 mm) of induration the result is considered positive. A positive result indicates TB exposure. 5 mm or more is positive in An HIV-positive person Persons with recent contacts with a TB patient Persons with nodular or fibrotic changes on chest X-ray consistent with old healed TB Patients with organ transplants, and other immunosuppressed patients 10 mm or more is positive in Recent arrivals (less than five years) from high-prevalence countries Injection drug users Residents and employees of high-risk congregate settings (e.g., prisons, nursing homes, hospitals, homeless shelters, etc.) Mycobacteriology lab personnel" }, { "id": "pubmed23n0291_417", "title": "Tuberculin reactivity in Bacillus Calmette-Guérin vaccinated subjects.", "score": 0.011123136123136123, "content": "The Centre for Prevention and Control of Tuberculosis in Barcelona, Spain, where the staff appointed to Training Centers are examined. To check for tuberculin sensitivity due to Bacillus Calmette-Guérin (BCG) vaccine and ascertain its duration. We compared the results of a tuberculin test (TT) on vaccinated and non-vaccinated subjects. The induration diameter and the time elapsed between BCG vaccination and the TT were determined. Of the 2424 vaccinated subjects, 1489 (61.4%) reacted to TT (&gt; or = 5 mm) and of the 3135 non-vaccinated, 905 (28.9%) reacted, a significant difference. Of 1978 subjects vaccinated between 6 and 14 years of age, 63.3% were TT reactors, compared to 23.9% of the 1948 non-vaccinated. Induration diameters &gt; or = 15 mm amounted to 11% for vaccinated subjects and 8% for those not vaccinated, a significant difference. The time from vaccination to TT was 13-25 years. Of the 446 subjects vaccinated at birth, 237 were reactors (53.1%); of the 887 non-vaccinated subjects of the same age, 154 (17.4%) reacted. Reactors &gt; or = 15 mm amounted to 40 (9%) for vaccinated subjects and 46 for non-vaccinated (5.2%), a significant difference. The time elapsed between vaccination and TT was 20-25 years. For 124 vaccinated subjects with a previous negative TT, a second test was positive for 87 (70.2%), and for 257 non-vaccinated it was positive for 64 (24.9%). The difference is due to a booster effect. BCG vaccination at birth and for school age children causes a reactivity to tuberculin which persists for 20 to 25 years. An induration diameter of &gt; or = 15 mm does not exclude a vaccinal origin. For vaccinated subjects with a previous negative TT, it is necessary to exclude the booster effect." }, { "id": "article-27584_38", "title": "PPD Skin Test -- Interfering Factors -- Two-step Testing and Boosted Reaction", "score": 0.010859394237872445, "content": "In some individuals, the reaction to tuberculin antigen wanes over time, which results in a false-negative reaction. In individuals with a prior TB infection from years earlier, sensitization to tuberculin may be weak, and there may be a false-negative PPD test. However, if a subsequent test is administered, the tuberculin PPD may stimulate the immune system. A boosted reaction is seen on subsequent testing due to \"recalling\" of the immune response." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 70, 220 ] ], "word_ranges": [ [ 13, 38 ] ], "text": "no study of first-degree relatives is appropriate, as it does not appear to be hereditary breast cancer since there is no family history of neoplasia." }, "4": { "exist": true, "char_ranges": [ [ 70, 220 ] ], "word_ranges": [ [ 13, 38 ] ], "text": "no study of first-degree relatives is appropriate, as it does not appear to be hereditary breast cancer since there is no family history of neoplasia." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Complete phenotypic study by flow cytometry.", "2": "Study of hormone receptors and HER2.", "3": "Study of hormone receptors, e-cadherin and study of first degree relatives.", "4": "Study of BRCA 1-2 and study of first-degree relatives.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0267_6734", "title": "The significance of family history for patients with carcinoma of the breast.", "score": 0.01526510212950891, "content": "Since the risk of carcinoma of the breast is increased in women with a family history of the disease, new primary carcinomas of the breast may be increased after treatment. Women with several relatives with carcinoma of the breast are thought to be at higher risk of having a second primary carcinoma of the breast develop and mastectomy is more frequently recommended. The computerized registry of the Mount Sinai Medical Center Breast Service was used to identify 1,337 patients with complete information concerning family history. Three hundred fifty-nine patients with a family history of carcinoma of the breast were compared with women with no family history. Compared with patients with no family history of carcinoma of the breast, patients with a family history of carcinoma of the breast were significantly younger (54.0 versus 55.8 years of age, p &lt; 0.01), were significantly more likely to have used oral contraceptives (26 versus 13 percent, p &lt; 0.001), had significantly more ductal carcinoma in situ (10 versus 4 percent, p &lt; 0.01), and were significantly more often treated with breast conservation (42 versus 31 percent, p &lt; 0.001). Simultaneous contralateral carcinoma of the breast was diagnosed more frequently in patients with a family history (3 versus 1 percent, p &lt; 0.025), but metachronous contralateral carcinomas were not increased. In comparing the two groups, there were no significant differences in proportion premenopausal, parity, use of postmenopausal hormones, tumor size, tumor differentiation, nodal involvement, TNM stage, estrogen receptor status, or use of adjuvant radiation, chemotherapy, or tamoxifen. Complete five-year follow-up evaluation for 748 patients, 179 with a family history, found no differences in local, distant, or disease-free survival rates for mastectomy or breast conservation in relation to family history. Outcome for patients with first-degree affected relatives and those with more than one affected relative was the same as those with no family history. These results indicate that women with a family history of carcinoma of the breast should be treated no differently than women with no family history." }, { "id": "wiki20220301en304_20305", "title": "BRCA mutation", "score": 0.013982004234297813, "content": "Relative indications for testing for a mutation in BRCA1 or BRCA2 for newly diagnosed or family members include a family history among 1st (FDR), 2nd (SDR), or 3rd(TDR) degree relatives usually on the same side of the family but not limited: A known mutation (BRCA1 or BRCA2) in a cancer susceptibility gene within the family Women affected with any breast cancer diagnosed under the age of 30 Women affected with triple negative breast cancer (TNBC) (estrogen receptor negative, progesterone receptor negative, and HER2/neu negative) under the age of 50 Two relatives (FDR/SDR) diagnosed under the age of 45 Three relatives (FDR/SDR) diagnosed with average age of 50 or less Four relatives at any ages Ovarian cancer with either an additional diagnosed relative or a relative with male breast cancer A single family member with both breast and ovarian cancer Male breast cancer Pancreatic cancer with breast or ovarian cancer in the same individual or on the same side of the family" }, { "id": "pubmed23n0556_5828", "title": "Influence of young age at diagnosis and family history of breast or ovarian cancer on breast cancer outcomes in a population-based cohort study.", "score": 0.013529894810933404, "content": "The objective of this study was to examine the association of: (i) diagnosis at age &lt;/=35, (ii) first-degree family history of breast or ovarian cancer (BOC) and (iii) a research based definition of genetic risk, with tumor characteristics, treatment and survival in breast cancer (BC). Consenting female participants in the population-based Ontario Familial Breast Cancer Registry diagnosed with primary invasive BC between 1996 and 1998 were followed prospectively until 2005. Among 967 women, 105 were &lt;/=35 years old at diagnosis and 686 were classified as genetic risk cases, including 349 with a first-degree family history. Individuals diagnosed at age &lt;/=35 were more likely to self-detect tumors, to present with inflammatory BC, to have invasive ductal carcinoma of no special type, high T stage, and tumors with lymphovascular invasion (LVI), high grade and negative estrogen receptors. Younger women were more likely to receive chemotherapy and less likely to receive hormonal therapy. Diagnosis &lt;/=35 years old was associated with significantly reduced distant recurrence free survival, an effect that did not persist after adjustment for tumor and treatment related variables. Poor outcomes were restricted to younger women with hormone responsive BC. Family history was associated with increased rates of mammographic detection of BC, lower tumor stage and less frequent inflammatory BC, but had no association with BC outcomes. Women diagnosed with BC at age &lt;/=35 have more aggressive tumors; these adverse tumor characteristics, rather than age, lead to poor outcomes. Family history was not associated with survival." }, { "id": "pubmed23n1012_9657", "title": "Clinical features and first degree relative breast cancer, their correlation with histological tumor grade: a 5-year retrospective case study of breast cancer in Mizoram, India.", "score": 0.013313871196036801, "content": "The aim was to assess the association of histological tumor grade with other clinical features and epidemiological factors of women with invasive breast carcinoma. A retrospective study of 103 Mizo breast cancer patients visiting hospitals was made in Aizawl, Mizoram, Northeast India. With a prior consent, information on epidemiological factors and family history in relation to cancer was obtained. Clinical reports were obtained from their medical records. The frequency of distribution was calculated for age at diagnosis and tumor characteristics. Statistical analysis for different variables was done using a chi-square test. p &lt; 0.05 was considered significant. The histological tumor grades in our studies were found to be associated with lymph node invasion (p &lt; 0.021), different subtype of hormone receptor such as ER status (p &lt; 0.004), ER/PR status (p &lt; 0.007), HER2/neu status (p &lt; 0.014), and ER/PR/HER2 status (p &lt; 0.025). A patient with a family history of breast cancer in their 1st degree relative is also seen to have association in determining the tumor grade (p &lt; 0.003). Reproductive history, lifestyle and dietary habits, tobacco, and alcohol consumption were found to have no influence on breast cancer tumor grade. Our results showing significant correlation between status of lymph node, ER, PR, and HER2/neu oncoprotein and family history with 1st degree relative breast cancer are the first time report to target and focus on the possible role of biomarkers for diagnosis among the Mizo tribal breast cancer patients." }, { "id": "wiki20220301en377_32343", "title": "Cancer biomarker", "score": 0.013310318373609513, "content": "Similarly, additional laboratory research has shown that tumor cells undergoing apoptosis can release cellular components such as cytochrome c, nucleosomes, cleaved cytokeratin-18, and E-cadherin. Studies have found that these macromolecules and others can be found in circulation during cancer therapy, providing a potential source of clinical metrics for monitoring treatment. Recurrence Cancer biomarkers can also offer value in predicting or monitoring cancer recurrence. The Oncotype DX® breast cancer assay is one such test used to predict the likelihood of breast cancer recurrence. This test is intended for women with early-stage (Stage I or II), node-negative, estrogen receptor-positive (ER+) invasive breast cancer who will be treated with hormone therapy. Oncotype DX looks at a panel of 21 genes in cells taken during tumor biopsy. The results of the test are given in the form of a recurrence score that indicates likelihood of recurrence at 10 years." }, { "id": "pubmed23n0887_4130", "title": "Seven-year survey of classical and pleomorphic invasive lobular breast carcinomas in women from southeastern Serbia: Differences in clinicopathological and immunohistochemical features.", "score": 0.013072155117609664, "content": "The occurrence of different variants of invasive lobular carcinoma (ILC) of the breast is variable. For example, the pleomorphic variant of ILC has an incidence of around 5%; however, the number of analyzed cases of ILC is shadowed by the number of ductal type carcinoma (IDC). Thus, we aimed to analyze the classical and pleomorphic ILCs in women from southeastern Serbia. Analyzed were 296 cases (11.91%) diagnosed with ILC, out of 2486 cases of all breast cancers (BCs), during a 7-year period (2005-2011) from southeastern Serbia. The differences in clinicopathological and immunohistochemical features (estrogen receptor/ER, progesterone receptor/ PR, HER-2, Ki-67, BRCA-1, p53 and E-cadherin) of these cases of ILCs were assessed and compared. Pleomorphic ILC occurred relatively rarely compared to other variants, however almost one fifth of the ILC cases were pleomorphic. No statistically significant correlation was found between patient age, tumor stage and the presence/absence of multifocality (MFC), multicentricity (MCC) and bilaterality (BL) on one side, and ILC variant on the other. Only the expression of two prognostic and predictive immunohistochemical markers, important for endocrine therapy, ER and PR, showed significant correlation with the ILC variant. Although higher tumor stage, incidence of multicentricity, overexpression of HER2 and higher p53 positivity were deemed to be characteristic of pleomorphic ILC, in our study that included a much larger number of cases than previous studies did, such correlations were not observed. Thus, it appears that the only two features of pleomorphic ILCs is absence of ER and PR positivity." }, { "id": "pubmed23n0519_19911", "title": "The molecular pathology of hereditary breast cancer: genetic testing and therapeutic implications.", "score": 0.012932269285860446, "content": "Cancer arising in carriers of mutations in the BRCA1 and BRCA2 genes differs from sporadic breast cancer of age-matched controls and from non-BRCA1/2 familial breast carcinomas in its morphological, immunophenotypic and molecular characteristics. Most BRCA1 carcinomas have the basal cell phenotype, a subtype of high-grade, highly proliferating, estrogen receptor- and HER2-negative breast carcinomas, characterized by the expression of basal or myoepithelial markers such as basal keratins, P-cadherin, epidermal growth factor receptor, etc. This phenotype is rarely found in BRCA2 carcinomas, which are of higher grade than sporadic age-matched controls, but tend to be estrogen receptor- and progesterone receptor-positive. The expression of the cell-cycle proteins cyclins A, B1 and E and SKP2 is associated with a BRCA1 phenotype, whereas cyclin D1 and p27 expression is associated with BRCA2 carcinomas. Recent studies have shown that hereditary carcinomas that are not attributable to BRCA1/2 mutations have phenotypic similarities to BRCA2 tumors, but tend to be of lower grade and proliferation index. Somatic mutations in the BRCA genes are rarely found in hereditary tumors; by contrast, BRCA1 and BRCA2 loss of heterozygosity (LOH) is found in almost all BRCA1 and BRCA2 carcinomas, respectively. Furthermore, all types of hereditary breast carcinomas have a low frequency of HER2 expression. Finally, comparative genomic hybridization studies have revealed differences in chromosomal gains and losses between genotypes. The pathological and molecular features of hereditary breast cancer can drive specific treatments and influence the process of mutation screening. In addition, detecting molecular changes such as BRCA1/2 LOH in nonatypical cells obtained by random fine-needle aspiration, ductal lavage or nipple aspirate fluid may help to earlier identify carrier women who are at an even higher risk of developing breast carcinoma." }, { "id": "pubmed23n0715_5826", "title": "Negative/low HER2 expression alone or combined with E-cadherin positivity is predictive of better prognosis in patients with breast carcinoma.", "score": 0.012849557522123894, "content": "The loss of E-cadherin expression leads to absence of tissue integrity, an essential step in tumor progression. Methylation of CpG islands in the promoter region of the CDH1 gene coding E-cadherin might be an alternative for gene silencing. In the present study, we investigate the expression of E-cadherin and hormone receptors in invasive ductal breast carcinoma (IDCs). Protein expression was analysed immunohistochemically in 87 cases, including 26 familial tumors. The most interesting results revealed a significantly reduced E-cadherin expression in cases with familial history compared to sporadic tumors (p=0.009), as well as with tumors ≤5 cm (p=0.022). Moreover, HER2 over-expression was associated with distant metastasis (p=0.011) and overall survival (p log rank=0.028). Tumors displaying negative/low HER2 expression combined with E-cadherin positivity confer better patient survival (p=0.052). Triple Negative tumors (TN) were more frequently found in patients with advanced grade (GIII) (p=0.001) and TNM (III+IV) (p=0.018) which supports the aggressive behavior of TN tumors. On the other hand, hypermethylation of CDH1 gene promoter was observed in 46% of hereditary cases and strongly associated with loss of E-cadherin expression (p=0.002). Furthermore, patients with unmethylated CDH1 pattern have a better 5-year disease free survival (p=0.021). In conclusion, in patients with hereditary breast cancer, the CpG methylation event contributes to the loss of E-cadherin expression. On the other hand, HER2 over-expression is predictive of worse prognosis, either alone or combined with loss of E-cadherin expression in Tunisian patients with breast cancer." }, { "id": "pubmed23n0657_19800", "title": "Four new cases of double heterozygosity for BRCA1 and BRCA2 gene mutations: clinical, pathological, and family characteristics.", "score": 0.012820512820512822, "content": "Double heterozygosity (DH) for BRCA1 and BRCA2 mutations is a very rare finding, particularly in non-Ashkenazi individuals, and only a few cases have been reported to date. In addition, little is known on the pathological features of the tumors that occur in DH cases and on their family history of cancer. Four carriers of pathogenic mutations in both BRCA1 and BRCA2 were identified among women who underwent genetic counseling for hereditary susceptibility to breast and ovarian carcinoma at three different Italian institutions. Clinical, pathological, and family history data were collected from medical records and during genetic counseling sessions. All identified DH cases developed breast carcinoma and three of them were also diagnosed with ovarian carcinoma. Mean ages of breast and ovarian cancer diagnosis were 42.7 and 48.6 years, respectively. The majority of breast cancers showed a BRCA1-related phenotype, being negative for hormone receptors and HER2. Two cases reported different gastrointestinal tumors among relatives. Although the individuals described in this study show more severe clinical features in comparison to previously reported BRCA1 and BRCA2 DH cases, our observations support the hypothesis of a non specific phenotype of DH cases in terms of age of disease onset. In addition, our observations indicate that in DH patients breast carcinogenesis appears to be driven mainly by the mutations in BRCA1. The possible association of DH for BRCA gene mutations with gastrointestinal tumors is in keeping with previous reports, but needs to be confirmed by further analyses." }, { "id": "pubmed23n0671_14807", "title": "Family history of breast cancer in first-degree relatives and triple-negative breast cancer risk.", "score": 0.012732365673542145, "content": "Triple-negative breast cancer accounts for less than 20% of breast cancers overall, but is the predominant subtype among carriers of mutations in BRCA1. However, few studies have assessed the association between breast cancer family history and risk of triple-negative breast cancer. We examined the relationship between having a family history of breast cancer in first-degree relatives and risk of triple-negative breast cancer, and risk of two other breast cancer subtypes defined by tumor marker expression. We evaluated data collected by the Breast Cancer Surveillance Consortium from 2,599,946 mammograms on 1,054,466 women, among whom 15% reported a first-degree family history of breast cancer. Using Cox regression in this cohort, we evaluated subtype-specific associations between family history and risk of triple-negative (N = 705), estrogen receptor-positive (ER+, N = 10,026), and hormone receptor-negative/HER2-expressing (ER-/PR-/HER2+, N = 308) breast cancer among women aged 40-84 years. First-degree family history was similarly and significantly associated with an increased risk of all the subtypes [hazard ratio (HR) = 1.73, 95% confidence interval (CI): 1.43-2.09, HR = 1.62, 95% CI: 1.54-1.70, and HR = 1.56, 95% CI: 1.15-2.13, for triple-negative, ER+, and ER-/PR-/HER2+, respectively]. Risk of all the subtypes was most pronounced among women with at least two affected first-degree relatives (versus women with no affected first-degree relatives, HR(triple-negative) = 2.66, 95% CI: 1.66-4.27, HR(ER+) = 2.05, 95% CI: 1.79-2.36, HR(ER)-(/PR)-(/HER2+) = 2.25, 95% CI: 0.99-5.08). Having a first-degree family history of breast cancer was associated with an increased risk of triple-negative breast cancer with a magnitude of association similar to that for the predominant ER+ subtype and ER-/PR-/HER2+ breast cancer." }, { "id": "pubmed23n0976_164", "title": "BRCA1/BRCA2 mutations in Japanese women with ductal carcinoma in situ.", "score": 0.011982922541527642, "content": "Ductal carcinoma in situ (DCIS) is considered a component of the clinical spectrum of breast cancer even in those with BRCA1/2 mutation. The aim of this study was to report the feature of DCIS raised in Japanese women with BRCA1/2 mutations. A total of 325 Japanese women with breast cancer (BC) (with or without invasive cancer) were referred for genetic counseling and underwent genetic testing for mutations in the BRCA1 and BRCA2 genes in Showa University Hospital between December 2011 and August 2016. And 49 of them who were pathologically diagnosed as DCIS were included in this study. Logistic regression models were fit to determine the associations between potential predictive factors and BRCA status. A Cox proportional hazards model is used to predictive value of parameters for Ipsilateral breast tumor recurrence (IBTR) and contralateral breast tumor recurrence (CBTR). (a) Of 325 patients (with or without invasive cancer), 19.1% (62/325) tested positive for BRCA1/BRCA2 mutations. And 18.4% (9/49) was positive for BRCA1/BRCA2 mutations in DCIS, compared with 19.2% (53/276) in IDC (p = 1.000). Among BRCA mutations, 14.5% (9/62) had DCIS compared with nonmutations (15.2%, 40/263). Incidence of DCIS was 3.0% (1/33) of BRCA1 mutations and 27.5% (8/29) of BRCA2 mutation (p = 0.009). (b) Median age of diagnosis in BRCA mutation carriers was 39 years, compared with 46 years in noncarriers. Age, Family history (FH) of BC, FH of first or second BC and total number of relatives with BC diagnosis (DX) has significant difference between BRCA mutation carriers and noncarriers in univariate analysis. In a multivariate logistic model, total relatives with BC DX ≥ 2 (odds ratio [OR], 5.128; 95% confidence interval [CI], 1.266-20.763; p = 0.022), age at diagnosis ≤35 years (OR 0.149, 95% CI 0.023-0.954, p = 0.045) and ER+/HER2+ status (OR 5.034, 95% CI 1.092-23.210, p = 0.038) remained as independent significant predictors for BRCA mutation. Ki67 index (cut off by 14% or 30%) did not differ between BRCA mutation carriers and noncarriers (p = 0.459 and p = 0.651). (c) There was a significant difference in ER-positive tumors among BRCA2 carriers and noncarriers (p = 0.042). Subgroup analysis showed BRCA2 carriers tend to be of higher grade (Grade 2 and 3), more frequently ER+/PR+ (p = 0.041) and lower proliferation (Ki67 index) than noncarriers, whereas differences in nuclear grade and ki67 index were not found significantly in our study. (d) BRCA mutation was not associated with an increased risk of IBTR and CBTR. DCIS is equally as prevalent in patients who were BRCA mutation carriers as in high familial-risk women who were noncarriers, but occurs at earlier age. BRCA2 carriers have higher incidence in DCIS than that of BRCA1 carriers, and tend to be higher grade and more frequently ER positive and lower proliferation. Total relatives with BC DX ≥2, age at diagnosis ≤35 years and ER+/HER2+ might be independent predictors for BRCA mutation in Japanese women with DCIS and patients of these risk factors should be recommended to receive genetic counseling and BRCA testing." }, { "id": "pubmed23n0289_14463", "title": "Breast cancer and family history: a multivariate analysis of levels of tumor HER2 protein and family history of cancer in women who have breast cancer.", "score": 0.011720169594185342, "content": "The HER2 gene, located on the long arm of chromosome 17, codes for a protein with the characteristics of a growth factor receptor. In a preliminary study, we reported that high levels of tumor HER2 (erbB-2/neu) protein are associated with a family history of breast cancer (that is, one or more female blood relatives with breast cancer). We have now collected a larger number of subjects (94) and performed a multivariate analysis of the independent variables family history of breast cancer, tumor estrogen receptor, age, and tumor DNA index. Family history of breast cancer was assessed by questioning the patient, in many cases by telephone. HER2 levels were significantly higher in women with a family history of breast cancer (p = 0.015, two-tailed t-test). The 27 women with family history were predominantly postmenopausal, mean age 61 +/- 2.3 (mean +/- SEM), versus a mean age of 56 +/- 1.7 for the 67 women with no family history. Of the 27 women with a family history of breast cancer, 13 had a first-degree relative (mother or sister) with the disease. The remaining 14 women had other relatives (grandmothers, aunts, cousins, or a niece) with breast cancer. The results of multiple linear regression analysis, with HER2 as the dependent variable, showed that family history of breast cancer was significantly associated with elevated HER2 levels in the tumors (p = 0.0038), after controlling for the effects of age, tumor estrogen receptor, and DNA index. The association of family history of breast cancer and elevated tumor HER2 protein suggests that postmenopausal familial breast cancer may be associated with altered HER2 expression." }, { "id": "wiki20220301en225_9126", "title": "Lobular carcinoma in situ", "score": 0.011028398125172319, "content": "Cells of Lobular Neoplasia (LN), including both Atypical Lobular Hyperplasia and LCIS, and ILC share common genetic alterations, perhaps accounting, in part, for the similarities in histologic appearance. Classic LCIS and invasive lobular lesions are low-grade ER and PR-positive cancers, referring to the positive expression of Estrogen and Progesterone receptors on the neoplastic cells (determined via immunohistochemistry). These entities are also both classically negative for HER2 (human epidermal growth factor receptor 2). These hormone and growth factor receptors are clinically significant, as they represent targets for chemotherapy. Chromosomal alterations have also been consistently observed between LCIS and ILC – namely, loss of 16q and gain of 1q, referring to the loss of the long arm (designated q) of chromosome 16 and an extra copy of the long arm of chromosome 1. Furthermore, e-cadherin, the transmembrane protein mediating epithelial cell adhesion, exhibits loss of" }, { "id": "wiki20220301en191_9178", "title": "Metaplastic carcinoma", "score": 0.009900990099009901, "content": "Metaplastic carcinoma, otherwise known as metaplastic carcinoma of the breast (MCB), is a heterogeneous group of cancers that exhibit varied patterns of metaplasia and differentiation along multiple cell lines. This rare and aggressive form of breast cancer is characterized as being composed of a mixed group of neoplasms containing both glandular and non-glandular patterns with epithelial and/or mesenchymal components. It accounts for fewer than 1% of all breast cancer diagnoses. It is most closely associated with invasive ductal carcinoma of no special type. (IDC), and shares similar treatment approaches. Relative to IDC, MCB generally has higher histological grade and larger tumor size at time of diagnosis, with a lower incidence of axillary lymph node involvement. MCB tumors are typically estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor-2 (HER-2) negative, meaning hormone therapy is generally not an effective treatment option, which correlates to" }, { "id": "pubmed23n0598_18737", "title": "Breast cancer expression of E-cadherin does not differ between patients with positive and negative oncological history.", "score": 0.009900990099009901, "content": "The question of whether or not non-sporadic breast malignancies have different immunohistochemical features than sporadic malignancies has not been investigated previously. Consequently, the purpose of this study was to compare the expression of E-cadherin (EC) in breast cancer patients with positive and negative oncologic histories. The study included 98 breast cancer patients divided into two groups: 1) without the personal or familial history of previous malignancies, and 2) with the personal history of previous malignancies and/or with the data on cancer episodes in first- and/or second-degree relatives. There were no significant differences in the expression of EC between breast malignancies of the two groups. Moreover, statistical relationships were not observed between the positive or negative oncologic history, the age, and the menopausal status of patients, or histological tumor grade. Although the results of our series revealed no significant differences in the expression of EC between assumed sporadic and assumed non-sporadic malignancies, there is a need for further comparative studies on the immunohistochemistry of both the breast carcinoma types in order to find the other biological markers that could suggest or exclude cancer susceptibility in a given patient. Nevertheless, the results of our study suggest that EC immunohistochemistry cannot be used as a surrogate marker for screening for hereditary breast cancer." }, { "id": "wiki20220301en188_32824", "title": "Somatostatin receptor 2", "score": 0.00980392156862745, "content": "other components of the endocrine system and nervous system, so it can be drawn that the receptor family has great influence among these systems. The family was first discovered in a segment of a rat's pituitary gland known as the tumor cell line. A cell line is grown as a culture under controlled conditions, so the first discovery was found by culturing these cells in controlled conditions and in an environment outside of its norm. There, researchers found that the tumor cell line expresses a cell dividing inhibitor known as the transforming growth factor beta (TGF-beta) and also acts as an inhibitor to the milk producing hormone in female mammals, prolactin, and growth hormones. Researchers studied the activity of the receptors by conducting an assay with Ligand binding studies, which basically means they were conducting studies to see how prevalent the binding of the receptors occurred. Differences in how prevalently they receptors bonded revealed the existence of multiple" }, { "id": "pubmed23n0396_8364", "title": "Does family history influence survival in breast cancer cases?", "score": 0.00980392156862745, "content": "A few studies have suggested a relatively better prognosis for breast cancer (BC) cases reporting a positive family history (FH). We aimed at comparing the survival of patients according to FH in a large hospital-based series of 1,278 BC cases. Information on FH for BC was obtained at diagnosis by interview. All cases reporting a first- or second-degree FH for breast carcinoma were compared with cases without FH. Overall survival was estimated using a product-limit method. Hazard ratios (HRs) and the corresponding 95% confidence intervals (95% CIs), adjusted for confounding factors, were computed using proportional hazard models. Overall, 240 (18.8%) cases reporting, at diagnosis, a positive FH (156 with at least 1 first-degree relative and 84 with at least 1 second-degree relative) were compared with 1,038 patients without FH for BC. No significant differences were found in terms of distribution of age at diagnosis, tumor stage, nodal involvement, receptor status and histology. Cumulative survival rates at 5 years for cases without FH and with first-degree and second-degree FH for BC were 79.8 (95% CI 77.0-83.0), 78.6 (95% CI 70.0-88.0) and 80.2 (95% CI 68.0-92.0), respectively (log-rank test, chi(2) (2) = 0.02, p = 1.0). After adjustment for age, pathologic size and nodal involvement, the HR among cases of invasive cancer with a first-degree FH of BC was 0.91 (95% CI 0.55-1.48); however, the HR for cases with second-degree FH was 1.18 (95% CI 0.62-2.25) compared to cases without FH. Our study, based on a large series of consecutive invasive BC cases, did not find any significant survival differences associated with a positive FH for breast carcinoma, suggesting the existence of a large heterogeneity among BC cases with FH." }, { "id": "wiki20220301en301_10160", "title": "Combined small-cell lung carcinoma", "score": 0.009708737864077669, "content": "Pemetrexed has been shown to improve survival in non-squamous cell NSCLC, and is the first drug to reveal differential survival benefit in large cell lung carcinoma. C-SCLC appear to express female hormone (i.e. estrogen and/or progesterone) receptors in a high (50–67%) proportion of cases, similar to breast carcinomas. However, it is at present unknown whether blockade of these receptors affects the growth of c-SCLC. Prognosis Current consensus is that the long-term prognosis of c-SCLC patients is determined by the SCLC component of their tumor, given that \"pure\" SCLC seems to have the worst long-term prognosis of all forms of lung cancer. Although data on c-SCLC is very sparse, some studies suggest that survival rates in c-SCLC may be even worse than that of pure SCLC, likely due to the lower rate of complete response to chemoradiation in c-SCLC, although not all studies have shown a significant difference in survival." }, { "id": "pubmed23n0324_15364", "title": "Clinical characteristics of breast cancer patients with family history.", "score": 0.009708737864077669, "content": "This study was conducted to acquire information as to the clinicopathological characteristics of breast cancer patients with family history. Of 583 patients with breast cancer, 60 (10.3%) had family history in at least one relative within the second-degree. The affected family member was most frequently a sister (43%), followed by the mother (23%) and an aunt (20%). Comparison of the data for the patients between with and without family history revealed no significant differences for any of mean age, menopausal status, histological type, histological staging, and estrogen receptor status. Although the sample size was small, neither the survival rate nor the bilaterality of disease was influenced by the family history of breast cancer." }, { "id": "article-18576_4", "title": "Male Breast Cancer -- Etiology", "score": 0.009684634309997763, "content": "Similarly to women, males have a higher risk of breast cancer if they have a first- or second-degree relative with breast cancer. Studies have shown that an affected sibling or parent of either gender may increase the risk of breast cancer in either the males or females in the family. Bevier et al. (2012) noted in their study that the relative risk (RR) of breast cancer was similar in either offspring when the father or mother was affected (RR = 1.73 and 1.74, respectively), but the risk was slightly higher in the females when the brother is affected as opposed to when the sister is affected (RR = 2.48 and 1.39, respectively). [3] Also, in addition to a family history of breast cancer, males with a BRCA mutation appear to have increased risk for breast cancer as well. Although rare for a male to have a BRCA mutation, those with BRCA2 carrier mutation have a 6% increased risk and BRCA1 with a 4% risk of developing the disease. [4] Other genetic disorders have been implicated in increasing the risk of MBC, including Klinefelter syndrome (47, XXY), Cowden syndrome ( PTEN tumor suppressor gene), Li-Fraumeni syndrome ( TP53 ), Lynch syndrome ( PALB2 and mismatch repair genes). [2] [4]" }, { "id": "wiki20220301en034_42642", "title": "Selective estrogen receptor modulator", "score": 0.009615384615384616, "content": "Tamoxifen is a first-line hormonal treatment of ER-positive metastatic breast cancer. It is used for breast cancer risk reduction in women at high risk, and as adjuvant treatment of axillary node-negative and node-positive, ductal carcinoma in situ. Tamoxifen treatment is also useful in the treatment of bone density and blood lipids in postmenopausal women. Adverse effects include hot flushes and more serious is two to three times higher relative risk of developing endometrial cancer compared to women of an age-matched population. Toremifene, a chlorinated tamoxifen derivative, causes fewer DNA adducts in liver than seen with tamoxifen in preclinical studies and was developed to avoid hepatic carcinomas. It is used as endocrine therapy in women with ER/PR-positive stage 4 or recurrent metastatic breast cancer and has demonstrated similar efficacy compared to tamoxifen as adjuvant treatment of breast cancer and in the treatment of metastatic breast cancer." }, { "id": "wiki20220301en188_32364", "title": "Parathyroid hormone 1 receptor", "score": 0.009523809523809525, "content": "Interactions Parathyroid hormone 1 receptor has been shown to interact with Sodium-hydrogen exchange regulatory cofactor 2 and Sodium-hydrogen antiporter 3 regulator 1. Model organisms Model organisms have been used in the study of PTH1R function. A conditional knockout mouse line called Pth1rtm1a(EUCOMM)Hmgu was generated at the Wellcome Trust Sanger Institute. Male and female animals underwent a standardized phenotypic screen to determine the effects of deletion. Additional screens performed: - In-depth immunological phenotyping See also Parathyroid hormone receptor References Further reading External links G protein-coupled receptors" }, { "id": "pubmed23n0494_12555", "title": "Prognosis of breast cancer patients with familial history classified according to their menopausal status.", "score": 0.009523809523809525, "content": "Breast cancer patients were classified in the family history positive (FHP) group when they had at least one second-degree relative who was a breast cancer patient. The results of a comparative study with patients classified in the family history negative (FHN) group showed the prognosis of the FHP group was significantly better than that of the FHN group. However, when those patients were classified according to their menopausal status at onset, there were no significant differences in survival rates between the FHP and FHN groups with onset before menopause, whereas the survival rate of the FHP group was significantly higher than that of the FHN group with onset after menopause. The same results were found when the FHP group was subgrouped into the FHP group with first-degree relatives and the FHP group with second-degree relatives. Further investigations on background factors revealed that the patients with onset before menopause showed no significant differences between the FHP and FHN groups in age at surgery, diameter of the tumor, histologic grade, the number of metastatic lymph nodes, body weight, estrogen receptor (ER) status, and the values of CEA and CA15-3 before surgery. On the other hand, the FHP patients with onset after menopause showed significantly lower numbers of metastatic lymph nodes and trends showing higher ER values and lower CA15-3-values. Therefore the favorable prognosis in the FHP group seems to be attributable to the higher survival rate of the FHP patients with onset after menopause." }, { "id": "wiki20220301en615_20221", "title": "Karen E. Knudsen", "score": 0.009433962264150943, "content": "Research Knudsen is an oncology researcher whose studies are focused on precision medicine in advanced prostate cancer, with an emphasis on understanding therapeutic relapse and designing new means of clinical intervention. Her translational studies have resulted in new clinical trials targeting DNA repair, cell cycle, and hormonal regulation pathways in patients with advanced disease. Knudsen and her colleagues discovered the mechanisms by which androgen signaling impacts cancer cell proliferation and DNA repair processes, and identified novel strategies for therapeutic intervention. Notable discoveries include identification of RB tumor suppressor loss as a major mechanism of therapeutic bypass, discovery of the androgen-DNA repair axis, and elucidation of androgen receptor function in the mitotic cell cycle. Her discoveries were amongst the first to propose utilization of PARP 1/2 inhibitors for advanced disease, now an FDA-approved agent for selected prostate cancers." }, { "id": "pubmed23n0263_11157", "title": "A clinicopathological analysis of breast cancer in patients with a family history.", "score": 0.009433962264150943, "content": "A study was conducted to investigate the clinical and pathological characteristics of breast cancer in patients with a family history (FH). Among 4,481 primary breast cancer patients, 394 (8.8%) had families which included two or more breast cancer patients within three generations (FH(+)group). This group was compared with the remaining 3,969 patients (FH(-) group) with the following results: (1) The tumor diameter in the FH(+) group was slightly less than that in the FH(-) group [not significant (NS)], with fewer lymph node metastases (P &lt; 0.05); (2) the positive rates for the estrogen receptor were 52% (138/266) and 49% (1,216/2,481), respectively (NS); (3) expression of the c-erbB-2 protein was observed in 14 out of 40 (35%) and 32 out of 100 cases (32%), respectively (NS); (4) the relative risk of bilateral occurrence in the FH(+) group was 1.4, with a 95% confidence interval of 0.9-2.4; (5) the 15-year survival rate was 72% and 60%, respectively, suggesting a better prognosis for the FH(+) group (P &lt; 0.01); and (6) multivariate analysis showed that the contribution of FH to postoperative survival was marginal (P = 0.07). Factors related to the hormonal environment such as age at menarche (P = 0.08) and age at menopause (P = 0.08) made a greater but non-significant contribution to the prognosis of the FH(+) group than to that of the FH(-) group. However, further genetic and molecular biological analyses of familial breast cancer are needed in order to clarify the mechanisms of cancer accumulation within families." }, { "id": "wiki20220301en490_9660", "title": "Abemaciclib", "score": 0.009345794392523364, "content": "As of early 2016, abemaciclib was involved in 3 Phase III clinical trials: The JUNIPER Study is comparing abemaciclib against erlotinib in patients with stage IV non-small-cell lung carcinoma Due to collect data until September 2017. The MONARCH 2 study is investigating the effectiveness of abemaciclib in combination with fulvestrant for women with breast cancer. It is due to end in Feb 2017. In March 2017, Eli Lilly announced that it had met its primary endpoint of superior progression-free survival (PFS) over placebo plus fulvestrant in patients with estrogen receptor positive and HER2 negative advanced or metastatic breast cancer. This result led to the September 2017 FDA approval. The MONARCH 3 study is investigating the effectiveness of abemaciclib, plus either anastrozole or letrozole, as a first-line treatment for women with breast cancer. The trial is expected to end in June 2017." }, { "id": "wiki20220301en406_12297", "title": "Dynamic angiothermography", "score": 0.009259259259259259, "content": "DATG is able to detect changes in blood flow that are indicative of breast cancer, may be used for younger patients, is completely non-invasive (no need for radiation or contrast agent, no need for compression of the breast) and is lower cost than alternatives requiring minimal facilities. This technology, performed quickly (5–6 minutes for visit) and very precise, is useful for screening and is also able to detect precancerous lesions. Studies have been conducted that have shown how it is possible, by means of this methodology, to diagnose invasive ductal carcinoma and infiltrating lobular carcinoma with the same accuracy. DATG can be strategic for young patients, or patients with dense breasts where the contrastive performance of mammography is challenged. Another application of DATG is the monitoring of at-risk patients with increased changes of breast cancer who take hormone replacement therapy (sometimes taken to reduce menopause symptoms) and participate in in-vitro" }, { "id": "pubmed23n0895_25005", "title": "Family history of cancer other than breast or ovarian cancer in first-degree relatives is associated with poor breast cancer prognosis.", "score": 0.009259259259259259, "content": "Whether a first-degree family history of others cancers (FHOC) than breast or ovarian cancer (BOC) is associated with breast cancer prognosis remains unknown. Thus, the aim of the present study was to clarify this issue. Women who were diagnosed with invasive breast cancer at the Renmin Hospital of Wuhan University from 2010 to 2013 were included in the study. The demographic and clinicopathological characteristics of these patients were extracted. FHOC was considered positive for any patient who had a relative who had been diagnosed with cancer other than BOC. Disease-free survival (DFS) was calculated based on the date of diagnosis. DFS was analyzed using the Cox proportional hazards model. A total of 434 breast cancer patients were included in this study. Among these patients, 61 (14.06%) had a positive FHOC in first-degree relatives. Patients with a positive FHOC tended to have HER2-positive breast cancer (p = 0.03). In the survival analysis, FHOC was associated with poor DFS in both univariate (HR = 2.21 (1.28-3.83), 95% CI: 1.28-3.83, p &lt; 0.01) and multivariate (HR = 2.50, 95% CI: 1.24-5.04, p = 0.01) analyses, especially in patients with luminal A subtypes. The results demonstrated an increased risk of recurrence in breast cancer patients with FHOC, especially in patients with luminal A subtype." }, { "id": "pubmed23n0416_23268", "title": "Linking Histopathology and Family History in Breast Cancer.", "score": 0.009174311926605505, "content": "In order to assess the prognostic value of family history (FH) of malignancies in patients afflicted with breast cancer (BC), we examined FH and histopathologic characteristics of 542 Iranian primary BC patients. Cases with distant metastasis at the time of diagnosis were excluded. Mean age of the studied population was 49 and the most common presenting stage was stage IIA followed by stage IIB. Data on a total of 6089 relatives (1st to 4th generations with the assumption of probands as the 3rd generation) were gathered. FH of BC and other malignancies (OM) was positive in 29 and 54% of cases, respectively. The most common OM's were gastric (67), lung (52) and uterus (47) cancers. We found that a FH of BC does not have any significant correlation with proven prognostic factors but a history of BC among relatives at or before the age of 36 is associated with more aggressive tumours. On the other hand, although FH of OM was associated with an older age of the probands (which is generally associated with a favourable prognosis), tumours of the cases with FH of OM had higher grades, lymphatic invasion being detected more frequently. Also we noted that the younger the age of the relatives diagnosed with cancer, the higher the stage of the probands themselves. All together our study indicates the possibility of a relation between FH of BC and OM, and histopathologic characteristics of the probands' tumours which would put forward FH as a prognostic factor rather than a simple risk factor in BC." }, { "id": "pubmed23n0759_12700", "title": "Retrospective analysis of clinicopathological characteristics and family history data of early-onset breast cancer: a single-institutional study of Hungarian patients.", "score": 0.00909090909090909, "content": "Patients at young age (≤ 35 years) diagnosed with breast cancer (BC) are considered to have poor prognosis. The aim of the present study was to retrospectively analyse clinicopathological characteristics and prognosis in a group of young BC patients. We included women diagnosed with invasive breast carcinoma younger than/or at the age of 35 years. Between 1999 and 2009, 107 women with early-onset BC were selected from the database of the 2nd Department of Pathology at Semmelweis University. For clinicopathological comparison, 55 women (36-45 years), 214 women (46-65 years), 110 women (66-75 years) and 58 women (76 ≤ years) were also included in the analysis. Family history, clinicopathological and follow-up data were analysed. The tissue specimens were reviewed for histological type, nuclear grade, and estrogen receptor (ER), progesterone receptor (PgR), Ki67 and HER2 status (IHC4). The mean age in the study group was 31.6 years at the time of diagnosis. Histology showed a high incidence of grade III tumours in this group of patients (67.9 %), while only four cases (3.8 %) were considered grade I. According to the immunohistochemical results, 35.3 % of the study cases were considered as Luminal B (LumB: either being higly proliferative or co-expressing HER2) and 33.3 % as triple negative breast carcinomas (TNBC). The detailed questionnaire related to family history was completed and received in 49/107 cases (45.8 %). Analysis of these data revealed an affected family history of breast or ovarian carcinoma in first and second degree relatives in 51.0 %. A high proportion (52.0 %) of TNBC was observed among young women with a family history of the disease. Survival analysis of the 107 patients showed that 25 (23.3 %) women died until 31 December 2012. No significant difference in survival was detectable considering the regimen of systemic treatment (p = 0.188). Regarding clinicopathological parameters, the immunophenotypes, grade, pT and pN values differred substantially between the age groups (p = 0.001, for all), and the shortest relapse-free survival was seen among the youngest BC patients. This analysis illustrates that breast cancer arising in young women is characterized by the presence of less favorable subtypes such as LumB and TNBC. The increased proportion of TNBC was especially remarquable in the group of patients presenting with family history of the disease. The fact that a high rate of death occurred and no significant difference in OS were notable regarding the scheme of systemic therapies (neoadjuvant vs. adjuvant) highlight the necessity of the development of new treatment strategies." }, { "id": "wiki20220301en200_7950", "title": "CDH1 (gene)", "score": 0.009009009009009009, "content": "Clinical significance Loss of E-cadherin function or expression has been implicated in cancer progression and metastasis. E-cadherin downregulation decreases the strength of cellular adhesion within a tissue, resulting in an increase in cellular motility. This in turn may allow cancer cells to cross the basement membrane and invade surrounding tissues. E-cadherin is also used by pathologists to diagnose different kinds of breast cancer. When compared with invasive ductal carcinoma, E-cadherin expression is markedly reduced or absent in the great majority of invasive lobular carcinomas when studied by immunohistochemistry. E-cadherin and N-cadherin temporal-spatial expression are tightly regulated during cranial suture fusion in craniofacial development. Interactions CDH1 (gene) has been shown to interact with CBLL1, CDC27, CDON, CDH3, C-Met, CTNND1, CTNNB1, CTNNA1 FOXM1, HDAC1, HDAC2, IQGAP1, FYN, NEDD9, Plakoglobin, Vinculin, PTPmu(PTPRM) PTPrho(PTPRT)" }, { "id": "pubmed23n0933_10246", "title": "Family History and Risk of Second Primary Breast Cancer after <i>In Situ</i> Breast Carcinoma.", "score": 0.009009009009009009, "content": "<bBackground:</b Incidence rates of <iin situ</i breast carcinomas have increased due to widespread adoption of mammography. Very little is known about why some women with <iin situ</i breast cancer later develop second primary breast cancers.<bMethods:</b In this population-based nested case-control study among <iin situ</i breast cancer survivors, including 539 cases with a second primary breast cancer and 994 matched controls, we evaluated the association between first-degree family history of breast cancer and risk of developing a second primary breast cancer.<bResults:</b First-degree family history of breast cancer was associated with an increased risk of developing a second primary breast cancer among women with a previous <iin situ</i breast cancer [odds ratio (OR) = 1.33, 95% confidence interval (CI), 1.05-1.69] and those with two or more affected first-degree relatives had an even higher risk (OR = 1.94; 95% CI, 1.15-3.28). Those whose relative was diagnosed at less than 50 years old were more likely to develop a second primary breast cancer (OR = 1.78; 95% CI, 1.24-2.57). No difference in risks associated with number or age of affected relatives was observed by menopausal status.<bConclusions:</b Results from this study suggest that first-degree family history of breast cancer may be an important risk factor for development of a second primary breast cancer among women with a previous <iin situ</i breast cancer.<bImpact:</b Given the growing population of <iin situ</i breast cancer survivors, a better understanding of risk factors associated with development of a second primary breast cancer is needed to further understand risk. <iCancer Epidemiol Biomarkers Prev; 27(3); 315-20. ©2018 AACR</i." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 134, 422 ] ], "word_ranges": [ [ 26, 76 ] ], "text": "The onset of the picture seems relatively rapid and it is also associated with an autoimmune disease, so it seems that they want you to associate it with an autoimmune hemolytic anemia. The low haptoglobin would tell us it is \"hemolytic\", the coombs test would tell us it is \"autoimmune\"." }, "3": { "exist": true, "char_ranges": [ [ 423, 532 ] ], "word_ranges": [ [ 76, 96 ] ], "text": "Vitamin B12, probably the MCV would be higher than 108 and the onset of the clinical picture would be slower." }, "4": { "exist": true, "char_ranges": [ [ 533, 628 ] ], "word_ranges": [ [ 96, 114 ] ], "text": "The ANA would not give us anything in relation to the anemia, since it already has a diagnosis." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

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

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1098_18165", "title": "Immune-mediated Coombs negative intravascular haemolysis in systemic lupus erythematosus (SLE).", "score": 0.019327731092436976, "content": "A 27-year-old woman presented with a history of excessive hair loss, loss of appetite, loss of weight, amenorrhoea and loss of axillary and pubic hair for 6 months followed by fever and vomiting for 5 months and abdominal pain for 1 month. During the course of her illness, the patient developed intravascular haemolysis as evidenced by a drop in haemoglobin, indirect hyperbilirubinaemia, raised lactate dehydrogenase (LDH) and haemoglobinuria. Examination revealed severe pallor, mild icterus, elevated jugular venous pressure, generalised lymphadenopathy and hyperpigmentation. Investigations revealed severe anaemia, indirect hyperbilirubinaemia, raised LDH and negative Coombs test. Antinuclear antibody and anti-dsDNA, anti-Sm and anti-SS-A/Ro antibodies were positive and complement C3 was low. The patient was diagnosed to have systemic lupus erythematosus and immune-mediated intravascular haemolysis and was treated with prednisolone and hydroxychloroquine. Haemolysis resolved following steroid therapy, and during follow-up, there were no further episodes of haemolysis." }, { "id": "pubmed23n0060_1206", "title": "[An elderly case of systemic lupus erythematosus associated with herpes zoster, anemia, and hemiparesis].", "score": 0.01906318082788671, "content": "An elderly case of systemic lupus erythematosus (SLE) with suspected hemolytic anemia was experienced. A 70 year-old female was admitted to our hospital on December 31 with complaints of herpetic eruption. She complained of arthralgia since 3 month prior to her admission. The positive findings on examination were skin eruption in the left chest, a systolic heart murmur and a palpable elastic hard liver. Laboratory data showed raised erythrocyte sedimentation rate of 149 mm per hour, decreased Hb (10.1 g/dl), decreased hematocrit (30.0%), increased reticulocytes (33%1000), decreased thrombocytes (73,000/mm3), increased gamma-globulin (33%) and positive rheumatoid factor. During admission, she developed anemia. A stool test for occult blood was negative. The haptoglobin was 38.8 mg/dl and bone marrow aspiration showed increased erythropoiesis, suggesting features of immune hemolytic anemia, except she was negative on Coomb'test. Eye fundi were similar to case of typical bleeding observed in SLE. Concerning immunological findings, the antinuclear factor was x 1280 and the anti-dsDNA antibody was x 80, on which a diagnosis of SLE was based. She experienced numbness of the left arm and developed left hemiparesis 2 days later. Therapy with 15 mg/day prednisone obtained a good response and anemia, abnormal immunological findings and hemiparesis disappeared." }, { "id": "pubmed23n1102_1154", "title": "Late-Onset Systemic Lupus Erythematosus Associated with Autoimmune Hemolytic Anemia and Sixth Cranial Nerve Palsy.", "score": 0.01896117900790798, "content": "BACKGROUND Patients with late-onset systemic lupus erythematosus (SLE) do not present with typical SLE symptoms or serology, and this can lead to a major delay in diagnosis. We report a complex case of an older woman who developed autoimmune hemolytic anemia and sixth cranial nerve palsy that posed considerable challenges in diagnosing late-onset SLE. CASE REPORT A 78-year-old Japanese woman presented with polyarthritis associated with generalized fatigue for 2 months, who later developed diplopia. Physical examination revealed conjunctival pallor, polyarthritis, and subsequent development of sixth cranial nerve palsy. Laboratory data revealed a decreased white blood cell count; macrocytic anemia; elevated levels of lactate dehydrogenase, indirect bilirubin, and erythrocyte sedimentation rate; hypocomplementemia; positive Coombs test; antinuclear antibodies (ANAs, 1: 40); and positive anti-double-strand DNA antibodies. Lymphoma, cerebral venous sinus thrombosis, and varicella-zoster virus infection were unlikely based on head computed tomography, brain magnetic resonance imaging, and cerebrospinal fluid analysis. She was diagnosed with late-onset SLE associated with autoimmune hemolytic anemia and sixth cranial nerve palsy. The patient was successfully treated with prednisone and hydroxychloroquine. CONCLUSIONS The difficulty in diagnosing late-onset SLE with atypical presentations and uncommon complications must be recognized. SLE cannot be excluded based on a low titer of ANA in a particular subgroup such as the elderly, and the prozone effect should be considered responsible for low ANA titers. In this case, late-onset SLE was diagnosed by considering multisystem pathologies despite low ANA titers." }, { "id": "pubmed23n0297_3204", "title": "[Autoimmune hemolytic anemia with eosinophilia in elderly patient].", "score": 0.018362533692722373, "content": "A 70-year-old woman was admitted to our hospital in November 1992 for evaluation of anemia. Physical examination revealed anemia, jaundice, swelling of axial and inguinal lymph nodes, and splenomegaly. Abnormal hematological findings were as follows: Hb of 3.9 g/dl, reticulocyte count of 58.2% (61.7 x 10(4)/microliters), hyperplasia of normal erythroblasts in bone marrow, and eosinophilia (21.0%, 2352/microliters) in peripheral blood. Routine laboratory examinations revealed polycolonal hypergammaglobulinemia 3.0 g/dl, a high level of serum LDH (797 IU/I) and a total bilirubin of 2.4 mg/dl (indirect, 1.6 mg/dl). The serum haptoglobin level was very low (&lt; 5 mg/dl). Results of serological examinations were as follows: IgG of 3366 mg/dl, CH50 of 16.0 U/ml, positive Coombs test 2+, and positive tests for antinuclear antibody, rheumatoid factor, and cold agglutinin. CRP was negative. PHA-stimulated lymphocyte blast formation, NK activity, and ADCC activity were found to be suppressed, and the percentage of CD4-positive lymphocytes in peripheral blood was also low. An axillary lymph node biopsy revealed reactive lymphadenitis. No signs or history suggested allergy, collagen disease, or parasitic infection. Autoimmune hemolytic anemia (AIHA) complicated by immunologic abnormalities and eosinophilia was diagnosed. Oral prednisolone markedly reduced the hemolytic anemia, eosinophilia, lymph node swelling, and splenomegaly, but NK activity remained low." }, { "id": "pubmed23n0479_1305", "title": "[Successful treatment of intravenous cyclophosphamide pulse therapy for systemic lupus erythematosus complicated with steroid-resistant hemolytic anemia].", "score": 0.018304351443547716, "content": "(Case 1) A 13-years-old female had multiple arthralgia and butterfly rush, when she admitted in our hospital in May 2001. Nephropathy, hemolytic anemia (Hb 6.3 g/dl and direct Coombs 3+) and high titers of antinuclear antibodies and anti-ds-DNA antibody were disclosed and she was diagnosed as systemic lupus erythematosus (SLE). Although combination therapy of PSL 60 mg/day with a steroid pulse therapy, cyclosporine or an immunosorbent treatment, severe hemolytic anemia remained. However, monthly cyclophosphamide pulse therapy (IV-CY), which was started for the steroid-resistant hemolytic anemia, has gradually become effective and Hb improved up to 11.4 g/dl after 6 courses of IV-CY. (Case 2) A 53-years-old woman diagnosed as SLE in 1978 and she had PSL 5 mg for over 10 years. Severe anemia (Hb 5.9 g/dl) was disclosed with a slight fever in June 2001, and she admitted in our hospital for further examinations. Progressive hemolytic anemia was revealed with marked decrease of Hb (3.4 g/dl) and high titer of direct Coombs (3+). Neither PSL (50 mg/day) nor steroid pulse therapy were effective against hemolytic anemia. In contrast, 3 courses of monthly IV-CY (500 mg/day) resulted in the resolution of hemolysis. It is well known that the steroid-resistant hemolytic anemia is extremely hard to treat and leads to miserable prognosis, but we here propose IV-CY as an alternative and invaluable choice for the treatment of refractory hemolytic anemia complicated with SLE." }, { "id": "pubmed23n0847_23036", "title": "Elderly female with Autoimmune hemolytic anemia.", "score": 0.01770873786407767, "content": "Autoimmune hemolytic anemia (AIHA) is a rare disease with an estimated prevalence of around 17/100,000. It is often difficult to diagnose and treat AIHA, especially in elderly. A 60-year-old female was admitted with the complaints of low grade fever, on-off for 6 months, progressive fatigue and dyspnea on exertion. She was transfused with three units of blood within these 6 months. Examination revealed pallor, edema, hemic murmur, and palpable liver. Hb was 2.9 gm%, T Bil 5.2 mg/dl, ESR 160 mm, and reticulocyte count 44.05%. Direct Coombs test was positive, anti-nuclear antibody (ANA) and Anti ds DNA were positive. A diagnosis of systemic lupus erythematosus (SLE) with AIHA was considered and patient was transfused with two units of packed red cells and put on steroid (prednisolone) at 1 mg/kg body weight daily. After 3 weeks, her Hb had increased to 10.4 gm% with gross clinical improvement. " }, { "id": "pubmed23n0688_12771", "title": "Frequency of anaemia in patients with systemic lupus erythematosus at tertiary care hospitals.", "score": 0.01694324362013666, "content": "To analyze the frequency and causes of anaemia in systemic lupus erythematosus (SLE) patients attending in department of medicine at tertiary care hospitals. This retrospective, descriptive and analytical study was planned to analyze the frequency and causes of anaemia in SLE patients attending the department of medicine at (MMC) and (LUMHS) hospitals during the period of Jan 2006 to Nov 2008. The criteria used in this study were from the American College of Rheumatology. Investigations recorded were blood complete picture, absolute values, peripheral smear, and reticulocyte count in all patients of anaemia. These investigations were necessary to analyse the cases of anaemia in SLE. All investigations were not done in all cases. Patients with hypochromic microcytic anaemia were advised to have serum iron and ferritin levels, seven patients with macrocytic anaemia were advised to have direct and indirect coomb's test, LFTs, serum LDH, serum B12 and folate levels. Patients with normochromic and normocytic anaemia were considered to have anaemia of chronic disease. Bone marrow aspiration and Hb electrophoresis were done in two patients with anaemia of chronic disease. Thirty adult patients were included in this study. Special proforma were prepared to record the information from case sheets of patients including basic information, symptomatology and laboratory investigations. Severity and various types of anaemias were recorded. Anaemia was graded according to severity, as mild (Hb 10-12 G/dl), Moderate (Hb 8-10 G/dl) and severe (Hb &lt; 8 G/dl). Haemoglobinopathies and other types of anaemias were excluded from study. Thirty adult diagnosed patients of SLE, were included. Their ages ranged from twenty years to fifty years at time of presentation. The mean age +/- SD (range) was 28 +/- 6.22 (20-50) years and median age was 31 years. Out of thirty patients, twenty seven (90%) were females and three (10%) were males. Twenty eight (93.33%) patients presented with anaemia, 14 (46.66%) patients were of mild anaemia, 8 (26.66%) patients were of moderate grade anaemia and 6 (20%) patients had severe anaemia. Iron deficiency anaemia was found in 9 (30%) patients, 12 (40%) patients had anaemia of chronic disease and 7 (23.33%) patients had haemolytic anaemia, out of theses 7 patients, 5 (16.66%) patients had Coomb's positive haemolytic anaemia. All thirty patients had ANA positive titres &gt; 1:80; and nineteen (63.33%) patients had anti ds DNA positive, titres &gt; 1:10. Haematologic abnormalities are common manifestations in patients with SLE. Most patients exhibit anaemia at some point during their disease course." }, { "id": "pubmed23n1019_11883", "title": "When systemic lupus erythematosus affects vision: a rare presentation of this condition.", "score": 0.014330885352917176, "content": "A 23-year-old woman with fever, oral ulcers, arthalgias and weight loss of 2-week duration suddenly developed blurred vision, with reduced visual acuity, cotton wool exudates and retinal vascular tortuosity. Laboratory testing revealed anaemia, lymphopaenia, positive antinuclear antibody and high anti-dsDNA antibody titre with low complement components. There was no evidence of infection, clinching the diagnosis of lupus retinopathy. Steroid therapy alone was highly effective and was also accompanied by a normalisation of haemoglobin and lymphocyte counts, after which azathioprine was added. Hydroxychloroquine was introduced after resolution of retinal changes. Immunosuppressive therapy was progressively tapered over the course of 12 months and then discontinued, and the patient remains in remission 48 months after the initial presentation. Our patient exemplifies a very rare manifestation of systemic lupus erythematosus. We emphasise the importance of its early detection and complexity of treatment in order to reduce visual morbidity." }, { "id": "pubmed23n0771_4606", "title": "A puzzle of hemolytic anemia, iron and vitamin B12 deficiencies in a 52-year-old male.", "score": 0.014238667183262301, "content": "A 52-year-old male with no significant past medical history reports increasing generalized fatigue and weakness for the past 2 weeks. Physical examination reveals jaundice and pallor without organomegaly or lymphadenopathy. His hemoglobin was 5.9 g/dL with a mean corpuscular volume of 87.1 fL and elevated red blood cell distribution width of 30.7%. His liver function test was normal except for elevated total bilirubin of 3.7 mg/dL. Serum LDH was 701 IU/L, and serum haptoglobin was undetectable. Further investigation revealed serum vitamin B12 of &lt;30 pg/mL with elevated methylmalonic acid and homocysteine level. In addition, serum ferritin and transferrin saturation were low. The patient was diagnosed with hemolytic anemia secondary to vitamin B12 deficiency with concomitant iron deficiency anemia. " }, { "id": "pubmed23n0501_23829", "title": "Klinefelter's syndrome presenting with leg ulcers.", "score": 0.013333333333333334, "content": "A 54-year-old man of Persian origin presented to our department with a 1-year history of ulcers on the right leg that had been unresponsive to numerous topical treatments, accompanied by lymphedema of the right leg. Medical history included hypergonadotropic hypogonadism, which had not been further investigated. He was treated for 20 years with testosterone IM once monthly, which he stopped a year before the current hospitalization for unclear reasons. The patient reported no congenital lymphedema. Physical examination revealed two deep skin ulcers (Figure 1) on the right leg measuring 10 cm in diameter with raised irregular inflammatory borders and a boggy, necrotic base discharging a purulent hemorrhagic exudate. Bilateral leg pitting edema and right lymphangitis with lymphadenitis were noted. He had low head hair implantment, sparse hair on the body and head, hyperpigmentation on both legs, onychodystrophia of the toenails (mainly the large toe and less prominent on the other toes), which was atrophic lichen-planus-like in appearance and needed no trimming (Figure 2), normal hand nails, oral thrush, and angular cheilitis. Other physical findings were gynecomastia, pectus excavatum, small and firm testicles, long extremities, asymmetrical goiter, systolic murmur 2/6 in left sternal border, and slow and inappropriate behavior. The patient's temperature on admission was 39 degrees C. Blood cultures were negative for bacterial growth. Results of laboratory investigations included hemoglobin (11.2 g/dL), hematocrit (26.8%), normal mean corpuscular volume and mean corpuscular hemoglobin volume, and red blood cell distribution width (16%). Blood smear showed spherocytes, slight hypochromia, anisocytosis, macrocytosis, and microcytosis. Blood chemistry values were taken for iron (4 micro g/dL [normal range 40-150 micro g/dL]), transferrin (193 mg/dL [normal range 220-400 mg/dL]), ferritin (1128 ng/mL [normal range 14-160 ng/mL]), transferrin saturation (1.5% [normal range 20%-55%]), serum folate (within normal limits), and vitamin B12 (within normal limits). Direct Coombs' test equaled positive 2 + IgG. All these values indicated anemia of chronic diseases combined with hemolytic anemia. Further blood work-up tested antinuclear antibody (positive &lt;1:80 homogeneous pattern), rheumatoid factors (143 IU/mL [positive &gt;8.5 IU/mL]), C-reactive protein (286 mg/L [normal range 0-5 mg/L]), anticardiolipin IgM antibody (9.0 monophosphoryl lipid U/mL [normal range 0-7.00 MPL U/mL]) and antithrombin III activity (135% [normal range 74%-114%]). Results of other blood tests were within normal limits or negative, including lupus anticoagulant, beta2 glycoprotein, anticardiolipin IgG Ab, anti-ss DNA Ab, C3, C4, anti-RO, anti-LA, anti-SC-70, anti-SM Ab, P-ANCA, C-ANCA, TSH, FT4, anti-T microsomal, antithyroglobulin, protein C activity, protein S free, cryoglobulins, serum immunoelectrophoresis, VDRL, hepatitis C antibodies, hepatitis B antigen, and human immunodeficiency virus. Endocrinological work-up examined luteinizing hormone (22.9 mIU/mL [normal range for adult men 0.8-6 mIU/mL]), follicle stimulating hormone (49.7 mIU/mL [normal range for adult men 1-11 mIU/mL]), testosterone (0.24 ng/mL [normal range for adult men 2.5-8.0 ng/mL]), bioavailable testosterone (0.02 ng/mL [normal range for adult men &gt;0.6 ng/mL]), and percent bioavailable test (8.1% [normal value &gt;20%]). These results indicate hypergonadotropic hypogonadism. Plasminogen activator inhibitor 1 was 6 U (normal value 5-20 U/mL). Karyotyping performed by G-banding technique revealed a 47 XXY karyotype, which is diagnostic of Klinefelter's syndrome. Doppler ultrasound of the leg ulcers disclosed partial thrombus in the distal right femoral vein. X-rays and bone scan displayed osteomyelitis along the right tibia. Histological examination of a 4-mm punch biopsy from the ulcer border revealed hyperkeratosis, acanthosis, hypergranulosis, and mixed inflammatory infiltrate containing eosinophils compatible with chronic ulcer. Multiple vessels were seen, compatible with a healing process. Direct immunofluorescence of the biopsy revealed granular IgM in the dermo-epidermal junction. Indirect immunofluorescence was negative. Thyroid function tests showed normal thyroid stimulating hormone and free throxine4. Multinodular goiter was seen on thyroid scan and ultrasound. Thyroid fine needle aspiration was compatible with multinodular goiter (normal follicular cells, free colloid, macrophages with pigment). IV treatment with amoxicillin-clavulanic acid 1 g t.i.d. was administered for 2 weeks, with a decrease in temperature and normalization of the leukocyte level. Oral antibiotic treatment with amoxicillin-clavulanic acid was continued for 10 more days, followed by 25 days of ciprofloxacin for the osteomyelitis. Local treatment included saline soakings followed by application of Promogran (Johnson &amp; Johnson, New Brunswick, NJ) and Kaltostat (ConvaTec Ltd., a Bristol-Myers Squibb Company, New York, NY) with slight improvement. At the same time, the patient was treated with warfarin sodium due to deep vein thrombosis under international normalized ratio 2-3. The patient was treated with IM testosterone once monthly for 1 year, which resulted in a reduction in the diameter and depth of the leg ulcers (Figure 3). Blood tests were not performed for follow-up of the immune state." }, { "id": "pubmed23n0273_11418", "title": "[Lupus erythematosus in old age].", "score": 0.013221609330919197, "content": "Over a period of 2 months an 88-year-old man developed progressively more severe breathing-related pain under the right shoulder blade, loss of appetite, general weakness, depressive mood, sub-febrile temperature and nocturnal sweating. Various inflammation parameters were raised (sedimentation rate 43 mm in the first hour; C-reactive protein 26 mg/dl; white cell count 12,500/microliters). There also were pleural effusion and signs of mild nonspecific hepatitis. Antibiotics were administered because bacterial pneumonia was suspected. But the patient's condition deteriorated and he developed nightly periods of disorientation. There was no evidence for any advanced malignancy. Immunological tests pointed towards older-onset systemic lupus erythematosus: titre for antinuclear antibodies markedly raised to 1:20 480; anti-DNA titre moderately raised to 1:125 IU/ml. The patient's general condition and the pleuritic pain improved within 2 days under treatment with prednisone (50 mg daily); the depression, disorientation and fever receded within a week. The anti-DNA titre fell to 47 IU/ml after 8 weeks. He was able to resume his usual social activities and was kept on a maintenance prednisone dose of 5.0 mg daily." }, { "id": "pubmed23n0870_7365", "title": "Paroxysmal Nocturnal Haemoglobinuria in the Differential Diagnosis of Unresponsive Iron Deficiency Anemia: A Case Report.", "score": 0.01286918988050038, "content": "A 16-year-old male patient who was on oral iron treatment for iron deficiency anemia for the last one year was seen at the Haematology clinic with complaints of weakness, pallor, and jaundice. A complete blood count revealed Hb of 4.2 mmol/L, Hct of 0.14, and MCV of 76 fl. A blood smear showed 50% neutrophils, 40% lymphocytes, and 10% monocytes with anisocytosis, poikilocytosis, polichromasia in erythrocytes and normoblasts. Reticulocyte count was under 1%. There was a slight erythroid hyperplasia in the bone marrow aspiration. Biochemical examinations showed total bilirubin of 3.9 mg/dL, indirect bilirubin of 3.4 mg/dL, and lactate dehydrogenase (LDH) of 6085 U/L (220-450). In re-evaluating the history of the patient, he was seen to be complaining of dark discoloration of morning urine. Perl's reaction was found to be positive for hemosiderin in the urine sediment. Because Ham's test was positive, the levels of CD55, 58, and 59 proteins on erythrocyte membranes were found to be lower. The patient was started 32 mg of methylprednisolone and his anaemia was improved by the 14th day of treatment. When evaluating iron deficiency anemia resistant to iron supplementation, PNH should be kept in mind. " }, { "id": "InternalMed_Harrison_1673", "title": "InternalMed_Harrison", "score": 0.011300075585789871, "content": "Fever >38.3°C (101°F) on at least two occasions 2. Illness duration of ≥3 weeks 3. 4. Diagnosis that remains uncertain after a thorough history-taking, physical examination, and the following obligatory investigations: determination of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level; platelet count; leukocyte count and differential; measurement of levels of hemoglobin, electrolytes, creatinine, total protein, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, creatine kinase, ferritin, antinuclear antibodies, and rheumatoid factor; protein electrophoresis; urinalysis; blood cultures (n = 3); urine culture; chest x-ray; abdominal ultrasonography; and tuberculin skin test (TST). The range of FUO etiologies has evolved over time as a result of changes in the spectrum of diseases causing FUO, the widespread Percentage of Cases Due to Indicated Cause" }, { "id": "pubmed23n1014_25815", "title": "[Adrenal hemorrhage in a patient with systemic lupus erythematosus].", "score": 0.010819120547627334, "content": "A 58-year-old female was referred to our department with intermittent suffocation for 1.5 years, aggravated for a month. 1.5 years before she developed oral ulcer, raynaud phenomenon, proteinuria, bilateral pleural effusion, ANA and anti-dsDNA positive. This patient was diagnosed with systemic lupus erythematosus (SLE). After given hormones, hydroxychloroquine sulfate (HCQ), her symptom relieved soon. The patient stopped her pills 1 year ago. One month ago, she had chest tightness, increased urine foam, and suffered from oliguria. Her admission medical examination: blood pressure (BP) 130/80 mmHg, conjunctiva pale, and lower lung breath sounds reduced. There was no tenderness, rebound pain and abdominal muscle tension in the abdomen. Liver and spleen rib inferior, mobile dullness negative, and lower extremity edema. Blood routine tests were performed with hemoglobin (HGB) 57 g/L. Urine routine: BLD (3+). 24-hour urinary protein 3.2 g. serum albumin 20.5 g/L, C-reactive protein (CRP) 12.85 mg/L, erythrocyte sedimentation rate (ESR) 140 mm/h. Antinuclear antibody (ANA) (H)1:10 000, anti-dsDNA antibody 1:3 200; anti-Smith antibody, anti-U1-snRNP/Sm antibody were positive, blood complement 3(C3) 0.43 g/L, complement 4(C4) 0.07 g /L. Anticardiolipin antibody (ACL), anti-β2-GP1, lupus anticoagulant (LA) were negative; HRCT suggested bilateral medial pleural cavity product liquid. Admission diagnosis: SLE lupus nephritis, anemia, pleural effusion, and hypoproteinemia. We treated her with methylprednisolone 1 000 mg×3 d, late to 48 mg/d and cyclophosphamide 1.0 g, HCQ 0.2 g bid, gamma globulin 10 g×5 d. Day 2 of treatment, this patient developed acute right upper quadrant pain, not accompanied by nausea, vomiting, blood stool and diarrhea. Antipyretic antispasmodic treatment was invalid, after the morning to ease their own abdominal pain. Day 4 of treatment, daytime blood HGB 77 g/L. Bilateral renal vascular ultrasound: bilateral renal artery blood flow velocity was reduced. The abdominal pain of the above symptoms recurred at night, BP was 120/80 mmHg, and no positive signs were found on abdominal examination. No abnormality was found in the vertical abdominal plain film. Blood routine examination: HGB 53 g/L, Plasma D dimer 2 515 μg/L, amylase in hematuria was normal, the stool occult blood was negative. Abdominal computed tomography (CT): normal structure of right adrenal gland disappeared, irregular mass shadow could be seen in adrenal region, CT value was about 50 HU. Morphological density of left adrenal gland was not abnormal. The retroperitoneum descended along the inferior vena cava to the right iliac blood vessel and showed a bolus shadow. The density of some segments increased. The lesion involved the right renal periphery and reached the left side of abdominal aorta. Most lesions surrounded the inferior vena cava, the right renal vein and part of the small intestine. The boundary between the upper lesion and the vena cava was unclear. Iodinecontaining contrast agent was taken orally. No sign of contrast agent overflowing was found in the abdominal cavity. Hematoma and exudative changes were considered in retroperitoneum. CONCLUSION of contrast-enhanced ultrasound of blood vessels: The retroperitoneal inferior vena cava (volume 3.5 cm×3.5 cm×1.5 cm) was hypoechoic and had no blood flow lesion. The adrenal gland had a high possibility of origin. Left renal vein thrombosis extended to inferior vena cava. According to the above data, it was analyzed that the cause of retroperitoneal hematoma of the patient was left adrenal vein thrombosis caused by hypercoagulable state, which led to vascular rupture and hemorrhage caused by increased vascular pressure in adrenal gland. Therefore, on the basis of continuing to actively treat the primary disease, and on the basis of dynamic observation of no active hemorrhage for 3 days, the anticoagulant therapy was continued with 10 mg/d of apixaban. Clinical symptoms were gradually eased, HGB did not decrease. Two weeks later, the ultrasonic examination showed that the irregular cluster hypoechoic range behind the inferior vena cava was significantly smaller than that before (1.8 cm×1.2 cm×0.7 cm). Abdominal CT examination after 1 month showed that there was no abnormal morphological density of bilateral adrenal glands and basic absorption of retroperitoneal exudation. Adrenal hemorrhage is uncommon. SLE with adrenal hemorrhage is rarer. In SLE patients, especially those complicated with APS, if abdominal pain accompanied by HGB decrease occurs, except after gastrointestinal hemorrhage, the possibility of adrenal hemorrhage should be warned." }, { "id": "wiki20220301en207_20836", "title": "Lupus erythematosus", "score": 0.009953017827033575, "content": "Photosensitivity Photosensitivity is the amount to which an object reacts upon receiving photons especially in visible light. Photosensitivity is a known symptom of lupus, but its relationship to and influence on other aspects of the disease remain to be defined. Causes of photosensitivity may include: change in autoantibody location cytotoxicity induction of apoptosis with autoantigens in apoptotic blebs upregulation of adhesion molecules and cytokines induction of nitric oxide synthase expression ultraviolet-generated antigenic DNA Diagnosis Some of the first steps to being diagnosed with Lupus is going to see your healthcare provider. Your doctor will need to know if any family members have Lupus or any other autoimmune diseases. A doctor will conduct a physical exam, blood and urine tests, and a skin or kidney biopsy. Some other test that may need to be run include: Antinuclear antibody (ANA) CBC with differential Chest X-ray Serum creatinine Urinalysis" }, { "id": "pubmed23n0715_15091", "title": "Coexistence of Crohn's disease in a patient with systemic lupus erythematosus.", "score": 0.009708737864077669, "content": "The concurrence of inflammatory bowel disease with systemic lupus erythematosus (SLE) is rare. The concomitant diagnosis of Crohn's disease and SLE is even more rare. The patient, a 40-year-old woman, was admitted to our hospital because of relapsing episodes of abdominal pain, diarrheas upper and lower extremities arthralgias, Raynaud's phenomenon with positive antinuclear antibodies, and fever for the last 2 years. The patient was diagnosed elsewhere with SLE and treated with hydroxychloroquine. Her medical history also included tonsillectomy and total hip replacement after a car accident. Family history was unremarkable. Physical examination was unremarkable except of very mild pain at lower left abdominal quadrant. Laboratory tests showed erythrocyte sedimentation rate at 32 mm/h, C-reactive protein at 36 mg/dl, positive rheumatoid factor, and increased C3, C4, positive antinuclear antibodies with the presence of anti-Sm and anti-RNP antibodies. Ileocolonoscopy revealed colonic inflammation with ulcers and pseudopolyps. Subsequent biopsies were diagnostic of Crohn's disease. Patient was diagnosed with Crohn's colitis concomitant to systemic lupus erythematosus and was started on therapy with azathioprine 2 mg/Kg, methylprednisolone 16 mg/d with slow tapering, mesalazine 1.5 g/day, and hydroxychloroquine. Patient is in excellent health status on the six-month follow-up." }, { "id": "pubmed23n0298_13034", "title": "[Sarcoidosis in a patient with autoimmune hemolytic anemia].", "score": 0.009615384615384616, "content": "A 65-year-old woman was admitted to our hospital because of severe anemia. A skin biopsy was done in January 1994 and sarcoidosis was diagnosed. Diffuse reticular shadows were seen in both lung fields on a chest X-ray film and mediastinal lymph node swelling was seen on a chest CT scan. She was followed as an outpatient and was not treated. She suddenly experienced vertigo and general fatigue in March 1995. Laboratory findings on admission were as follows: Hb 6.2 g/dl, MCV 115.9 fl, Ret 198%, LDH 732 IU/L, I-Bil 1.9 mg/dl, and Coombs' test was positive. Autoimmune hemolytic anemia was diagnosed, and she was treated with prednisolone (1 mg/kg). As of the time of this writing, she has no relapse of hemolytic anemia though prednisolone was discontinued 6 months ago." }, { "id": "pubmed23n0740_15281", "title": "Prevalence of hematinics deficiency amongst female students and its correction.", "score": 0.009523809523809525, "content": "Nutritional anemia (NA) is common in India. While iron deficiency (ID) is a well recognized cause of NA, prevalence of deficiencies of other hematinics is not systematically investigated. Seventy students of a junior class of a polytechnic and 202 inmates of girl students home were taken up for study. Students were given a questionnaire to elicit anemia related symptoms. Blood was collected for complete blood count (CBC), serum ferritin, folic acid and vitamin B12. Students of polytechnic received hematinic at bed time during their menstrual periods whereas inmates of students home received hematinic at bed time, 3 days in a week. After 6 months blood tests were repeated in those who completed the treatment. CBC was done on Coulter counter and ferritin, folic acid and vitamin B12 were assayed by chemiluminescence. Students were divided into three groups-(1) Control group with Hb 12.0 g/dl or more and ferritin 15.0 ng/ml or more; (2) ID Group with Hb 12.0 g/dl or more and ferritin less than 15.0 ng/ml; and (3) Iron Deficiency Anemia (IDA) group with Hb less tha 12.0 g/dl and ferritin less than 15.0 ng/ml. Basal parameters of three groups were compared using students t test. Change in parameters with treatment was compared using paired students t test. Median age-16 years (range 10-25). Anemia ( Hb &lt; 12.0 g/dl)-94 (34.6%); MCV &lt; 80 fl-153 (56.3%); MCH &lt; 27 pg-167 (61.4%); Ferritin &lt; 15.0 ng/ml-161 (59.2%); Folic acid &lt; 3.5 ng/ml-34 (12.5%); Vitamin B12 &lt; 258 pg/ml-133 (48.9%) Pre-therapy: (1) Hb, MCV, MCH and ferritin significantly lower in ID and IDA Groups compared to control group. (2) Hb, MCV, MCH and Ferritin significantly lower in IDA Group as compared to ID Group. POST-THERAPY: (1) IDA group showed significant increase in Hb, MCV, MCH, ferritin, folic acid and vitamin B12. (2) final Hb (11.26+1.07) and ferritin (7.46+4.81) in IDA Group were subnormal. (3) MCV, MCH, ferritin, folic acid and vitamin B12 increased significantly in ID Group and control group. (1) Nutritional anemia is common amongst asymptomatic young female students. (2) Deficiencies of iron, folic acid and vitamin B12 are common and coexist. (3) 105 mg elemental iron for 3 days in a week for 6 months is not adequate to correct IDA. (4) 105 mg iron for 3 days in a week is enough to correct ID. (5) Non-anemic individuals with ID have iron deficient erythropoiesis. (6) Non-anemic individuals without ID, in this cohort, also had iron deficient eryhtropoiesis." }, { "id": "pubmed23n0834_13001", "title": "Borderline tuberculoid leprosy in childhood onset systemic lupus erythematosus patient.", "score": 0.009433962264150943, "content": "Leprosy is a contagious and chronic systemic granulomatous disease caused by the bacillus Mycobacterium leprae. To our knowledge, no case of leprosy in a childhood-onset systemic lupus erythematosus (c-SLE) patient has been reported. For a period of 31 years, 312 c-SLE patients were followed at the Pediatric Rheumatology Unit of our University Hospital. One of them (0.3%) had tuberculoid leprosy skin lesions during the disease course and is here reported. A 10-year-old boy from Northwest of Brazil was diagnosed with c-SLE based on malar rash, photosensitivity, oral ulcers, lymphopenia, proteinuria, positive antinuclear antibodies, anti-double-stranded DNA, anti-Sm and anti-Ro/SSA autoantibodies. He was treated with prednisone, hydroxychloroquine and intravenous cyclophosphamide, followed by mycophenolate mofetil. At 12-years-old, he presented asymmetric skin lesions characterized by erythematous plaques with elevated external borders and hypochromic center with sensory loss. Peripheral nerve involvement was not evidenced. No history of familial cases of leprosy was reported, although the region where the patient resides is considered to be endemic for leprosy. Skin biopsy revealed a well-defined tuberculoid form. A marked thickening of nerves was observed, often destroyed by granulomas, without evidence of Mycobacterium leprae bacilli. At that time, the SLEDAI-2K score was 4 and he had been receiving prednisone 15 mg/day, hydroxychloroquine 200 mg/day and mycophenolate mofetil 3 g/day. Paucibacillary treatment for leprosy with dapsone and rifampicine was also introduced. In conclusion, we have reported a rare case of leprosy in the course of c-SLE. Leprosy should always be considered in children and adolescents with lupus who present skin abnormalities, particularly with hypoesthesic or anesthesic cutaneous lesions. " }, { "id": "InternalMed_Harrison_1704", "title": "InternalMed_Harrison", "score": 0.00941479684657368, "content": "Fever ˜38.3° C (101° F) and illness lasting ˜3 weeks and no known immunocompromised state History and physical examination Stop antibiotic treatment and glucocorticoids Obligatory investigations: ESR and CRP, hemoglobin, platelet count, leukocyte count and differential, electrolytes, creatinine, total protein, protein electrophoresis, alkaline phosphatase, AST, ALT, LDH, creatine kinase, antinuclear antibodies, rheumatoid factor, urinalysis, blood cultures (n=3), urine culture, chest x-ray, abdominal ultrasonography, and tuberculin skin test" }, { "id": "pubmed23n0223_13278", "title": "[Central nervous system involvement in systemic lupus erythematosus].", "score": 0.009345794392523364, "content": "Three cases are presented, in two of which the CNS lesions revealed the presence of systemic lupus erythematosus (SLE). The diagnosis of SLE was certain according to the criteria of the ARA, and it was further confirmed by results of renal needle puncture biopsy. Case 1: A 16-year-old adolescent developed choreic movements followed, one month later, by psychotic symptoms suggesting a mixed hebephrenic-catatonic schizophrenic affection. Cutaneous lesions and signs of renal insufficiency 3 months later established that these disorders were related to SLE. A favourable outcome was observed rapidly for the systemic signs, recovery from neuropsychic symptoms being obtained after 3 months only but then in a few days. This course suggests the diagnosis of a \"functional psychosis\" of lupus origin. Case 2: A 24-year-old woman developed left hemiparesis followed by febrile coma. The slowly favourable course of the disease led to the appearance of a progressive dementia, with numerous epileptic seizures. Although tests for antinuclear antibodies were negative and the ESR was normal, several minor biological anomalies were suggestive of a systemic disease and the diagnosis of SLE was finally established. Corticotherapy produced only slight transient improvement. This progression towards dementia with progressive cerebral atrophy is most probably related to cerebral lupus lesions, the initial coma in the absence of any other apparent cause possibly being the first sign. Case 3: A 47-year-old woman developed simultaneously or separately episodes of arthralgia and uveitis of unknown origin over a 12-year period, and attacks of regressive multilocular neurological deficiency over a 15-year period.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "Obstentrics_Williams_8205", "title": "Obstentrics_Williams", "score": 0.00932442641854547, "content": "TABLE 59-1. Some Autoantibodies Produced in Patients with Systemic Lupus Erythematosus (SLE) Best screening test, multiple antibodies; a second negative test makes SLE unlikely High titers SLE-specific; may correlate with disease activity, nephritis, and vasculitis Specific for SLE Not SLE-specific, high titers associated with rheumatic syndromes Not SLE-specific; associated with sicca syndrome, predisposes to cutaneous lupus, neonatal lupus with heart block, reduced risk of nephritis Associated with anti-Ro Common in drug-induced lupus Lupus anticoagulant and anticardiolipin antibodies associated with thrombosis, fetal loss, thrombocytopenia, valvular heart disease; false-positive test for syphilis Direct Coombs test, may develop hemolysis Thrombocytopenia in 15%; poor clinical test dsDNA = double-stranded DNA; RNP = ribonucleoprotein. Data from Arbuckle, 2003; Hahn, 2015. TABLE 59-2. Some Clinical Manifestations of Systemic Lupus Erythematosus Modified from Kasper, 201r5." }, { "id": "wiki20220301en249_18865", "title": "Systemic vasculitis", "score": 0.009297839506172838, "content": "Lab tests. Basic lab tests may include a complete blood count, chemiestries (look for creatinine), creatine phosphokinase level, liver function tests, erythrocyte sedimentation rate, hepatitis serologies, urinalysis, chest X-ray, and an electrocardiogram. Additional, more specific tests include: Antinuclear antibody test can detect an underlying connective tissue disorder, especially lupus erythematosus Complement levels that are low can suggest mixed cryoglobulinemia, hepatitis C infection, and lupus erythematosus], but not most other vasculitides. Antineutrophil cytoplasmic antibody may suggest granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis, or drug-induced vasculitis, but is not diagnostic. Electromyography. It is useful if a systemic vasculitis is suspected and neuromuscular symptoms are present." }, { "id": "pubmed23n0754_14208", "title": "Subacute cutaneous lupus erythematosus induced and exacerbated by proton pump inhibitors.", "score": 0.009174311926605505, "content": "Subacute cutaneous lupus erythematosus (SCLE) can be induced by numerous drugs. We report 3 cases of SCLE induced by proton pump inhibitors (PPIs). To highlight a rare cutaneous side effect induced by a frequently prescribed drug such as a PPI. Case 1 was a 30-year-old man who developed multiple annular plaques over the trunk and lower limbs 1 month after the initiation of pantoprazole. Antinuclear antibodies (ANA) were positive with anti-Ro/SSA and anti-La/SSB antibodies, and histology confirmed the diagnosis. Clinical improvement was achieved 8 weeks after the discontinuation of pantoprazole and the introduction of a treatment combining topical steroids and hydroxychloroquine. Lesions relapsed when pantoprazole was accidentally rechallenged. The second case was a 31-year-old woman, 28 weeks pregnant, who presented erythematous annular plaques over the trunk 7 weeks after starting esomeprazole. ANA and anti-Ro/SSA antibodies were positive, and the histology was compatible with SCLE. Fetal ultrasound was normal. She was treated with topical and oral steroids and hydroxychloroquine. Clinical improvement was achieved 4 weeks after the discontinuation of esomeprazole. The third case was a 57-year-old woman with systemic erythematosus lupus presenting annular and psoriasiform lesions on the trunk for 15 months. She was treated successively with hydroxychloroquine, azathioprine, mycophenolate mofetil and methotrexate with prednisone. A review of her drug history revealed the introduction of omeprazole a few weeks before the first appearance of skin lesions and omeprazole was contraindicated. SCLE should systematically be suspected in case of eruption after the introduction of PPI. The risk of fetal cardiac complications is important in pregnant women." }, { "id": "pubmed23n0575_6282", "title": "[Hematological abnormalities in systemic lupus erythematosus and clinical significance thereof: comparative analysis of 236 cases].", "score": 0.009174311926605505, "content": "To investigate the hematological abnormalities and their relationship to the disease activity of systemic lupus erythematosus (SLE). The clinical data of 236 SLE patients, 29 males and 207 females with the age of confirmed diagnosis of 33.4, were divided into 3 groups: anemia group, with the hemoglobin (Hgb) &lt; 100 g/L, including 2 subgroups, i.e. subgroup of anemia caused by chronic diseases (ACD) and subgroup of hemolytic anemia; low white blood cell group 1 (Group WBC1) with the WBC count &lt; 4.0 x 10(9)/L, white blood cell group 2 (Group WBC2) with the WBC count 3.0 approximately 3.9 x 10(9)/L, immune thrombopenic purpura group (ITP group) with a platelet count &lt; 100 x 10(9)/L, and control group without hematological changes. 72 patients underwent morphologic characterization of their bone marrow. The hematological data and the relationship thereof to the disease activity in different groups were analyzed. Among the 236 SLE patients 168 (71.18%) had hematological abnormalities and 68 of them (28.82%) without hematological abnormalities. 123 of the 168 patients with hematological abnormalities (52.1%) had anemia, 82 of which (66.7%) had characteristics of anemia caused by chronic diseases, 18 (14.6%) had hemolytic anemia, 8 (6.6%) had hematopoietic abnormalities, and the remaining 15 patients (12%) had anemia caused by unknown reasons. 73 of the 236 SLE patients (30.9%) had a WBC count &lt; 4.0 x 10(9)/L and 57 patients (24.2%) had a platelet count &lt; 100 x 10(9)/L. In the groups with hemolytic anemia, WBC count &lt; 3.0 x 10(9)/L and thrombocytopenia, the complement levels were significant lower, and the levels of C-reactive protein (CRP) and positive anti-dsDNA antibody were significantly higher than those of the controls (all P &lt; 0.05) The rate of positive antiphospholipid antibody of the hemolytic anemic patients and patients with thrombocytopenia were 22.2% and 15.8% respectively, both significantly higher than that of the controls (2.9%, both P &lt; 0.05). 49 of the 72 patients undergoing morphologic characterization of bone marrow had normal cell morphology and a normal appearing bone marrow, 10 had varying degrees of pathologic hematopoietic changes, 2 lacked megakaryocytes, 9 expressed decreased proliferation in all three hematopoietic lineages, and 2 had only a decrease in erythropoiesis. The reason of the high proportion of anemia among the SLE patients in China may be the higher proportion of anemia caused by ACD in comparison with that abroad. Although SLE patients have lower rates of hemolytic anemia, HA is an important index of SLE disease activity. Thrombocytopenia and a WBC count &lt; 3.0 x 10(9)/L are related to SLE disease activity. Abnormalities of hemopoiesis by bone marrow is one of the reasons of sever hematological changes in part of the SLE patients." }, { "id": "InternalMed_Harrison_8268", "title": "InternalMed_Harrison", "score": 0.009173976608187135, "content": "clinical features AIHA is a serious condition; without appropriate treatment, it may have a mortality of approximately 10%. The onset is often abrupt and can be dramatic. The hemoglobin level can drop, within days, to as low as 4 g/dL; the massive red cell removal will produce jaundice; and sometimes the spleen is enlarged. When this triad is present, the suspicion of AIHA must be high. When hemolysis is (in part) intravascular, the telltale sign will be hemoglobinuria, which the patient may report or about which we must enquire or test for. The diagnostic test for AIHA is the direct antiglobulin test developed in 1945 by R. R. A. Coombs and known since by this name. The beauty of this test is that it detects directly the pathogenetic mediator of the disease, i.e., the presence of antibody on the red cells themselves. When the test is positive, it clinches the diagnosis; when it is negative, the diagnosis is unlikely. However, the sensitivity of the Coombs test varies depending on the" }, { "id": "pubmed23n0942_16096", "title": "The devil's in the dosing: severe drug-induced liver injury in a hydroxychloroquine-naive patient with subacute cutaneous lupus erythematosus and porphyria cutanea tarda.", "score": 0.00909090909090909, "content": "A 29-year-old woman with a 1.5 year history of photosensitive skin lesions on her hands presented with a malar rash, bullous lesions on her hands, and was diagnosed with subacute lupus erythematosus after serologies revealed a positive antinuclear antibody test (1:2560), and antibodies to Ro/SSA and dsDNA. Hydroxychloroquine (400 mg/day) was prescribed and the patient developed severe drug-induced liver injury. Biopsy of her bullous skin lesions was consistent with porphyria cutanea tarda, as were her serological and urinary exams. She was successfully treated with therapeutic phlebotomy. This case identifies porphyria cutanea tarda as an important differential diagnosis for the rheumatologist to consider when evaluating patients with bullous skin lesions. Hydroxychloroquine in lower doses is an effective treatment for porphyria cutanea tarda; at doses used to treat systemic lupus erythematosus and subacute cutaneous lupus, there is a potentially life-threatening complication of hepatotoxicity." }, { "id": "pubmed23n0053_2677", "title": "[Interstitial lupus nephritis].", "score": 0.00909090909090909, "content": "A 17-year old-male presented with a 6-week history of weight loss, lassitude and calf pains. On examination he was very pale. Laboratory tests showed a very high erythrocyte sedimentation rate (155 mm in the first hour), anaemia (haemoglobin 10.1 g/dl), and a raised serum creatinine of 1.54 mg/dl. Microhaematuria (5-10 erythrocytes/microliter) and pronounced pyuria (500 leucocytes/microliter) were present, but the urine was sterile and there was no increase in albumin excretion. The serum IgG was raised to 75.7 g/l, suggesting an autoimmune disorder. Anti-nuclear antibodies (titre 1 : 1920) and anti-double-stranded DNA antibodies (31 U/ml) were present, while the serum complement C4 was decreased to 0.11 g/l. Renal histology showed an interstitial nephritis without glomerular involvement, while the bone marrow showed vasculitis accompanied by a prominent plasma-cell infiltrate. A diagnosis of interstitial nephritis associated with systemic lupus erythematosus was made, with asymptomatic cardiac and hepatic involvement. Renal function recovered rapidly with prednisolone therapy (initial dose 2 mg/kg.d). While glomerulonephritis is the most common lupus-associated renal disorder, isolated interstitial nephritis may occur in some cases, often with an absence of proteinuria." }, { "id": "pubmed23n1004_25990", "title": "Rowell Syndrome in Nigeria: Systemic Lupus Erythematosus Presenting as Recurrent Erythema Multiforme in a Young Woman.", "score": 0.009009009009009009, "content": "Dear Editor, Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease characterized by diverse patterns of auto-antibody production with multi-organ affectation. Cutaneous involvement, either alone or in association with other systemic illnesses, is one of its most common manifestations (1). Dermatologic disorders like malar and discoid rashes are quite suggestive of SLE. However, the occurrence of non-specific skin lesions like erythema multiforme (EM) in patients with SLE (Rowell syndrome) can rarely occur (1). In such patients, a diagnosis of SLE may be missed or delayed in the absence of other overt clinical features of lupus. Herein we report a case of recurring EM-like eruptions as the cardinal cutaneous manifestation of previously undiagnosed, active SLE in a young Nigerian woman. A 26-year-old Nigerian woman presented with a three-day history of non-pruritic, generalized, and target-like, erythematous annular patches and plaques which mostly affected the trunk. A few lesions had presented with crusting and erosions at the time of examination (Figure 1). Associated symptoms included oral painful ulcers, low grade fever, and malaise. The patient had no other systemic symptoms and her prior drug history was not remarkable. Her erythrocyte sedimentation rate (ESR) was 66 mm/hour using the Westergren method. Screening for HIV and hepatitis B and C was negative. Herpes simplex, cytomegalovirus, and Epstein Barr viruses could not be screened for. Other baseline investigations (complete blood count, electrolytes, urea and creatinine as well as urinalysis) were within normal limits. The patient was managed as a case of EM of an unidentified inciting agent and her symptoms resolved with supportive care and antibiotics. However, she developed a recurrence about 5 weeks later, with more extensive and coalescent skin lesions (Figure 2). Additionally, there was a new onset of alopecia and pain in the small joints of the hands as well as both knees and ankles. At this time, the patient's ESR had gone up to 112 mm/h and she had developed significant proteinuria, with a protein creatinine ratio of 1.3 g/g (reference &lt;0.5 g/g). Her antinuclear antibody (ANA) titer was high (1:320) with a speckled pattern. Anti-Smith antibody was also positive. A renal biopsy was declined. A tentative diagnosis of Rowell syndrome was made. The patient was started on high-dose steroids and hydroxychloroquine 200 mg twice daily. Subsequent care included the use of mycophenolate mofetil 1 g twice daily for 6 months. This was then changed to azathioprine at 50 mg twice daily. Follow-up after 6 months showed sustained clearance of skin lesions, resolution of fever and joint pains, as well as improvement in the renal profile, with a urine protein-creatinine ratio of 0.77 g/g. The presence of systemic lupus erythematosus, EM-like lesions, and a speckled pattern of antinuclear antibody in our patient fulfils the revised diagnostic criteria for RS put forward by Zeitouni et al. at the turn of the twenty-first century (2). Considering the rarity of EM-like lesions in SLE and the possibility of constitutional symptoms in EM, a diagnosis of RS may be readily overlooked in patients like the one described, whose major cutaneous manifestation of severe active SLE was EM-like lesions. In contrast to classic EM, where skin lesions are concentrated in the extremities, a predominant truncal distribution of EM-like lesions as found in our patient may favor a clinical consideration of RS (3). However, some authors have challenged the existence of Rowell syndrome as a distinct clinical laboratory entity. Arguments put forward in this regard include the fact that none of the immunological markers that have been described in RS are specific to any disorder. Additionally, the annular polycyclic dermatosis seen in sub-acute cutaneous lupus erythematosus (SCLE) can be difficult to clinically and histologically differentiate from EM (4,5). Patients with SLE also have a higher likelihood of developing adverse drug reactions (6). The inherent complexity of SLE may make for delayed and oftentimes difficult diagnosis, especially in a country where immunologic tests are expensive and rheumatologists are scarce. When patients do occasionally present with recurrences of skin lesions in the spectrum of EM, Steven-Johnson syndrome, and toxic epidermal necrolysis in the absence of a definite inciting agent, undiagnosed lupus may indeed be present in some of these individuals and should be considered in the differential diagnosis. In conclusion, while it is very rare, SLE may present first with recurrent episodes of EM-like rash. Despite the various possibilities which underlie their association, prompt identification and treatment of SLE in patients presenting with EM is important to prevent death or irreversible organ damage." }, { "id": "pubmed23n0519_12026", "title": "Automatic laboratory-initiated reflex testing to identify patients with autoimmune hemolytic anemia.", "score": 0.009009009009009009, "content": "The clinical usefulness of automatic laboratory-initiated testing of patients with recent-onset normocytic anemia to diagnose autoimmune hemolytic anemia (AIHA) is uncertain. During a 28-month period, we performed 784,185 CBC counts. Patients without a history of anemia had reticulocyte count testing if hemoglobin values were less than 10 g/dL (&lt; 100 g/L) and mean corpuscular volume was 80 microm3 (80 fL) or more. A direct antiglobulin test (DAT) was performed if the uncorrected reticulocyte count was 2% or more of the RBCs (&gt; or equal 0.02). Of 784,185 CBC counts, 3,841 (0.49%) revealed recent-onset normocytic anemia, 424 (11.04%) with reticulocyte counts of 2% (0.02) or more. Of those with elevated reticulocytes counts, 52 (12.3%) had positive DAT results. Patient information was available for 40 patients. Physicians were unaware of the existence of AIHA in 33 (83%) of them. Of the 40 patients, 11 (28%) were treated with steroids and 6 (15%) were hospitalized; in 2 patients (5%), medications were stopped because they were suspected to have caused the hemolytic anemia. Automatic laboratory testing for patients with recent-onset normocytic anemia ensures recommended practices, probably saves physician visits, and, for some patients, results in more timely diagnosis and appropriate treatment." }, { "id": "pubmed23n0309_14382", "title": "[Human parvovirus B19 infection mimicking systemic lupus erythematosus: case report].", "score": 0.008928571428571428, "content": "Human parvovirus B19 (HPV-B19) has been known as the etiologic agents of erythema infectiosum in normal childhood, and chronic anemia and thrombocytopenia in immuno-compromised patients. Recently, this virus has been reported as the association with rheumatic manifestation such as rheumatoid arthritis and systemic lupus erythematosus (SLE). We described here a patient whose HPV-B19 infection was mimiking atypical symptoms of SLE at diagnosis, and was persistent because of immuno-suppressive therapy for SLE. A 34-year-old female was admitted to our hospital on 22 June 1995, presenting fever episode and cervical lymph node swelling. Before eighteen months, she was received methyl-predonisolone pulse therapy and plasma exchange by fresh frozen plasma for the treatment of Stevens-Johnson syndrome, and after several weeks these therapy she was suffered from viral infection with lymphadenopathies with a transient appearance of atypical lymphocytes in her peripheral blood smear. On laboratory examination at the present admission, her peripheral blood showed anemia, thrombocytopenia with atypical lymphocytes. Throughout her hospitalization, anti-nuclear antibody (ANA) suspected SLE including anti-DNA and anti-Sm antibody were all negative except of transient week positive ANA screening test. Her physical condition presented poor clinical course with fever elevation, increased ascites and renal dysfunction showing the elevation of CRP and circulating immune-complex (Clq binding method). Her serum was positive for IgM and IgG antibody against VP-1 and VP-2 antigen of HPV-B19 by ELISA in April 1996. And then, HPV-B19 DNA by polymerase chain reaction (PCR) was positive in bone marrow sample in March 1996, and also positive in spleen necropsy at death. We confirmed persistent chronic HPV-B19 infection by measurement of HPV-B19 IgM and IgG antibody by ELISA and HPV-B19 DNA by PCR. The plasmapheresis and administration of intravenous immunoglobulin showed the possible efficacy for her symptom throughout this clinical course. Moreover, bone marrow smear showed the finding of virus-associated hemophagocytic syndrome, and finally, she was died of cervical hemorrhage accompanied with disseminated intravascular coagulation syndrome on July 1996. HPV-B19 infection can present an atypical clinical picture that is highly suggestive of SLE. We suggest that the therapy of steroids and immuno-suppressive agents should be cautious, because these may potentially cause persistent chronic HPV-B19 infection and induced life-threatening clinical course." }, { "id": "pubmed23n0956_21239", "title": "Hardness and Painful Lesion of the Breast.", "score": 0.008849557522123894, "content": "Dear Editor, Lupus panniculitis or lupus profundus is a rare inflammatory complication found in patients with systemic lupus erythematosus (SLE), or discoid lupus erythematosus (DLE) (1). When the breast is involved, the term lupus mastitis (LM) is used. This disease involving the breast is rare, and the lesions may precede, coincide with, or occur later than the onset of other lupus lesions. Tissue biopsy is required to confirm the suspected diagnoses of LM. We report a case of a patient with lupus mastitis due to the important differential diagnosis. A 60-year-old woman presented with a painful nodular lesion in her left breast that had appeared 15 days ago (Figure 1, a). She had been previously diagnosed with discoid lupus erythematosus 3 years ago. Physical examination revealed a deep and firm erythematous subcutaneous nodule without overlying skin involvement in the lower-central portion of the left breast. Laboratory findings were positive for antinuclear antibodies (1:80) and double-stranded deoxynucleic acid antibodies (1:10). Mammography and ultrasounds showed an area of increased density and irregular breast tissue along with an important thickening of the overlying skin (Figure 1, b). On suspicion of malignancy, a needle biopsy of the breast lesion was performed and showed vacuolar alteration and lymphocytic infiltrate in the basal layer. Subcutaneous fat showed a lobular panniculitis with a prominent lymphocytic infiltrate and hyalinization of the fat lobules (hyaline fat necrosis). Direct immunofluorescence of the face biopsy revealed IgA, IgG, IgM, and C3 granular deposition. Based on these results, a diagnosis of lupus mastitis associated with DLE was established. Antimalarial therapy resulted in complete resolution of the clinical features. Three years later, the patient presented with a disfiguring atrophy with retraction in the damaged areas of the breast (Figure 2). Lupus mastitis is a very unusual disease that most commonly affects middle-aged women. The first case of LM was described by Tuffanelli in 1971. The lesions usually present following the diagnosis of SLE/DLE; however, on rare occasions they may be observed earlier (2). The histophysiology of this disease remains unclear, but the predominant theory suggests an autoimmune-related etiology. Corroborating evidence for this theory includes the finding of immune complexes, both at the basement membrane of the dermal-epidermal junction and in the blood vessels in the areas of panniculitis (3). Lupus mastitis may be present in the breast as single or multiple subcutaneous nodules that may be tender or painful and can progress to chronic ulcers over time or resolve, leaving atrophic scars. The overlying skin can be normal, erythematous, poikilodermic or ulcerated. When skin changes are prominent, the lesion may clinically and radiologically mimic inflammatory breast carcinoma. Mammographic and ultrasounds findings include an ill-defined breast density with or without associated microcalcifications (4). Histologically, this disease is characterized by lobular lymphocytic panniculitis and predominantly involves the fat lobule and the presence of anucleated adipocytes in a background of a glassy-appearing collagenous stroma (hyaline fat necrosis). Fibrinoid necrosis of the vessel wall has also been reported, but is usually absent (5). Differential diagnosis of lupus mastitis includes inflammatory breast carcinoma, primary medullary carcinoma, and other immune-mediated inflammatory conditions such as diabetic mastopathy. The first line of treatment the use of antimalarial drugs such as hydroxychloroquine. Systemic steroids and cyclophosphamide have also been used. Surgical treatment should be considered only in patients who do not respond to management with medications. In summary, we reported a case of lupus mastitis in a patient with discoid lupus erythematosus. This dermatosis should be considered in the differential diagnosis of breast lesions in lupus patients, and a biopsy of the breast lesion is essential to reject suspected malignancy. If the disease is left untreated, unsightly atrophy will appear; it is thus important to diagnose early on. The course of the disease tends to be chronic with remission and flares, so patients should be followed-up regularly due to the risk of recurrences in the same area or in a different location." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 267, 329 ] ], "word_ranges": [ [ 39, 48 ] ], "text": "An L1/L2 (posterolateral) herniation would affect the L2 root," }, "2": { "exist": true, "char_ranges": [ [ 374, 448 ] ], "word_ranges": [ [ 56, 66 ] ], "text": "cauda equina would involve more symptomatology than simple S1 involvement." }, "3": { "exist": true, "char_ranges": [ [ 330, 369 ] ], "word_ranges": [ [ 48, 55 ] ], "text": "an L4/L5 herniation would affect the L5" }, "4": { "exist": true, "char_ranges": [ [ 0, 266 ] ], "word_ranges": [ [ 0, 39 ] ], "text": "Acute sciatica probably due to disc extrusion. Both the sensory distribution, the paresis for plantar flexion (tiptoe) and the absence of the Achilles reflex are typical of S1 root involvement, which is typically affected with L5/S1 disc herniation (posterolateral)." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Herniated disc L1/L2.", "2": "Horsetail syndrome.", "3": "L4/L5 disc herniation.", "4": "Herniated disc L5/S1.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0751_23524", "title": "Intradural lumbar disc herniation associated with degenerative spine disease and rheumatoid arthritis.", "score": 0.0172823023290313, "content": "A case report. To demonstrate a case of intradural lumbar disc herniation including imaging studies, intraoperative imaging, and an intraoperative video. The first case of lumbar intradural disc herniation was reported as early as 1942; since then more than 150 cases have been reported, mostly in the lumbar spine. Gadolinium-enhanced magnetic resonance image (MRI) is considered the \"gold standard\" for diagnosing this entity, although it is rarely performed routinely in lumbar disc disease and diagnosis is often made intraoperatively. A 70-year-old man presented to the emergency department as a referral complaining of lower back pain, loss of sensation in the right thigh, and difficulty walking. On examination, he showed uneven gait, right-sided foot drop (1/5), hypesthesias in the right inguinal area and ventral thigh, and a positive straight leg raise test on the right. Anal sphincter tone was within normal limits. A magnetic resonance image of the lumbar spine showed a large mediolateral herniated disc at L3-L4, with caudal displacement and unclear signal changes intradurally. Intraoperatively, the herniated disc was found upon opening the dural sac. Intradural disc herniations are a rare entity. The opening and inspection of the dural sack should be considered when the correct spinal level can be confirmed and insufficient herniated disc material can be visualized extradurally." }, { "id": "pubmed23n0968_3045", "title": "Report of an Isolated L5 Radiculopathy Caused by an L2-3 Disc Herniation and Review of the Literature.", "score": 0.016361950185479597, "content": "Intervertebral disc herniation is a common cause of radiculopathy. Disc herniations occurring in the lumbar spine typically affect the nerve root exiting under the pedicle of the vertebral body, one level caudal. However, in rare cases, a disc herniation can cause remote isolated radicular symptoms. The authors present the case of a 70-year-old male who presented with an acute, new-onset, left-sided foot drop, low back pain, and a classic L5 monoradiculopathy. Imaging revealed a large, left-sided paracentral extruded L2-3 disc and the absence of any pathology at the L4/5 level. Although the patient's clinical presentation and imaging did not classically correlate, it was felt that the L2-L3 disc was the etiology of the patient's L5 radiculopathy and a left L2-3 microsurgical discectomy was performed. At the six-week follow-up, his foot drop was near normal, sensation was intact with minimal paresthesias, and he remained pain-free. At the one-year follow-up, he experienced full resolution of his foot drop and remained symptom-free. Although rare, disc herniations may cause isolated, remote, painful mononeuropathies not related to the direct level of nerve root compression and should be considered along with other etiologies of peripheral neuropathies." }, { "id": "pubmed23n0309_17716", "title": "Intraradicular lumbar disc herniation: case report and review of the literature.", "score": 0.0154524089306698, "content": "Intradural or intraradicular herniation of a lumbar disc is a rare complication of disc disease. The mechanism of the tearing of the dura mater by a herniated disc is not known with certainty. Only six cases of intraradicular disc herniation have been reported. By reporting the seventh case of this rare neurosurgical entity, we emphasize its importance and review the literature on intraradicular disc herniation. A 41-year-old man was admitted with a 3-year history of low back pain and sciatica. A neurological examination revealed motor weakness during plantar flexion, positive Lasègue's sign, sensory deficit on the S1 dermatoma, and loss of Achilles reflex. Magnetic resonance imaging revealed disc protrusion at the L5-S1 level. Therefore, we decided to operate on the patient having made a diagnosis of lumbar disc disease. The patient underwent a standard hemilaminotomy and foraminotomy for a removal of the L5-S1 disc. There was no disc protrusion or extruded fragment. The left S1 nerve root was observed to be swollen and immobile. A longitudinal incision was made on the radicular sheet of the S1 root, and a free disc fragment, approximately 2 x 1 x 1 cm, was extirpated in one piece. The patient was immediately relieved of pain and was discharged on the 7th day after the operation with normal muscle strength. It seems probable that in some patients with \"failed back syndrome,\" intraradicular or intradural disc herniation is the cause of failure." }, { "id": "pubmed23n0928_15050", "title": "Acute Bilateral Isolated Foot Drop: Changing the Paradigm in Management of Degenerative Spine Surgery with Percutaneous Endoscopy.", "score": 0.014824029440729799, "content": "Acute bilateral isolated foot drop due to lumbar disk prolapse with canal stenosis is rare with only 3 cases reported in literature. Our patient was managed using the percutaneous full endoscopic technique. This is mainly to highlight the ease of access and patient outcome with preoperative and postoperative images to support our minimally invasive treatment for this rare condition. A 46-year-old male presented with sudden-onset severe back pain with bilateral foot drop. Clinical examination showed a bilateral L5 radiculopathy with normal perianal sensation. Investigations excluded other causes of bilateral foot drop. A magnetic resonance imaging scan showed disk herniation at the right L4-L5 (inferior migrated) and L5-S1 level (paracentral and extraforaminal) with spinal canal stenosis at the L2-L3 and L5-S1 levels due to ligamentum flavum hypertrophy. The patient underwent percutaneous endoscopic stenosis lumbar decompression at the L2-L3 and L5-S1 level. At the right L4-L5, L5-S1 level, transforaminal endoscopic diskectomy was done using the conventional percutaneous approach. The inferior migrated disk of the L4-L5 level was removed using a left L5-S1 contralateral approach. The patient recovered with favorable outcome and added benefits of minimally invasive surgery. Lumbar disk prolapse with canal stenosis should be considered in patients presenting with bilateral isolated foot drop. To our best knowledge, this is the first report of percutaneous endoscopic treatment to address multiple-lumbar-level pathology for this rare condition of acute bilateral isolated foot drop." }, { "id": "article-20584_16", "title": "Disc Herniation -- History and Physical -- Physical Examination", "score": 0.01443355119825708, "content": "L5 Nerve - back, radiating into buttock, lateral thigh, lateral calf, and dorsum foot, great toe; sensory loss on the lateral calf, dorsum of the foot, webspace between first and second toe; weakness on hip abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot inversion and eversion; decreased semitendinosus/semimembranosus reflex. S1 Nerve - back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot; sensory loss on the posterior calf, lateral or plantar aspect of foot;  weakness on hip extension, knee flexion, plantar flexion of the foot; Achilles tendon; Medial buttock, perineal, and perianal region; weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction. S2-S4 Nerves - sacral or buttock pain radiating into the posterior aspect of the leg or the perineum; sensory deficit on the medial buttock, perineal, and perianal region; absent bulbocavernosus, anal wink reflex." }, { "id": "pubmed23n0385_1694", "title": "Intraradicular disc herniations in the lumbar spine and a new classification of intradural disc herniations.", "score": 0.014359900654775343, "content": "A case report of intraradicular disc herniation. Intraradicular disc herniation is a special type of intradural disc herniations. In this report, we present the tenth case of intraradicular lumbar disc herniation and suggest a new classification for intradural disc herniations. A 32-year-old male was admitted to hospital having experienced pain in the lower back and right leg for 1 month prior to admission. Neurological examination revealed weakness of the extensor hallucis longus, positive Laségue's sign, decreased ankle reflex in his right lower extremity, and bilateral paravertebral muscle spasm. Magnetic resonance imaging (MRI) revealed a disc herniation with a posterolateral extruded fragment on the right at the level of the L5-S1 space. He underwent L5 laminectomy. During the operation, the right S1 root was found to be swollen and immobile. A longitudinal incision was made in the dura of the right S1 root and an intradural free disc fragment was removed, and the S1 root was relieved. The patient was free of pain postoperatively. We suggest a new classification for intradural disc herniations with this unusual case presentation and review the literature for pathogenesis, clinical picture, diagnosis and treatment." }, { "id": "Neurology_Adams_1606", "title": "Neurology_Adams", "score": 0.01411988911988912, "content": "Table 10-1. Generally, disc herniation compresses the root of the level just below the herniation (see below). Hypotonia may be evident on inspection and palpation of the buttock and calf. In only a few patients is a foot drop (L5 root) or weakness of plantar flexion (S1 root) the main feature of disc protrusion, but it is notable that some patients have little pain with disc rupture. The reflex changes noted below have little relationship to the severity of the pain or sensory loss. Furthermore, compression of the fourth, or sometimes fifth, lumbar root may occur without any change in the tendon reflexes. Bilaterality of symptoms and signs is rare, as is sphincteric paralysis, but they occur with large central protrusions that compress the cauda equina. The cerebrospinal fluid (CSF) protein is then slightly elevated, usually in the range of 55 to 85 mg/dL, sometimes higher." }, { "id": "pubmed23n0690_11268", "title": "Motor evoked potential study suggesting L5 radiculopathy caused by l1-2 disc herniation: case report.", "score": 0.013980263157894735, "content": "A 38-year-old male was referred because of pain in the left 5th lumbar (L5) root territory. Physical examination found moderate motor weakness in the left extensor hallucis longus (EHL) and the left tibialis anterior muscles. Magnetic resonance imaging found no stenotic lesion between L4-L5, but disc herniation was observed on the left between L1-L2. An L5 nerve root block provided temporary relief of the pain but the left foot weakness was exacerbated. Therefore, surgery was performed. Partial laminectomy and left herniotomy were performed at L1-L2, L2-L3, and L3-L4 with motor evoked potential (MEP) monitoring. The MEP amplitude of the left EHL muscle increased immediately after L1-L2 herniotomy. The MEP amplitude of the right EHL muscle also increased after both laminectomy and herniotomy. The postoperative course was uneventful. The left leg pain and motor weakness disappeared. The patient has been doing fine without recurrence for 12 months. Since the MEP of both left and right EHL muscles improved after the L1-2 herniotomy, circulatory insufficiency might have caused the L5 symptoms. Monitoring of the MEP during the surgery was useful for confirming the responsible lesion and also for predicting the postoperative course." }, { "id": "pubmed23n1164_7209", "title": "Quantifying Neurological Examination in 21^st Century: Yilmaz- Ilbay Plantar Flexion Test, A Novel and Reliable Test for Evaluation of Plantar Flexion in L5-S1 Disc Herniation.", "score": 0.013666519239274658, "content": "Current methods used to measure the muscle strength required to achieve plantar flexion may yield highly variable results depending on the perception of the physician conducting the examination because these tests involve subjective and qualitative evaluation. To describe and evaluate the efficacy of a novel examination technique that can quantitatively measure plantar flexion in L5-S1 disc herniation. A total of 32 patients (average age: 49.4 years, range: 23-78) with L5-S1 disc herniations were included. The patient to be tested stood next to a table on which they could lean with their hands. The leg closer to the table was fully flexed at the knee, and the other foot was brought to maximum plantar flexion on the toes. At this point, a stopwatch was started to measure the time that passed until the muscles fatigued and the heel fell. The differences between the right and left plantar flexion times were noted. In addition, three different physicians graded muscle strength by using the classical \"The Medical Research Council of the United Kingdom\" method. The time until fatigue in right and left plantar flexion was measured using the proposed method, and each test underwent a video recording. The Yilmaz-Ilbay plantar flexion test yielded the correct classification for all cases. We suggest that the proposed method \"Yilmaz-Ilbay plantar flexion test\" can serve as a useful, practical, and effective test to detect quantitative evaluation of plantar flexion in L5-S1 herniation." }, { "id": "article-24453_17", "title": "Lumbar Disc Herniation -- History and Physical", "score": 0.013554463554463554, "content": "L5 nerve root exits at the L5-S1 foramina. When compressed by a herniated disc, it causes back pain that radiates into the buttock, lateral thigh, lateral calf, the dorsum of the foot, and the great toe. Sensory loss is present on the web space between the big toe and second toe, the dorsum of the foot, and lateral calf. There is a weakness in hip abduction, knee flexion, foot dorsiflexion, big toe dorsiflexion, foot inversion, and eversion. Patients present with decreased semitendinosus/semimembranosus reflex. Weakness in foot dorsiflexion makes it challenging to walk on the heels. Chronic L5 radiculopathy may cause atrophy of the extensor digitorum brevis and the tibialis anterior of the anterior leg." }, { "id": "article-24453_18", "title": "Lumbar Disc Herniation -- History and Physical", "score": 0.013423092615259077, "content": "S1 nerve root exits at the S1-S2 foramina, assessed with the Achilles reflex. When compressed with a herniated disc, it presents with sacral or buttock pain that radiates into the posterolateral thigh, the calf, plantar or lateral foot or the perineum. Sensory loss is present on the calf, lateral, or plantar aspect of the foot. There is weakness on foot plantar flexion, hip extension, and flexion of the knee. Weakness in foot plantar flexion causes an inability to tiptoe walk. It could also cause urinary and fecal incontinence and sexual dysfunction. [5] [8] [9]" }, { "id": "Neurology_Adams_10937", "title": "Neurology_Adams", "score": 0.013401377479047382, "content": "Rupture of one of the lower lumbar intervertebral discs is the most common cause of sciatica, although it does, of course, not directly involve the sciatic nerve. The associated motor and sensory findings allow localization of the root compression (L4-L5 disc compressing L5 root: pain in posterolateral thigh and leg with numbness over the inner foot and weakness of dorsiflexion of the foot and toes; L5-S1 disc compressing S1 root: pain in posterior thigh and leg, numbness of lateral foot, weakness of foot plantar flexion and loss of ankle jerk), as discussed in Chap. 10." }, { "id": "InternalMed_Harrison_1475", "title": "InternalMed_Harrison", "score": 0.01327433628318584, "content": "The straight leg–raising (SLR) maneuver is a simple bedside test for nerve root disease. With the patient supine, passive flexion of the extended leg at the hip stretches the L5 and S1 nerve roots and 113 CHAPTER 22 Back and Neck Pain 4th Lumbar vertebral body 5th Lumbar vertebral body 4th Lumbar pedicle L4 root Protruded L4-L5 disk L5 Root S1 Root S2 Root Protruded L5-S1 disk FIguRE 22-3 Compression of L5 and S1 roots by herniated disks. (From AH Ropper, MA Samuels: Adams and Victor’s Principles of Neurology, 9th ed. New York, McGraw-Hill, 2009; with permission.) the sciatic nerve. Passive dorsiflexion of the foot during the maneuver adds to the stretch. In healthy individuals, flexion to at least 80° is normally possible without causing pain, although a tight, stretching sensation in the hamstring muscles is common. The SLR test is positive if the maneuver reproduces the patient’s usual back or limb pain. Eliciting the SLR sign in both the supine and sitting positions can help" }, { "id": "article-145849_48", "title": "Foot Drop in Obstetrics -- History and Physical", "score": 0.012901960784313726, "content": "If positive, the Lasegue straight-leg raising test indicates a proximal lesion such as a herniated lumbar disc. [19] For the foot drop, the appropriate disc would be the L4/L5 disc. If there is a herniated L4/L5 lumbar disc, the pain pattern will follow the L5 dermatome (area of skin innervated by a single dorsal root). If the test is positive, examine the patient for paralumbar muscle spasm, which will probably accompany the herniated lumbar disc. The presence of a herniated lumbar disc can be confirmed by an MRI. [20] MR neurography can be especially helpful in localizing the lesion. [21] The Achilles tendon reflex should be normal (unless the lesion also involves the S1 nerve root). [3] One should then obtain a neurological consultation to determine the precise localization of the patient’s lesion. It is important to reassure the patient that she did nothing wrong and that an obstetrical foot drop should respond well to treatment if she follows the treatment plan." }, { "id": "article-145849_51", "title": "Foot Drop in Obstetrics -- Evaluation -- Lasegue Straight Leg Raising Test for Radicular Pain Due to a Herniated Lumbar Disc", "score": 0.01265167209233501, "content": "For disc L5/S1, the S1 dermatome covers the heel and posterior side of the foot and both anterior and posterior sides of the fourth and fifth toes (Foerster). The S1 nerve root is associated with the Achilles tendon reflex. [3] Damage to this root will cause loss of the Achilles tendon reflex." }, { "id": "pubmed23n0387_10194", "title": "Symptoms of thoracolumbar junction disc herniation.", "score": 0.012223479135243843, "content": "A retrospective clinical review of patients with thoracolumbar junction disc herniation. To evaluate the clinical features of thoracolumbar junction disc herniation and to prepare a chart for the level diagnosis in the neurologic findings and symptoms. Thoracolumbar junction disc herniations show a variety of signs and symptoms because of the complexity of the upper and lower neurons of the spinal cord, cauda equina, and nerve roots. Furthermore, much is still unknown about thoracolumbar junction disc herniations because of their rare frequency. The clinical features of 26 patients who had undergone operations for single disc herniations at T10-T11 through L2-L3 were investigated. Affected levels were as follows: 2 patients with disc herniation at T10-T11 disc, 4 patients at T11-T12, 3 patients at T12-L1, 6 patients at L1-L2, and 11 patients at L2-L3. The level of disc space of interest was confirmed with whole-spine plain roentgenograms. The caudal end of the cord was judged by magnetic resonance imaging and computed tomographic myelogram. Two patients with T10-T11 disc herniation showed moderate lower extremity weakness, increased patellar tendon reflex, and sensory disturbance of the entire lower extremities. Three of four patients with T11-T12 disc herniation experienced lower extremity weakness, and three patients had accentuated patellar tendon reflex. Sensory disturbance was observed in the anterolateral aspect of the thigh in one patient and on the entire leg in three patients. Bowel and bladder dysfunction was noted in three patients. In the T12-L1 disc herniation group (n = 3), muscle weakness and atrophy below the leg were advanced, and bowel and bladder dysfunction were also noted. Two of these three patients had bilateral drop foot, and one patient had unilateral drop foot; sensory disturbance was noted in the sole or foot and around the circumference of the anus, and the patellar tendon reflex and Achilles tendon reflex were absent. All six patients with L1-L2 disc herniation showed severe thigh pain and sensory disturbance at the anterior aspect or lateral aspect of the thigh. On the other hand, there were no clear signs of lower extremity weakness, muscle atrophy, deep tendon reflex, or bowel and bladder dysfunction in these patients. In the L2-L3 disc herniation group (n = 11), all patients had severe thigh pain and sensory disturbance of the anterior aspect or the lateral aspect of the thigh. Weakness in the quadriceps was noted in five patients and weakness in the tibialis anterior in two patients. Decreased or absence of patellar tendon reflex was observed in nine patients. Five patients had positive straight leg raising test results, and eight patients showed positive femoral nerve stretch test results. Among thoracolumbar junction disc herniations, T10-T11 and T11-T12 disc herniations were considered upper neuron disorders, T12-L1 disc herniations were considered lower neuron disorders, L1-L2 disc herniations were considered mild disorders of the cauda equina and radiculopathy, and L2-L3 disc herniations were considered radiculopathy. These findings had relatively distinct differences among herniated disc levels." }, { "id": "article-24453_19", "title": "Lumbar Disc Herniation -- History and Physical", "score": 0.012087771895132998, "content": "A straight leg raise test is a neurological maneuver performed while examining a patient presenting with lower back pain. It is conducted with the patient lying supine while keeping the symptomatic leg straight by flexing the quadriceps. The examiner slowly elevates the leg progressively at a slow pace. The test is positive when it reproduces the patient's symptoms (pain and paresthesia) at an angle lower than 45 degrees with radiation below the knee (Lasegue sign). It is most helpful in diagnosing L4, L5, and S1 radiculopathies. The patient is asked to dorsiflex the foot while the examiner is raising the leg (Bragaad's sign) to increase the sensitivity of the test." }, { "id": "pubmed23n0294_21092", "title": "[L1-2 lumbar disc herniation: a case report].", "score": 0.011943441636582432, "content": "A 49-year-old female presented a two-year history of pain in the right thigh and lower back. Neurological examination on admission demonstrated weakness of the right iliopsoas and quadriceps, hypesthesia on the right L1-2 dermatome. Radiological examination including myelography, CT myelography and discography disclosed an L1-2 herniated disc. Sagittal MRI also revealed an L1-2, an L4-5 and L5-S1 protruded disc. A posterior microdiscectomy (Love's method) was performed for the L1-2 disc. A controlateral protruded disc which compressed the L-2 nerve root was identified and partially removed. The postoperative myelography showed residual disc. The patient was free from pain and regained normal sensorimotor function. Love's posterior microdiscectomy has a disadvantage in that the operative field is limited. Careful surgical procedure was needed to avoid injury to nerve roots and the cauda equina in a tight L1-2 lumbar canal." }, { "id": "article-28772_11", "title": "Sciatica -- History and Physical", "score": 0.011916488479926962, "content": "Another maneuver is the crossed straight leg test, similar to the straight leg raise test but is conducted on the asymptomatic leg instead. The crossed straight leg test is considered positive if the patient reports pain in the symptomatic leg while the asymptomatic leg is at a 40° angle, representing a central disc herniation with severe nerve root irritation. L3 radiculopathy includes weakness of hip adduction, knee extension, and sensory pain in the anteromedial dermatome of the thigh. Ankle dorsiflexion weakness and absent patellar reflex are present in L4 radiculopathy. Hip abduction and big toe extension weakness show L5 radiculopathy. S1 nerve root compression presents as absent ankle reflexes." }, { "id": "First_Aid_Step2_548", "title": "First_Aid_Step2", "score": 0.011644695543000627, "content": "Associated with sciatica, paresthesias, muscle weakness, atrophy, contractions, or spasms. T AB LE 2.9-2. Motor and Sensory Deficits in Back Pain L4 L5 S1 Foot dorsifexion (tibialis anterior) Patellar Medial aspect of the lower leg. Big toe dorsifexion (extensor hallucis longus), foot eversion (peroneus muscles) None Dorsum of the foot and lateral aspect of the lower leg. Plantar fexion (gastrocnemius/soleus), hip extension (gluteus maximus). Achilles Plantar and lateral aspects of the foot. A passive straight leg raise ↑pain (highly sensitive but not specific). A crossed straight leg raise ↑ pain (highly specific but not sensitive). Large midline herniations can cause cauda equina syndrome. Obtain an ESR and a plain radiograph if other causes of back pain are suspected (e.g., infection, trauma, compression fracture). Order a stat MRI for cauda equina syndrome or for a severe or rapidly progressing neurologic deficit." }, { "id": "wiki20220301en108_15323", "title": "Nerve root", "score": 0.011577760084925691, "content": "Lower limb radiculopathies The cause is a herniated intervertebral disc, often on a single nerve root. The first sign of the nerve root sickness is usually lumbago, which usually occurs with periods of remission. The time to develop a full radicular syndrome may take several months or several years. Pain generally increases gradually, but it can also be sudden. Cold causes muscle contraction, which leads to increased previously hidden symptoms. Symptoms Scoliosis Paraspinal muscle contracture The reduction of lumbar lordosis Tingling or numbness Increased sensitivity Other inflammatory diseases L4 radiculopathy Pain located on the front of the thigh and shin further radiates towards the inner ankle, sometimes the medial toe Occasionally, failure of the quadriceps muscle and reflex weakness L5 radiculopathy Pain radiates to the side of the thigh and lower leg towards the back of the foot and toes 1–3 All reflexes are preserved" }, { "id": "Neurology_Adams_1608", "title": "Neurology_Adams", "score": 0.011543980173051003, "content": "Fig. 10-3) and between the fourth and fifth lumbar vertebrae (compressing the L5 root). Lesions of the fifth lumbar root (L5) produce pain in the region of the hip and posterolateral thigh (i.e., sciatica) and, in more than half such cases, lateral calf (to the lateral malleolus), and less often, the dorsal surface of the foot and the first or second and third toes. Pain is elicited by the straight-leg raising test or one of its variants, and protective nocifensive reflexes come into play, limiting further elevation of the leg. Paresthesia may be felt in the entire territory or only in its distal parts. The tenderness is in the lateral gluteal region and near the head of the femur. Weakness, if present, involves the extensors of the big toe and foot and the foot invertors (a distinguishing feature of foot drop originating from peroneal nerve damage, which spares inversion because it is a tibial nerve function). The ankle jerk may be diminished (more often it is normal), but the knee" }, { "id": "pubmed23n0854_2558", "title": "[Treatment of thoracic disc herniation. Case report].", "score": 0.011473905061631262, "content": "Herniated thoracic intervertebral disc is a rare cause of spinal cord compression. Its frequency varies from 0.15% to 1.7% of all disc herniations, and produces symptoms in 0.5% to 0.8%. Case 1. A 50-year-old woman, with pain and burning sensation in left hemithorax of four months of onset. It was treated as a herpetic syndrome, with no improvement. She was seen after thirteen days of exacerbation of clinical symptoms. The physical examination showed asymmetric paraparesis, lower left pelvic limb 1/5, and right pelvic limb 3/5¸ sensory level T8, with left Babinski positive. A thoracic disc herniation in space T8-T9 was diagnosed. A 55-year-old patient with a history of presenting pain in lumbar area of 5 years onset. She also had radicular pain that radiated to the right pelvic limb, with intensity 10/10 on a Visual Analogue Scale. Her physical examination showed muscle strength 5/5, with normal sensitivity in all dermatomes and tendon reflexes, and a positive right Babinski. Thoracic disc herniation T7-T8 level was diagnosed. Due to anatomical conditions that define this type of hernia, the extracavitary posterolateral approach should be the recommended surgical procedure when the simultaneously performed anterior decompression and fixation with posterior instrumentation are the treatments proposed. Despite the different anatomical structures of this special area, it was possible to obtain satisfactory results for both clinical cases." }, { "id": "Anatomy_Gray_263", "title": "Anatomy_Gray", "score": 0.01146268656716418, "content": "The patient’s symptoms and physical examination findings raised serious concern for compression of multiple lumbar and sacral nerve roots in the spine, affecting both motor and sensory pathways. His reduced power in extending his knees and reduced knee reflexes was suggestive of compression of the L4 nerve roots. His reduced ability to dorsiflex his feet and toes was suggestive of compression of the L5 nerve roots. His reduced ankle reflexes was suggestive of compression of the S1 and S2 nerve roots, and his perineal numbness was suggestive of compression of the S3, S4, and S5 nerve roots. A diagnosis of cauda equina syndrome was made, and the patient was transferred for an urgent MRI scan, which confirmed the presence of a severely herniating L2-3 disc compressing the cauda equina, giving rise to the cauda equina syndrome (Fig. 2.70). The patient underwent surgical decompression of the cauda equina and made a full recovery." }, { "id": "pubmed23n0303_10583", "title": "[L5-S1 herniated disk migrated to the anterior part of the right sacral wing with compression of the right lumbosacral roots].", "score": 0.011191440138808559, "content": "The goal of this study was to report an exceptional case of far lateral and anterior disc herniation at L5-S1 level. A 47 year-old man presented a right L5 radicular pain with motor deficit of tibialis anterior and extensor hallucis longus resisting to medical management. Standard X-rays showed a degenerative process of L5-S1 disc. The CT scan was at first considered as normal. The myelogram was normal. A second study of the CT scan showed an opacity next to the L5 right root in front of the sacral wing. A discography combined with CT scan was then performed showing the migrated herniated disc from L5-S1 to the anterior part of the right sacral wing in contact with L5 root. Surgery was performed by transperitoneal approach and needed a difficult dissection of hypogastric vessels. The herniated disc was found behind the L5 root. A L5-S1 disc excision and arthrodesis with iliac grafts were performed. The result has been very good with relief of the pain and recovery of the palsy within a month. The lecture of a CT scan should include the far extraforaminal zone if there is no compression in the spinal canal. Such an anterior migration of an herniated disc has not been already described as far as we know." }, { "id": "InternalMed_Harrison_1490", "title": "InternalMed_Harrison", "score": 0.0111526546309155, "content": "Fever, constant pain uninfluenced by position, sphincter abnormali-115 ties, or signs of spinal cord disease suggest an etiology other than lumbar disk disease. Absence of ankle reflexes can be a normal finding in persons older than age 60 years or a sign of bilateral S1 radiculopathy. An absent deep tendon reflex or focal sensory loss may indicate injury to a nerve root, but other sites of injury along the nerve must also be considered. For example, an absent knee reflex may be due to a femoral neuropathy or an L4 nerve root injury. A loss of sensation over the foot and lateral lower calf may result from a peroneal or lateral sciatic neuropathy or an L5 nerve root injury. Focal muscle atrophy may reflect injury to the anterior horn cells of the spinal cord, a nerve root, peripheral nerve, or disuse." }, { "id": "pubmed23n0756_13717", "title": "A diagnosis challenge-L4 nerve root compression as the initial presentation of chronic inflammatory demyelinating polyneuropathy.", "score": 0.011124510099487488, "content": "The authors present the case of a 65-year-old woman who was admitted for paraparesis and paresthesias in the inferior limbs. The neurological examination revealed the difficulty in extension of the right foot and of the right toe, accompanied by paresthesias located in the anterolateral area of the right leg, dorsum and plantar area of the foot, the reduction of the right knee jerk, and of the ankle tendon jerk both sides. The vertebro-spinal MRI showed lumbar canal stenosis with L4 intraforaminal compression on the right, and L2-L3 on the left. CSF examination revealed mild increase in protein concentration. The morphological picture of the sural nerve biopsy was compatible with a chronic inflammatory neuropathy and severe muscular lesions of neurogenic origin were observed on right gastrocnemius muscle biopsy. The diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) was established. Solu-medrol (0.5 g/d)-5 days, then medrol (prednisolone) was done, followed by improving of the symptomatology. For the relapse of the disease intravenous immunoglobulins (IVIG)-0.4 g/kg/d-5 days was the elective treatment. Six months later she presented a new relapse. IVIG were administered with the remission of the sensitive symptoms. A chronic treatment with medrol was recommended. The diagnosis of L4 disc herniation was obvious in the studied case, but the electroneurographic examination brought extra data for the associated diagnosis of CIDP whose onset was asymmetrical and initially paucisymptomatic. Neither the electroneurographic examination nor the CSF examination were total relevant for CIDP, imposing the sural nerve biopsy. The diagnosis of CIDP involves a team-work composed of neurologist, electroneurophysiologist and neuropathologist." }, { "id": "pubmed23n1139_11102", "title": "Pediatric lumbar disc herniation: a report of two cases and review of the literature.", "score": 0.011091445427728615, "content": "Lumbar disc herniation (LDH) is not a common condition in children. Most reports on pediatric LDH concern the outcomes of surgeries performed in children in whom nonsurgical treatment failed while the outcome of nonsurgical treatment of LDH in children was rarely reported. Case 1: a 10-year-old girl presented with back pain and sciatica in her left leg for over 3 months. The physical examination revealed exacerbation of back pain by waist extension or flexion, and a positive Lasegue's sign was revealed in her left leg. Magnetic resonance imaging (MRI) revealed lumbar disc herniation at the L5/S1 level. She was diagnosed with LDH. After receiving nonsurgical treatment of traditional Chinese medicine (TCM) for 30 days, the girl had mild low back pain and sciatica and the symptoms had resolved completely at the 3-month follow-up. There was no recurrence within the following 2 years. MRI performed 30 months later revealed that the herniated disc did not shrink significantly. However, she was totally asymptomatic at the follow-up performed 30 months later. Case 2: a 13-year-old boy presented with sciatica in his left leg for over 3 months. The physical examination revealed that Lasegue's sign was positive in the left leg, the level of muscle strength in the left ankle plantar flexors was grade 4. MRI revealed a lumbar disc herniation at the L5/S1 level. He was diagnosed with LDH. The boy underwent 2 weeks of TCM treatment, and exhibited a favorable outcome: only mild pain was noticed in his left buttocks after walking for more than 15 min. He was asymptomatic at the 3-month follow-up and there was no recurrence within the next 3 years. MRI scan performed at 40 months later showed no significant resorption of the herniated disc. However, he was totally asymptomatic at the follow-up performed 40 months later. For the nonsurgical treatment of pediatric LDH, resorption of herniated discs is not necessary for favorable long-term outcomes, and children with symptomatic LDH may become asymptomatic without resorption." }, { "id": "pubmed23n1109_10578", "title": "Posterior epidural sequestrated disc presenting with contralateral radiculopathy: a very rare case.", "score": 0.010940722805129584, "content": "Posterior epidural sequestrated disc is a fairly uncommon condition. We report a case of an unusual presentation of posterior epidural migration with contralateral symptoms. We emphasize a high index of suspicion for early recognition and treatment to promote a good neurological recovery. A 58-year-old man with a history of severe back pain for 1 week developed sudden right leg weakness while walking. Neurological examination revealed motor and sensory impairments of the right lower extremities (positive right straight leg raising test, right tibialis anterior grade 2/5, right extensor hallucis longus grade 1/5, decreased pinprick sensation of L4-5 dermatome right side) according to the Standards for Neurological Classification of Spinal Cord Injury as Asia Impairment Scale D. Magnetic resonance images showed an acute disc herniation at L4-5 on the left side, cranially migrated and sequestrated to the posterior epidural area, causing severe compression to the cauda equina in the thecal sac. The patient was successfully treated with surgery (transforaminal lumbar interbody fusion) on an urgent basis. We saw significant neurological recovery on the first day after surgery. Motor power recovery was achieved with a minor deficit at 4 weeks. At the follow-up examination at 3 months, the patient had no residual neurological deficits as Asia Impairment Scale E. Posterior epidural sequestrated disc with contralateral radiculopathy is very rare. This case brings a new presentation of posterior epidural sequestrated disc. To our knowledge, this is the first report of a case with an unusual presentation of contralateral radiculopathy." }, { "id": "article-24475_12", "title": "Lumbosacral Disc Injuries -- History and Physical", "score": 0.010879471405787195, "content": "L5 at the L5/S1 level, a disc herniation far laterally into the left/right neural foramen would compress the L5 nerve, resulting in weakness of hip abduction muscles, ankle dorsiflexion (anterior tibialis muscle), and/or extension of the great toe (extensor hallucis longus muscle). S1 at the L5/S1 level, a disc herniation centrally into the canal would compress the S1 nerve, resulting in weakness of ankle plantar flexion (gastrocnemius muscle)." }, { "id": "article-24451_15", "title": "Lumbar Degenerative Disk Disease -- History and Physical", "score": 0.010681265672556037, "content": "The straight leg raise (SLR) test consists of a supine patient having his/her fully extended leg passively stretched from 0 to about 80 degrees. The onset of radiating back pain in either leg supports a diagnosis of a stenotic canal. A herniation compressing the L5 nerve root will present as a weakness of ankle dorsiflexion and an extension of the great toe. This deficit also may diminish the Achilles tendon reflex. L4 radiculopathy may present with weakness in the quadriceps and a decreased patellar tendon reflex. Documentation is paramount, as these initial findings likely will be used as a baseline for all future evaluations." }, { "id": "article-29356_9", "title": "Spinal Stenosis -- History and Physical", "score": 0.010659856202981429, "content": "Stenosis in the lumbar spine can lead to neurogenic claudication, myeloradiculopathy symptoms, sensory disturbances, motor weakness, and pathologic reflexes. Patients will present with complaints of cramping pain in the leg, calf, and or buttocks. They might report an increase in pain with walking or standing for prolonged periods and relief when sitting or leaning forward while using a shopping cart. [9] Disk herniation is most common at the L4-5 and L5-S1 levels. A herniated disk at L5-S1 can lead to plantarflexion weakness, decrease sensation in the lateral foot, and cause pain in the posterior leg. A disk herniation at L4-5 can lead to a foot drop and numbness in the large toe web and dorsal aspect of the foot. Lastly, an L3-4 disk herniation can lead to knee extension weakness, numbness in the medial foot, and pain in the anterior thigh." } ] } } }

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{ "1": "Given the patient's age, he most likely suffers from non-specific low back pain and tendonitis of the feet. If the diarrhea persists, a digestive study would be performed.", "2": "Perform a digestive study to rule out tumor pathology. Low back pain may be due to visceral pathology.", "3": "The clinical picture is very suggestive of spondyloarthritis. Inflammatory bowel disease should be ruled out.", "4": "I would request a lumbar MRI to rule out disc herniation and if diarrhea persists, a digestive study.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0071_5433", "title": "[Chronic diarrhea: clinical aspects].", "score": 0.016700473292765382, "content": "A retrospective study on the syndrome of chronic diarrhea was carried out on 50 revised clinical histories. The patients were hospitalized at the E. Rebaglati M. Hospital between April 1983 and March 1988. The purpose of the study was to evaluate the signs and symptoms of the syndrome, as well as the etiological agents and the methodology used for diagnoses. The selection criteria involved patients diagnosed as suffering from \"chronic diarrhea of undetermined causes\" upon entry. Seven were excluded due to incomplete study whereas 2 were diagnosed as acute infections diarrhea. Forty one patients were definite cases of chronic diarrhea and they were divided between 2 groups: the first one or Chronic Organic Diarrhea (58.53%) and the second one or Chronic Functional Diarrhea (41.46%). Out of the 41 revised clinical histories with chronic diarrhea, the following were the foundings: (1) the syndrome affects the economically active populations mainly and the length of the disease was more than 3 weeks in all the patients; (2) anemia, fever, weight loss, nightime bowel movements and bloody stools suggest organic problems whereas psychiatric disorders, daytime bowel movements, abdominal pain, disease recurrence and absence of detectable organic pathology suggest functional problems; (3) the most common cause of chronic diarrhea is the Irritable Bowel Syndrome followed by infectious diseases, with parasitosis in the first place; and (4) bearing in mind the mainly colonic affection and the predominant infectious diseases, the methodology used for their diagnosis would bring out good results." }, { "id": "pubmed23n0265_14729", "title": "[The diagnostic significance of the small bowel enema in lesions of the small intestine requiring surgery].", "score": 0.01371072690091095, "content": "Given its anatomical location the small intestine is the section of the digestive tract most inaccessible to objective clinical and instrumental examination. For this reason, traditional investigation methods provide inadequate data. In the barium meal X-ray, images are superimposed and the barium excessively fragmented due to the tortuosity and length of the intestinal loop. Access problems limit the value of endoscopy. The indications to angiography are fairly restrictive. Ultrasound and CT scans provide no conclusive evidence in this area. The so-called Small Bowel Enema technique based on the direct infusion of an opaque contrast medium after duodenal intubation remains the only way to obtain images with a satisfactory diagnostic value and should be the method of choice in examinations of the small intestine. Introduced in the twenties, the value of the technique was long questioned, mainly because it was difficult to perform correctly and it is only quite recently that several decisive technological innovations have made it highly reliable. The present paper describes its use on a series of patients with suspected pathologies of the small intestine requiring surgical treatment. The aim is to specify the correct indications to this technique as well as its limitations with a view to promoting its appropriate use in routine practice. MATERIALS AND METHODS. The study covers 42 small bowel enemas performed on 29 male and 13 female patients aged 12-85 years. Indications to the enema included chronic abdominal pain in 28.5%, chronic diarrhea in 21.4%, pain+diarrhea in 14%, subocclusion in 16.5%, faecal blood in 11.9%, abdominal pain+diarrhea+intestinal haemorrhage in 4.7%, anaemia in 2.4%. We adopted the Sellink technique involving intubation with a French 14 Bilbao-Dotter probe and the infusion of 200-350 cc barium sulphate in a 90%-70% P/V concentration at a speed of 100 ml/min, followed by the infusion of 1000-1500 cc 0.5-1% methylcellulose in a 50-50 mixture with water for double contrast purposes. Mean duration of procedure 35-40 mins. RESULTS. We found lesions of the small intestine in 18 cases or 45% (true positives) and no alterations in 18 or 42.8% (true negatives). In 3 cases (7%) the examination was inconclusive. One false positive and one false negative complete the series, making a diagnostic accuracy of 89.1%. In 23.8% of the total series the diagnosis of Crohn's disease was confirmed; cancerous lesions were found in 11.9% and adhesions following earlier surgery in 9.7%. Surgery confirmed this diagnosis in 10 cases (5 tumours, 3 stenoses caused by adhesion fragments, 2 Crohn's disease) and disproved it in one case. Biopsy was used, for objective confirmation in 5 cases (2 Crohn's disease, 3 negatives). In the other cases reliance was placed on clinical course and the patients' response to treatment. DISCUSSION AND CONCLUSIONS. Examination of our results reveals that in most clinical cases the small bowel enema was used to confirm suspected Crohn's disease (31 cases out of 42) and with a very high degree of diagnostic accuracy (96.7%). In line with data in the literature we decided to base the indication to this examination on certain primary symptoms such as chronic abdominal pain, diarrhea, blood in the faeces, whether in isolation or in combination. On this rather general basis the diagnosis of Crohn's disease concerned only 23.8% of the cases studied, an incidence that rose dramatically in the few cases in which the indications were made more specific. We therefore conclude that the adoption of more restrictive criteria will improve the cost-benefit ratio for this test. Another major pathology in which small bowel enema possesses a high diagnostic value is partial obstruction of the small intestine.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0383_17946", "title": "[Collagenous colitis. A study of 11 cases].", "score": 0.01216715976331361, "content": "Collagenous colitis (CC) is a rare large bowel inflammatory disorder. The aim of this retrospective study was to analyze extra-digestive manifestations of CC, associated systemic diseases, clinical course and response to therapeutic regimens. Between 1989 and 1999, eleven patients were diagnosed as having CC, in two Departments of Internal Medicine and Gastroenterology, on the basis of usual criteria: chronic watery diarrhea, endoscopic examination showing normal findings and subepithelial collagen band thicker than 10 micrometer. Ten women and one man, age 39 to 88 years (mean: 66.6), had had their diarrhea for 1 to 240 months before diagnosis (mean: 48). Associated extra-digestive manifestations were: weight loss (3 cases out of 11), inflammatory arthralgia (4 cases), fever (2 cases), pelvispondylitis (2 cases), autoimmune thyroiditis (2 cases), and Sharp syndrome (1 cases). Laboratory abnormalities were: inflammatory syndrome (3 cases), anemia (5 cases), hypogammaglobulinemia (3 cases), and hypoalbuminemia (4 cases). Stool cultures and parasite examination were negative in all patients. Therapy used successively for CC until resolution of chronic diarrhea (uncontrolled with symptomatic treatment) was: sulfasalazine in 7 patients (beneficial (B) in 5 out of 7), 5-aminosalicylic acid in 6 (B: 2/6), corticosteroids in 2 (B: 2/2), azathioprine in 1 (B: 1/1). After a mean follow-up of 18 months (range: 1-72), resolution of CC was observed in 8 out of 11 patients. Mean characteristics of CC were: female predominance (91%), presence of extra-digestive manifestations (36%); mucosal inflammation with subepithelial collagen band and frequent association to rheumatic or autoimmune diseases suggest an immune basis for CC. Usefulness of systematic colon biopsies is underlined. Clinical course is often favorable with sulfasalazine and 5-aminosalicylate acid. Corticosteroids are rarely used." }, { "id": "wiki20220301en019_114604", "title": "Ankylosing spondylitis", "score": 0.009900990099009901, "content": "These diagnostic criteria include: Inflammatory back pain:Chronic, inflammatory back pain is defined when at least four out of five of the following parameters are present: (1) Age of onset below 40 years old, (2) insidious onset, (3) improvement with exercise, (4) no improvement with rest, and (5) pain at night (with improvement upon getting up) Past history of inflammation in the joints, heels, or tendon-bone attachments Family history for axial spondyloarthritis or other associated rheumatic/autoimmune conditions Positive for the biomarker HLA-B27 Good response to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) Signs of elevated inflammation (C-reactive protein and erythrocyte sedimentation rate) Manifestation of psoriasis, inflammatory bowel disease, or inflammation of the eye (uveitis) If these criteria still do not give a compelling diagnosis magnetic resonance imaging (MRI) may be useful. MRI can show inflammation of the sacroiliac joint. Imaging" }, { "id": "pubmed23n0092_13841", "title": "[Late initial manifestations of Crohn disease with atypical symptoms].", "score": 0.009900990099009901, "content": "The case of a 55-year-old patient with Crohn's disease and chronic intermittent diarrhea as well as progressive weight loss of 20 percent of his body weight is reported. The establishment of the diagnosis was difficult at the beginning, since characteristic symptoms were missing and radiological and endoscopical findings were normal. Loam-coloured glossy stools, repeated registration of a reduced chymotrypsin concentration of the stool and the response of the symptoms to a substitution of pancreatic enzymes were initially regarded as signs of an exocrine pancreas insufficiency. Not before multiple biopsies were taken from the macroscopically largely normal small and large intestine during persisting complaints, an extensive infiltration with Crohn's disease could be shown. This case report emphasizes the importance of taking multiple biopsies in etiologically unexplained chronic diarrhea even from macroscopic inconspicuous intestinal mucosa. Because of the rising incidence of Crohn's disease late onset is gaining increasing significance in the differential diagnosis of chronic diarrhea in the elderly patients." }, { "id": "pubmed23n1146_5621", "title": "Seropositive Neuromyelitis Optica in a Case of Undiagnosed Ankylosing Spondylitis: A Neuro-Rheumatological Conundrum.", "score": 0.00980392156862745, "content": "Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune astrocytopathy against foot processes of aquaporin-4 (AQP4) water channels. Patients with NMOSD tend to have other coexisting autoimmune/connective tissue diseases. However, AQP-4-antibody-positive NMOSD coexisting with ankylosing spondylitis (AS) is rare. AS is an immune-mediated disorder, a subset of axial spondyloarthropathies, which commonly manifests as chronic inflammatory back pain in young people, and it has a strong association with HLA-B27. In this study, a 35-year-old Indian man with an undiagnosed progressive axial spondyloarthropathy (i.e., AS) is reported presenting with acute-onset longitudinally extensive transverse myelitis, a clinical subset of NMOSD. Neuromyelitis optica spectrum disorder (NMOSD), a primary demyelinating disorder of the central nervous system (CNS), is an autoimmune astrocytopathy against foot processes of aquaporin-4 (AQP4) water channels, which manifests with optic neuritis, longitudinally extensive transverse myelitis (LETM), area-postrema syndrome, brainstem syndrome diencephalic syndrome, and cerebral syndrome.<sup1-4</sup Ankylosing spondylitis (AS) is an immune-mediated disorder, a subset of axial spondyloarthropathies, which commonly manifests as chronic inflammatory back pain in young people, and it has a strong association with HLA-B27.<sup5,6</sup AS characteristically targets the axial skeleton, peripheral joints, entheses (connective tissues between tendons/ligaments and bones), and gut.<sup5,6</sup Patients with NMOSD tend to have other coexisting autoimmune/connective tissue diseases.<sup7</sup For example, cases with NMOSD and multiple sclerosis, which are other autoimmune primary demyelinating disorders of the CNS, have been reported.<sup8,9</sup However, concurrent existence of AS and NMOSD in the same patient even over years of disease course is rare.<sup10,11</sup In addition, studies describing neurological manifestations of AS are limited,<sup12</sup and they focus on joint inflammation and long-standing bony pathology (ankylosis) related to compressive myelopathy, myelo-radiculopathy, and cauda equina syndromes.<sup12,13</sup The authors present a case of a young Indian man with an undiagnosed progressive AS (misdiagnosed and mismanaged by an indigenous medical practitioner) presenting with acute-onset LETM variant of AQP4-positive NMOSD. A 35-year-old healthy, non-comorbid man from rural India came to the outpatient department with complaints of persistent tingling, numbness, and weakness of both lower limbs (right more than left) for 10 days. The clinical picture showed acute-onset urinary retention, which was relieved by urinary catheterization. An indigenous medical practitioner had prescribed drugs to treat a urinary tract infection. His weakness gradually progressed over the following week, causing him to become bedridden. During the removal of the catheter, he felt urgency, increased frequency of micturition, and overt urinary incontinence. He gave no history suggestive of any girdle-like sensations, root/radicular/tract pain, vertebral pain, trauma, recent vaccination, and diarrheal or febrile illness. For the last 8 months, he had a complaint of an insidious-onset, persistent, bilateral, dull aching pain in the gluteal region accompanied by low-back pain and morning stiffness up to 1 h, which markedly improved with activity and reoccurred following long periods of inactivity. He sometimes had to rise in the middle of the night because of excruciating pain, which could be relieved after moving around the room and corridors for half an hour. He was taking over-the-counter diclofenac tablets for pain relief prescribed by some indigenous medical practitioners who told him that it was due to overwork in agricultural fields, that is, mechanical back pain. He also had a normal X-ray of the lumbosacral spine. He had no addiction liabilities, and none of the family members had ever suffered from a similar kind of illness. He had never consulted any trained medical practitioner, as his previous back-pain-related symptoms responded well to the tablets prescribed by the indigenous medical practitioner(s). During examination, he was found to have recent-onset, asymmetric spastic paraparesis (right more than left) with upper motor neuron-type urinary bladder symptoms. Cognitive assessment (assessed by the Montreal cognitive assessment test) was normal, and posterior column sensations were preserved. Sensory system examination revealed no definite sensory level. Except for the paretic lower limbs, cerebellar functions were normal in other regions. Neuro-ophthalmological examinations were also normal, and no signs of meningeal irritation were observed. The history and course of the disease and clinical examinations were analyzed. Selective tractopathy (early and predominant motor and autonomic tract affection) was suggested for an intramedullary demyelinating pathology affecting the anterior central cord. This case was initially classified as acute-onset non-compressive myelopathy at the lower cervical/upper dorsal region level in a patient with a pre-existing axial spondyloarthropathy. Complete blood cell count; liver, kidney, and thyroid function tests; and plasma glucose and electrolytes were normal, except for an increased erythrocyte sedimentation rate (66 mm in the first hour). Magnetic resonance imaging (MRI) of the spinal cord revealed a demyelinating LETM from C5 to D4 level (Figure 1). Meanwhile, an MRI of the sacroiliac joints revealed bilateral sacroiliitis. Brain and orbital MRIs were devoid of any lesions. Anti-aquaporin 4 (AQP-4) antibodies were tested by cell-based assay in serum and cerebrospinal fluid (CSF), and both were positive. CSF further revealed lymphocytic pleocytosis and increased intrathecal protein production. Visually evoked potential recordings were also normal. In addition, anti-myelin oligodendrocyte glycoprotein antibodies were negative. Anti-nuclear antibody (ANA), ANA-profile, autoimmune vasculitis profile (c-ANCA, p-ANCA), neurovirus panel (i.e., polymerase chain reaction for adenovirus, Epstein-Barr virus, herpes simplex viruses 1 and 2, human herpesviruses 6 and 7, cytomegalovirus, enteroviruses, varicella-zoster virus, Japanese encephalitis, and dengue virus), CSF-polymerase chain reaction for <iMycobacterium tuberculosis</i, angiotensin-converting enzyme, anti-phospholipid, and anti-thyroid antibodies were negative. Anti-CCP-antibody and rheumatoid factor were also negative, including creatine phosphokinase level and serum vitamin B12. Moreover, serologies for hepatitis B, C, human immunodeficiency virus, and scrub typhus were negative. However, HLA-B27 assay was positive. The final diagnosis was AQP4-positive NMOSD associated with AS. He was placed on pulse intravenous methylprednisolone (1 g/day for 5 days). Consequently, his lower limb power improved remarkably. Cyclical rituximab therapy was initiated to prevent relapses. At 3-month follow-up, he had no residual neurological deficit except for persistence of paresthesias. Neuroimaging and visually evoked potential studies revealed no active or new lesions. After 6 months of therapy, a subjective and objective improvement was observed in disease severity based on the Ankylosing Spondylitis Disease Activity Score. Our patient satisfied the new Assessment of SpondyloArthritis International Society diagnostic/classification criteria for AS and the Wingerchuk criteria for NMOSD,<sup4,14</sup an association that has been rarely reported.<sup10,11</sup Amid the extra-articular complications of long-standing AS, neurological manifestations are considered infrequent.<sup15</sup However, subclinical neurological complications may be frequent in AS.<sup12</sup Common neurological manifestations result from bony (vertebral) ankylosis, subluxation of joints, ossification of anterior and posterior longitudinal ligaments, secondary spinal canal stenosis, bony (vertebral) fractures, and subsequent compressions over nerve radicles/roots/cauda equina, and inflammation-related (entrapment) peripheral neuropathies.<sup12,16,17</sup Acute transverse myelitis can occur as a subset of several primary demyelinating disorders of the CNS (i.e., multiple sclerosis, NMOSD, myelin oligodendrocyte glycoprotein antibody disease, and acute disseminated encephalomyelitis) and various systemic autoimmune connective tissue disorders (i.e., systemic lupus erythematosus, mixed connective tissue disease, Sjögren syndrome, inflammatory bowel disease, and neurosarcoidosis).<sup18</sup Acute transverse myelitis (short or long segment) is an infrequent extra-articular complication of AS.<sup18</sup It has been reported to evolve either as a distinct neurological complication of AS, or it may develop secondary to TNF-alpha-inhibitor therapy for the treatment of AS.<sup18,19</sup AS is a heritable inflammatory spondyloarthropathy that primarily affects the axial skeleton, which is mediated by T-cells; B-cells only play a minor role.<sup5</sup On the contrary, the key for the pathogenesis of NMOSD is the production of autoantibodies against AQP-4 channels expressed on astrocytes, leading to complement-mediated damage, with ensuing demyelination. Myelitis usually shows high signal intensity on the tbl2-weighted image and contrast enhancement in the spinal cord.<sup1-4</sup Despite the difference in molecular mechanisms, the diagnosis of these diseases in the same individual may not be coincidental. Recent evidence has shown T-cell-mediated inflammatory responses in cases of NMOSD.<sup20</sup In particular, Th17 and Th2-related cytokines are elevated in the CSF of NMO patients.<sup20</sup Environmental factors such as <iEscherichia coli</i have also been proven to aggravate autoimmunity in AS and NMOSD (however, body fluid cultures for <iEscherichia coli</i, performed in our patient, showed similar association, and they were found negative two times).<sup21,22</sup Although large-scale epidemiological studies investigating the underlying pathogenesis related to these diseases are lacking, studies have demonstrated an increased incidence of optic neuritis among patients with AS.<sup23</sup Systemic sclerosis and mixed and undifferentiated connective tissue diseases were excluded after expert opinions (from two board-certified rheumatologists and two dermatologists) because of the lack of suggestive clinical findings (e.g., absence of skin thickening, salt-and-pepper appearance, nail changes, Mauskopf facies, sclerodactyly, calcinosis cutis, Raynaud's phenomenon, other cutaneous manifestations, pulmonary arterial hypertension/interstitial lung disease, dysphagia, muscular pain/weakness renal impairments, absence of ANA, anti-centromere antibodies, anti-Scl-70, PM-Scl antibodies, anti-ds DNA, PCNA, CENP-B, anti-nucleosomes, anti-Smith, anti-U1-RNP, anti-Jo1, anti-Mi2, anti-Ro52, anti-La antibodies, and normal C3 and C4 complement levels) (The European League Against Rheumatism and the American College of Rheumatology classification criteria 2019).<sup24</sup Finally, our patient was treated with intravenous steroids followed by rituximab infusions, a monoclonal anti-CD20 antibody directed against B-cells. In particular, this patient clinically and radiologically responded to immunomodulatory drugs, which might support a possible common pathogenic basis of the two processes. TNF-alpha inhibitors are commonly used as novel therapeutics in AS; however, they can potentially result in serious complications, that is, secondary demyelinating disorders.<sup25</sup However, such inhibitors in this patient were not used. When used in cases of AS, they show satisfactory results.<sup25,26</sup Therefore, it was decided to treat him with rituximab only without adding any second immunomodulatory. Other possible therapeutic options include cyclophosphamide and mycophenolate mofetil, but they were not used because of their low efficacy-safety balance. Moreover, plasmapheresis was not available in our specific setting, despite solid evidence that early treatment with therapeutic strategy (5-7 courses) provides good long-term outcomes in patients with NMOSD.<sup27</sup Therefore, when dealing with a case of acute non-compressive myelopathy, history and clinical examination are important to determine the potential underlying etiology and identify an undermined systemic disorder with apparently unrelated non-specific features. Connective tissue disorders should always be considered as a differential diagnosis and be ruled out in all cases of either seropositive or seronegative NMOSD. A diagnosis of AS should be considered in relevant circumstances when dealing with a case of isolated seronegative LETM. Moreover, early diagnosis and treatment of AS are quintessential to prevent lifelong distressing disabilities. However, whether patients with AS have any extra predilection to develop NMOSD throughout their life requires further studies." }, { "id": "wiki20220301en017_53095", "title": "Dysmenorrhea", "score": 0.009708737864077669, "content": "Dysmenorrhea, also known as painful periods or menstrual cramps, is pain during menstruation. Its usual onset occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in the pelvis or lower abdomen. Other symptoms may include back pain, diarrhea or nausea. Dysmenorrhea can occur without an underlying problem. Underlying issues that can cause dysmenorrhea include uterine fibroids, adenomyosis, and most commonly, endometriosis. It is more common among those with heavy periods, irregular periods, those whose periods started before twelve years of age and those who have a low body weight. A pelvic exam and ultrasound in individuals who are sexually active may be useful for diagnosis. Conditions that should be ruled out include ectopic pregnancy, pelvic inflammatory disease, interstitial cystitis and chronic pelvic pain." }, { "id": "pubmed23n0075_3781", "title": "[Clinical picture of Crohn's disease in children and adolescents].", "score": 0.009708737864077669, "content": "The authors describe the course of Crohn's disease in two boys and six girls aged 11.1-15.6 years. In three patients with terminal ileitis and affection of the ascendent colon the disease is characterized by prolonged growth retardation, subfebrile temperatures, abdominal pain. For patients with granulomatous colitis, blood-stained diarrhoea is typical abdominal pain and loss of body weight. Three patients were treated first for idiopathic proctocolitis and only in the course of the disease the diagnosis of Crohn's disease was established. In 87.5% of the patients on admission anaemia was found and all patients had a varying elevated red cell sedimentation rate and CRP. The author draws attention to extraintestinal symptoms (dermal, ophthalmological, articular, somatic retardation) which precede in particular somatic retardation) which precede in particular in affections of the small intestine intestinal manifestations. Their erroneous interpretation may delay the establishment of the diagnosis of Crohn's disease. The author emphasizes the importance of basic laboratory examinations and examination by ultrasound for early detection of patients." }, { "id": "wiki20220301en040_63435", "title": "Spondylolisthesis", "score": 0.009615384615384616, "content": "In adults with non-specific low back pain, strong evidence suggests medical imaging should not be done within the first six weeks. It is also suggested to avoid advanced imaging, such as CT or MRI, for adults without neurological symptoms or \"red flags\" in the patient's history. General recommendations for initial low back pain treatment is remaining active, avoiding twisting and bending, avoiding activities that worsen pain, avoiding bed rest, and possibly initiating a trial of non-steroidal anti-inflammatory drugs after consulting a physician. Children and adolescents with persistent low back pain may require earlier imaging and should be seen by physician. Once imaging is deemed necessary, a combination of plain radiography, computed tomography, and magnetic resonance imaging may be used. Images are most often taken of the lumbar spine due to spondylolisthesis most commonly involving the lumbar region. Images of the thoracic spine can be taken if a patient's history and physical" }, { "id": "pubmed23n0287_3672", "title": "Colonoscopic findings in patients with lower gastrointestinal bleeding send to a hospital for their study. Value of clinical data in predicting normal or pathological findings.", "score": 0.009615384615384616, "content": "Lower gastrointestinal bleeding is a highly frequent clinical problem that may reflect serious pathology in the colon. Colonoscopy is generally accepted as the diagnostic procedure of choice. Decisions as to whether to carry out colonoscopy or not, are not well defined. 536 colonoscopies, made to discover the cause of lower gastrointestinal bleeding were analyzed and a final 457 included in the study. All of these patients came to the hospital because they had presented at least in one occasion, one episode of rectal bleeding, and were send by the specialist of the zone, in order to achieve a correct diagnosis of its process. In all cases the following associated symptoms were analyzed: the presence of diarrhea, constipation, abdominal pain and rectal mass on examination. The characteristics of lower gastrointestinal bleeding were analyzed in a subset of 150 consecutive patients. Mean age was 59 +/- 16.9 years. 54.5% were male and 45.5% female. The exploration was normal until the cecum in 146 patients (32%). In the remaining 311, the findings were: polyps (25.1%), diverticular disease (24%), neoplasia (12.6%), inflammatory bowel disease (9.4%), unspecific proctitis (2.4%), ischemic colitis (2.4%), angiodysplasia (1.9%), infectious colitis (1.1%), and miscellaneous (0.7%). An age of less than 40 years and the existence of anal pathology were significantly more frequent among patients with a normal examination (p &lt; 0.001), but with a sensitivity of only 66%. No differences were found among patients with disordered bowel frequency or abdominal pain in relation to the colonoscopic findings. Previous presence of a rectal mass when the examination proved abnormal (p=0.06). Intermittent bleeding and the presence of blood in the stools were more frequent in patients with normal examination (p= 0.07 and p&lt; 0.05, respectively). No significant differences in relation to colour, duration of bleeding, or to whether toilet paper was stained with blood were found. 1) The more frequent endoscopic findings were polyps and diverticular disease. 2) Clinical data are of little value in predicting a normal examination. 3) Total colonoscopy appears to be the first procedure of choice in all patients with lower gastrointestinal bleeding, irrespective of the clinical data and the presence of anal pathology." }, { "id": "wiki20220301en119_13371", "title": "Spinal disc herniation", "score": 0.009523809523809525, "content": "Magnetic resonance imaging is the gold standard study for confirming a suspected LDH. With a diagnostic accuracy of 97%, it is the most sensitive study to visualize a herniated disc due to its significant ability in soft tissue visualization. MRI also has higher inter-observer reliability than other imaging modalities. It suggests disc herniation when it shows an increased T2-weighted signal at the posterior 10% of the disc. Degenerative disc diseases have shown a correlation with Modic type 1 changes. When evaluating for postoperative lumbar radiculopathies, the recommendation is that the MRI is performed with contrast unless otherwise contraindicated. MRI is more effective than CT in distinguishing inflammatory, malignant, or inflammatory etiologies of LDH. It is indicated relatively early in the course of evaluation (<8 weeks) when the patient presents with relative indications like significant pain, neurological motor deficits, and cauda equina syndrome. Diffusion tensor imaging" }, { "id": "pubmed23n0058_7537", "title": "Chronic diarrhea with normal stool and colonic examinations: organic or functional?", "score": 0.009523809523809525, "content": "To investigate whether the clinical history and basic laboratory test results can differentiate between an organic or functional cause of chronic diarrhea and thus avoid unnecessary hospital admissions and invasive procedures, we reviewed the charts of 58 adult patients admitted during 6 years because of chronic diarrhea who had normal stool and colonic examinations. The final diagnoses were irritable bowel syndrome in 34 patients, organic diarrhea in 21, and unknown cause in three. The following clinical data did not help in the differential diagnosis: age, sex, duration of diarrhea, presence of continuous diarrhea, abdominal pain, stool frequency or volume, and presence of stool mucus. Significant weight loss, nocturnal diarrhea, and the absence of tenesmus were associated with an organic cause. One or more laboratory alterations (increased erythrocyte sedimentation rate, anemia, hypokalemia, and low serum albumin level) were found in 62% of patients with organic diarrhea but in only 3% of those with functional disease; p less than 0.001. In 20 of 21 patients with organic diarrhea, an syndromic diagnosis (fat malabsorption, n = 13; inflammatory bowel disease, n = 4; and secretory diarrhea, n = 3) could be obtained with three simple tests (stool fat, rectal biopsy, and fecal water osmolality and electrolyte determination, respectively). Our study confirms that a detailed history and a few simple laboratory data can help to distinguish between functional and organic diarrhea and so avoid extensive investigation. The syndromic diagnosis of organic diarrhea can also be approximated with relatively easy tests." }, { "id": "wiki20220301en084_6406", "title": "List of dog diseases", "score": 0.009433962264150943, "content": "Exocrine pancreatic insufficiency is the inability to properly digest food due to a lack of digestive enzymes made by the pancreas. This disease is found frequently in dogs. Pancreatitis*, or inflammation of the pancreas, is common in dogs. It is most commonly seen in middle-aged and older overweight dogs. Miniature Schnauzers are predisposed. Contributing factors include diabetes, hyperlipidemia, obesity, and dietary indiscretion. Signs include vomiting, diarrhea, abdominal pain, lethargy, and anorexia. Inflammatory bowel disease (IBD)* is a group of diseases in dogs that are idiopathic and characterized by the presence of inflammatory cell infiltrates in the stomach and/or intestinal walls. It is a common condition. Signs include vomiting, diarrhea, and weight loss. Treatment is with dietary modification and use of medications such as corticosteroids, metronidazole, sulfasalazine, and azathioprine." }, { "id": "pubmed23n0624_481", "title": "[Implication of late diagnosis for survival of patients with colorectal carcinoma].", "score": 0.009433962264150943, "content": "Colorectal cancer (CRC) is one of the most frequent diseases and early diagnosis has a potential role to improve survival. The aim of this study was to analyze influence of delay in diagnosis on survival in patiens with colorectal cancer. A total of 119 patients with pathohystological diagnosis of CRC were included in the study. They were operated at our Department for Surgery from 2000 to 2002. They were divided into two groups according to the duration of symptoms: early operated patients - EOP (symptoms were presented for 3 months) and late operated patients - LOP (duration of symptoms was more than 3 months). Follow-up period was 5 year. Weight loss, intermittent abdominal pain and anorexia were more frequent in LOP (p &lt; 0.01). Young age, blood in stool, and tumor localized in rectum were dominant characteristics in EOP (p &lt; 0.05). Overall delay in diagnosis was 2.19 +/- 0.79 months in EOP and 11.37 +/- 5.68 months in LOP. There was highly statistically significant difference between these two groups (p &lt; 0.01). Overall survival was 44.75%. Five years survival was 65.9% in the group of EOP and 26.5% in the group of LOP (chi2 = 28.16, p &lt; 0.01) Weight loss was dominant characteristics in the patients who did not survive five years (chi2 = 14.26, p &lt; 0.01). A period of 2 months in delay in diagnosis is \"cut-off' value in prediction of death (sensitivity of 75.5% and specificity of 90.3%). A delay in diagnosis and stage of the disease are highly significant factors of patients with CRC survival. In everyday medical practice higher importance should be put on weight loss, intermittent abdominal pain, change in bowel habits, as well as on syderopenic anaemia." }, { "id": "pubmed23n0767_24044", "title": "Severe early-onset colitis revealing mevalonate kinase deficiency.", "score": 0.009345794392523364, "content": "Hyperimmunoglobulinemia D is the less severe form of mevalonate kinase deficiency (MKD) caused by recessive inherited mutation in the mevalonate kinase gene. Hyperimmunoglobulinemia D is characterized by febrile attacks, often associated with transient digestive manifestations, such as abdominal pain, diarrhea, and vomiting. Here we report for the first time 2 patients with MKD revealed by severe neonatal colitis. Both patients had chronic bloody diarrhea and failure to thrive; 1 patient since the age of 1 month and the other since the age of 12 days. Total parenteral nutrition was required. A marked elevation of acute phase reactants was present, and no evidence of infection was found. In patient 1, ileocolonoscopy revealed ulcerative colitis at the age of 5 months. Patient 2 suffered from enterocolitis and shock, associated with multiple bowel adhesions at age 5 weeks; the rectosigmoidoscopy showed aphtoid lesions of the sigmoid colon. Pathologic findings of colonic biopsies revealed a dense polymorph inflammatory infiltrate associated with deep ulcerations. Febrile attacks occurred 2 months after the onset of digestive symptoms in patient 1, and at onset of disease in patient 2. Genomic sequencing of the mevalonate kinase gene revealed compound heterozygous mutations in both patients. Anti-interleukin-1 agent produced long-term remission of all digestive features and laboratory parameters. This report emphasizes that MKD may be the cause of severe early-onset inflammatory colitis, and must be considered by physicians, even in the absence of fever, after ruling out infections. Anti-interleukin-1 therapy may result in a dramatic improvement of MKD-related inflammatory bowel disease. " }, { "id": "pubmed23n0065_4192", "title": "Giardiasis--a simple diagnosis that is often delayed.", "score": 0.009345794392523364, "content": "In a retrospective study performed on 125 patients with histologically diagnosed giardiasis, it is shown that this disease can lead to a variegated picture involving numerous gastroenterological symptoms. The main symptoms noted were epigastralgia (41%), diarrhoea (32%), nausea and vomiting (23%), and loss of weight (20%). The material for histological diagnosis was obtained in hospitals in 49% of the cases, in the doctor's office in 32%, and in two gastroenterological rehabilitation centres in 19%. The average duration of symptoms before establishment of the diagnosis was 2.01 years (range: 1 week to 30 years). In only 8% of the cases was the disease preceded by a visit to an endemic area. Treatment with nitroamidazole preparations completely relieved symptoms in 78% of the patients and remained unsuccessful in 4%; for the remaining 18% of the patients, no follow-up data were available. On the basis of these results, it is recommended that in patients with upper abdominal pain, diarrhoea, loss of weight, meteorism, flatulence, nausea and vomiting, the possibility of giardiasis should be considered, and that during endoscopy, two or three forceps biopsies should be obtained from macroscopically normally-appearing mucosa of the descending part of the duodenum to enable a histological search for Giardia lamblia." }, { "id": "wiki20220301en029_14019", "title": "Gastroenteritis", "score": 0.009259259259259259, "content": "Differential diagnosis Other potential causes of signs and symptoms that mimic those seen in gastroenteritis that need to be ruled out include appendicitis, volvulus, inflammatory bowel disease, urinary tract infections, and diabetes mellitus. Pancreatic insufficiency, short bowel syndrome, Whipple's disease, coeliac disease, and laxative abuse should also be considered. The differential diagnosis can be complicated somewhat if the person exhibits only vomiting or diarrhea (rather than both). Appendicitis may present with vomiting, abdominal pain, and a small amount of diarrhea in up to 33% of cases. This is in contrast to the large amount of diarrhea that is typical of gastroenteritis. Infections of the lungs or urinary tract in children may also cause vomiting or diarrhea. Classical diabetic ketoacidosis (DKA) presents with abdominal pain, nausea, and vomiting, but without diarrhea. One study found that 17% of children with DKA were initially diagnosed as having gastroenteritis." }, { "id": "pubmed23n0375_12984", "title": "[X-ray of small bowel with a probe--indications and diagnostic yield in a 10-year material].", "score": 0.009259259259259259, "content": "We wanted to evaluate the indications for ordering small bowel enema, and whether specific clinical symptoms and signs are associated with the diagnostic yield. Medical charts and requisition slips for 241 patients examined with small bowel enema at Harstad Hospital from 1986 to 1995 were reviewed. The most common symptom leading to small bowel radiography was pain, registered in almost three fourths of the patients; about one half reported diarrhoea. Elevated sedimentation rate and occult blood in the faeces were reported in one fourth of the patients. For a large proportion of the patients, there was no information about adequate preliminary tests in the medical charts. Normal radiography was reported in three fourths of the patients. Lesions consistent with Crohn's disease were found in one of eight patients. No symptoms or signs, except for elevated sedimentation rate, clearly indicate a positive diagnostic finding. Many requisition slips did not contain available information. Small bowel radiography is performed on wide indications. It is difficult to make a careful selection of patients based on reported symptoms and signs. However, some preliminary tests are helpful and should be done." }, { "id": "wiki20220301en023_60315", "title": "Low back pain", "score": 0.009174311926605505, "content": "Classification There are a number of ways to classify low back pain with no consensus that any one method is best. There are three general types of low back pain by cause: mechanical back pain (including nonspecific musculoskeletal strains, herniated discs, compressed nerve roots, degenerative discs or joint disease, and broken vertebra), non-mechanical back pain (tumors, inflammatory conditions such as spondyloarthritis, and infections), and referred pain from internal organs (gallbladder disease, kidney stones, kidney infections, and aortic aneurysm, among others). Mechanical or musculoskeletal problems underlie most cases (around 90% or more), and of those, most (around 75%) do not have a specific cause identified, but are thought to be due to muscle strain or injury to ligaments. Rarely, complaints of low back pain result from systemic or psychological problems, such as fibromyalgia and somatoform disorders." }, { "id": "pubmed23n0254_9902", "title": "[What is the value of clinical symptoms in the diagnosis of nonspecific inflammatory bowel disease?].", "score": 0.009174311926605505, "content": "Due to controversial evaluation of the contribution of clinical signs for the diagnosing of non-specific inflammatory bowel disease, as well as due to the lack of similar data, we tried to find our own answer to the question as to whether the clinical signs of ulcerative colitis (UC) and Crohn's disease (MC) are helpful, unhelpful, or even confusing for the diagnosis. A group of patients with MC and UC was analyzed from this aspect. Individuals in their twenties and thirties prevailed in the sample, mostly intellectual workers, the number of males and females was equal. Our attempt to analyze all the available diagnostic methods originated in an observation that a long period of health problems precedes the diagnosis of MC, namely 1.5 y in males and as long as 4 y in females. Other striking information was that surgery represented the initial treatment in 66% of cases and the correct diagnosis was made peroperatively only in 56% of cases. We compared our results with those of the OMGE study, one of the largest projects which evaluated positively the contribution of clinical signs to the diagnosing of MC and UC. We found that the main signs of CU have not changed in the last century, and some additional signs occur rather due to complications than due to the disease per se. Frequency of pain increased by 25% in our patients, and approximately 1/3 of it represented intermittent pain caused by tenesms. Pain in MC must be properly analyzed in order to discriminate acute appendicitis. Other indicators did not differ from the OMGE study. In accordance with its results, we confirmed the importance of correct evaluation of clinical signs for the diagnosis and differential diagnosis of UC and MC. The number of diagnostic methods still increases. Their validity must be continuously re-evaluated, however the clinical examination in the dynamic process stays to be of crucial value." }, { "id": "pubmed23n0827_6331", "title": "Should routine MRI of the lumbar spine be required prior to lumbar epidural steroid injection for sciatica pain?", "score": 0.00909090909090909, "content": "We describe three patients who received lumbar epidural steroid injections (LESI) for lumbosacral radicular pain that resulted in worsening of their symptoms. The procedures were performed following a review of remote diagnostic imaging studies. These cases demonstrate the lack of consensus in pain management domains for how to approach the workup and treatment of persistent/chronic low back pain, with a noted fragmentation in pain management strategies and applied therapies. We present three patients; two female patients (37 and 38 years old) undergoing LESI for remotely diagnosed disc herniations, and one 61-year-old male receiving an LESI for a presumed, unverified lumbar intervertebral disc disorder. Following a worsening of symptoms after LESI, neurosurgical consultations ultimately determined the presence of, respectively, an epidural hematoma, a neurilemoma, and a lung cancer metastasis to the sacrum as the source of symptoms, instead of being due to the intervertebral disc pathology. We would like to emphasize several principles in the diagnosis and use of imaging of the lumbosacral region prior to undertaking invasive neuraxial procedures." }, { "id": "pubmed23n0523_13294", "title": "[Circumstances of the diagnosis and clinical course of inflammatory bowel disease].", "score": 0.00909090909090909, "content": "The diagnosis of inflammatory bowel disease is sometimes difficult. The cardinal symptom of ulcerative colitis is bloody diarrhoea. The clinical characteristics of Crohn's disease are more heterogeneous, but typically include abdominal pain in the right lower quadrant, diarrhoea, weight loss and/or perianal disease. Extra intestinal (joint, cutaneaous and eye) manifestations can precede digestive symptoms and lead to the diagnosis of inflammatory bowel disease. The clinical course of these two diseases is unpredictable. The risk of colorectal cancer is significantly increased 8 years after diagnosis of pancolitis. Thus, regular surveillance by colonoscopy with random biopsies is recommended." }, { "id": "pubmed23n1129_13383", "title": "Lumbar Spondylodiscitis Mimicking Cholecystitis: A Case Report and Review of Literature.", "score": 0.009009009009009009, "content": "Lower back pain is a frequent cause of emergency department visits and one of the leading causes of the disease burden worldwide. The purpose of this case report and literature review was to discuss atypical abdominal entities mimicking spinal diseases typically presenting with lower back pain. A 79-year-old man presented with lower back pain and urinary incontinence after receiving a non-image-guided lumbar infiltration treatment 4 weeks prior to admission. The magnetic resonance imaging (MRI) highlighted multisegmental hyperintensities in the intervertebral disk spaces of the lumbar spine indicative for spondylodiscitis. Antibiotic treatment over a week did not lead to significant clinical improvement. Blood cultures, cardiologic, otorhinolaryngologic, and dental examinations turned out negative for a focus of infection. A computed tomography (CT) guided biopsy was indicated after discontinuation of antibiotic treatment for less than 24 hours. Rapid clinical deterioration with concomitant onset of abdominal pain resulted in the diagnosis of cholecystitis, which required cholecystectomy. We performed a systematic literature review using the Pubmed database for the keywords \"spondylodiscitis,\" \"spine,\" \"abdominal,\" and \"cholecystitis,\" to identify abdominal diseases that mimic spine pathologies and spinal diseases that mimic abdominal pathologies. No other report in English literature of cholecystitis associated with initial onset of lower back pain was identified. Eighteen reports referred to abdominal conditions that mimic spinal diseases, among them a patient with cyclic lumbar back pain who received a lumbar spinal fusion who, after persisting symptoms led to further diagnostic procedures, was ultimately diagnosed with endometriosis. Spinal symptoms included paraplegia and urinary incontinence as results of acute aortic pathologies. Eleven reports presented spinal pain mimicking abdominal conditions including abdominal pain and diarrhea as well as have had surgical procedures such as an appendectomy before the spinal condition was discovered. Clinical symptoms of the spine such as lower back pain can be unspecific and lead to false conclusions in the presence of concomitant pathologies in MRI. Only clinical deterioration in our case patient prompted correction of the diagnosis on day 7. Initial workup for alternative common infectious foci such as lung and urinary tract was performed, but further abdominal workup despite the absence of abdominal symptoms may have led to an earlier diagnosis. Our literature review found several cases of misdiagnosed spinal and abdominal conditions. Some had undergone unnecessary surgical procedures before the right diagnosis was made. Because of the high incidence of symptoms such as lumbar back pain and abdominal pain, considering optimal patient care as well as economic aspects, it would be essential to conduct an interdisciplinary clinical management to avoid errors in the early stage of diagnostics." }, { "id": "pubmed23n0120_13676", "title": "[Early clinical diagnosis of stomach and large intestine cancer].", "score": 0.009009009009009009, "content": "Gastric and colonic cancer, which affect alarmingly also younger age groups to a growing extent, are developing into a serious problem of public health. Not recognized in time, the survival probability is low. The 5-year survival time is 10% with a manifest gastric carcinoma, with colonic cancer it is 30%. If these neoplasias are recognized in a stage in which they correspond to the criteria of an early carcinoma, the chance of recovery will be 90% for the patients. The early gastric carcinoma does not occur without any symptoms, but in more than 80% of the cases it causes differently intensely pronounced symptoms in the epigastric region, with pain, dyspepsia, haemorrhage and loss of weight prevailing. Therefore, epigastric, complaint for more than 4 weeks should give reason for a thorough gastroenterological examination, with endoscopy being superior to radiological examination, even when using advanced methods of examination. Special control is needed for patients of the various risk groups. Patients with a morbus Ménétrie, a pernicious anaemia and a chronic-atrophic gastritis with intestinal metaplasia of the colonic type are exposed to a particularly high risk of carcinoma. Of a special practical importance is the circumstance that a peptic ulcus of the stomach may develop in an already carcinomatously changed mucosa and thus the carcinoma continues growing below a healed peptic lesion. Thus, a gastric ulcer requires a regular and short-term endoscopic control until its final macroscopic and histological healing. The malignant diseases of stomach and large intestine show an inverse behaviour over the past 20 years. The colonic carcinoma develops from an adenoma in 90% of the cases. In most of the cases, this development from the precursors is without any symptoms. Symptoms such as blood in the stools, abdominal pain, change in the action of the bowels, loss of weight, decrease in power and the like indicate already an advanced carcinoma. Among the laboratory tests, only the examination of the faeces for concealed haemorrhage is of some importance as a diagnostic test. The CEA test in not suitable therefore. As also larger adenomas bleed intermittently, there is the chance of recognizing also these prestages of carcinomas by regular examinations of the faeces. In contrast to the simple barium enema, the radiological examination in double contrast reveals changes of the mucosa of the colon up to a size of 1 cm in more than 80% of the cases. Coloscopy, however, is superior to X-ray examination, regarding both expressiveness and efficiency.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0991_16550", "title": "Vertebral body chondrosarcoma with metastasis to the scalp.", "score": 0.008928571428571428, "content": "We present a case of a 30-year-old man who had a 3-year history of low back pain. MRI demonstrated an infiltrative mass, affecting the vertebral body and pedicles of L4, with some extension to the vertebral canal. There was also tumor invasion in the inferior vena cava and in the left iliopsoas muscle. The anatomopathological examination of the resected L4 vertebral body was of a malignant neoplasia compatible with mesenchymal chondrosarcoma (high histological grade). About 2 months after surgery, he developed a progressive bladder incontinence, bilateral leg weakness and severe back pain. A new MRI was obtained, confirming progression of the disease. An occipital scalp lesion was detected and biopsy confirmed cutaneous metastasis. Primary malignant bone tumors are rare but should be ruled out in young patients with persistent low back pain. We present a case of a confirmed mesenchymal chondrosarcoma affecting lumbar spine, with MRI and pathological illustrations. Early diagnosis may improve the chances of local disease control and even cure." }, { "id": "Obstentrics_Williams_7455", "title": "Obstentrics_Williams", "score": 0.008928571428571428, "content": "Symptoms depend on which bowel segment(s) is involved. Thus, complaints may include lower-right-sided cramping abdominal pain, diarrhea, weight loss, lowgrade fever, and obstructive symptoms. The disease is chronic with exacerbations and remissions, and importantly, it cannot be cured medically or surgically. Approximately a third of patients require surgery within the first year ater diagnosis, and thereater, 5 percent per year. Reactive arthritis is common, and the gastrointestinal cancer risk, although not as great as. with ulcerative colitis, is increased substantially. FIGURE 54-2 Causes of colitis. A.Chronic ulcerative colitis with diffuse ulcerations and exudates. B. Crohn colitis with deep ulcers. (Reproduced with permission from Song LM Topazian M: Gastointestinal endoscopy. Kasper DL, Fauci AS, Hauser SL, et al (eds): Harrison's Principles of Internal Medicine, 19th ed. New York: McGraw-Hili Education; 201o5.)" }, { "id": "wiki20220301en573_3535", "title": "Indolent T cell lymphoproliferative disorder of the gastrointestinal tract", "score": 0.008849557522123894, "content": "Presentation ITCLD-GT occurs more commonly in males of middle age (median age 48.4, range 15–77 years in one study). Individuals with the disease present with GI tract symptoms which often are serious and/or debilitating and may mimic those occurring in malignant lymphoproliferative, inflammatory, or autoimmune bowel diseases. These symptoms include chronic epigastric pain, abdominal pain, heartburn, nausea, diarrhea, vomiting, weight loss, relapsing oral ulcers, relapsing colorectal ulcers, rectal bleeding, and/or night sweats. Several patients presenting with these symptoms have been diagnosed with and unsuccessfully treated for peripheral T-cell lymphoma, an inflammatory bowel disease (either Crohn disease or ulcerative colitis), or the autoimmune GI tract disorder, celiac disease. It has been shown or appears very likely that these patients had ITCLD-GT rather than the cited diagnoses." }, { "id": "pubmed23n0742_24378", "title": "Diverticulosis of the colon: a report of two cases.", "score": 0.008849557522123894, "content": "Diverticula are bulging pouch-like herniations in the wall of the hollow organ anywhere in the gastrointestinal tract from the oesophagus to the colon. Diverticula are thought to occur more commonly in the colon than in any other segment of the gastrointestinal tract. It may be asymptomatic or complicated by diverticulitis (diverticular inflammation), bleeding, or perforation with peritonitis. It could be potentially life threatening. It was thought to be rare in this part of the world, but is increasingly diagnosed with the advent of modern imaging techniques and colonoscopy. Two cases of colonic diverticula discovered during colonoscopy were highlighted. Case 1--This patient was a 79-year old traditional ruler who presented with 2 months history of progressive left- sided abdominal pain, dull in nature and sometimes colicky but non-radiating. There was no known aggravating or relieving factors. There was associated history of chronic constipation dating back to over 15 years relieved with use of laxatives. There was no diarrhoea, vomiting or haematochezia. He had no history of previous surgeries. Physical examination showed mild tenderness at the left iliac fossa. Digital rectal examination was normal. Plain abdominal x-ray and abdomino-pelvic ultrasound scan showed no abnormalities. Colonoscopy revealed multiple diverticula with diverticulitis at the descending and sigmoid colon 40 cm-60 cm from the anal verge. Case 2--This patient is a 64-year old retired military officer who presented with constipation of 5 years and rectal bleeding of 10 months. Pre-morbid bowel habit was 1-2 bowel motions per day but now once in 2 days. Constipation was characterized by recurrent passage of hard pellet-like stools. This became associated with passage of fresh blood in the stool 10 months ago, and anal pain. Volume of blood was about 5 mls per episode, and this occurred only when stool was hard. The anal pain was sometimes severe enough to prevent the patient from sitting comfortably on both buttocks. There was no weight loss or constipation alternating with diarrhoea. He had no history of any chronic medical illness. Colonoscopy revealed anal fissure, internal haemorrhoids, and multiple diverticula in the sigmoid and descending colon. Both patients are being managed conservatively with dietary advice and antibiotics, and still being followed up in the clinic. Reports of colonic diverticula with diverticulitis in this part of the world are few. This is the first report of colonic diverticulosis from Ilorin." }, { "id": "wiki20220301en084_38796", "title": "Menstrual disorder", "score": 0.008771929824561403, "content": "Dysmenorrhea Especially painful or persistent menstrual cramping that occurs in the absence of any underlying pelvic disease. Pain radiating to the low back or upper thighs with onset of menstruation and lasting anywhere from 12–72 hours. Headache, nausea, vomiting, diarrhea, and fatigue may also accompany the pain. Pain may begin gradually, with the first several years of menses, and then intensified as menstruation becomes regular. Patients who also have secondary amenorrhea report symptoms beginning after age 20 and lasting 5–7 days with progressive worsening of pain over time. Pelvic pain is also reported." }, { "id": "pubmed23n0323_22952", "title": "Crohn's disease in the elderly: a comparison with young adults.", "score": 0.008771929824561403, "content": "We compare the clinicopathological features of 98 Crohn's disease (CD) patients with initial symptoms at 40 years of age or older (elderly; male n = 56, female n = 42) with those of 347 CD patients with onset of symptoms between the age of 16 and 40 years (young adults; male n = 166, female n = 181). The frequency of presenting symptoms, such as diarrhea, rectal blood loss, and weight loss were comparable in both groups, except for abdominal pain/cramps, which occurred somewhat less frequently in the elderly (59% vs. 71%, p &lt; 0.05). The mean lag time between onset of symptoms and first visit to a general practitioner (GP) was considerably shorter in the elderly than in the young adults (0.2 years vs. 0.6 years, p &lt; 0.001), as was the lag time between GP and referral to a specialist (0.6 years vs. 1.0 years, p &lt; 0.07). Overall, this resulted in a significantly (p &lt; 0.01) shorter time to establish the diagnosis in the elderly (1.8 years vs. 2.7 years). Crohn's disease as correct initial diagnosis was in the elderly less frequently observed than in the young adults (49% vs. 61%, p &lt; 0.05), in contrast to diverticulitis (7.1% vs. 0%) and malignancy (6.1% vs. 0.9%), which were more frequently encountered as incorrect preliminary diagnosis in the elderly (both p &lt; 0.005). The percentage of patients who underwent an abdominal operation was similar in both groups (83% vs. 77%), but the diagnosis CD was in the elderly more frequently established at first operation than in young adults (25% and 12%, p &lt; 0.005). The elderly were found to undergo a bowel operation or resection earlier after onset of symptoms. The development of recurrence after bowel resection, although occurring in a lower percentage of patients, was significantly shorter than in the young adults (3.7 years vs. 5.8 years, p &lt; 0.02). Arthritic extraintestinal manifestations were equally frequent in both groups, but elderly patients had significantly less relatives in the first or second degree affected by CD (3.1% vs. 12%, p &lt; 0.02). We conclude that the diagnosis Crohn's disease is more readily established in elderly patients. Moreover, these patients less frequently have abdominal pain/cramps as a presenting symptom, a shorter time interval between onset of symptoms and first resection, and subsequent recurrence of the disease. In addition, elderly CD patients have less relatives affected by the same disease. Thus, CD in the elderly appears to be characterized by a more rapid development." }, { "id": "pubmed23n0672_24678", "title": "Butterfly vertebra anomaly: A case report.", "score": 0.008695652173913044, "content": "Butterfly vertebra is an uncommon congenital spinal anomaly. Only a small number of cases with butterfly vertebra have thus far been reported in the literature.We herewith describe a 32-year-old male admitted to our clinic with low back pain. He has been suffering from low back pain since early adolescence. Radiologic investigations confirmed presence of butterfly vertebra at Lumbar(L)2 level and L3-4, L4-5 posterior disc protrusion and slight osteoarthritic changes in lumbar spine which proved to be a coincidental finding along with nonspecific low back pain. Routine examination of the motor and sensory system was found to be normal. Hematologic evaluation was made to rule out pathologic causes of anterior wedging of the vertebra like infections and metastases in the spine. Butterfly vertebra anomaly is considered to be incidental and usually asymptomatic. Awareness of this anomaly is important for correct diagnosis, while its imaging features may be confused with traumatic compression fracture, or with a pathologic fracture. Also, this spinal anomaly may be associated with many syndromes. This taken into account, all the necessary investigations should be carried out for purposes of achieving a correct diagnosis." }, { "id": "pubmed23n0107_11200", "title": "[Clinical study of 105 cases of isolated weight loss in internal medicine].", "score": 0.008695652173913044, "content": "We arbitrarily define \"isolated weight loss\" as the loss of at least 10 p. 100 of body weight over less than one year, without any single cause being disclosed by questioning, physical examination and such paraclinical examinations as blood electrolytes, blood count and differential, routine dipstick urinalysis and X-ray of the chest. Among the 105 patients we studied, the causes of isolated weight loss were: (1) psychic disorders (chiefly depression) in 60 p. 100 of the cases; (2) a variety of organic diseases in 29 p. 100, including gastrointestinal diseases (8 p. 100), cardiovascular and respiratory diseases (6 p. 100), Horton's disease (4 p. 100), Portuguese amyloidosis (1 p. 100), unexplained inflammatory syndrome (1 p. 100), endocrine disease (hyperthyroidism, 4 p. 100) and intoxication with medicines, alcohol or heroin (5 p. 100); (3) no definite cause could be found in 11 p. 100 of the cases. We suggest a diagnostic approach involving a limited number of examinations, viz.: erythrocyte sedimentation rate, measurement of transaminases, gamma GT and alkaline phosphatase enzymes, abdominal ultrasonography and ultra-sensitive TSH assay. We consider it important to switch from useless paraclinical tests to the detection and management of psychic disorders. Weight loss is a frequent motive of consultation, but its diagnostic value is often misunderstood. The purpose of this study was to provide data for the artiological diagnosis of isolated weight loss--a relatively frequent problem in internal medicine." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 223 ] ], "word_ranges": [ [ 0, 39 ] ], "text": "I believe that the correct answer is 3. The patient, due to the mechanism of injury (foot fall), the calcaneal fracture and the neurological symptoms, suggests a low spinal cord injury due to a fracture of the lumbar spine." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "The patient will be seated on the stretcher so that the cervical spine can be explored.", "2": "Refer to radiology for study of the lower extremities (feet, femurs, pelvis).", "3": "We will palpate the abdomen and roll en bloc to palpate the thoracolumbar spine.", "4": "We will place a cervical collar and refer to radiology for imaging of the lower extremities and cervical spine.", "5": "We will request an abdominal ultrasound." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en031_2112", "title": "Casualty lifting", "score": 0.014709063378758382, "content": "The first in place is the chief. The stretcher is slid besides the casualty, the pole against the thigh of the chief. Then, the third team member takes place. Once the both extremities of the pole are blocked, the other team members can step over the casualty (one by one, holding the others' shoulder to avoid falling) without any risk of rocking for the stretcher. On the order of the chief, the casualty is lifted and translated on the stretcher. This method can be performed with only three first responders. In this case, the chief plays the role of the first team member; blocking the pole with his/her ankle, and putting one hand under the neck, the other one under the back, between the shoulder blades. Only the team member at the hips steps over the stretcher. Rolling methods (log roll)" }, { "id": "wiki20220301en086_1447", "title": "May–Thurner syndrome", "score": 0.01409470277635837, "content": "Signs and symptoms Because of its similarities to Deep Vein Thrombosis (DVT), May-Thurner’s syndrome is rarely diagnosed amongst the general population. In this condition, the right iliac artery sequesters and compresses the left common iliac vein against the lumbar section of the spine, resulting in swelling of the legs and ankles, pain, tingling, and/or numbness in the legs and feet. The pain is often presented as dull, and may progress up and down the leg depending on the patient. Lower extremities may feel warm to the touch and swelling may maintain or dissipate throughout the day." }, { "id": "Anatomy_Gray_262", "title": "Anatomy_Gray", "score": 0.010987103174603174, "content": "In all patients back pain requires careful assessment not only of the vertebral column but also of the chest and abdomen in order not to miss other important anatomical structures that may produce signs and symptoms radiating to the back. A 50-year-old man was brought to the emergency department with severe lower back pain that had started several days ago. In the past 24 hours he has had two episodes of fecal incontinence and inability to pass urine and now reports numbness and weakness in both his legs. The attending physician performed a physical examination and found that the man had reduced strength during knee extension and when dorsiflexing his feet and toes. He also had reduced reflexes in his knees and ankles, numbness in the perineal (saddle) region, as well as reduced anal sphincter tone." }, { "id": "wiki20220301en030_53220", "title": "Vacuum mattress", "score": 0.009900990099009901, "content": "A vacuum mattress, or vacmat, is a medical device used for the immobilisation of patients, especially in case of a vertebra, pelvis or limb trauma (especially for femur trauma). It is also used for manual transportation of patients for short distances (it replaces the stretcher). It was invented by Loed and Haederlé, who called it \"shell\" mattress (matelas coquille in French). Medical uses The full spine immobilisation (splint) is performed with: a rigid cervical collar, a vacuum mattress ,and a stretcher under it (the longitudinal stiffness of the mattress alone is not sufficient). Preparation of the vacuum mattress" }, { "id": "Neurology_Adams_1600", "title": "Neurology_Adams", "score": 0.009900990099009901, "content": "The pain of herniated intervertebral disc varies in severity from a mild aching discomfort to severe knife-like stabs that radiate the length of the leg and are superimposed on a constant intense ache. Sciatic pain is perceived by the patient as originating deep in the buttock and radiating to the posterolateral thigh; it may progress to the calf and ankle—to the medial malleolus (L4), lateral malleolus (L5), or heel (S1). Distal radiation to the foot is infrequent and should raise concern of an alternative process. Abortive forms of sciatica may produce aching discomfort only in the lower buttock or proximal thigh and occasionally only in the lower hamstring or upper calf. With the most severe pain, the patient is forced to stay in bed, avoiding the slightest movement; a cough, sneeze, or strain is intolerable. The most comfortable position is lying on the back with legs flexed at the knees and hips and the shoulders raised on pillows to obliterate the lumbar lordosis. For some" }, { "id": "article-115850_4", "title": "Electrodiagnostic Evaluation of Spinal Stenosis -- Introduction", "score": 0.009812003619181662, "content": "In clinical practice, the physician will encounter patients who complain of pain, numbness, or weakness. If it involves the cervical spine, the patient will complain of neck pain that radiates to one or both of their upper extremities. If the patient is coming with lumbar stenosis, they will complain of dull achy pain in the legs, calves, thighs, and buttocks area. They may report that the pain is worse with standing or walking for prolonged periods and relieved with sitting. The reason for this is that during sitting, the diameter of the spinal canal increases because of the flexion that occurs. Often spinal stenosis is associated with neurologic claudication; this refers to the intermittent compression of the lumbar nerve roots resulting in sporadic leg pain. [2] Cervical stenosis can also progress to myelopathy. This condition refers to compression on the spinal cord that is often associated with clumsiness in hands and gait imbalance. [1]" }, { "id": "pubmed23n0345_11842", "title": "Reduction of posterior hip dislocations in the lateral position using traction-countertraction: safer for the surgeon?", "score": 0.00980392156862745, "content": "Closed reduction of a hip dislocation is a physically demanding task for the orthopaedic surgeon. The most commonly used methods for reduction of the hip involve vigorous axial traction on the lower extremity with the patient in the supine position, using an assistant who attempts to hold the pelvis down. The surgeon generally stands over the patient to pull up on the bent knee, which puts the surgeon at risk for a low back injury and, if done while the patient remains on a stretcher, can put the surgeon at risk for a fall from a height. Reduction in the prone position is advocated by some, but caring for the sedated patient in the prone position can be difficult and the patient's pelvis tends to roll off the edge of the stretcher, preventing the achievement of hip flexion, which is desirable in achieving reduction. We describe a traction-countertraction technique that appears to be significantly less dangerous for the surgeon. In this technique the hip is reduced with the patient remaining on the stretcher in the lateral position. In addition, fluoroscopy can be carried out during the reduction maneuver, and the images can be quite helpful in adjusting the direction of manipulative forces." }, { "id": "InternalMed_Harrison_1475", "title": "InternalMed_Harrison", "score": 0.00980392156862745, "content": "The straight leg–raising (SLR) maneuver is a simple bedside test for nerve root disease. With the patient supine, passive flexion of the extended leg at the hip stretches the L5 and S1 nerve roots and 113 CHAPTER 22 Back and Neck Pain 4th Lumbar vertebral body 5th Lumbar vertebral body 4th Lumbar pedicle L4 root Protruded L4-L5 disk L5 Root S1 Root S2 Root Protruded L5-S1 disk FIguRE 22-3 Compression of L5 and S1 roots by herniated disks. (From AH Ropper, MA Samuels: Adams and Victor’s Principles of Neurology, 9th ed. New York, McGraw-Hill, 2009; with permission.) the sciatic nerve. Passive dorsiflexion of the foot during the maneuver adds to the stretch. In healthy individuals, flexion to at least 80° is normally possible without causing pain, although a tight, stretching sensation in the hamstring muscles is common. The SLR test is positive if the maneuver reproduces the patient’s usual back or limb pain. Eliciting the SLR sign in both the supine and sitting positions can help" }, { "id": "wiki20220301en191_24071", "title": "GALS screen", "score": 0.009734409734409734, "content": "Now ask the patient to do the following noting any painful, restricted or asymmetrical movements: Test rotation of the thoracic and lumbar spine. Gently hold the patient's hips still and ask them to: \"Turn your shoulders round as far as you can to the left, then do the same to the right.\" Test lateral flexion of the thoracic and lumbar spine: \"Stand up straight and then slide the palm of your right hand down your thigh towards your knee, bending your shoulder down to the side.\" \"Now do the same with your left hand down your left leg.\" \"Bend your left ear down towards your left shoulder and then your right ear down towards your right shoulder\" to test for pain free cervical spine lateral flexion. Now test for stiffness or pain flexing or extending the cervical spine: \"bend your neck forwards to try to touch your chin against your chest.\" \"bend your neck back to lift your chin.\"" }, { "id": "pubmed23n1099_9475", "title": "Acute Thromboembolism from Trauma in a Patient with Abdominal Aortic Aneurysm.", "score": 0.009708737864077669, "content": "A 64-year-old man with a history of a 5.5-centimeter (cm) abdominal aortic aneurysm (AAA) presented to the emergency department (ED) complaining of severe back pain after climbing over a fence and falling a distance of eight feet. Prior to arrival, the prehospital paramedics reported that the patient did not have palpable pulses in either lower extremity. The initial physical examination in the ED was significant for absent dorsalis pedis pulses bilaterally as well as absent posterior tibialis pulses bilaterally and cold, insensate lower extremities. Point-of-care ultrasound identified an approximate 7-cm infrarenal AAA with a mural thrombus present. After receiving several computed tomography (CT) studies including CT head without contrast and CT angiography of the chest, abdomen and pelvis, the patient was diagnosed with acute thrombosis of AAA and associated thromboembolic occlusion of both his right and left distal iliac vessels causing bilateral acute limb ischemia. He immediately received unfractionated heparin and was admitted to the hospital for embolectomy and intra-arterial tissue plasminogen activator. Acute thrombosis of AAA and subsequent thromboembolic events are a rare but significant complication that can occur in patients with a history of AAA. Thromboembolic events may occur spontaneously or in the setting of blunt abdominal trauma. Common presenting signs and symptoms include distal limb ischemia and absent femoral pulses. Timely management and recognition of this rare complication is vital as this condition can ultimately result in limb loss or death if not treated in a timely manner. Heparinization after confirmation of non-ruptured AAA as well as vascular surgery, and therapeutic and vascular interventional radiology consultations are key steps that should be taken to decrease patient morbidity and mortality." }, { "id": "pubmed23n1082_2481", "title": "[The position of the head during treatment in the emergency room-an explorative analysis of immobilization of the cervical spine].", "score": 0.009615384615384616, "content": "Immobilization of the cervical spine is a standard procedure in emergency medicine mostly achieved via a cervical collar. In the emergency room other forms of immobilization are utilized as cervical collars have certain drawbacks. The present study aimed to provide preliminary data on the efficiency of immobilization in the emergency room by analyzing the residual spinal motion of the patient's head on different kinds of head rests. In the present study biomechanical motion data of the cervical spine of a test subject were analyzed. The test subject was placed in a supine position on a mobile stretcher (Stryker M1 Roll-In System, Kalamazoo, MI, USA) wearing a cervical collar (Perfit ACE, Ballerup, Denmark). Three different head rests were tested: standard pillow, concave pillow and cavity pillow. The test subject carried out a predetermined motion protocol: right side inclination, left side inclination, flexion and extension. The residual spinal motion was recorded with wireless motion trackers (inertial measurement unit, Xsens Technologies, Enschede, The Netherlands). The first measurement was performed without a cervical collar or positioning on the pillows to measure the physiological baseline motion. Subsequently, three measurements were taken with the cervical collar applied and the pillows in place. From these measurements, a motion score was calculated that can represent the motion of the cervical spine. When the test subject's head was positioned on a standard pillow the physiological motion score was reduced from 69 to 40. When the test subject's head was placed on concave pillow the motion score was further reduced from 69 to 35. When the test subject's head was placed on cavity pillow the motion score was reduced from 69 to 59. The observed differences in the overall motion score of the cervical spine are mainly due to reduced flexion and extension rather than rotation or lateral inclination. The motion score of the cervical spine using motion sensors can provide important information for future analyses. The results of the present study suggest that trauma patients can be immobilized in the early trauma phase with a cervical collar and a head rest. The application of a cervical collar and the positioning on the concave pillow may achieve a good immobilization of the cervical spine in trauma patients in the early trauma phase." }, { "id": "InternalMed_Harrison_1471", "title": "InternalMed_Harrison", "score": 0.009615384615384616, "content": "PART 2 Cardinal Manifestations and Presentation of Diseases FIguRE 22-1 Vertebral anatomy. (From A Gauthier Cornuelle, DH Gronefeld: Radiographic Anatomy Positioning. New York, McGraw-Hill, 1998; with permission.) Radicular pain is typically sharp and radiates from the low back to a leg within the territory of a nerve root (see “Lumbar Disk Disease,” below). Coughing, sneezing, or voluntary contraction of abdominal muscles (lifting heavy objects or straining at stool) may elicit the radiating pain. The pain may increase in postures that stretch the nerves and nerve roots. Sitting with the leg outstretched places traction on the sciatic nerve and L5 and S1 roots because the nerve passes posterior to the hip. The femoral nerve (L2, L3, and L4 roots) passes anterior to the hip and is not stretched by sitting. FIguRE 22-2 Spinal column. (From A Gauthier Cornuelle, DH Gronefeld: Radiographic Anatomy Positioning. New York, McGraw-Hill, 1998; with permission.)" }, { "id": "pubmed23n0858_3836", "title": "Cervical Intradural Disc Herniation Causing Progressive Quadriparesis After Spinal Manipulation Therapy: A Case Report and Literature Review.", "score": 0.009523809523809525, "content": "Cervical intradural disc herniation (IDH) is an extremely rare condition, comprising only 0.27% of all disc herniations. Three percent of IDHs occur in the cervical, 5% in the thoracic, and over 92% in the lumbar spinal canal. There have been a total of 31 cervical IDHs reported in the literature. The pathogenesis and imaging characteristics of IDH are not fully understood. A preoperative diagnosis is key to facilitating prompt intradural exploration in patients with ambivalent findings, as well as in preventing reoperation. The purpose of reporting our case is to remind clinicians to consider the possibility of cervical IDH during spinal manipulation therapy in patient with chronic neck pain.The patient signed informed consent for publication of this case report and any accompanying image. The ethical approval of this study was waived by the ethics committee of Chonbuk National University Hospital, because this study was case report and the number of patients was &lt;3.A 32-year-old man was transferred our emergency department with progressive quadriparesis. He had no history of trauma, but had received physical therapy with spinal manipulation for chronic neck pain over the course of a month. The day prior, he had noticed neck pain and tingling in the bilateral upper and lower extremities during the manipulation procedure. The following day, he presented with bilateral weakness of all 4 extremities, which rendered him unable to walk. Neurological examination demonstrated a positive Hoffmann sign and ankle clonus bilaterally, hypoesthesia below the C5 dermatome, 3/5 strength in the bilateral upper extremities, and 2/5 strength in the lower extremities. This motor weakness was progressive, and he further complained of voiding difficulty.Urgent magnetic resonance imaging (MRI) of the cervical spine revealed large, central disc herniations at C4-C5 and C5-C6 that caused severe spinal cord compression and surrounding edema. We performed C4-C5-C6 anterior cervical discectomy and fusion.The patient's limb weakness improved rapidly within 1 day postoperatively, and he was discharged 4 weeks later. At his 12-month follow-up, the patient had recovered nearly full muscle power.We presented an extremely rare case of cervical IDH causing progressive quadriparesis after excessive spinal manipulation therapy. The presence of a \"halo\" and \"Y-sign\" were useful MRI markers for cervical IDH in this case." }, { "id": "InternalMed_Harrison_30828", "title": "InternalMed_Harrison", "score": 0.009523809523809525, "content": "in the arms, atrophy of intrinsic hand muscles, increased deep-tendon reflexes in the legs, and extensor plantar responses are common. Urinary urgency or incontinence occurs in advanced cases, but there are many alternative causes of these problems in older individuals. A tendon reflex in the arms is often diminished at some level; most often at the biceps (C5-C6). In individual cases, radicular, myelopathic, or combined signs may predominate. The diagnosis should be considered in appropriate cases of progressive cervical myelopathy, paresthesias of the feet and hands, or wasting of the hands." }, { "id": "pubmed23n0097_16142", "title": "Traumatic extradural hematoma of the cervical spine.", "score": 0.009433962264150943, "content": "An example of a traumatic extradural hematoma of the cervical spine that occurred in a 32-year-old man who suffered from chronic ankylosing spondylitis is reported. Progressive sensory and motor deficit ensued some 3 hours after the patient fell from a standing position. The patient landed on his back, striking his head on the floor. After being helped up, he was able to walk unassisted to a nearby chair, where he sat down until his left lower extremity--and shortly afterwards, the right one--became numb and weak. On admission, the patient was found to have tetraparesis that was more pronounced in the lower extremities and associated with incomplete sensation to pinprick at level T7-T10. He also had painless distention of the urinary bladder. After a few hours, the weakness in his limbs increased and his sensory level rose to C5 bilaterally. A horizontal diastatic fracture across the vertebral body of C7 was discovered on plain x-ray films of the spine, and an extradural hematoma extending dorsally from C5 to T1 was revealed by emergency magnetic resonance imaging. After an emergency decompressive cervical laminectomy and removal of the clot, the patient rapidly regained complete neurological function, except with regard to both the urinary bladder and the rectum, which remained abnormal for almost 7 weeks after the operation." }, { "id": "wiki20220301en551_27069", "title": "Glossary of medicine", "score": 0.009433962264150943, "content": "Back pain – is pain felt in the back. It is divided into neck pain (cervical), middle back pain (thoracic), lower back pain (lumbar) or coccydynia (tailbone or sacral pain) based on the segment affected. The lumbar area is the most common area for pain, as it supports most of the weight in the upper body. Episodes of back pain may be acute, sub-acute, or chronic depending on the duration. The pain may be characterized as a dull ache, shooting or piercing pain, or a burning sensation. Discomfort can radiate into the arms and hands as well as the legs or feet, and may include numbness, or weakness in the legs and arms. Basal Anatomy: In the direction of the base. Antonym apical. Physiology: Lowest sustained level or minimum level required, as in basal metabolic rate." }, { "id": "pubmed23n0600_15188", "title": "Cervical spine motion in manual versus Jackson table turning methods in a cadaveric global instability model.", "score": 0.009345794392523364, "content": "A study of spine biomechanics in a cadaver model. To quantify motion in multiple axes created by transfer methods from stretcher to operating table in the prone position in a cervical global instability model. Patients with an unstable cervical spine remain at high risk for further secondary injury until their spine is adequately surgically stabilized. Previous studies have revealed that collars have significant, but limited benefit in preventing cervical motion when manually transferring patients. The literature proposes multiple methods of patient transfer, although no one method has been universally adopted. To date, no study has effectively evaluated the relationship between spine motion and various patient transfer methods to an operating room table for prone positioning. A global instability was surgically created at C5-6 in 4 fresh cadavers with no history of spine pathology. All cadavers were tested both with and without a rigid cervical collar in the intact and unstable state. Three headrest permutations were evaluated Mayfield (SM USA Inc), Prone View (Dupaco, Oceanside, CA), and Foam Pillow (OSI, Union City, CA). A trained group of medical staff performed each of 2 transfer methods: the \"manual\" and the \"Jackson table\" transfer. The manual technique entailed performing a standard rotation of the supine patient on a stretcher to the prone position on the operating room table with in-line manual cervical stabilization. The \"Jackson\" technique involved sliding the supine patient to the Jackson table (OSI, Union City, CA) with manual in-line cervical stabilization, securing them to the table, then initiating the table's lock and turn mechanism and rotating them into a prone position. An electromagnetic tracking device captured angular motion between the C5 and C6 vertebral segments. Repeated measures statistical analysis was performed to evaluate the following conditions: collar use (2 levels), headrest (3 levels), and turning technique (2 levels). For all measures, there was significantly more cervical spine motion during manual prone positioning compared with using the Jackson table. The use of a collar provided a slight reduction in motion in all the planes of movement; however, this was only significantly different from the no collar condition in axial rotation. Differences in gross motion between the headrest type were observed in lateral bending (Foam Pillow&lt;Prone View, P=0.045), medial lateral translation (Foam Pillow&lt;Mayfield, P=0.032), and anterior posterior translation (Prone View&lt;Mayfield, P=0.030). The data suggest that the manual transfer technique produces 2 to 3 times more cervical spine angular motion than the Jackson table method of transfer. The use of a collar provides significant benefit in limiting spine motion that is only observed in axial rotation. Choice of headrest does have a significant effect on the amount of motion allowed during turning, with the Foam Pillow and Prone View generally providing more effective stabilization compared with the Mayfield." }, { "id": "InternalMed_Harrison_30827", "title": "InternalMed_Harrison", "score": 0.009345794392523364, "content": "Spondylotic myelopathy is one of the most common causes of chronic cord compression and of gait difficulty in the elderly. Neck and shoulder pain with stiffness are early symptoms; impingement of bone and soft tissue overgrowth on nerve roots results in radicular arm pain, most often in a C5 or C6 distribution. Compression of the cervical cord, which occurs in fewer than one-third of cases, produces a slowly progressive spastic paraparesis, at times asymmetric and often accompanied by paresthesias in the feet and hands. Vibratory sense is diminished in the legs, there is a Romberg sign, and occasionally there is a sensory level for vibration or pinprick on the upper thorax. In some cases, coughing or straining produces leg weakness or radiating arm or shoulder pain. Dermatomal sensory loss in the arms, atrophy of intrinsic hand muscles, increased deep-tendon reflexes in the legs, and extensor plantar responses are common. Urinary urgency or incontinence occurs in advanced cases, but" }, { "id": "wiki20220301en062_70616", "title": "Psoas major muscle", "score": 0.009259259259259259, "content": "For example, when one performs a sit-up that brings the torso (including the lower back) away from the ground and towards the front of the leg, the hip flexors (including the iliopsoas) will flex the spine upon the pelvis. Owing to the frontal attachment on the vertebrae, rotation of the spine will stretch the psoas. Clinical significance Tightness of the psoas can result in spasms or lower-back pain by compressing the lumbar discs. A hypertonic and inflamed psoas can lead to irritation and entrapment of the ilioinguinal and the iliohypogastric nerves, resulting in a sensation of heat or water running down the front of the thigh. Psoas can be palpated with active flexion of the hip. A positive psoas contracture test and pain with palpation reported by the patient indicate clinical significance. Care should be taken around the abdominal organs, especially the colon when palpating deeply." }, { "id": "InternalMed_Harrison_29591", "title": "InternalMed_Harrison", "score": 0.009259259259259259, "content": "Proper positioning of the patient is essential. The procedure should be performed on a firm surface; if the procedure is to be performed at the bedside, the patient should be positioned at the edge of the bed and not in the middle. The patient is asked to lie on his or her side, facing away from the examiner, and to “roll up into a ball.” The neck is gently ante-flexed and the thighs pulled up toward the abdomen; the shoulders and pelvis should be vertically aligned without forward or backward tilt (Fig. 443e-1). The spinal cord terminates at approximately the L1 vertebral level in 94% of individuals. In the remaining 6%, the conus extends to the L2–L3 interspace. LP is therefore performed at or below the L3–L4 interspace. A useful anatomic guide is a line drawn between the posterior superior iliac crests, which corresponds closely to the level of the L3–L4 interspace. The interspace is chosen following gentle palpation to identify the spinous processes at each lumbar level." }, { "id": "pubmed23n0847_6624", "title": "Epstein-Barr Virus-Associated Atraumatic Spleen Laceration Presenting with Neck and Shoulder Pain.", "score": 0.009174311926605505, "content": "Infectious mononucleosis, caused by the Epstein-Barr virus (EBV), is a common infection with worldwide distribution; more than 90% of people have been infected by adulthood. One of the most feared, albeit rare, complications, occurring in less than 0.5% of those infected, is splenic injury or rupture. A febrile 15-year-old male presented to the emergency department with the chief compliant of headache, neck pain, and upper shoulder pain. He did not recall any specific traumatic injury. His abdomen was soft, nondistended, and was tender in the right and left lower quadrants. Right lower quadrant ultrasound demonstrated non-visualization of the appendix, moderate right lower quadrant free fluid, and positive McBurney's sign. CT of the abdomen and pelvis was ordered, which demonstrated moderate splenomegaly, with findings compatible with laceration through the anterior aspect of the spleen, with moderate hemoperitoneum. Monospot was negative and EBV panel demonstrated IGG negative, IGM positive, and, IGG negative. The patient was transferred to interventional radiology for a splenic angiogram and proximal splenic artery embolization. The angiogram demonstrated grade 3 laceration with moderate hemoperitoneum and no active extravasation or evidence of pseudoaneurysm. The patient was admitted and made a prompt recovery without any other sequelae. The presentation of splenic injury or rupture can vary; the patient may complain of abdominal pain or left upper quadrant pain, may exhibit referred left shoulder pain when the LUQ is palpated (Kehr's Sign), or may exhibit hemodynamic instability. Given the spectrum of non-specific symptoms, diagnosing EBV-induced splenic laceration can be difficult." }, { "id": "Neurology_Adams_1643", "title": "Neurology_Adams", "score": 0.009174311926605505, "content": "patients with lumbar stenosis, neurologic symptoms persist without relation to body position. The process is distinguished from vascular claudication of the legs by its appearance in the standing position, the prominence of numbness in some cases, relief by bending forward at the waist and elongating the lumbar spine, and, of course, by the preservation of distal leg pulses and loss of ankle reflexes. This “claudication of the cauda equina” was known to Dejerine and described by van Gelderen in 1948, and it was shown by Verbiest to be caused not by ischemia but by encroachment on the cauda, for which reason his name has been attached to the claudication syndrome." }, { "id": "pubmed23n1029_22122", "title": "Effect of 5 different cervical collars on optic nerve sheath diameter: A randomized crossover trial.", "score": 0.00909090909090909, "content": "There is considerable evidence that prolonged use of cervical collars potentially cause detrimental effects including increase in optic nerve sheath diameter (ONSD) among healthy volunteers. Different types of cervical collars immobilize cervical spine variably well and may presumably differently influence the venous compression and hence the intracranial pressure. We therefore aimed to evaluate the influence of cervical spine immobilization with 5 different types of cervical collars on ONSD measured noninvasively by ultrasound on healthy volunteers. We conducted a randomized crossover trial including 60 adult healthy volunteers. Control assessment of the optic nerve sheath thickness was performed in both sagittal and transverse planes. Patient was placed supine on a transport stretcher, cervical collar was placed, and ONSD measurement was performed after 5 and 20 minutes. During the next days, the procedure was repeated with random allocation of participants and random cervical collar. Sixty healthy volunteers were included in our study. ONSD left diameter [mm] for the baseline was 3.8 [interquartile range (IQR): 3.65-3.93)] mm. Using AMBU after 5 min, ONSD was changed up to 4.505 (IQR 4.285-4.61; P &lt; .001) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.73 (IQR: 4.49-4.895; P &lt; .001) and 4.925 (IQR: 4.65-5.06; P &lt; .001), respectively. Necklite reported the lower change in ONSD: 3.92 (IQR: 3.795-4; P = 1.0) mm in 5 minutes and 3.995 (IQR: 3.875 - 4.1; P = 1.0) mm in 20 minutes. ONSD right diameter [mm] for the baseline was 3.8 (IQR 3.675-3.9) mm. Using AMBU after 5 minutes, ONSD was changed up to 4.5 (IQR 4.21-4.6) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.705 (IQR 4.455-4.9) and 4.93 (IQR 4.645-5.075), respectively. Necklite reported the lower change in ONSD -33.9 (IQR 3.795-3.99) mm in 5 minutes and 3.995 (IQR 3.86-4.09) mm in 20 minutes. We report significant increase of ONSD from the baseline after cervical collar placement among healthy volunteers at 5 minutes and 20 minutes interval. In addition, no significant difference was noted between ONSD measurements at 5 and 20 minutes. Clinicians should take proactive steps to assess the actual need of cervical collar case by case basis. Nonetheless, when needed, Necklite moldable neck brace seems to be a reasonable option.Registration: ClinicalTrials database (www.clinicaltrials.gov, NCT03609879)." }, { "id": "pubmed23n1091_10550", "title": "May-Thurner syndrome: A cause of unexplained unilateral leg edema.", "score": 0.00909090909090909, "content": "Physicians should be familiar with May-Thurner syndrome, characterized by the compression of the left common iliac vein by the right common iliac artery and the vertebral body, resulting in pain and swelling of the left lower extremity and DVT. A 64-year-old woman presented with unexplained edema in the left lower extremity. Computed tomography with contrast enhancement revealed that the left common iliac vein was compressed and narrowed by the right common iliac artery and the vertebral body, leading to the diagnosis of May-Thurner syndrome." }, { "id": "wiki20220301en020_102214", "title": "Stretcher", "score": 0.009009009009009009, "content": "Wheeled stretchers For ambulances, a collapsible wheeled stretcher, or gurney, is a type of stretcher on a variable-height wheeled frame. Normally, an integral lug on the stretcher locks into a sprung latch within the ambulance in order to prevent movement during transport, often referred to as antlers due to their shape. It is usually covered with a disposable sheet and cleaned after each patient in order to prevent the spread of infection. Its key value is to facilitate moving the patient and sheet onto a fixed bed or table on arrival at the emergency department. Both types may have straps to secure the patient. Other types of stretchers The Nimier stretcher (brancard Nimier) was a type of stretcher used by the French army during World War I. The casualty was placed on their back, but in a \"seated position\", (that is, the thighs were perpendicular to the abdomen). Thus, the stretcher was shorter and could turn in the trenches. This type of stretcher is rarely seen today." }, { "id": "wiki20220301en104_43735", "title": "Hip examination", "score": 0.009009009009009009, "content": "Special maneuvers Trendelenburg test/sign: Make sure pelvis is horizontal by palpating ASIS. Ask patient to stand on one leg and then on the other. Assess any pelvic tilt by keeping an index finger on each ASIS. Normal (Trendelenburg negative): In the one-legged stance, the unsupported side of the pelvis remains at the same level as the side the patient is standing or even rise a little, because of powerful contraction of hip abductors on the stance leg. Abnormal (Trendelenburg positive): In the one-legged stance, the unsupported side of the pelvis drops below the level as the side the patient isstanding on. This is because of (abnormal) weakness of hip abductors on the stance leg. The latter hip joint may therefore be abnormal." }, { "id": "pubmed23n1137_22164", "title": "A Case Report of Bilateral Calcaneal Spur Fracture after Fall from a Height.", "score": 0.008928571428571428, "content": "A calcaneal spur (also known as a heel spur) is a bony outgrowth from the calcaneal tuberosity. Calcaneal spurs are typically detected by X-ray examination. It is a form of exostosis, and it can be fractured as result of trauma as any other bone. An inferior calcaneal spur is located on the inferior aspect of the calcaneus and is typically a response to plantar fasciitis over a period but may also be associated with ankylosing spondylitis (typically in children). A posterior calcaneal spur develops on the back of the heel at the insertion of the Achilles tendon. The only abnormal physical sings are localized tenderness beneath the calcaneum, X-ray sometimes shows a bony spur projecting forward from the under surface of the calcaneal tuberosity. We report a -60-year-old male presented with painful swelling of both heels, after fall from height about 1-2 m, the patient had chronic plantar fasciitis. X-ray done, revealed bilateral calcaneal spur fracture (distal tip), associated with posterior calcaneal spur. The patient treated with well-padded posterior slab for 2-3 weeks, ice pack, analgesia, and non-weight bearing. A 60-year-old man had history of trauma (fall from height about 1-2 m) on his heels, he presented with painful swelling on both heels, with mild limitation of ankle movement. On examination, there were a tender, swelling, mild ecchymosis around the heels, with painful limitation of ankle motion, and pain on weight-bearing. Radiological examination was done for spine, pelvis, hips, all within normal, and ankle X-ray. A/P and lateral revealed bilateral fracture of calcaneal spur. The patient was treated with rest, elevation, ice pack ,and analgesia for 2-3 days, then applications of back slab for 2-3 weeks. By the end of 3rd weeks, the back slab was removed and continue crepe bandage and non-steroidal anti-inflammatory drugs. After 2-3 months of follow-up, the patient no longer had swelling and pain, only mild symptoms of painful heel syndrome. This article presents a rare case of bilateral calcaneal spur fracture in the patient with plantar fasciitis and calcaneal spur, following trauma to both heels, so an awareness of this condition as one of the differential diagnoses of painful heels following trauma." }, { "id": "pubmed23n0344_1642", "title": "[What is your diagnosis? Aneurysm of the abdominal aorta destroying the lumbar spine].", "score": 0.008928571428571428, "content": "A 58 year old woman suffering from lumbalgia over 3 years is admitted for bilateral cruralgia. Ten years before, she was treated for cervix carcinoma by hysterectomy, pelvic and lumbo-aortic radiotherapy and chemotherapy. On admission, physical examination reveals L2 level hypoesthesia and abolition of deep tendon reflexes. Plain films and CT scan show a lysis of L3, L4 and L5 vertebral bodies and a cuneiform appearance of vertebral body of L2 due to a large abdominal aortic aneurysm." }, { "id": "pubmed23n1130_5605", "title": "Intraspinal periosteal chondroma in upper thoracic spine causing cord compression and myelopathy: A case report.", "score": 0.008849557522123894, "content": "Chondromas are slow-growing cartilage-forming benign tumors, rarely occurring in the spine. Generally, most spinal chondromas are asymptomatic; however, with slow progressive growth, these lesions may enlarge and expand and cause compressive neurological symptoms, resulting in radiculopathy or more commonly myelopathy due to direct neural compression. A 15-year-old male adolescent presented to Emergency Department with history of fall (slippage) on concrete ground while playing three months back. On neurological examination, the motor power in bilateral upper limbs was 5/5 while it was 1/5 in both lower extremities. Some muscle wasting was noted in the lower limbs. The planter reflexes were upgoing; and the sensory loss was below T6 spinal level. CT scan of dorsolumbar spine demonstrated a well-defined high-density lesion in lateral aspect of spinal canal at T2-T3 vertebral level adjacent to left T2-T3 facet joint. MRI of dorsal spine revealed a 3 × 2 × 1 cm<sup3</sup-sized, well-defined, non-enhancing T1 low to isointense and T2/STIR heterogeneous hyperintense lesion with osseous and cartilaginous components in the left lateral aspect of spinal canal at T1-T3 level, causing compression and contralateral displacement of spinal cord. The patient was then subjected to posterior laminectomy, complete excision, followed by laminoplasty using minicranial plates and screws. Histopathology of the mass showed bony trabeculae with hematopoietic elements and attached lobules of hyaline cartilage, chondroid matrix and lobules of mature chondrocyte and myxoid changes. Postoperatively his power was improved slightly and he was able to stand up with some assistance. On six-month follow up, patient showed significant neurological improvement. He was able to walk independently with minimal assistance. He was able to control bowel and bladder functions. Chondromas occurring in the spine are rare, accounting for only about 3% of all chondromas. Spinal chondromas are commonly encountered in the thoracic spine as in our case. Complete en bloc surgical excision is generally recommended as the treatment of choice for cases with local and/or neurological symptoms." }, { "id": "wiki20220301en011_28665", "title": "Embalming", "score": 0.008849557522123894, "content": "and tibial vessels if necessary) are used. The corresponding veins are commonly also raised and utilized for drainage. Cases where more than one vessel is raised are referred to as multiple-point injection, with a reference to the number of vessels raised (i.e. a six-point injection or six-pointer). As a general rule, the more points needing to be raised, the greater the difficulty of the case. In some cases draining from a different site from injection (i.e. injecting arterial fluid into the right common carotid artery and draining from the right femoral vein) is referred to as a split (or sometimes cut) injection. In certain cases the embalmer may deem it necessary to perform a restricted cervical injection, which involves injecting the head of the deceased separately from the rest of body. This is done in cases where distention (swelling) has a greater chance of occurring. In many cases, an embalmer may select to perform what is known as a pre-injection. A pre-injection is a" }, { "id": "wiki20220301en131_44115", "title": "Campomelic dysplasia", "score": 0.008771929824561403, "content": "Signs and symptoms While the definitive presentation of the disease is a patient having bowed lower limbs and sex reversal in 46,XY males, there are other clinical criteria that can be used, absent these characteristics, to make the diagnosis. Patients may present with shortened and angulated lower limbs, a vertically oriented and narrow pelvis, an enlarged head, an undersized jaw, cleft palate, flat nasal bridge, low set ears, club feet. On radiographs, underdeveloped shoulder blades, dislocated hips, hypoplastic vertebral pedicles in the thoracic region, 11 pairs of ribs instead of 12, or kyphosis of the cervical spine are useful diagnostic clues. Respiratory distress can be caused by an underdeveloped trachea which collapses on inhalation or by insufficient rib cage development." }, { "id": "pubmed23n0073_2261", "title": "The sensitivity and specificity of seven lumbo-pelvic orthopedic tests and the arm-fossa test.", "score": 0.008771929824561403, "content": "Twenty-nine lumbosacral asymptomatic and 39 symptomatic patients who attended a chiropractic clinic were examined by a practitioner who was blinded to their symptoms. Seven lumbosacral orthopedic tests, along with the arm-fossa test were scrutinized for sensitivity, specificity and diagnostic competency values. Only the arm-fossa test and heel-buttock tests had a significantly higher percentage of positive findings in symptomatic than asymptomatic cases. These same tests were the only ones which could be considered to have an acceptable diagnostic value, when both the sensitivity and specificity were taken into consideration by Youden's index. The number of positive tests was unrelated to the presence of lumbosacral symptoms. Orthopedic tests which appeared to strain several adjacent anatomical structures were most commonly positive. No particular combination of tests could predict if the patient was symptomatic or asymptomatic. Only the heel-buttock test had some predictive value. It appears that these tests were of limited value in differentiating between the symptomatic and asymptomatic subjects who attended the study clinic." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 200 ] ], "word_ranges": [ [ 0, 34 ] ], "text": "In this case we describe a case of cervicobrachialgia without alarm signs at the present time, so the most indicated treatment at this time would be conservative, based on NSAIDs, local heat and rest." }, "2": { "exist": true, "char_ranges": [ [ 201, 260 ] ], "word_ranges": [ [ 34, 47 ] ], "text": "This is not an urgent case, so answer 2 would not be valid." }, "3": { "exist": true, "char_ranges": [ [ 261, 540 ] ], "word_ranges": [ [ 47, 95 ] ], "text": "The performance of an MRI and an electromyogram are valid options for the etiological study of the picture, however, it is necessary to emphasize that we should first perform a correct pain management, so since we are asked about the first attitude, option 1 would be more valid." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Conservative treatment with non-steroidal anti-inflammatory drugs, local heat and relative rest.", "2": "Urgent call to the neurosurgeon for surgical evaluation.", "3": "Preferential request for MRI and electromyogram.", "4": "Preferential referral to traumatology outpatients.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0938_6536", "title": "Sudden Onset of Severe Cervical Pain in an Adolescent Girl: Case Report and Review of Literature.", "score": 0.01890999910801891, "content": "A previously healthy 13-year-old girl presented with a 9-day history of acute onset severe neck pain associated with limited range of movement. Medical evaluation at day 2 was suggestive of muscle contracture, and she was discharged home with diazepam, antiinflammatory agents, and rest; however, she returned because of progressive clinical worsening with left arm distal paresthesia and paralysis since day 3. There was no history of trauma or other systemic complaints, and her familial medical history was unremarkable.Physical examination revealed left cervical and paravertebral tenderness on palpation with severe limitation of cervical and trunk movements; neurologic examination revealed left forearm and hand weakness and paralysis (grade II/V) with thenarhypothenar atrophy. Laboratory studies including coagulation profile were normal. Magnetic resonance imaging revealed an epidural hematoma from C4-T1 without underlying cause apparent on magnetic resonance angiography. On day 12, she underwent C3-7 laminotomy with laminoplasty and complete drainage of the hematoma. After 5 months of follow-up, she displays no neurological deficits. The spontaneous spinal epidural hematoma is a rare neurosurgical emergency in children. It usually presents acutely with neurologic deficits, but the initial presentation may be atypical or insidious, delaying diagnosis and intervention. Definitive diagnosis is made by magnetic resonance imaging and implies a high index of suspicion. Surgical drainage of the hematoma is the mainstay of treatment with favorable prognosis even in cases with a delayed diagnosis." }, { "id": "wiki20220301en050_22369", "title": "Stinger (medicine)", "score": 0.013875598086124402, "content": "Diagnosis and treatment Stingers are best diagnosed by a medical professional. This person will assess the athlete's pain, range of head and neck motion, arm numbness, and muscle strength. Often, the affected athlete is allowed to return to play within a short time, but persistent symptoms will result in removal. Athletes are also advised to receive regular evaluations until symptoms have ceased, specifically, the restoration of pain-free mobility. If they have not after two weeks, or increase, additional tests such as magnetic resonance imaging (MRI) can be performed to detect a more serious injury, such as a herniated disc. The order of treatments applied depends on whether the athlete's main complaint is pain or weakness. Both can be treated with an analgesic, anti-inflammatory medication, ice and heat, restriction of movement, and if necessary, cervical collar or traction. Surgery is only necessary in the most severe cases." }, { "id": "Neurology_Adams_1692", "title": "Neurology_Adams", "score": 0.011479591836734693, "content": "A common cause of neck, shoulder, and arm pain is disc herniation in the lower cervical region; the process is comparable to disc herniation in the lumbar region but gives rise, of course, to a different set of symptoms (Table 10-1). The problem appears most often without a clear and immediate cause, but it may develop after trauma, which may be major or minor (from sudden hyperextension of the neck, falls, diving accidents, forceful manipulations as discussed by Kristoff and Odom). The roots most commonly involved are the seventh (in 70 percent of cases) and the sixth (in 20 percent of cases); fifthand eighth-root compression makes up the remaining 10 percent (Yoss et al). The clinical diagnosis is established by a fairly discrete distribution of pain or paresthesias that corresponds to a single cervical root, reflex loss in the segment of the root, and by elicitation of exaggerated root pain with mechanical tests such as the Spurling maneuver, in which the examiner exerts downward" }, { "id": "pubmed23n0628_22580", "title": "[Hyperextension trauma in patients with cervical spondylosis].", "score": 0.010723937668909205, "content": "PURPOSE OF THE STUDY To evaluate retrospectively a group of patients with hyperextension injury to the cervical spine who were treated at the Department of Spinal Surgery of the University Hospital in Motol, Prague, between 2003 and 2006. MATERIAL The group comprised 22 patients, 17 men (77 %) and five women (23 %) in the age range of 35 to 81 years, with an average of 59.5 years. All patients had, in association with the injury, neurological deficit of varying degree. METHODS All patients underwent X-ray and magnetic resonance imaging examination and received methylprednisolone according to the National Acute Spinal Cord Injury Study (NASCIS) 2 trial. Eleven patients had urgent surgery within 24 hours of injury; eight patients were operated on within an interval of 3 days to 2 months because of the seriousness of their state and multiple morbidity; and three patients were treated conservatively. Neurological deficit in terms of upper- and lower-limb mobility was evaluated by the American Spinal Injury Association (ASIA) motor score. The values obtained for the urgently operated patients and for those operated on after a time interval were compared by Wilcoxons two-sample test. The other aspects evaluated included trauma aetiology, level of spinal cord injury, manner of treatment, and intra-operative and post-operative complications. RESULTS The most frequent cause of injury was a low-height fall (13 patients; 59 %); car accidents ranked second (9 patients; 41 %). In five patients (22.7 %) ebriety was found. Eighteen patients had no skeletal injury (81.8 %). Four patients (18.2 %). Four patients (18.2 %) suffered fractures of articular or spinous processes, but the anterior column skeleton was intact in all. The segment most frequently affected by myopathy was C3-C4, then C4-C5 and C5-C6. Decompression was carried out to the extent of myopathy; and in the adjacent segments only if significant stenosis was present. In both subgroups of surgically treated patients (urgent and delayed management), comparisons of the ASIA scores at the time of injury and at one-year follow-up showed no significat improvement in post-operative mobility, as evaluated by Wilcoxons two-sample test at a level of significance a = 5 %. No intra-operative or post-operative complications, except for early death, were recorded. In all patients the wound healed by first intention and no loosening of instrumentation was foud on follow-ups at the out-patient departments. DISCUSSION Although the greatest narrowing of the spinal canal due to spondylosis occurs at the C5-C6 segment, the C4-C5 segment sustained most injuries. Although some relevant papers report no significant difference in improved neurological deficit between patients treated surgically and those undergoing conservative therapy, we prefer surgical management, in most of the cases from the anterior approach, which allows us to remove dorsal osteophytes and perform careful decompression to prevent damage to nerve structures and to preserve those which are still intact. There was no significant difference in the outcome between urgent and delayed trauma management, which is unusual amongst other injuries associated with neurological lesions and this indicates that the timing of surgery must be strictly individual and should be carried out at a time when operative benefit outweighs operative burden. The surgical treatment used should, in the first place, lead to early recuperation and rehabilitation. CONCLUSIONS Hyperextension injuries of the cervical spine are usually associated with serious neurological deficit. A correct algorithm of examination will result in good treatment outcomes. However, these injuries require a therapy that is long-lasting and difficult, with a need for cooperation of anaesthesiologists, spinal surgeons, physical therapists and, last but not least, psychologists. Key words: cervical spine, hyperextension injury, spondylosis, myelopathy." }, { "id": "article-19244_2", "title": "Cervical Radiculopathy -- Introduction", "score": 0.010347417840375586, "content": "Neck pain is a common condition that can cause significant discomfort and disability in patients of different ages. Workers who have experienced neck pain account for up to 40% of work absenteeism. [1] [2] [3] Cervical radiculopathy, on the other hand, is a condition where the nerve root of a spinal nerve is compressed or impaired, causing the pain and symptoms to spread beyond the neck and radiate to other areas of the body, such as the arms, neck, chest, upper back, and shoulders. Due to the nerve impingement, muscle weakness and impaired deep tendon reflexes are often observed." }, { "id": "article-19241_6", "title": "Cervical Myofascial Pain -- History and Physical", "score": 0.010257687604728047, "content": "The history of a patient presenting with the cervical myofascial syndrome can vary greatly. Patients can sometimes present with a history of acute trauma, or the pain may be insidious. Symptoms may be worse with repetitive tasks, certain movements, or even certain postural positions throughout the day. The pain can be nagging or acute, and it can be local or radiate out from the neck to the surrounding area. The range of motion of the cervical spine may be limited and painful, and the patient may also complain of some tightness or a local twitch response, similar to a spasm. Generally, the area is tender to palpation and can be described as deep, and constant. On physical exam, poor posture may be noted, with slumped shoulders or decreased cervical lordosis. No atrophy should be noted in cervical musculature. On palpation, finding trigger points in the area of pain is very likely. A trigger point is an area of hyperirritability that radiates pain when palpated. A taut band may be noted in the skeletal muscle or surrounding fascia. [4] Limitation of the range of motion of the cervical spine may be associated. The neurological exam, including strength, sensation, and reflexes of the upper extremities will be normal." }, { "id": "InternalMed_Harrison_1577", "title": "InternalMed_Harrison", "score": 0.009900990099009901, "content": "The natural history of neck pain with acute radiculopathy due to disk disease is favorable, and many patients will improve without specific therapy. Although there are no randomized trials of NSAIDs for neck pain, a course of NSAIDs, acetaminophen, or both, with or without muscle relaxants, is reasonable as initial therapy. Other nonsurgical treatments are commonly used, including opioid analgesics, oral glucocorticoids, cervical traction, and immobilization with a hard or soft cervical collar. However, there are no randomized trials that establish the effectiveness of these treatments. Soft cervical collars can be modestly helpful by limiting spontaneous and reflex neck movements that exacerbate pain." }, { "id": "pubmed23n1155_11644", "title": "Spinal Cord Injury and Postdural Puncture Headache following Cervical Interlaminar Epidural Steroid Injection: A Case Report.", "score": 0.00980392156862745, "content": "<iBackground</i: Cervical interlaminar epidural steroid injection (CIESI) is increasingly used as an interventional treatment for pain originating from the cervical spine. However, serious neurological complications may occur during CIESI because of direct nerve damage following inappropriate needle placement. <iCase report</i: A 35-year-old woman presented with posterior neck pain radiating to the left upper arm. Cervical magnetic resonance imaging (MRI) revealed left C6 nerve impingement. CIESI under fluoroscopic guidance was performed at another hospital using the left C5/6 interlaminar approach. Immediately after the procedure, the patient experienced dizziness, decreased blood pressure, motor weakness in the left upper arm, and sensory loss. She visited our emergency department with postdural puncture headache (PDPH) that worsened after the procedure. Post-admission cervical MRI revealed intramedullary T2 high signal intensity and cord swelling from the C4/5 to C6/7 levels; thus, a diagnosis of spinal cord injury was made. The patient's PDPH spontaneously improved after 48 h. However, despite conservative treatment with steroids, the decrease in abduction of the left fifth finger and loss of sensation in the dorsum of the left hand persisted for up to 6 months after the procedure. As noticed in the follow-up MRI performed 6 months post-procedure, the T2 high signal intensity in the left intramedullary region had decreased compared to that observed previously; however, cord swelling persisted. Furthermore, left C7/8 radiculopathy with acute denervation was confirmed by electromyography performed 6 months after the procedure. <iConclusions</i: Fluoroscopy does not guarantee the prevention of spinal cord penetration during CIESI. Moreover, persistent neurological deficits may occur, particularly due to intrathecal perforation or drug administration during CIESI. Therefore, in accordance with the recommendations of the Multisociety Pain Workgroup, we recommend performing CIESI at the C6/7 or C7/T1 levels, where the epidural space is relatively large, rather than at the C5/6 level or higher." }, { "id": "article-19244_7", "title": "Cervical Radiculopathy -- History and Physical", "score": 0.00980392156862745, "content": "When performing a physical examination, it is crucial to position the patient in a way that allows for the isolation of individual reflex arcs. This helps accurately assess the patient's overall reflex response. Given the individual variation in deep tendon reflexes, comparing both sides of the neck is more important than overall magnitude. If there is nerve impingement, the affected side is reduced relative to the unaffected side. Reduced muscle strength, innervated by the affected nerve, is a significant physical sign." }, { "id": "pubmed23n0930_14385", "title": "Nicolau's syndrome: A rare but preventable iatrogenic disease.", "score": 0.009708737864077669, "content": "Dear Editor, Nicolau's syndrome, also called embolia cutis medicamentosa or livedoid dermatitis, is a rare injection site reaction characterized by immediate intense pain at the injection site followed by erythema and a hemorrhagic patch with a livedoid reticular pattern after injections of non-steroidal anti-inflammatory drugs (NSAIDS), antiepileptics, antibiotics, antihistaminics, corticosteroids, etc. (1). To the best of our knowledge, only one case of Nicolau's syndrome has been reported after the use of triamcinolone acetonide. Herein we report two cases of Nicolau's syndrome caused by intramuscular injections of triamcinolone acetonide and diclofenac sodium, respectively. CASE 1 A 24-year-old male patient presented with severe pain and bluish discoloration of the right arm for 2 days, which he had noticed shortly after receiving an intramuscular injection of triamcinolone for recurrent episodes of urticaria by a local practitioner in the right deltoid region. On examination, there was a livedoid pattern of non-blanchable, violaceous discoloration extending from the deltoid area to the distal third of the forearm with associated induration (Figure 1, a, b). The local area was warm and tender to the touch. There was no regional lymphadenopathy, and the rest of the examination was normal. The patient's platelet count, bleeding and clotting times, prothrombin time, and international normalized ratio (INR) were unremarkable. There was no previous history of any bleeding disorder. The patient denied any intake of drugs like aspirin, warfarin, etc. Subsequently, the patient developed an ulcer on the forearm, which was managed by topical and systemic antibiotics to prevent any secondary infection of the wound. CASE 2 A 40-year-old female patient presented with complaints of pain and discoloration of the left gluteal region after receiving an intramuscular injection of diclofenac sodium for her arthralgia. A large ecchymotic patch with reticular borders was found on the gluteal region, extending to the lateral aspect of thigh (Figure 2). It was tender to the touch, non-indurated, and the local temperature was raised. There was no regional lymphadenopathy. No other abnormality was detected on examination. All routine investigations were within normal limits. Platelet count, bleeding, clotting and prothrombin times, and international normalized ratio (INR) were within normal limits. The lesions resolved within few weeks without any complications. Nicolau syndrome was first described in the early 1920s by Freudenthal and Nicolau as an adverse effect of using intramuscular injections of bismuth salts in the treatment of syphilis. Since then, several case reports of this disease occurring after intramuscular, intra-articular, intravenous, and subcutaneous injections have appeared in the literature associated with a variety of drugs like NSAIDs, vitamin K, penicillin, antihistamines, corticosteroids, local anesthetics, vaccines, polidocanol, and pegylated interferon alpha (1). The pathogenesis of Nicolau syndrome is unknown, though intra and periarterial injection of the drug is a possible cause. Stimulation of the sympathetic nerve due to periarterial injection causes spasms and consequent ischemia. Inadvertent intra-arterial injections may cause emboli and occlusion. A lipophilic drug may penetrate the vessel and produce physical occlusion like fat embolism. Cytotoxic drugs may produce perivascular inflammation and ischemic necrosis. NSAIDs are believed to additionally induce ischemic necrosis due to their inhibition of cyclooxygenase and, consequently, prostaglandins (2). The clinical features of the disease have been divided into three phases in a review by Kim et al. (3). The authors describe an initial phase characterized by intense pain with subsequent erythema. This is followed 1-3 days later by an acute phase, when an indurated, tender plaque with livedoid pattern develops. The final phase occurs between 5 days and 2 weeks later. Necrosis ensues in this stage, with possible ulceration. Diagnosis is chiefly clinical, and histopathology shows necrotic changes and vascular thrombosis. However, a biopsy was not performed in our cases because both lesions were painful. Management strategies are variable and range from conservative management with analgesics and antibiotics to active surgical debridement (4). Complications include deformities, contractures or even death. The patient in our first case developed ulceration which healed normally, while the second case resolved without any complications. Nicolau syndrome can be avoided by precautions such as aspirating the needle before injecting to check for blood, use of Z-track injection technique, proper site of injection, avoiding large doses at a single site, and regular change of sites if multiple injections are to be given (5). Nicolau syndrome is a rare disease. There are a few case reports of it occurring after diclofenac injection (1-5). We could only find one case report of this syndrome after intramuscular injection (IM) of triamcinolone in a patient with lichen planus (3), and our case is the second reported case of this syndrome as a result of triamcinolone acetonide injection, which adds to the significance to the present article." }, { "id": "pubmed23n0573_731", "title": "[A case of delayed cervical epidural hematoma with C5 nerve root palsy after posterior cervical laminoplasty].", "score": 0.009708737864077669, "content": "Delayed postoperative spinal epidural hematoma (DPSEH) is a rare and potentially devastating complication of laminoplasty, and cervical nerve root palsy occurs more frequently than DPSEH, especially with C5 nerve root palsy. The authors describe a case of DPSEH with C5 nerve root palsy that developed in a patient 3 days after he underwent laminoplasty. In this case, a 78-year-old man with a history that having taken Aspirin without the doctor's instruction for 5-6 years, he underwent cervical laminoplasty for mild myelopathy. On the 3rd postoperative day, he complained of weakness of his left upper extremity and could not raise his left arm. The symptom aggravated in the next few days. On the 9th postoperative day, there was an obvious motor deficit of both upper and lower extremities. Magnetic resonance imaging demonstrated abnormal signal characteristics consistent with a hematoma at levels C3-C4, compressing spinal cord. The clot was evacuated during emergency revision surgery, and the postoperative course after the operation was uneventful and the muscle strength was improved five days later. Therefore, the symptoms of DPSEH are not so typical that its possibility should be kept in mind. Sometimes a differential diagnosis should be made with C5 nerve root palsy which may only represent weakness of upper extremities. The authors recommend that magnetic resonance imaging is helpful for the diagnosis of DPSEH and a revision surgery should be taken as soon as possible once the hematoma causing the neurologic deterioration was confirmed." }, { "id": "pubmed23n0794_24328", "title": "The potential contributing effect of ketorolac and fluoxetine to a spinal epidural hematoma following a cervical interlaminar epidural steroid injection: a case report and narrative review.", "score": 0.009615384615384616, "content": "Cervical interlaminar epidural steroid injections (ESIs) are commonly performed as one part of a multi-modal analgesic regimen in the management of upper extremity radicular pain. Spinal epidural hematoma (SEH) is a rare complication with a reported incidence ranging from 1.38 in 10,000 to 1 in 190,000 epidurals. Current American Society of Regional Anesthesia (ASRA), American Society of Interventional Pain Physicians (ASIPP), and the International Spine Intervention Society (ISIS) recommendations are that non-steroidal anti-inflammatory drugs (NSAIDs) do not need to be withheld prior to epidural anesthesia. We report a case wherein intramuscular ketorolac and oral fluoxetine contributed to a SEH and tetraplegia following a cervical interlaminar (ESI). A 66 year-old woman with chronic renal insufficiency and neck pain radiating into her right upper extremity presented for evaluation and was deemed an appropriate CESI candidate. Cervical magnetic resonance imaging (MRI) revealed multi-level neuroforaminal stenosis and degenerative intervertebral discs. Utilizing a loss of resistance to saline technique, an 18-gauge Tuohy-type needle entered the epidural space at C6-7. After negative aspiration, 4 mL of saline with 80 mg of methyl-prednisolone was injected. Immediately thereafter, the patient reported significant spasmodic-type localized neck pain with no neurologic status changes. A decision was made to administer 30 mg intramuscular ketorolac as treatment for the spasmodic-type pain. En route home, she developed a sudden onset of acute tetraplegia. She was brought to the emergency department for evaluation including platelet and coagulation studies which were normal. MRI demonstrated an epidural hematoma extending from C5 to T7. She underwent a bilateral C5-T6 laminectomy with epidural hematoma evacuation and was discharged to an acute inpatient rehabilitation hospital. Chronic renal insufficiency, spinal stenosis, female gender, and increasing age have been identified as risk factors for SEH following epidural anesthesia. In the present case, it is postulated that after the spinal vascular system was penetrated, hemostasis was compromised by the combined antiplatelet effects of ketorolac, fluoxetine, fish oil, and vitamin E. Although generally well tolerated, the role of ketorolac, a potent anti-platelet medication used for pain relief in the peri-neuraxial intervention period, should be seriously scrutinized when other analgesic options are readily available. Although the increased risk of bleeding for the alternative medications are minimal, they are nevertheless well documented. Additionally, their additive impairment on hemostasis has not been well characterized. Withholding NSAIDs, fluoxetine, fish oil, and vitamin E in the peri-procedural period is relatively low risk and should be considered for all patients with multiple risk factors for SEH. " }, { "id": "pubmed23n0069_11718", "title": "[Acute radicular paralysis of arm and hand].", "score": 0.009615384615384616, "content": "Patients with cervical radicular lesions present themselves with neck pain and stiffness on the one side and with neurological deficits of radicular distribution on the other side. The most frequent cause is a root compression due to a herniated disk or spondylotic changes of the spine. The management of the patients and the differential diagnosis are discussed." }, { "id": "pubmed23n0842_9815", "title": "[Pediatric intervertebral disc calcification: A rare cause of acquired torticollis. Case report].", "score": 0.009523809523809525, "content": "Pain and cervical muscle spasm are common reasons why parents bring children to the pediatric emergency department. The first steps are the gathering of medical history of the patient and a physical examination. If musculoskeletal damage is suspected, cervical spine x-rays should be obtained. An intervertebral disc calcification finding, in the absence of other radiological lesions should suggest pediatric intervertebral disc calcification. To present a case of intervertebral disc calcification, a rare condition that must be considered in the differential diagnosis of torticollis and neck pain in childhood. A seven-year-old male patient without morbid history and no history of trauma or rough sport practice. He consulted the emergency room for pain and cervical contracture for the last six days. C reactive protein and red cell sedimentatio rates were slightly elevated. Imaging studies showed calcification of the C5-C6 intrvertebral disc and anterior disc protrusion. The patient was hospitalized for evaluation and pain management, with good clinical response and continue afterwards with non-steroidal anti-inflammatory drugs and a soft collar. At the 6-month-follow up, the patient had resolved symptoms and calcifications. Pediatric intervertebral disc calcification is a rare cause of acquired torticollis, with a benign and self-limited outcome. Conservative management, as well as clinical and imaging follow-up is recommended." }, { "id": "wiki20220301en001_83509", "title": "Radium", "score": 0.009523809523809525, "content": "History" }, { "id": "wiki20220301en162_876", "title": "Vertebral compression fracture", "score": 0.009433962264150943, "content": "Diagnosis Compression fractures are usually diagnosed on spinal radiographs, where a wedge-shaped vertebra may be visible or there may be loss of height of the vertebra. In addition, bone density measurement may be performed to evaluate for osteoporosis. When a tumor is suspected as the underlying cause, or the fracture was caused by severe trauma, CT or MRI scans may be performed. Treatment Conservative treatment Back brace for support while the bone heals—either a Jewett brace for relatively stable and mild injuries, or a thoracic lumbar sacral orthosis (TLSO) for more severe ones. Opioids or non-steroidal anti-inflammatory drugs (NSAIDs) for pain. For osteoporotic patients, calcitonin may be helpful. Surgical Kyphoplasty and vertebroplasty are minimally invasive procedures that inject cement into the bone of the back that is fractured. However, the data examining the effectiveness of these procedures is mixed. References Further reading" }, { "id": "pubmed23n1148_1011", "title": "Diagnostic Uncertainty in Cervical Radiculopathy.", "score": 0.009433962264150943, "content": "Cervical radiculopathy is defined as a pathological process affecting the cervical nerve root(s). While not an uncommon entity, this report describes a case of cervical radiculopathy in an active duty Marine with unique features to include the C5 nerve root as the primary point of injury with corresponding severe motor weakness that warranted expedited workup. This expedited workup included early referral to Neurology for nerve conduction and electromyography (EMG) studies that were ultimately diagnostic in the setting of equivocal Magnetic Resonance Imaging findings. This highlight of this case is the demonstration of the utility of EMG in cervical radiculopathy evaluation, which aided in an efficient and effective treatment course. We contend that in cases of cervical radiculopathy with a focal deficit of profound weakness with shoulder abduction and elbow flexion, obtaining nerve conduction studies and EMGs within the first 4 to 6 weeks of presentation should be viewed as essential for the long-term recovery and effective management of the injured service member, particularly when injury to the upper trunk of the brachial plexus can also account for these specific motor deficits. This report will cover a brief review of the pathophysiology, evaluation, and natural history of cervical radiculopathy with special attention paid to the timing and efficacy of EMG." }, { "id": "pubmed23n1138_15678", "title": "Contralateral Recurrence of a Lumbar Juxtafacet Cyst Following Spontaneous Resolution.", "score": 0.009345794392523364, "content": "We present a patient who had spontaneous resolution of a right L3/4 lumbar juxtafacet cyst (LJFC); and in whom, 2.5 years after regression of the previous cyst, a new contralateral L3/4 LJFC developed. Furthermore, with an extensive review, we discuss the selection criteria for patients for conservative treatment. A 44-year woman presented with right leg pain for two months. Neurological examination findings were normal; however, hypoesthesia was observed in right L4. There was no medical history of any trauma or a specific condition. Magnetic resonance imaging (MRI) revealed a right L3/4 LJFC and L4/5 spondylolysis. The patient refused surgical treatment and was referred to a physical therapy department. A non-steroidal anti-inflammatory drug was administered for four weeks. At two months' follow-up, her leg pain was relieved. After 2.5 years, she was readmitted due to radiating left leg pain. The MRI showed regression of the previous right L3/4 LJFC and a newly formed left L3/4 LJFC. Thus, cyst excision and posterior fusion were performed. The symptoms were resolved immediately following the surgery and the patient continued to be symptom-free at a one-year follow-up. In the setting of significant instability, conservative treatment for LJFCs can still be beneficial; however, its role in preventing recurrence of LJFCs may be inadequate. In such patients, early surgical correction of instability may result in better long-term outcomes. Key Words: Degeneration, Juxtafacet cyst, Recurrence, Spinal instability, Spontaneous resolution." }, { "id": "InternalMed_Harrison_31118", "title": "InternalMed_Harrison", "score": 0.009345794392523364, "content": "lumbosacral radiculoplexus neuropathy, some patients develop thoracic radiculopathy or, even less commonly, a cervical polyradiculoneuropathy. CSF protein is usually elevated, while the cell count is normal. ESR is often increased. EDx reveals evidence of active denervation in affected proximal and distal muscles in the affected limbs and in paraspinal muscles. Nerve biopsies may demonstrate axonal degeneration along with perivascular inflammation. Patients with severe pain are sometimes treated in the acute period with glucocorticoids, although a randomized controlled trial has yet to be performed, and the natural history of this neuropathy is gradual improvement." }, { "id": "pubmed23n1163_12266", "title": "Cervical Spondylosis as a Hidden Contributing Factor to Fibromyalgia: A Case Report.", "score": 0.009259259259259259, "content": "The present case study describes the long-term symptomatic remission in a patient with fibromyalgia (FM) after multimodal spinal manipulation. A 44-year-old woman presented with a chronic headache, severe neck pain, shoulder pain, and back pain lasting for 2 years after experiencing domestic violence. She had sleep disorders, fatigue, and depressive mood. Her primary care physician diagnosed her with FM and comorbid depression. Despite treatment with non-steroidal anti-inflammatory drugs, muscle relaxants, anti-depressants, anti-epileptics, acupuncture, and aqua-therapy, she experienced no appreciable relief from her symptoms. The patient then sought a chiropractic evaluation and potential treatment for her symptoms. At presentation, widespread tenderness was palpable over the neck, shoulder, back, anterior chest, abdominal wall, and buttock. Radiographs showed loss of cervical lordosis, widespread degenerative spondylosis, and osteitis pubis. Surface electromyography (sEMG) revealed neck and thoracic paraspinal muscular spasms. The patient was diagnosed with FM based on the American College of Rheumatology diagnostic criteria and the associated comorbidities. Multimodal chiropractic approaches, which consisted of spinal manipulation, massage, and intermittent motorized cervical traction, were used twice weekly to relieve soft-tissues and intervertebral joints and stretch core musculatures. The patient's physical and mental complaints were mostly resolved near the end of 9 months of treatment. Her symptom alleviation was associated with corresponding change in normalized sEMG signal and cervical spine realignment at the 16th- and 26th-month follow-ups. Widespread pain in FM can lead to confused thinking and a lack of awareness of cervical spondylosis. In this example, it is assumed that the noxious cervical inputs triggered an ongoing FM process. Chiropractic treatment blocked noxious inputs coming from pain sources, corrected pain thresholds, and lowered excitability, thereby eradicating FM symptoms." }, { "id": "pubmed23n0836_18100", "title": "[Cervical radiculopathy].", "score": 0.009259259259259259, "content": "Cervical radiculopathy is a common cause of pain in the arm. It is caused by nerve root compression in the neck, as a consequence of a herniated disc, or spondyliotic foraminal stenosis. It causes severe pain, especially during the first few weeks, and paraesthesias in the forearm and hand. Patients also suffer from neck pain and loss of strength in the relevant arm. The arm pain can be exacerbated by certain movements of the head; these should be avoided as much as possible. Diagnosis can be made on the basis of history and physical examination. The pain generally disappears without active patient treatment. A semi-rigid cervical collar is recommended to accelerate pain relief. In cases of persistent pain, surgery will be considered. In such cases an MRI should be performed to show the cause and level of nerve root compression. " }, { "id": "pubmed23n1046_22458", "title": "Acute Calcific Tendonitis of the Longus Colli: An Uncommon Cause of Neck Pain in the Emergency Department.", "score": 0.009174311926605505, "content": "The longus colli muscle has three major parts that originate and insert in the upper cervical and thoracic spine. It is a weak flexor of the neck, and when contracted also serves to rotate the neck to the ipsilateral side. It is innervated by the anterior rami of the C2-C6 spinal nerves and receives its blood supply from the anterior cervical and inferior thyroid arteries. In a post motor vehicle collision (MVC) patients presenting weeks later, the physician has to ensure there is no subacute fracture. Clinically, these patients present with severe anterior neck pain that will often be described as a deep pain. A 43-year-old female with a past medical history of diabetes and prior surgical history of a tonsillectomy and uvulectomy presented with sudden onset of sore throat that woke her up from sleep at 3:00 am. Associated with the sore throat, she had hoarseness of her voice, difficulty breathing and felt that her throat was closing. She forced herself to vomit and then felt better. She denied any fevers or chills. Later, the patient mentioned that she had chronic neck pain from a prior accident and had been told that she has C5-C6 stenosis. About a week prior, she had been involved in another MVC and had some neck pain after that. Significantly, she was also on lisinopril for her hypertension (HTN). She was tolerating secretions, protecting her airway and no gross inflammation was noted on physical exam. On labs, there was no leukocytosis noted. Soft tissue neck X-ray showed reversal of the cervical lordosis, degenerative and erosive changes at C4-C5 and C5-C6, and thickening of the prevertebral soft tissues. She obtained a CT of the neck and cervical spine that showed osteophyte complexes at C4-C5 and C5-C6, as well as calcific tendonitis of the longus colli with a moderate amount of prevertebral free fluid. Neurosurgery was consulted from the ED who recommended getting an MRI of the neck, and consulting ENT as well. ENT happened to be in the ED and performed a bedside laryngoscopy that showed edema of the left arytenoid with full functionality of the vocal cords, and no signs of airway compromise. The patient was started on steroids, antibiotics, H2 blockers, and the ACE-inhibitor was discontinued due to suspected angioedema per ENT. She was also admitted to the ICU for airway monitoring. The MRI of the neck again showed calcific tendonitis of the longus colli with moderate prevertebral fluid. Meanwhile, the patient had complete resolution of her symptoms in 24 hours and she was cleared from both neurosurgery and ENT to be discharged. Acute calcific tendonitis is due to the deposition of calcium hydroxyapatite, which can cause significant pain and edema. In terms of calcific tendonitis of the longus colli muscle, this condition is frequently misdiagnosed and continues to be a challenge, especially in the emergency department. The differential diagnosis is diverse in etiology and severity, ranging from meningitis and retropharyngeal abscess to vertebral fracture and muscle strain." }, { "id": "pubmed23n0867_19728", "title": "Nonoperative Management of Cervical Radiculopathy.", "score": 0.009174311926605505, "content": "Cervical radiculopathy describes pain in one or both of the upper extremities, often in the setting of neck pain, secondary to compression or irritation of nerve roots in the cervical spine. It can be accompanied by motor, sensory, or reflex deficits and is most prevalent in persons 50 to 54 years of age. Cervical radiculopathy most often stems from degenerative disease in the cervical spine. The most common examination findings are painful neck movements and muscle spasm. Diminished deep tendon reflexes, particularly of the triceps, are the most common neurologic finding. The Spurling test, shoulder abduction test, and upper limb tension test can be used to confirm the diagnosis. Imaging is not required unless there is a history of trauma, persistent symptoms, or red flags for malignancy, myelopathy, or abscess. Electrodiagnostic testing is not needed if the diagnosis is clear, but has clinical utility when peripheral neuropathy of the upper extremity is a likely alternate diagnosis. Patients should be reassured that most cases will resolve regardless of the type of treatment. Nonoperative treatment includes physical therapy involving strengthening, stretching, and potentially traction, as well as nonsteroidal anti-inflammatory drugs, muscle relaxants, and massage. Epidural steroid injections may be helpful but have higher risks of serious complications. In patients with red flag symptoms or persistent symptoms after four to six weeks of treatment, magnetic resonance imaging can identify pathology amenable to epidural steroid injections or surgery. " }, { "id": "wiki20220301en009_63191", "title": "Radish", "score": 0.00909090909090909, "content": "History" }, { "id": "pubmed23n1136_2938", "title": "Case Report: Posterolateral Epidural Supra-C2-Root Approach (PESCA) for Biopsy of a Retro-Odontoid Lesions in Same Sitting After Occipitocervical Fixation and Decompression in a Case of Crowned Dens Syndrome With Brainstem Compression and Displacement.", "score": 0.009009009009009009, "content": "'Crowned dens syndrome' (CDS) is a special form of calcium pyrophosphate dihydrate deposition disease which is characterized radiologically by a halo-like or crown-like distribution in the periodontoid region and clinically by cervical pain. Herein, we will describe our experience of posterolateral epidural supra-C2-root approach (PESCA) for biopsy of retro-odontoid lesions in one surgical session after occipitocervical fixation and decompression in a patient with CDS and massive brainstem compression. A 70-year-old woman presented to our department with a 4-week history of progressive walking impairment, neck pain, neck rigidity, fever, dizziness, slight palsy of the left hand, and multiple fall episodes. Magnetic resonance imaging (MRI) of the craniovertebral junction (CVJ) and cervical spine revealed a lesion of the odontoid process and the retro-odontoid region with mainly solid components, as well as small cystic components, and brainstem compression and displacement. In first step, fusion surgery of the CVJ C0-C4 was performed with occiptocervical decompression. After fusion and decompression the lower lateral part of the C1 arc and the lateral superior part of the left side of the C2 arc were removed. The entry point was located directly above the superior part of the C2 root. A biopsy of the lateral portions of the lesions was obtained by bioptic forceps under microscope guidance. Pathologic examination of the mass revealed deposition of birefringent crystals compatible with calcium pyrophosphate. In addition to the clinical symptoms (especially neck pain), the diagnosis of CDS was made. Non-steroidal inflammatory drugs (NSAIDs) and colchicine (and later magnesium) were started. At follow-up examination 6 months after surgery, an MRI scan of the cervical spine revealed regression of the pannus and the cyst with replacement of the brainstem, clinical improvement of walking, and increased strength of the left hand. This study demonstrates that PESCA can be used to obtain tissue for pathological analysis in one surgical sitting after fusion and decompression and that fusion, decompression, and PESCA (in the same session) together with subsequent conservative management could be a good alternative for the treatment of CDS." }, { "id": "pubmed23n0854_13954", "title": "Basilar impression presenting as intermittent mechanical neck pain: a rare case report.", "score": 0.008928571428571428, "content": "Neck pain is one of the most common musculoskeletal disorders in clinical practice. However neck pain may mask more serious pathology. Although uncommon in most musculoskeletal physiotherapy practices, it is possible to encounter rare and extremely life-threatening conditions, such as craniovertebral congenital anomalies. Basilar invagination is an abnormality where the odontoid peg projects above the foramen magnum and is the commonest malformation of the craniocervical junction. Its prevalence in the general population is estimated to be 1%. Furthermore, it is a well-recognised cause of neck pain insomuch as it can be easily overlooked and mistaken for a musculoskeletal disorder. Diagnosis is based on the patient's symptoms in conjunction with magnetic resonance imaging (MRI). If life-threatening symptoms, or pressure on the spinal cord are present, the recommended treatment is typically surgical correction. This case report describes the history, relevant examination findings, and clinical reasoning used for a 37 year old male who had the chief complaint of neck pain and occipital headache. After the history and the physical examination, there were several key indicators in the patient's presentation that appeared to warrant further investigation with diagnostic imaging: (1) the drop attack after a triggering event (i.e., heading a football), (2) several episodes of facial numbness immediately and shortly after the trauma, (3) the poorly defined muscle upper extremity muscle weakness, and (4) the modification of symptoms during the modified Sharp-Purser test. Therefore, the decision was made to contact the referring neurosurgeon to discuss the patient's history and his physical examination. The physician requested immediate cervical spine MRI, which revealed a \"basilar impression\". This case report highlights the need for more research into a number of issues surrounding the prevalence, diagnosis, and the central role of primary care clinicians such as physiotherapists. Furthermore it underlines the importance of including Basilar invagination in the differential diagnosis. Physiotherapists working within a direct access environment must take a comprehensive history and be capable of screening for non-musculoskeletal medical conditions (on a systems, not diagnosis level) in order to avoid providing potentially harmful musculoskeletal treatments (e.g., cervical mobilization or manipulation, stretching, exercise) to patients with sinister medical pathologies, not benign musculoskeletal disorders." }, { "id": "pubmed23n0763_14041", "title": "History of head trauma in a 6-year-old boy: maybe more than meets the eye (and head).", "score": 0.008849557522123894, "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": "wiki20220301en417_9693", "title": "Radico Khaitan", "score": 0.008849557522123894, "content": "History" }, { "id": "pubmed23n0643_12500", "title": "Acute posterior neck pain in adult: a case series.", "score": 0.008771929824561403, "content": "Calcification around the cervical spine is thought to be relatively rare case, among these conditions the calcification at the longus colli muscle is called retropharyngeal tendinitis and only several cases were reported in the literature. In this disease, the three characteristic clinical features are acute severe posterior neck pain without any trigger, severely restricted range of motion, and odynophagia. The radiographic findings include swelling of the retropharyngeal space and amorphous calcification anterior to C1-C2 in lateral view of the cervical spine. Diagnosis is established by sound history taking coupled with computed tomography (CT) scan of the affected area, treatment is the administration of oral non-steroidal anti-inflammatory drugs (NSAID), for a few weeks and/or oral steroid. We present a new 3 cases (27, 35, and 24 years old, male) and review of literature." }, { "id": "pubmed23n0660_9781", "title": "9. Painful shoulder complaints.", "score": 0.008771929824561403, "content": "Painful shoulder complaints have a high incidence and prevalence. The etiology is not always clear. Clinical history and the active and passive motion examination of the shoulder are the cornerstones of the diagnostic process. Three shoulder tests are important for the examination of shoulder complaints: shoulder abduction, shoulder external rotation, and horizontal shoulder adduction. These tests can guide the examiner to the correct diagnosis. Based on this diagnosis, in most cases, primarily a conservative treatment with nonsteroidal anti-inflammatory drugs possibly in combination with manual and/or exercise therapy can be started. When conservative treatment fails, injection with local anesthetics and corticosteroids can be considered. In the case of frozen shoulder, a continuous cervical epidural infusion of local anesthetic and small doses of opioids or a pulsed radiofrequency treatment of the nervus suprascapularis can be considered." }, { "id": "wiki20220301en069_46071", "title": "Sacroiliitis", "score": 0.008695652173913044, "content": "Treatment Treatment of sacroiliitis can vary depending on the severity of the condition and the amount of pain the patient is currently experiencing. However, it typically falls into one of two categories non-surgical and surgical: Non-surgical In most cases sacroiliitis can be treated without surgery. Often patients will find relief through a combination of rest, heat / ice therapy, physical therapy and anti-inflammatory medication, like ibuprofen. Together these simple treatments help reduce inflammation in the affected SI joints. For more severe forms of sacroiliitis, sacroiliac joint injections might be recommended to help combat symptoms. If chosen, a physician will inject a numbing agent, usually lidocaine, and a steroid containing powerful anti-inflammatory medication into the joint using fluoroscopic guidance. These steroid injections can be delivered up to three or four times a year and should be accompanied with physical therapy to help rehabilitate the affected joint." }, { "id": "article-24839_21", "title": "Median Nerve Palsy -- History and Physical", "score": 0.008695652173913044, "content": "Diagnosticians must always evaluate the neck in patients with presumed median nerve injury or carpal tunnel syndrome. Double crush syndrome is defined as an injury to a nerve at both a distal site of compression as well as proximally such as in the case of a coexistent cervical disk herniation or foraminal stenosis. This condition is most commonly identified when patients have an unsatisfactory resolution of symptoms after a carpal tunnel release. [10] Osterman et al. found in a prospective study that patients who suffered from double crush syndrome reported more \"paresthesias\" rather than \"numbness\" compared to patients who had isolated carpal tunnel syndrome. He also found that grip strength was decreased more with double crush syndrome compared to carpal tunnel syndrome. [11] Of note, radiography of the cervical spine is not currently recommended for evaluation of double crush syndrome by current literature, particularly in the older patient population as there is a very high incidence of asymptomatic degenerative changes of the spine. MRI may be useful but is cost-prohibitive and not necessary in most cases. Therefore, history and physical examination with documentation of such examination techniques as Spurling's cervical spine maneuver to identify cervical nerve root compression, are important tools to identify double crush syndromes. [10] [12] [13]" } ] } } }

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{ "1": "Adjuvant hormone therapy including aromatase inhibitors.", "2": "Adjuvant chemotherapy, preferably with anthracyclines and taxanes, followed by hormone therapy.", "3": "Adjuvant chemotherapy in association with the monoclonal antibody trastuzumab, followed by hormone therapy.", "4": "Adjuvant chemotherapy, preferably with anthracyclines and taxanes.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0911_8278", "title": "Maximizing the Clinical Benefit of Anthracyclines in Addition to Taxanes in the Adjuvant Treatment of Early Breast Cancer.", "score": 0.016866619618913198, "content": "The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A healthy 56-year-old postmenopausal woman discovered a palpable mass at the one o'clock position of the left breast. After an initial biopsy confirmed breast cancer, she underwent mastectomy and axillary node dissection for a left-sided breast cancer that measured 3.5 cm. There was extensive lymphovascular invasion. Pathology review indicated a poorly differentiated, grade 3 invasive ductal carcinoma and ductal carcinoma in situ (largest focus, 3.5 cm). The margins were negative. Two of the 11 axillary lymph nodes contained metastatic carcinoma. Immunohistochemical studies previously obtained on the core biopsy indicated that the tumor was positive for estrogen receptor expression (50%), negative for progesterone receptor expression, and had a Ki-67 score of 60%. There was no amplification of the human epidermal growth factor receptor 2/ neu gene. Staging scans were negative for metastatic disease. Our multidisciplinary tumor board recommended adjuvant chemotherapy, postmastectomy radiation therapy, and endocrine therapy. A 52-year-old postmenopausal woman presented with a palpable mass of the right breast. An initial core biopsy confirmed carcinoma in the breast. She underwent quadrantectomy and axillary node dissection. The final pathology report disclosed a moderately differentiated invasive ductal carcinoma (diameter, 2.5 cm). The margins were negative. None of the three sentinel lymph nodes contained metastatic carcinoma. Immunohistochemical studies showed that the tumor was positive for estrogen receptor expression (90%) and for progesterone receptor expression (40%) and had a Ki-67 score of 20%. There was no amplification of the human epidermal growth factor receptor 2/ neu gene. Staging scans were negative for metastatic disease. A genomic assay was obtained and suggested an intermediate to high risk of recurrence. Her past medical history was notable for hypertension and moderately overweight status (body mass index, 39 kg/m<sup2</sup). Our multidisciplinary tumor board recommended adjuvant chemotherapy, postsurgical radiation therapy, and endocrine therapy." }, { "id": "wiki20220301en054_78747", "title": "Invasive carcinoma of no special type", "score": 0.015429338103756709, "content": "Overall, the five-year survival rate of invasive ductal carcinoma was approximately 85% in 2003. Treatment Treatment of invasive carcinoma of no special type (NST) depends on the size of the mass (size of the tumor measured in its longest direction): <4 cm mass: surgery to remove the main tumor mass and to sample the lymph nodes in the axilla. The stage of the tumor is ascertained after this first surgery. Adjuvant therapy (i.e., treatment after surgery) may include a combination of chemotherapy, radiotherapy, hormonal therapy (e.g., tamoxifen) and/or targeted therapy (e.g., trastuzumab). More surgery is occasionally needed to complete the removal of the initial tumor or to remove recurrences. 4 cm or larger mass: modified (a less aggressive form of radical mastectomy) radical mastectomy (because any malignant mass in excess of 4 cm in size exceeds the criteria for a lumpectomy) along with sampling of the lymph nodes in the axilla." }, { "id": "pubmed23n0728_3658", "title": "Biological characterization and selection criteria of adjuvant chemotherapy for early breast cancer: experience from the Italian observational NEMESI study.", "score": 0.01498917748917749, "content": "International treatment guidelines recommend administration of adjuvant chemotherapy in early breast cancer based on clinical, prognostic and predictive parameters. An observational study (NEMESI) was conducted in 63 Italian oncology centres in patients with early breast cancer. Age, performance status, concomitant disease, menopausal status, histology, tumor dimension (pT), axillary lymph node status (pN), grading (G), estrogen and progesterone receptor (ER and PgR), proliferative index (ki67 or MIB-1), human epidermal growth factor receptor 2 (HER2) and type of adjuvant treatment were recorded. The primary objective of the study was to define parameters influencing the decision to prescribe adjuvant chemotherapy and the type of chemotherapy. Data for 1894 patients were available. 69.0% postmenopausal, 67.0% pT1, 22.3% pTmic/pT1a/pT1b, 61.0% pN0, 48.7% luminal A, 18.1% luminal B, 16.1% HER2 positive, 8.7% triple negative, 8.4% unknown. 57.8% received adjuvant chemotherapy: 38.1% of luminal A, 67.3% luminal B, 88.2% HER2-positive, 97.6% triple negative. Regimens administered: 9.1% CMF-like, 48.8% anthracyclines, 38.4% anthracyclines plus taxanes, 3.7% taxanes alone. Increasing pT/pN and, marginally, HER2-positive were associated with the prescription of anthracyclines plus taxanes. Suboptimal schedules (CMF-like or AC/EC or FEC-75) were prescribed in 37.3% receiving chemotherapy, even in HER2-positive and triple negative disease (36.5% and 34.0%, respectively). This study showed an overprescription of adjuvant chemotherapy for early breast cancer, particularly referred to luminal A. pT, pN and, marginally, HER2 were the principal determinants for the choice of chemotherapy type. Suboptimal chemotherapy regimens were adopted in at least one third of HER2-positive and triple negative." }, { "id": "pubmed23n1058_947", "title": "Nodal staging affects adjuvant treatment choices in elderly patients with clinically node-negative, estrogen receptor-positive breast cancer.", "score": 0.014617971231085373, "content": "In response to Choosing Wisely recommendations that sentinel lymph node biopsy (slnb) should not be routinely performed in elderly patients with node-negative (cN0), estrogen receptor-positive (er+) breast cancer, we sought to evaluate how nodal staging affects adjuvant treatment in this population. From a prospective database, we identified patients 70 or more years of age with cN0 breast cancer treated with surgery for er+ her2-negative invasive disease during 2012-2016. We determined rates of, and factors associated with, nodal positivity (pN+), and compared the use of adjuvant radiation (rt) and systemic therapy by nodal status. Of 364 patients who met the inclusion criteria, 331 (91%) underwent slnb, with 75 (23%) being pN+. Axillary node dissection was performed in 11 patients (3%). On multivariate analysis, tumour size was the only factor associated with pN+ (<ip</i = 0.007). Nodal positivity rates were 0%, 13%, 23%, 33%, and 27% for lesions preoperatively sized at 0-0.5 cm, 0.5-1 cm, 1.1-2.0 cm, 2.1-5.0 cm, and more than 5.0 cm. Compared with patients assessed as node-negative, those who were pN+ were more likely to receive axillary rt (lumpectomy: 53% vs. 1%, <ip</i &lt; 0.001; mastectomy: 43% vs. 2%, <ip</i &lt; 0.001), and adjuvant systemic therapy (endocrine: 82% vs. 69%; chemotherapy plus endocrine: 7% vs. 2%, <ip</i = 0.002). Of elderly patients with cN0 er+ breast cancer, 23% were pN+ on slnb. Size was the primary predictor of nodal status, and yet significant rates of nodal positivity were observed even in tumours preoperatively sized at 1 cm or less. The use of rt and systemic adjuvant therapies differed by nodal status, although the long-term oncologic implications require further investigation. Multidisciplinary input on a case-by-case basis should be considered before omission of slnb." }, { "id": "wiki20220301en239_9459", "title": "Male breast cancer", "score": 0.014345434543454345, "content": "Treatment Treatment largely follows patterns that have been set for the management of postmenopausal breast cancer. The initial treatment is surgical and consists of a modified radical mastectomy with axillary dissection or lumpectomy and radiation therapy with similar treatment results as in females. Also, mastectomy with sentinel lymph node biopsy is a treatment option. In males with node-negative tumors, adjuvant therapy is applied under the same considerations as in females with node-negative breast cancer. Similarly, with node-positive tumors, males increase survival using the same adjuvants as affected females, namely both chemotherapy plus tamoxifen and other hormonal therapy. There are no controlled studies in males comparing adjuvant options. In the vast majority of males with breast cancer hormone receptor studies are positive, and those situations are typically treated with hormonal therapy." }, { "id": "pubmed23n0658_8053", "title": "Clinical outcome of breast cancer patients with N3a (≥10 positive lymph nodes) disease: has it changed over years?", "score": 0.014035260514133754, "content": "It has been shown that breast cancer patients with N3a (10 positive lymph nodes) had a poor prognosis. We planned to investigate the clinical outcome BC patients who presented with N3a disease and had no evidence of systemic metastasis at the time of diagnosis. We made a retrospective chart review of breast cancer patients who had ≥10 positive lymph nodes and received adjuvant systemic therapy in Marmara University Hospital between 1998 and 2008. We recorded clinical, pathologic and treatment characteristics of the patients and analyzed the survival outcome. We identified 73 patients with N3a disease who were treated in Marmara University Hospital between 1998 and 2008. The median age was 52. Most (75%) of the patients had invasive ductal histology, 75% had T2/T3 tumors, 36% had grade 3 tumors. The median number of metastatic lymph nodes was 15. Estrogen and progesterone receptors were both positive in 61% and both negative in 16+ tumors. Her-2/neu status was assessed in 68% of the tumors; 18% of patients had 3+ and 50% had negative scores. Six patients had triple negative tumors. All patients except one received adjuvant chemotherapy and radiotherapy. Seventy-four percent of patients received anthracycline/taxane-based chemotherapy. Fifty-nine patients received adjuvant endocrine therapy, 42% them received aromatase inhibitors. Five of the 13 Her-2 positive patients received adjuvant trastuzumab. With a median follow-up of 47 months, 5-year disease and overall survival rates were 66 and 81%, respectively. Twenty-four patients had relapsed and 14 patients died. Her-2 status and the number of lymph nodes (&lt;20 vs. ≥20) had significant impact on disease-free survival in the univariate analysis (P=0.03 and 0.05, respectively) and Her-2 retained its significant impact on disease-free survival in the multivariate analysis (P=0.05). The prognosis of BC patients with N3a disease has changed favorably in the past decade with the current standards of care." }, { "id": "wiki20220301en045_46397", "title": "Lumpectomy", "score": 0.013807098519815375, "content": "After a lumpectomy is performed for DCIS, local radiation therapy is typically performed to help eliminate microscopic-level disease. Axillary sentinel lymph node biopsy, as a method of screening for metastatic disease in otherwise non-invasive DCIS, is falling out of favor because the risks of procedure outweigh any effect on outcomes. For DCIS, chemotherapy is not recommended, but tamoxifen may be recommended for tumors which contain an abundance of estrogen receptors. For patients with invasive ductal carcinoma who have lumpectomies, lymph node biopsy and radiation therapy are usually recommended. Adjuvant chemotherapy is often recommended, but it may not be recommended if the tumor is small and there are no lymph node metastases. For larger tumors, neoadjuvant chemotherapy may be recommended." }, { "id": "pubmed23n0761_13315", "title": "Does the result of completion axillary lymph node dissection influence the recommendation for adjuvant treatment in sentinel lymph node-positive patients?", "score": 0.013775328830430145, "content": "The Hungarian National Institute of Oncology has just closed a single-center randomized clinical study. The Optimal Treatment of the Axilla-Surgery or Radiotherapy (OTOASOR) trial compares completion axillary lymph node dissection (cALND) with regional nodal irradiation (RNI) in patients with sentinel lymph node-positive (SLN+) primary invasive breast cancer. In the investigational treatment arm, patients received 50 Gy RNI instead of cALND. In these patients we had information only about the sentinel lymph node (SLN) status, but the further axillary nodal involvement remained unknown. The aim of this study was to investigate whether the result of cALND influenced the recommendation for adjuvant treatment in patients with SLN+ breast cancer. Patients with SLN+ primary breast cancer were randomized for cALND (arm A, standard treatment) or RNI (arm B, investigational treatment). Adjuvant systemic treatments were given according to the standard institutional protocol, and patients were followed according to the actual institutional guidelines. Between August 2002 and June 2009, 474 SLN+ patients were randomized to cALND (arm A, standard treatment = 244 patients) or RNI (arm B, investigational treatment = 230 patients). The 2 arms were well balanced according to the majority of main prognostic factors. However, more patients were premenopausal (34% vs. 27%; P = .095) and had pT2-3 tumors (57% vs. 40%; P = .003) in the completion axillary lymph node dissection (ALND) arm. On the other hand, there were more patients with known human epidermal growth factor receptor type 2 positive tumor (12% vs. 17%, P = .066) in the RNI arm. In the ALND and RNI arms, 78% (190/244) and 69% (159/230), respectively, received chemotherapy (P = .020). Endocrine therapy was administered in 87% (213/244) of the patients in the ALND arm and 89% (204/230) of the patients in the RNI arm (P = .372). Six patients (2.5%) on arm A and 13 patients (5.7%) on arm B received adjuvant trastuzumab treatment (P = not significant). Subgroup analyses explored that more frequent administration of adjuvant chemotherapy in arm A was associated with the higher percentage of premenopausal patients and patients with larger (pT2-3) tumors. The result of cALND after positive SLN biopsy seems to have no major impact on the administration of adjuvant systemic therapy." }, { "id": "wiki20220301en073_5613", "title": "Adjuvant therapy", "score": 0.013762966593155273, "content": "Breast cancer It has been known for at least 30 years that adjuvant chemotherapy increases the relapse-free survival rate for patients with breast cancer In 2001 after a national consensus conference, a US National Institute of Health panel concluded: “Because adjuvant polychemotherapy improves survival, it should be recommended to the majority of women with localized breast cancer regardless of lymph node, menopausal, or hormone receptor status.” Agents used include: However, ethical concerns have been raised about the magnitude of benefit of this therapy since it involves further treatment of patients without knowing the possibility of relapse. Dr. Bernard Fisher, among the first to conduct a clinical trial evaluating the efficacy of adjuvant therapy on patients with breast cancer, described it as a \"value judgement\" in which the potential benefits must be evaluated against the toxicity and cost of treatment and other potential side effects." }, { "id": "wiki20220301en202_20712", "title": "Breast International Group", "score": 0.013493313941744436, "content": "BIG clinical trials and research programmes Over the years, BIG has developed and successfully run numerous large, phase 3 clinical trials involving thousands of international investigators and institutions. These clinical trials include HERA (HERceptin Adjuvant), MINDACT (Microarray In Node-Negative and 1 to 3 Positive Lymph Node Disease May Avoid Chemotherapy), and ALTTO (Adjuvant Lapatinib and/or Trastuzumab Treatment Optimisation). Many BIG studies have been practice-changing, for example, putting aromatase inhibitors on the map (BIG 1-98), changing how we treat young women with breast cancer (SOFT), leading to a major breakthrough in treating HER2-positive breast cancer (HERA), or helping physicians evaluate which women with early breast cancer could be spared chemotherapy after surgery (MINDACT). Most BIG trials incorporate a substantial translational research component and emphasise the collection and banking of biological specimens for the purpose of future research." }, { "id": "pubmed23n0551_18098", "title": "[Two cases of recurrent breast cancer with regional lymph node metastases showing a complete response to trastuzumab and paclitaxel treatment].", "score": 0.012347560975609757, "content": "We report two cases of recurrent breast cancer with regional lymph node metastases that responded completely to treatment with trastuzumab and paclitaxel. Case 1: A 52-year-old woman, who presented with left breast cancer, underwent mastectomy and axillary lymph node dissection in July 2002. Pathological findings were as follows: invasive ductal carcinoma (scirrhous type), 2.2 cm in size, histological grade 3, positive invasion to the lymphatic and blood vessels, negative nodal status (0/11), negative ER/PgR status, and overexpression of HER 2/neu. Left axillary lymph node metastasis was noted after five months, ie, in December 2002. Four cycles of chemotherapy with doxorubicin and cyclophosphamide were administered from January 2003; however, they were not effective. The patient showed a complete response after three months of chemotherapy with trastuzumab and paclitaxel. This treatment was stopped in September 2003. She has maintained a complete response for two and a half years and was not administered any further treatment as of February 2006. Case 2: A 59-year-old woman, who presented with right breast cancer, underwent mastectomy and axillary lymph node dissection in May 2002. Pathological findings were as follows: invasive ductal carcinoma (scirrhous type), 1.8 cm in size, histological grade 2, positive invasion to the lymphatic and blood vessels, negative nodal status (0/5), positive ER and uncertain PgR status, and overexpression of HER 2/neu. She had received adjuvant hormonal therapy with tamoxifen; however, a right supraclavicular lymph node metastasis was noted in October 2004. Treatment with exemestane was not effective. However, a complete response was observed with trastuzumab and paclitaxel for four months. She has maintained a complete response for six months and was not administered any further treatment as of February 2006." }, { "id": "wiki20220301en026_30655", "title": "Paget's disease of the breast", "score": 0.012285797269822828, "content": "In most cases, adjuvant treatment is part of the treatment schema. This type of treatment is normally given to patients with cancer to prevent a potential recurrence of the disease. Whether adjuvant therapy is needed depends upon the type of cancer and whether the cancer cells have spread to the lymph nodes. In Paget's disease, the most common type of adjuvant therapy is radiation following breast-conservative surgery. Adjuvant therapy may also consist of anticancer drugs or hormone therapies. Hormonal therapy reduces the production of hormones within the body, or prevents the hormones from stimulating the cancer cells to grow, and it is commonly used in cases of invasive cancer by means of drugs such as tamoxifen and anastrozole." }, { "id": "pubmed23n0515_17142", "title": "[San Antonio Breast Cancer Symposium -- highlights 2004].", "score": 0.012087350277534326, "content": "The adjuvant therapy of postmenopausal, hormonereceptor positive breast cancer patients with aromatase inhibitors in ATAC, ABCSG 8/ ARNO 95 and IES trial revealed just a benefit in terms of disease-free survival, but not for over-all survival. Thus MA-17 trial is so far the only study which could demonstrate a survival benefit for node positive disease by \"extended adjuvant\" therapy with letrozole. Node- and receptorpositive, postmenopausal women show a higher benefit by anthracycline containing chemotherapy in combination with tamoxifen, than by endocrine therapy alone. But tamoxifen should given sequentially to chemotherapy (Intergroup 0100/ SWOG-8814 trial). Adjuvant chemotherapy with three cycles FEC followed by three cycles docetaxel reveals a survival benefit compared to six cycles FEC, especially in women older than 50 years (PACS 01 trial). Furthermore there is evolving evidence that dose-dense, interval shortened chemotherapy is superior to standard chemotherapy in adjuvant setting. The impaired survival of receptornegative, nodalpositive breast cancer patients seems to be converted to a survival improvement compared with receptorpositive patients by modern adjuvant cytotoxic regimens (metaanalysis CALGB 8541, 9344, 9741). In primary systemic chemotherapy survival is strongly associated with the rate of pathohistological complete remissions (NSABP B-27). The combination of cytotoxic drugs has no further influence on survival, but the sequential administration of taxane increases the rate of pCR. A difference in survival stratified by pCR and non-pCR in breast and positive nodal status could not be detected, so that the number of involved lymph nodes seems to be the strongest prognostic factor and is independent of tumor response in the breast. The sentinel node biopsy is a safe and reliable method, but the rate of false negative findings depends on the pathohistological methods (NSABP B-32). The morbidity of this method is low compared with conventional axillary dissection in multicenter studies. Local tumor control is an important parameter which offers a significant survival benefit in all age cohorts." }, { "id": "wiki20220301en073_5601", "title": "Adjuvant therapy", "score": 0.011940673705379587, "content": "Concomitant or concurrent systemic cancer therapy Concomitant or concurrent systemic cancer therapy refers to administering medical treatments at the same time as other therapies, such as radiation. Adjuvant hormonal therapy is given after prostate removal in prostate cancer, but there are concerns that the side effects, in particular the cardiovascular ones, may outweigh the risk of recurrence.In breast cancer, adjuvant therapy may consist of chemotherapy (doxorubicin, trastuzumab, paclitaxel, docetaxel, cyclophosphamide, fluorouracil, and methotrexate) and radiotherapy, especially after lumpectomy, and hormonal therapy (tamoxifen, letrozole). Adjuvant therapy in breast cancer is used in stage one and two breast cancer following lumpectomy, and in stage three breast cancer due to lymph node involvement. In glioblastoma multiforme, adjuvant chemoradiotherapy is critical in the case of a completely removed tumor, as with no other therapy, recurrence occurs in 1–3 months." }, { "id": "wiki20220301en423_10852", "title": "Eric Winer", "score": 0.011591821832785688, "content": "Berry DA, Cirrincione C, Henderson IC, et al. Estrogen-Receptor Status and Outcomes of Modern Chemotherapy for Patients with Node-Positive Breast Cancer. JAMA. 2006;295:1658-67. Muss HB, Berry DA, Cirrincione CT, et al. Adjuvant chemotherapy in older women with early-stage breast cancer. New England Journal of Medicine. 2009;360:2055-2065. Sikov WM, Berry DA, Perou CM, et al. Impact of the Addition of Carboplatin and/or Bevacizumab to Neoadjuvant Once-per-Week Paclitaxel Followed by Dose-Dense Doxorubicin and Cyclophosphamide on Pathologic Complete Response Rates in Stage II to III Triple-Negative Breast Cancer: CALGB 40603 (Alliance). Journal of Clinical Oncology. 2015;33:13-21. Tolaney SM, Barry WT, Dang CT, et al. Adjuvant Paclitaxel and Trastuzumab for Node-Negative, HER2-Positive Breast Cancer. New England Journal of Medicine. 2015;372:134-41." }, { "id": "pubmed23n1145_17047", "title": "How Often Do Sentinel Lymph Node Biopsy Results Affect Adjuvant Therapy Decisions Among Postmenopausal Women with Early-Stage HR⁺/HER2^- Breast Cancer in the Post-RxPONDER Era?", "score": 0.011376858435681966, "content": "The RxPONDER trial reported no benefit to chemotherapy among postmenopausal patients with HR<sup+</sup/HER2<sup-</sup tumors, one to three positive nodes, and low recurrence scores, questioning the role of axillary staging in this population. Here, we evaluate the impact of sentinel lymph node biopsy (SLNB) results on adjuvant therapy decisions in postmenopausal women with HR<sup+</sup/HER2<sup-</sup breast cancer. Postmenopausal women with cT1-2N0, HR<sup+</sup/HER2<sup-</sup breast cancer treated with lumpectomy and SLNB from 2012 to 2018 were identified. Receipt of nodal irradiation, indication for axillary lymph node dissection (ALND) and chemotherapy, and partial breast irradiation (PBI) eligibility were reviewed with pre- and post-SLNB results. A total of 1786 women were identified: median age 62 years, 84% with pT1 tumors, and 16% with pT2-3 tumors. Of those, 85% (n = 1525) remained pN0, 14% (n = 244) were pN1, and 1% (n = 17) were pN2-3. A total of 20 (1%) patients had &gt; 2 positive SLNs, necessitating ALND. Pre-SLNB, 1478 women were considered PBI eligible; post-SLNB, 227 (13%) converted to PBI ineligible. In total, 58 patients with positive nodes received nodal irradiation, representing 3% of the entire cohort and 22% of pN+ patients. Overall, 1401 patients had an Oncotype DX recurrence score available, including 1273 patients with pN0 stage and 128 with pN1, with 173 (14%) and 16 (13%), respectively, having a recurrence score &gt; 25, warranting chemotherapy. While few cN0 postmenopausal women with HR<sup+</sup/HER2<sup-</sup tumors had nodal pathology that warranted ALND, receipt of nodal irradiation, or indicated need for chemotherapy, in 13%, SLNB would have an impact on consideration for PBI. Among patients eligible for PBI, findings from SLNB may help refine selection among postmenopausal women with this tumor profile." }, { "id": "InternalMed_Harrison_6879", "title": "InternalMed_Harrison", "score": 0.010957154088050314, "content": "Data on postmenopausal women are also controversial. The impact of adjuvant chemotherapy is quantitatively less clear-cut than in premenopausal patients, particularly in estrogen receptor– positive cases, although survival advantages have been shown. The first decision is whether chemotherapy or endocrine therapy should be used. While adjuvant endocrine therapy (aromatase inhibitors and tamoxifen) improves survival regardless of axillary lymph node status, the improvement in survival is modest for patients in whom multiple lymph nodes are involved. For this reason, it has been usual to give chemotherapy to postmenopausal patients who have no medical contraindications and who have more than one positive lymph node; hormone therapy is commonly given subsequently. For postmenopausal women for whom systemic therapy is warranted but who have a more favorable prognosis (based more commonly on analysis such as the Oncotype DX methodology), hormone therapy may be used alone. Large clinical" }, { "id": "wiki20220301en026_30656", "title": "Paget's disease of the breast", "score": 0.010897013614404918, "content": "Prognosis The presence of three factors for the prognosis has been suggested, whether there is a palpable mass of the disease, whether lymph nodes are positive and whether there is an underlying malignant cancer. If there is none of these, the five- and 10-year survival is 85% and 80% respectively, with adjuvant chemotherapy even 95% and 90%. If there is a palpable mass, it is 32% and 31% respectively, with adjuvant chemotherapy (40% and 35%). Positive lymph-nodes have been positively associated with a palpable mass and affect the prognosis to be now just 28% survival after 10 years (vs 79% without palpable mass and without affected lymph-nodes). Involvement of the lymph nodes does not directly cause any harm, but is merely an indicator of systemic spread." }, { "id": "wiki20220301en511_21847", "title": "Estrogen deprivation therapy", "score": 0.010747741719638675, "content": "Endocrine therapy should not be confused with menopausal hormone therapy or hormone replacement therapy, which is using estrogen and/or progesterone supplements to relieve symptoms of menopause. Estrogen feeds breast cancer cells, so when a woman on hormone replacement therapy (HRT) is diagnosed with ER/PR positive breast cancer, her doctor will ask her to stop the HRT. Patients that have tumors small enough to take out with surgery will receive endocrine therapy after their surgery, which is part of adjuvant therapy. Large tumors may receive neo-adjuvant therapy via chemotherapy or radiation to shrink the tumor small enough to operate on. Types of Endocrine Therapy Medication" }, { "id": "wiki20220301en073_5594", "title": "Adjuvant therapy", "score": 0.01043811831213406, "content": "Despite the initial pushback from the breast cancer surgeons who believed that their radical mastectomies were sufficient in removing all traces of cancer, the success of Bonadonna's and Fisher's trials brought adjuvant therapy to the mainstream in oncology. Since then, the field of adjuvant therapy has greatly expanded to include a wide range of adjuvant therapies to include chemotherapy, immunotherapy, hormone therapy, and radiation. Neoadjuvant therapy Neoadjuvant therapy, in contrast to adjuvant therapy, is given before the main treatment. For example, systemic therapy for breast cancer that is given before removal of a breast is considered neoadjuvant chemotherapy. The most common reason for neoadjuvant therapy for cancer is to reduce the size of the tumor so as to facilitate more effective surgery." }, { "id": "wiki20220301en003_102934", "title": "Breast cancer", "score": 0.010019607843137254, "content": "Medication Medications used after and in addition to surgery are called adjuvant therapy. Chemotherapy or other types of therapy prior to surgery are called neoadjuvant therapy. Aspirin may reduce mortality from breast cancer when used with other treatments. There are currently three main groups of medications used for adjuvant breast cancer treatment: hormone-blocking agents, chemotherapy, and monoclonal antibodies." }, { "id": "pubmed23n0477_1742", "title": "[Adjuvant chemotherapy in primary carcinoma of the breast].", "score": 0.009975124378109452, "content": "The 2003 St. Gallen consensus on primary therapy of early breast cancer confirmed the importance of adjuvant chemotherapy. In endocrine non-responsive tumors, chemotherapy is adjuvant treatment of choice, independent of patient age or lymph node status. In endocrine-responsive disease, chemotherapy plays an important role next to endocrine treatment. The questions, which patients need combined chemo-endocrine therapy, and for whom endocrine therapy alone is sufficient, are still unsolved. Anthracyclines are standard adjuvant chemotherapy; superiority over CMF has only been shown for anthracyclin-containing polychemotherapy with at least 3 substances. Recent published evidence suggest that adding taxanes to anthracyclin regimens may benefit patient survival and that taxanes are a valid therapeutic option in node-positive, hormone receptor negative breast cancer. The optimal use of taxanes in different risk collectives is currently being investigated in clinical trials. Generally, adjuvant chemotherapy should be administered before radiotherapy, and endocrine therapy should be given sequentially. In view of the international St. Gallen panel, the final publication may only represent a minimal consensus. Individual countries are requested to adapt these recommendations to national conditions. In Germany, up-to-date evidence-based therapy recommendations have just been issued by the AGO \"breast\" expert panel. Interdisciplinary S3 breast cancer guidelines are currently being finalized." }, { "id": "pubmed23n0323_21134", "title": "[Results of 10 years of a randomized trial of neoadjuvant chemotherapy in breast cancers larger than 3 cm].", "score": 0.00980392156862745, "content": "The aim of this randomised trial was to determine advantages and drawbacks of neo-adjuvant chemotherapy in patients with operable breast cancers &gt; 3 cm. Two hundred and seventy-two women (age 70) with operable breast cancers larger than 3 cm (T2-3/N0-1/M0) were included in a randomised trial from January 1, 1985 to April 30, 1989. Patients in group A (n = 138) were treated by mastectomy and axillary node dissection. Adjuvant chemotherapy was indicated for 104 patients with axillary node involvement (n = 82) or negative oestrogen and progesterone receptors (EPR-) (n = 22). Patients in group B (n = 134) were treated by initial chemotherapy (identical as in group A) followed by locoregional treatment according to the response. Before treatment, the average of clinical tumoural diameter was 43 mm. The median follow-up was 124 months. In group B, 49 patients (36.5%) were resistant to chemotherapy; a conservative breast surgical treatment was performed in the other 84 patients sensitive to chemotherapy (62.6%). In this last subgroup, 19 (22.6%) needed a secondary mastectomy because of locoregional recurrence. Survival rates were not different in groups A and B, but loco-regional recurrences were frequent in group B. At 10 years, the overall survival rate was 60% and half of living patients in group B were free of cancer and with their breast. Neoadjuvant chemotherapy permitted in two-thirds of cases breast conservation treatment, initially considered to be impossible. Locoregional recurrences are more frequent than after mastectomy and adjuvant chemotherapy." }, { "id": "pubmed23n0352_18391", "title": "[Effectiveness of adjuvant systemic therapy in organ preserving treatment of pT1-2N0M0 breast cancer].", "score": 0.009708737864077669, "content": "Randomized study was made of 317 patients with early stages (pT1-2N0M0, tumor size of 0.1-3.0 cm in diameter) of infiltrative duct breast cancer, underwent an organ sparing treatment (sectorial resection +/- axillary dissection) either in combination with adjuvant chemotherapy or hormone therapy with tamoxifen or without them. It was shown that probability of recurrence development (in residual breast and regional nodes) was practically similar in women underwent organ sparing treatment if tumor size was not more than 3 cm. It was also found that prescription of adjuvant chemotherapy or hormone therapy with tamoxifen as additional to surgical treatment of tumors within the range from 0.1 to 3.0 cm in diameter did not result in significant reduction in local and regional relapses." }, { "id": "pubmed23n0066_6970", "title": "[Breast cancer: adjuvant hormone and chemotherapy].", "score": 0.009615384615384616, "content": "Indications and types of adjuvant treatment depend on the number of infiltrated axillary lymph nodes, menopausal and hormonal receptor status. In N0 situation is to date no indication for hormonal or cytotoxic therapy outside of clinical trials: disease-free survival may be improved but overall survival is not influenced. In N+ situation premenopausal patients should receive polychemotherapy independent from hormonal receptor status, postmenopausal patients with positive receptor status should be treated with tamoxifen up to 5 years: in this situation disease-free interval and overall survival can be enhanced significantly." }, { "id": "wiki20220301en239_8897", "title": "Breast cancer classification", "score": 0.009613943028485757, "content": "Receptor status is a critical assessment for all breast cancers as it determines the suitability of using targeted treatments such as tamoxifen and or trastuzumab. These treatments are now some of the most effective adjuvant treatments of breast cancer. Estrogen receptor positive (ER+) cancer cells depend on estrogen for their growth, so they can be treated with drugs to reduce either the effect of estrogen (e.g. tamoxifen) or the actual level of estrogen (e.g. aromatase inhibitors), and generally have a better prognosis. Generally, prior to modern treatments, HER+ had a worse prognosis, however HER2+ cancer cells respond to drugs such as the monoclonal antibody, trastuzumab, (in combination with conventional chemotherapy) and this has improved the prognosis significantly. Conversely, triple negative cancer (i.e. no positive receptors), lacking targeted treatments, now has a comparatively poor prognosis." }, { "id": "pubmed23n0381_15201", "title": "Adjuvant therapy of primary breast cancer: a review of key findings from the 7th international conference, St. Gallen, February 2001.", "score": 0.009523809523809525, "content": "Breast cancer research has developed at a rapid pace over the last decades. Recent discoveries promise to provide individualized treatment options, increased long-term survival for women with breast cancer, and the possibility of moving toward curative intent in the treatment of advanced breast cancer. Age, race, tumor size, histological tumor type, axillary nodal status, standardized pathological grade, and hormone-receptor status are accepted as established prognostic and/or predictive factors for selection of systemic adjuvant treatment of breast cancer. The role of other promising new factors, such as p53 mutations, HER-2 status, plasminogen activator system, histological evidence of vascular invasion, and quantitative parameters of angiogenesis will be determined in ongoing prospective studies. Currently, 5 years' treatment with adjuvant tamoxifen in women with hormone-positive receptor status, is regarded as the optimal duration of treatment. Long-term follow-up on the randomized trials will determine the added benefit of treatment beyond 5 years. Ovarian ablation has shown a reduction in recurrence and death, and the exact role and extent of adjuvant chemotherapy in premenopausal women with hormone-responsive tumors is under discussion. Combination hormonal and chemo-hormonal therapies are also being evaluated. There are no convincing data on the survival impact of tamoxifen as a preventative therapy for breast cancer: longer-term follow-up is required, and the planned meta-analyses in 2005 should help shed light on this issue. Statistically significant benefits have been observed with adjuvant chemotherapy (particularly with anthracycline-containing regimens in premenopausal women) versus no adjuvant chemotherapy. The optimal length of adjuvant anthracycline/cyclophosphamide (AC) regimens needs further evaluation as do randomized comparisons of AC to cyclophosphamide/ doxorubicin/5-fluorouracil (5-FU) and cyclophosphamide/epirubicin/5-FU. Although taxanes promise to provide an additive benefit to adjuvant chemotherapy regimens, the Cancer and Leukemia Group B 9344 and the National Surgical Adjuvant Breast and Bowel Project B-28 studies evaluating paclitaxel in the adjuvant setting have not yet demonstrated statistically significant benefits on disease-free survival and overall survival. In the year 2000, all adjuvant therapy studies conducted by the Co-operative Groups in both node-negative and node-positive disease involve a taxane. High-dose chemotherapy evaluations are still ongoing. The numerous prospective adjuvant therapy trials (hormonal; selective estrogen-receptor modulators; aromatase inhibitors; chemotherapy, involving anthracyclines/taxanes/platinum/trastuzumab; biological factors; elderly women (&gt;70 years); high-risk patients; radiotherapy in 1-3 positive lymph nodes), and neoadjuvant studies might further define the chances to enhance cure rates in the treatment of primary breast cancer." }, { "id": "pubmed23n1024_21836", "title": "[Differences in Treatment Effect between Local and Distant Lesions in Breast Cancer Patients Administered Neoadjuvant Endocrine TherapyGuided byOncoty pe DX-A Case Report].", "score": 0.009523809523809525, "content": "We report different treatment effects between local and distant lesions based on oncotype DX in a patient with breast cancer administered neoadjuvant endocrine therapy. The patient was a 50-year-old woman. Ultrasound(US)showed a mass 16×11×11mm in diameter in the C area of her right breast. Histological examination revealed invasive ductal carcinoma positive for estrogen and progesterone receptor and negative for human epidermal growth factor receptor type 2(HER2), and a Ki-67 index of 38%. The recurrence score(RS)calculated from the core needle biopsy was 4(low-risk group)with a predicted 10-year risk of distant recurrence of 4% after 5 years of endocrine therapy. Oncotype DX showed that this patient would not benefit from chemotherapy. We administered neoadjuvant endocrine therapy. However, the tumor size increased to 26×18×15mm 1 month after treatment initiation. Therefore, right breast-conserving surgery and sentinel lymph node biopsy were performed. Histopathologically, the effect of the endocrine therapy was grade 0 and the surgical margins were negative. Even though RS was low in the breast, the effect of endocrine therapy differed between local and distant lesions such as circulating tumor cells." }, { "id": "pubmed23n1025_9180", "title": "[The importance of the extracapsular extension of the sentinel node metastasis in the surgical treatment of breast cancer].", "score": 0.009433962264150943, "content": "Introduction: The introduction of sentinel node biopsy (SNB) has led to a significant decrease of axillary lymph node dissections (ALND). The importance of the extracapsular extension (ECE) in the sentinel lymph node (SN) remains unclear. Method: The data of 635 patients with T1-T2N0M0 invasive breast cancer who underwent SNB between 2014 and 2018 were retrospectively analysed. 25% of the SNB patients (158) had metastasis in the SNs. These patients were grouped based on the presence or absence of ECE. The main objective of our study was to analyse the occurrence of massive (&gt;3) node metastasis in the case of ECE negative and ECE positive patients, where ALND was performed. Results: There were 91/158 patients (58%) in the ECE negative group and 67/158 patients (42%) in the ECE positive group. ALND was performed in 42% of the ECE negative and in 69% of the ECE positive patients. There were no significant differences in the mean age of the patients; size, histological type and grade of the tumours, presence of lymphovascular invasion and proportion of hormone and HER2 receptor positivities. In the ECE negative ALND group, pN1 involvement was 82%, pN2+pN3 involvement represented 18% of cases. In the ECE positive ALND group, pN1 involvement was 60%, pN2+pN3 involvement was found in 40% of cases. The presence of ECE was associated with greater axillary disease burden. These results show a significant difference (<ip</i = 0.038). Conclusions: ECE of the SN is an important predictor for non-sentinel lymph node involvement. These data suggest, when ECE is confirmed, it is a further factor to be considered in deciding about ALND." }, { "id": "pubmed23n0560_14019", "title": "Strategies in treating male breast cancer.", "score": 0.009414780763790664, "content": "Male breast cancer is rare. Median age at diagnosis is approximately 65 years, and &gt; 35% of male breast cancers occur in elderly men. Retroareolar lump is the most frequent symptom, and 25-30% of tumours are T(4) lesions. Infiltrating ductal carcinoma represents almost 90% of the cases, and 10% are ductal carcinoma in situ. Axillary nodal involvement is present in 50-60% of the cases. Estrogen and progesterone receptors are positive in 75-92% and 54-77% of the cases. Mastectomy with axillary dissection remains the standard treatment. Sentinel lymph node biopsy could be proposed in small tumours (&lt; or = 2 cm). Locoregional radiotherapy is very often indicated. Tamoxifen is the standard adjuvant treatment, but chemotherapy is proposed in young men with axillary nodal involvement and/or negative hormone receptors. Tumour size and, more particularly, histopathological axillary involvement are the strongest predictive factors for both locoregional recurrence and metastasis. Globally, the prognosis is similar to that in women (at identical stage), but the intercurrent death rate is higher due to the important impact of comorbidities and second neoplasm." }, { "id": "pubmed23n0889_13709", "title": "Neoadjuvant Chemotherapy with Docetaxel, Carboplatin and Weekly Trastuzumab Is Active in HER2-Positive Early Breast Cancer: Results after a Median Follow-Up of over 4 Years.", "score": 0.009345794392523364, "content": "Most patients with HER2-positive breast cancer receive chemotherapy and trastuzumab. Data from adjuvant trials have shown that the combination of docetaxel, carboplatin and weekly trastuzumab (TCH) is well tolerated and as effective as anthracycline-containing regimes. Previous investigations on neoadjuvant treatment with taxanes, platinum salts and trastuzumab showed pathological complete remission (pCR) rates between 43.3 and 76%. To date, the longest published follow-up in this indication is 3 years. Here we present 4-year follow-up data for a cohort of 78 patients treated with neoadjuvant TCH. Between 2009 and 2014 we treated 78 patients with operable HER2-positive breast cancer with a neoadjuvant schedule of docetaxel (75 mg/m<sup2</sup) and carboplatin (AUC 6) every 3 weeks (q3w) and trastuzumab (4 mg/kg loading dose then 2 mg/kg) q1w. Lymph node involvement was verified by sentinel lymph node or core-cut biopsy. Patients were diagnosed at a mean age of 55.5 years; 65.4% had hormone receptor-positive tumors, 34.6% presented with grade 3 disease and 51.3% of patients were node positive. Patients were monitored every 2 cycles by ultrasound. After 6 cycles of chemotherapy all patients had surgery. Axillary dissection was performed in case of positive lymph node status prior to TCH. After surgery, trastuzumab was continued q3w up to 1 year. No grade III/IV toxicities occurred and no case of congestive heart failure was observed. Neither dose modifications nor dose delays were necessary. 34 of the 78 patients (43.6%) achieved a pCR, 27 of the 40 node-positive patients (67.5%) experienced nodal conversion. After a median follow up of 48.5 months the disease-free survival (DFS) was 84.6%, the distant disease-free survival (DDFS) was 87.2% and the overall survival (OS) was 91%. Only T stage and nodal status at baseline were found to be significantly associated with survival estimates. The anthracycline-free regimen TCH is effective and safe in the neoadjuvant therapy of HER2-positive breast cancer, yielding DFS, DDFS and OS probabilities comparable to the results of adjuvant trials. Our data support the use of TCH as a neoadjuvant therapy regimen for patients with HER2-positive breast cancer. They also strongly encourage the use of taxanes and platinum salts as the chemotherapy backbone in studies investigating dual blockade with trastuzumab and pertuzumab in the neoadjuvant setting." }, { "id": "pubmed23n0519_9242", "title": "Adjuvant chemotherapy for elderly patients (&gt; or =70 years) with early high-risk breast cancer: a retrospective analysis of 260 patients.", "score": 0.009345794392523364, "content": "Adjuvant chemotherapy in elderly women is currently perceived as one of the priorities in breast cancer (BC) research and, to date, we lack practical guidelines in this age group. Therefore we performed a retrospective analysis of the actual use of adjuvant chemotherapy according to each negative prognostic factor. Charts of all consecutive elderly patients aged 70 years or more with operable BC referred to our institution between 1999 and 2003 were reviewed for tumour stage and treatment, and compared with an equal cohort of younger randomly selected postmenopausal patients (control group). A total of 260 elderly patients (mean age 75.6 years, age range 70-97 years) with histological diagnosis of early BC were eligible. Conserving surgery was performed in 54.6% of patients, nodal dissection in 84.6% and sentinel node biopsy in 5.8%. Tumour size was pT2-pT3 in 45.4% of patients; grading was G3 in 27.3%, hormonal status was negative (HR-) in 16.9% and lymph nodes were involved N+ in 36.1%. Of 188 patients presenting one or more risk factors (pT2-3, G3, N+, HR-), 48.4% were not proposed for adjuvant chemotherapy (compared with 7.2% in the control group), 39.8% of those with nodal involvement (compared with 4.3% of controls, P &lt;0.0001) and 22.7% of those who were HR- (compared with 0.0% of controls, P=0.0002). Considering only patients receiving non-anthracycline-based chemotherapy, 20 elderly patients (25.9%) were unable to complete the planned number of cycles (compared with 4.7% of controls, P=0.0002). The 2-year disease-free survival was significantly decreased in N+ HR- patients compared with the remaining elderly patients (49.9% compared with 90.9%, P=0.0006). Elderly BC patients receive much less adjuvant chemotherapy, according to each prognostic factor. N+ HR- disease probably represents the most reasonable indication. As the toxicity of the CMF regimen frequently caused interruption of treatment, alternative regimens should be assessed in this age class." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 739, 840 ] ], "word_ranges": [ [ 113, 128 ] ], "text": "The most appropriate drugs for the treatment of absences are Valproate and Ethosuximide (CTO Manual)." }, "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": "Valproate.", "2": "Carbamazepine.", "3": "Phenytoin.", "4": "Gabapentin.", "5": "Clonazepam." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0516_2345", "title": "[Electroencephalography in status epilepticus in sleep (ESES) in various clinical pictures].", "score": 0.018354803401532373, "content": "Electroencephalographic epileptic status during sleep (ESES--according to Electrical Status Epilepticus in Sleep) is characterized with paroxysmal attacks of 1.5-3.5 (even to 5) Hz/s spikes and waves during NREM. A case is presented of a 7-year-old boy who had normal development until 3 years of age when epileptic attacks started. First to appear were left-sided, hemifacial twitches with orofacio-lingual deficits. Despite treatment with various types and combinations of antiepileptic medications, the attacks persisted and became more frequent. About a year after the onset of the disease, the spectrum of epileptic attacks had expanded (left-sided tonic-clonic, atonic-astatic, myoclonic, atypical absences, and then drop attacks and negative myoclonic seizures became dominant). The boy appeared mentally retarded. During the course of the disease, the diagnoses varied: hemifacial twitches, partial epilepsy, left-sided partial epilepsy, atypical benign epilepsy, Landau-Kleffner syndrome, myoclonic-astatic epilepsy. A year and a half after the onset of the disease EEG (polysomnographic whole-night recording) revealed electrical status epilepticus in sleep (ESES) with spike-wave index &gt; 85%. It appeared that this was continuous spike and wave during slow wave sleep syndrome (CSWS) with characteristic attacks, bifrontal atrophies on brain CT and right frontotemporal EEG focus. Treatment with valproate and ethosuximide combined with vigabatrin and clonazepam seemed to be effective. In the last 20 months ESES is rare and transitory, mental and neuropsychological functions have improved, but he still has several hemifacial twitches daily. The two brain MRI scans were normal. Differential diagnosis can be atypical benign epilepsy (suspected familial diagnosis). Family history of atopy, 'persistent' colds and obstructive bronchitis in the boy and treatment with antiepileptic medications (especially carbamazepine, phenobarbital and phenytoin) could have been provoking or modulating factors of the epileptic disease. So far we have not identified an epileptic syndrome because it seems that multiple clinical pictures overlap. ESES could be diagnosed using polysomnographic whole-night recording with calculated spike-wave index. Follow-up of the spike-wave index could be useful in differentiation, but not in precise diagnosis of epileptic syndrome. Clinical course could be modulated by different factors. Continuous following over a long period could be helpful in the classification of epilepsy." }, { "id": "First_Aid_Step2_628", "title": "First_Aid_Step2", "score": 0.01805465191932336, "content": "EEG typically shows 10-Hz activity during the tonic phase and slow waves during the clonic phase. Protect the airway. Treat the underlying cause if known. 1° generalized tonic-clonic seizures: Phenytoin, fosphenytoin, or valproate constitutes first-line therapy. Lamotrigine or topiramate may be used as adjunctive therapy. Secondarily generalized tonic-clonic seizures: Treatment is the same as that for partial seizures. Begin in childhood; subside before adulthood. Often familial. Hx/PE: Present with brief (5to 10-second), often unnoticeable episodes of impaired consciousness occurring up to hundreds of times per day. Patients are amnestic during and immediately after seizures and may appear to be daydreaming or staring. Eye fluttering or lip smacking is common. Dx: EEG shows classic three-per-second spike-and-wave discharges. Tx: Ethosuximide is the first-line agent." }, { "id": "pubmed23n0374_22188", "title": "Perioral myoclonia with absence seizures: a rare epileptic syndrome.", "score": 0.017812105926860028, "content": "We present the clinical and video-EEG data on an epileptic boy whose absence seizures with marked perioral movements had started at the age of 1.5 years. From age 12 years, he experienced frequent episodes of typical absence status epilepticus (ASE) lasting 1-2 hours with marked perioral myoclonia and moderate confusion. Initial therapy with carbamazepine was substituted by valproate because of worsening of the absence seizures. At the age of 17, the patient was admitted to our clinic with his usual, but long lasting ASE attack, accompanied by 2 generalized tonic-clonic convulsions. ASE was confirmed with the EEG which showed continuous 3 Hz spike and wave paroxysms with occasional normal intervals of 1-5 seconds. IV injection of clonazepam improved the clinical and EEG findings immediately. Video- EEG examination performed after a few weeks demonstrated typical absence seizures with perioral myoclonia. Based on the characteristics of seizure semiology, other clinical data and EEG findings, the patient was diagnosed as having the syndrome of \"perioral myoclonia with absence seizures\" described by Panayiotopoulos." }, { "id": "pubmed23n0688_17774", "title": "[A late-onset case of nonconvulsive status epilepticus of generalized epilepsy].", "score": 0.01568986568986569, "content": "We report a 78-year-old woman who had episodes of nonconvulsive status epilepticus (NCSE) with dizziness. At 75 years of age, she had first seizure, but was not well examined. At 78 years of age, she had brief myoclonic jerks of her arms, soon after awakening, in May. She suffered from strong dizziness and was admitted in our hospital at the end of June. The symptoms regressed with bed rest in few days and she was discharged. However, she was admitted again with dizziness in the middle of July. There were no myoclonic jerks of her arms or legs and she could converse and interact normally, but was slightly disoriented (JCS: 2). Blood test, Cerebrospinal fluid analyses and brain MRI were normal. An EEG showed frequent intermittent generalized multiple spikes and slow wave complexes and a 3-4 Hz generalized spike and slow wave complexes every 2-4 seconds during whole 20 minutes record. Intravenous injection of 5 mg diazepam terminated status immediately. Thereafter, she was treated with sodium valproate (400 mg/day). Her symptoms improved, and interictal epileptic discharges extremely decreased. Late-onset NCSE of generalized epilepsy is rare. We discussed this case as an important case for diagnosis of NCSE with subtle symptom of dizziness." }, { "id": "pubmed23n0349_541", "title": "Epileptic negative myoclonus induced by carbamazepine in a child with BECTS. Benign childhood epilepsy with centrotemporal spikes.", "score": 0.015669515669515667, "content": "A 7-year-old female with benign childhood epilepsy with centrotemporal spikes developed epileptic negative myoclonus (ENM) seizures during carbamazepine (CBZ) treatment. She had experienced nocturnal partial seizures since 5 years of age. Interictal electroencephalography demonstrated typical rolandic discharges. Valproate was first initiated at 6 years of age, but the seizures were uncontrollable. Carbamazepine was added and valproate withdrawn. The frequency of partial seizures did not decrease. Moreover, she had brief episodes of tone loss in each or both arms and eye blinking several weeks after CBZ introduction. Unilateral loss of arm tone corresponded to spike-and-wave discharges in the contralateral centrotemporal region, and a loss of tone in arms was associated with bilateral synchronous discharges. Eye blinking was also related to bilateral synchronous discharges and classified as a myoclonic seizure. The ENM and myoclonic seizures disappeared soon after CBZ withdrawal. Therefore the authors concluded that CBZ induced the ENM and myoclonic seizures in this patient. CBZ sometimes induces generalized seizures in the treatment of partial epilepsy and generalized epilepsy. CBZ-induced ENM seizures should be considered when a brief lapse of tone appears during CBZ treatment." }, { "id": "pubmed23n0759_10444", "title": "Effects of clonazepam on self-induced photoparoxysmal responses.", "score": 0.015648116535791512, "content": "A 5-year-old girl exhibited daily episodes of repetitive blinking lasting 5-10 s. Electroencephalography (EEG) revealed marked photoparoxysmal responses (PPR) at 3-20 Hz of photic stimulation and diffuse spike-wave bursts during sleep. A 24-h video EEG identified 11 episodes of repetitive blinking, 3 of which resulted in widespread spike-wave discharges. These suggested that the behavior of the patient represented self-induction of PPR. Valproate sodium was ineffective in decreasing PPR, as revealed by EEG, and the frequency of blinking episodes, but clonazepam attenuated PPR and significantly decreased the blinking behavior." }, { "id": "pubmed23n0077_18368", "title": "Somnambulism in adults.", "score": 0.015444245676803817, "content": "We evaluated with clinical interviews and polysomnographic examinations 10 adults with the complaint of sleepwalking, often accompanied by violent behavior or self-injury. During the polysomnographic studies, 8 patients had 47 distinct somnambulistic episodes. All episodes occurred in non-REM sleep, with 91% occurring in slow-wave sleep. Contrary to previous reports, episodes were not confined to the 1st 3rd of the night. Clinical EEGs were normal in 5 of 6 patients. In the 7 patients tried on 1 or more treatment regimens, clonazepam effectively suppressed the somnambulism in 5 of 6 patients in whom it was tried, carbamazepine in 1 of 3, flurazepam in 2 of 2, and a combination of clonazepam and phenytoin in one." }, { "id": "pubmed23n0396_4994", "title": "Gabapentin: new indication. Little impact on partial epilepsy in children between 3 and 12.", "score": 0.015136054421768706, "content": "(1) The standard treatment for partial epilepsy in children is carbamazepine. The efficacy of other antiepileptics has also been documented, either alone (phenobarbital, oxcarbazepine, valproate sodium, phenytoin), or in drug combinations (lamotrigine, topiramate). (2) A licence extension has been granted in France for gabapentin in partial epilepsy in children aged 3 to 12 years, in combination with other antiepileptics. (3) The clinical file contains no data from trials comparing gabapentin with other antiepileptics. (4) The main double-blind trial involved 247 children who were treated either with their usual treatment + gabapentin or usual treatment + placebo. Gabapentin was only moderately effective, and the overall number of responders did not differ significantly between the gabapentin and placebo groups. (5) In this trial the main adverse effects among the children on their usual treatment + gabapentin were behavioural disorders (hostility and mood swings). (6) In practice, the licensing of gabapentin for children with partial epilepsy aged between 3 and 12 years changes nothing in their practical management." }, { "id": "pubmed23n0074_6149", "title": "[Chronological change of EEG findings in a case of pyridoxine dependency seizures].", "score": 0.01501831501831502, "content": "A patient of pyridoxine dependent seizures was reported. He was born at 34 weeks' gestation and weighted 2,760 g. Apgar scores were 6 and 9 at 1 and 5 minutes, respectively. He showed the first seizure 2 hours after his birth. Phenobarbital, phenytoin, sodium valproate, diazepam and clonazepam were not effective. Pyridoxal phosphate (50 mg) was given intravenously, resulting in suppression of convulsions. However, muscle tonus was severely depressed. In EEG, a discontinuous pattern was found in quiet and indeterminate sleep on the 2nd day of life. At 5th week multifocal spikes were found, and the discontinuous pattern persisted. Ictal discharges at 13th week showed generalized, continuous, irregular and high voltage slow waves with multifocal spikes. At 27th week of life, high voltage slow waves disappeared and multifocal spike discharges decreased. At 2 years and 10 months of age, the patient was suffering from athetotic cerebral palsy and severe mental retardation. Pyridoxal phosphate at the doses of 35-40 mg/kg/day had been administered. Irritability sometimes occurred and additional 50 mg of pyridoxal phosphate controlled this irritability effectively." }, { "id": "wiki20220301en228_22021", "title": "Rolandic epilepsy", "score": 0.013315525335923587, "content": "Treatment Given the benign nature of the condition and the low seizure frequency, treatment is often unnecessary. If treatment is warranted or preferred by the child and his or her family, antiepileptic drugs can usually control the seizures easily. Carbamazepine is the most frequently used first-line drug, but many other antiepileptic drugs, including valproate, phenytoin, gabapentin, levetiracetam and sultiame have been found effective as well. Bedtime dosing is advised by some. Treatment can be short and drugs can almost certainly be discontinued after two years without seizures and with normal EEG findings, perhaps even earlier. Parental education about Rolandic epilepsy is the cornerstone of correct management. The traumatizing, sometimes long-lasting effect on parents is significant. It is unclear if there are any benefits to clobazam over other seizure medications." }, { "id": "pubmed23n0624_4104", "title": "[Idiopathic generalised epilepsies in the elderly: the viewpoint of a geriatrician].", "score": 0.0132150930272996, "content": "Long-term follow-up studies indicate a low remission rate in idiopathic generalised epilepsies (IGE) (Martinez-Juarez et al., 2006), suggesting they may persist to an advanced age. However there are few estimates of IGE frequency in the elderly. EEGs of 700 patients aged over 70 years, recorded between January 2006 and March 2007, were reviewed for anomalies consistent with IGE. We then examined the clinical history of patients with these anomalies. A persistent IGE was identified in four female patients (mean age: 79 years); in two cases it was a juvenile myoclonic epilepsy (JME) and in two an epilepsy with grand mal seizures. Seizures in three patients had begun in childhood or adolescence and in one at 40 years. Before hospitalization, few or no seizures were reported and IGE had not been diagnosed. IGE was revealed in each patient by a relatively severe event: an absence status (AS), subcontinuous myoclonic seizures or repeated convulsive generalised seizures (CGS). These events were not situation-related but in one patient the relapse of simple convulsive seizures, may have been related to the withdrawal of anti-epileptic drugs (AED) several months previously. EEG records showed generalised spikes or polyspikes and waves organised in a status epilepticus or in interictal rhythmic discharges. In one case they were evident only from a 24 hours recording. Clonazepam injection was used to suppress the AS episode and the subintrant myoclonia. After the AS, interictal generalised epileptic discharges persisted. Two of the four patients had familial history of epilepsy or febrile seizures but in no case was an epileptogenic lesion evident in brain CT scan or MRI. Clinical exams and biologic parameters were normal. All of the patients had worked and were married with children. Appropriate therapies were followed after the diagnosis of IGE. One patient with JME had been treated by Valproate which was discontinued by the general practitioner because of lethargy and replaced by Carbamazepine; seizures were aggravated under both Carbamazepine and then Lamotrigine and until the patient became seizure-free on Levetiracetam. The antiepiletic treatment was also modified in a second patient, while the two others responded well to Valproate. IGE can exacerbate in the elderly, as different types of seizures including AS, subintrant myoclonia or repeated CGS. Our data suggest persistent IGE are quite frequent in an aged population and may be underestimated due to difficulties in diagnosis. Correctly diagnosed, adjustment of AED may offer substantial clinical improvements in IGE of the elderly." }, { "id": "pubmed23n0648_13197", "title": "[Clinical and electroencephalographic characteristics of epilepsy with myoclonic absences].", "score": 0.012772015456579215, "content": "Epilepsy with myoclonic absences (EMA) is a type of childhood epilepsy characterized by a specific seizure type, i.e. myoclonic absences (MA). This study aimed to investigate the clinical and electrophysiological characteristics of EMA. Video-EEG monitoring was carried out in 6 patients with EMA, and 2 of them were examined with simultaneous deltoid muscle surface electromyogram (EMG). The clinical and EEG characteristics, treatment and prognoses of EMA were analyzed. Of the 6 patients, 3 were female, and 3 were male. The age of onset was from 2 years and 3 months to 11 years (average 5 years and 2 months). MA was the sole seizure type in 5 patients. One patient presented generalized tonic clonic seizures (GTCS) at the onset and then switched to MA. The manifestations of MA included an impairment of consciousness of variable intensity, rhythmic myoclonic jerks with evident tonic contraction mainly involving the upper extremities, a deviation of head and body to one side or asymmetrical jerks observed in some cases, a duration ranging from 2 to 30 s, an abrupt onset and termination, a high frequency of attacks, at least several times to over 30 times per day, and easily provoked by hyperventilation. The ictal EEG consisted of rhythmic 3 Hz spike and wave discharges that were bilateral, synchronous and symmetrical in all patients. The deltoid muscle EMG recording in 2 patients showed rhythmic myoclonus at the same frequency as the spike and waves. The interictal EEG showed generalized spike and wave discharges in all patients, and focal discharges in some patients. Valproate was the drug of choice, which was often combined with other antiepileptic drugs. The ages at follow up ranged from 6 years and 4 months to 19 years. Seizures were controlled from 8 months to 3 years in 4 cases. The treatment at the onset was late in one case and was irregular in another who had GTCS during the course of the disease. These two cases were followed up for 2 years and 6 months and 5 years, respectively. Seizures could not be controlled in the 2 patients with intellectual impairment. EMA was a rare type of childhood epilepsy characterized by MA. Clinical observation and ictal video-EEG and EMG were essential to diagnose EMA. Valproate alone or combined with other antiepileptic drugs given early could have a favorable effect to EMA. Delayed therapy and the presence of GTCS might suggest poor prognosis." }, { "id": "Neurology_Adams_1482", "title": "Neurology_Adams", "score": 0.012762501450284255, "content": "Carbamazepine is effective in 70 to 80 percent of patients (600 to 1,200 mg/d), but half become tolerant over a period of several years. Other antiepileptic drugs such as phenytoin (300 to 400 mg/d), valproic acid (800 to 1,200 mg/d), clonazepam (2 to 6 mg/d), gabapentin (300 to 900 mg/d or more), pregabalin (150 to 300 mg/d), and carbamazepine in combination with other medications, suppress or shorten the duration and severity of the attacks in most patients for varying times. Baclofen may be useful in patients who cannot tolerate carbamazepine or gabapentin, but it is most effective as an adjunct to one of the anticonvulsant drugs. Capsaicin applied locally to the trigger zones or the topical instillation in the eye of an anesthetic has been helpful in some patients. By temporizing and using these drugs, one may permit a spontaneous remission to occur in perhaps 1 in 5 patients over a year or two." }, { "id": "wiki20220301en345_10658", "title": "Jeavons syndrome", "score": 0.012363387978142078, "content": "Management Based on anecdotal evidence, the drugs of choice are those used for other idiopathic generalized epilepsies. Valproate alone, or most probably in combination with clonazepam, levetiracetam, lamotrigine or ethosuximide, appears to be the most effective regimen. The choice of the second drug depends on the main seizure type. Clonazepam is highly efficacious in eyelid myoclonia and myoclonic jerks. Of the newer antiepileptic drugs, levetiracetam may be the most effective, because of its anti myoclonic and anti photosensitive properties. Lamotrigine is very effective in absence seizures but may exaggerate myoclonic jerks. Contra-indicated drugs are: Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine and vigabatrin." }, { "id": "wiki20220301en233_6184", "title": "Panayiotopoulos syndrome", "score": 0.011637653127014829, "content": "At the age of 2 years, a girl had an autonomic status epilepticus during sleep. This was characterized by pallor, progressive impairment of consciousness, and vomiting that lasted 45 minutes. A second episode occurred after 11 months, during sleep, and consisted of impairment of consciousness, hypotonia, deviation of the eyes to the right, hypersalivation, and right-sided clonic convulsions. It was terminated after 45 minutes with rectal diazepam. Treatment with carbamazepine was initiated. After 6 months, she had a third episode similar to the previous ones, but shorter. At the age of 4 years 9 months, during an ambulatory EEG, she had another autonomic seizure with marked ictal EEG abnormalities, but again, the interictal did not show any spikes. Carbamazepine was replaced with phenobarbital. All 12 interictal EEGs during the active seizure period, 6 of them during sleep, were normal. At last follow-up at the age of 16 years, she was well, a good student, unmedicated, and" }, { "id": "pubmed23n0131_3226", "title": "Exacerbation of seizures in children by carbamazepine.", "score": 0.01142673728133526, "content": "We studied 15 children with complex partial seizures in whom one or more seizure type was exacerbated during treatment with carbamazepine. The most common seizure type that was exacerbated was generalized atypical absence (11 patients). Four patients had more frequent and severe generalized convulsive seizures. Monitoring with video-electroencephalographic telemetry suggested that the electroencephalogram can be used to predict the risk of seizure exacerbation with carbamazepine. A bilaterally synchronous spike-and-wave discharge of 2.5 to 3 cycles per second is predictive of increased atypical absence seizures with carbamazepine, whereas generalized bursts of spikes and slow waves of 1 to 2 cycles per second suggest a risk of increased generalized convulsive seizures. Carbamazepine should be used with caution in children with a mixed seizure disorder, particularly those with a generalized bilaterally synchronous discharge of 2.5 to 3 cycles per second on the electroencephalogram. The drug should be considered a possible precipitating factor in any child with an increased frequency of generalized convulsive or generalized absence seizures concomitant with administration of this anticonvulsant agent." }, { "id": "pubmed23n0305_14516", "title": "The effectiveness of clonazepam on the Rolandic discharges.", "score": 0.010922619047619047, "content": "Rolandic discharge (RD), noted in the electroencephalography (EEG) of patients with benign epilepsy in childhood with centrotemporal spikes (BECCT) has several unique features. One feature is that the amount or frequency of RDs does not correlate well with the incidence of seizures in BECCT although it is a key finding in the diagnosis of this epileptic syndrome. In this study, we examined the efficacy of antiepileptic drugs focusing on the disappearance of RDs in relationship with seizure control. Forty patients with BECCT who were not medically treated prior to this study were randomly sorted into three groups. Twenty patients were assigned for clonazepam (CZP) treatment, 10 patients for valproate (VPA) and the remaining 10 patients for carbamazepine (CBZ). Each drug was administered for 4 consecutive weeks. EEGs were recorded twice during the study, before and 4 weeks after the medication trial. The effects of each treatment on RDs were assessed. RDs disappeared in 15 of the 20 cases treated with CZP (75%) within 4 weeks while the same was observed in only one of the 10 cases treated with VPA (10%). CBZ failed to demonstrate any effect on RD. In the group treated with CZP, there were no differences in seizure incidence, seizure type and blood concentration of CZP between the patients whose RDs disappeared and those whose RDs remained." }, { "id": "wiki20220301en481_36919", "title": "Hypomania", "score": 0.010441087088651558, "content": "Treatment Medications Antimanic drugs are used to control acute attacks and prevent recurring episodes of hypomania combined with a range of psychological therapies. The recommended length of treatment ranges from 2 years to 5 years. Anti-depressants may also be required for existing treatments but are avoided in patients who have had a recent history with hypomania. Sertraline has often been debated to have side effects that can trigger hypomania. These include antipsychotics such as: Aripiprazole Clozapine Haloperidol Olanzapine Paliperidone Quetiapine Risperidone Ziprasidone Other anti-manic drugs that are not antipsychotics include: Carbamazepine Lithium Oxcarbazepine Valproate Benzodiazepines such as clonazepam or lorazepam may be used to control agitation and excitement in the short-term. Other drugs used to treat symptoms of mania/hypomania but considered less effective include: Gabapentin Lamotrigine Levetiracetam Topiramate" }, { "id": "pubmed23n0310_8579", "title": "[Benign myoclonic epilepsy in childhood. A case report].", "score": 0.009900990099009901, "content": "Benign myoclonic epilepsy of childhood is a rare syndrome which appears at between 4 months and 3 years of age. The prognosis is good if diagnosed and treated early. It is characterized by many short crises (usually of 3 seconds and not more than 5-10 seconds long), proximal and cephalic jerking movements without falling to the ground, and at no particular time of the day. In the EEG polygraph background activity continues and crises coincide with generalized spike and wave or multiple spike and wave discharges of 1 to 2 seconds, accompanied by isolated myoclonic movements in the neck and deltoid muscles, which persist during NREM sleep. Benign epilepsy of childhood usually responds to monotherapy with valproic acid. In our case photosensitivity appeared at 7 years of age with persistence of generalized spikes and waves during sleep. We suggest that photosensitivity may be used as an index of the clinical course, and that treatment should continue to be given until photosensitivity disappears." }, { "id": "article-23343_32", "title": "Idiopathic (Genetic) Generalized Epilepsy -- History and Physical -- Childhood Absence Epilepsy (CAE)", "score": 0.009842331581462017, "content": "CAE occurs in early childhood, with a peak onset between 4 to 7, usually before age 10. Clinically, CAE patients experience staring and altered awareness. They usually have only absence seizures and fewer than 20 spells per day at the time of diagnosis. The hyperventilation test provokes seizures. [34] Typical absence seizures are brief (4 to 30 seconds) vacant episodes (loss of awareness and unresponsiveness) with impairment of consciousness associated with abrupt onset and cessation, as well as behavioral arrest or staring with no post-ictal symptoms. These episodes may be associated with orofacial automatisms. [10] EEG will show typical 3 Hz spike-and-wave pattern ictally. Ethosuximide is used as first-line treatment and is effective over 50% of the time. However, ethosuximide is ineffective against non-absence seizures, so valproate is the preferred medication if another type is also present. Poor prognosis includes EEGs that have abnormal baseline slowing and generalized-tonic-clonic or myoclonic seizures as well as absence seizures. [35]" }, { "id": "pubmed23n1078_305", "title": "A 73-Year-Old Woman with Respiratory Failure and Stimulus-Induced Rhythmic, Periodic, or Ictal Discharges (SIRPIDs) in the Absence of a Detectable Brain Insult Diagnosed and Monitored by Continuous Electroencephalogram (EEG) and Treated with Valproate, Carbamazepine, and Clonazepam.", "score": 0.00980392156862745, "content": "BACKGROUND Stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs) commonly occur in critically ill patients and can be distinguished from spontaneous epileptic seizures by continuous electroencephalogram (CEEG) monitoring. There are no current treatment guidelines for SIRPIDs. This report is of a 73-year-old woman with respiratory failure and without any detectable gross brain lesions. She had developed SIRPIDs, which were diagnosed through CEEG monitoring. She responded well to valproate, carbamazepine, and clonazepam. CASE REPORT A 73-year-old woman was admitted to the intensive care unit (ICU) with a chest infection. After 3 days, this infection was complicated by respiratory failure and coma, for which she was intubated. After that, recurrent brief episodes of abnormal head and right upper limb jerky movements with right gaze deviation occurred. Nurses noticed that these episodes occurred exclusively upon physical interaction with the patient, and lasted up to 3 minutes. No focal findings were noted on neurological examination. The brain computed tomography (CT) scan revealed no acute brain insult. CEEG revealed SIRPIDs, which abated with midazolam boluses, followed by infusion at 15 mg/hour. Later, they were controlled by valproate, carbamazepine, and clonazepam in succession, guided by CEEG data. CONCLUSIONS This report shows the importance of CEEG monitoring to diagnose SIRPIDs and monitor treatment response. It also suggests that SIRPIDs can occur even in the absence of gross brain pathology. Although there are no current treatment guidelines for SIRPIDs, the use of valproate, carbamazepine, and clonazepam can help control them, as evidenced in this case." }, { "id": "pubmed23n0374_22186", "title": "Epigastric sensations as an unusual manifestation of adult absence epilepsy.", "score": 0.009708737864077669, "content": "We report the case of a 39-year-old woman with onset of daily epigastric sensations associated with brief episodes of unresponsive blank stare, which have been interpreted as complex partial seizures with occasional secondary generalisation. Phenytoin as monotherapy and in combination with valproate had not been effective. During video-EEG we recorded typical absences with brief 3 second spike, and slow-wave discharges of up to 5 seconds, which were recognized by the patient herself. All absences were preceded by epigastric sensations. There was no indication of focal epilepsy. Monotherapy with valproate substantially decreased the frequency of the absences. In conclusion, this case is peculiar for several reasons: 1) late onset of absence epilepsy, 2) epigastric sensation at onset of absence seizures, 3) recognition of brief \"phantom\" absences and 4) presumable adverse effects of phenytoin." }, { "id": "pubmed23n0272_637", "title": "[Absence seizures in adulthood: four cases].", "score": 0.009708737864077669, "content": "We present four patients between 40 and 60 years of age with irregular control of seizures in adulthood, with a mean duration of history of 44 years and the following characteristics in common; a) history of childhood absence seizures beginning between age 4 and 7; b) appearance of generalized tonic-clonic seizures during adolescence; and c) persistence of typical absence seizures upon awakening during adulthood, manifested as \"clumsiness during the first half hour after awakening\". Waking and sleeping EEG polygraphs were done on all patients, including the first half hour after awakening, confirming the presence of generalized polyspike/wave during non-REM sleep and generalized spike/wave periods accompanied by simultaneous loss of consciousness, or intermittent slow generalized polyspike/wave accompanied by bradypsychia. We comment on the usefulness of valproic acid alone or in combination with ethosuximide in the treatment of these patients." }, { "id": "pubmed23n0311_9127", "title": "Gabapentin for familial paroxysmal dystonic choreoathetosis.", "score": 0.009615384615384616, "content": "We present a 4-year-old girl with stereotyped episodes of inability to speak and dystonic posturing of the face and extremities lasting 20 minutes. An older brother and mother had similar spells in childhood. Routine and video-EEG during events were normal. The diagnosis was non-kinesigenic paroxysmal dystonic choreoathetosis since the episodes were not exacerbated by movement. Gabapentin 10 mg/kg/d eliminated most attacks." }, { "id": "pubmed23n0510_11498", "title": "Induction of epileptic negative myoclonus by oxcarbazepine in symptomatic epilepsy.", "score": 0.009523809523809525, "content": "Provocation of various seizure types including epileptic negative myoclonus and generalised atonic seizures is rarely observed in children treated with carbamazepine (CBZ). Provocation of the latter seizure types by oxcarbazepine (OXC) is not described in the literature. We report a four year-old boy with symptomatic epilepsy caused by left-sided cerebral atrophy of unknown origin who developed numerous daily drop attacks when exposed to OXC. Polygraphic analysis revealed secondary generalised precentral sharp-slow waves frequently associated with a silent period lasting for 100-150 ms in the electromyogram recorded from the deltoid and neck muscles. These seizures stopped promptly within 36 hours after discontinuation of OXC. This case demonstrates that OXC, similar to CBZ, can provoke epileptic negative myoclonus in some children with focal epilepsies. [Published with videosequences]." }, { "id": "pubmed23n0014_1788", "title": "Treatment of generalized epilepsies of childhood and adolescence with sodium valproate (\"epilim\").", "score": 0.009433962264150943, "content": "A total of 142 patients (84 per cent aged less than 20 years) with various forms of generalized epilepsy have been treated with sodium valproate alone or in combination with other drugs. The mean duration of symptoms was six years, and half the patients had daily seizures. Nine patients had typical absences, 33 had absences with automatisms, 28 had tonic-clonic seizures with or without photosensitivity, and 72 had various forms of myoclonic epilepsy. Dosage varied from 23 to 54mg/kg and twice-daily administration was usual. Estimation of serum levels did not assist in management. Fits ceased in 63 per cent of all cases and a further 18 per cent showed improvement greater than 50 per cent. Of the 69 with 3c/sec spike-and-wave discharges, 81 per cent became free from all fits, as did 77 percent of those with myoclonic jerks. Fits ceased in eight of the 32 patients with myoclonic astatic epilepsy and there was improvement greater than 50 per cent in a further eight patients. Other anticonvulsants were often withdrawn and always reduced. 21 patients received sodium valproate alone from the start of treatment and all other drugs were withdrawn in another 38. Sodium valproate alone controlled all fits in four children with absences, in 18 with absences with automatisms, 10 with tonic-clonic seizures and 22 with myoclonic epilepsy. Side-effects were rare, mild and often temporary. Potentiation of barbiturates and benzodiazepines occurred, especially clonazepam, which should be avoided. Many patients were more alert. Sodium valproate appears to be the drug of choice for epilepsies associated with generalized spike-and-wave discharges, myoclonic epilepsies or photosensitive epilepsies, and is of especial value in children and mentally retarded patients because it lacks sedating effects and often induces liveliness." }, { "id": "pubmed23n0309_10163", "title": "Gabapentin monotherapy: II. A 26-week, double-blind, dose-controlled, multicenter study of conversion from polytherapy in outpatients with refractory complex partial or secondarily generalized seizures. The US Gabapentin Study Group 82/83.", "score": 0.009345794392523364, "content": "This study evaluated gabapentin monotherapy in 275 patients with medically refractory complex partial or secondarily generalized seizures who were taking one or two antiepileptic drugs (AEDs). Following an 8-week baseline, patients received randomized dosages of gabapentin (600, 1,200, or 2,400 mg/d) during a 26-week double-blind phase comprising 2 weeks gabapentin add-on therapy, an 8-week AED taper, and a 16-week gabapentin monotherapy period. Patients exited the study if they experienced a protocol-defined exit event. Results of outcome measures, including time to exit, completion rate, and mean time on monotherapy, showed no significant differences among dosage groups. Possible reasons for this lack of a dose-response relationship include withdrawal seizures and the limited range of gabapentin dosages studied. Overall, 20% of patients completed the study. Completion rates were higher among patients who had discontinued one AED (23%) than two AEDs (14%), and higher among patients who were not withdrawn from carbamazepine (27%) than among those who were (16%)." }, { "id": "pubmed23n0293_21369", "title": "Movement disorders associated with the use of gabapentin.", "score": 0.009259259259259259, "content": "We report two cases of unusual movement disorders associated with the use of gabapentin (GBP) in patients being treated for epilepsy who were otherwise neurologically intact. We describe two cases of unusual movement disorders associated with the use of GBP. There were significant differences in the clinical findings between the two cases. In the first case, movements were very pronounced and the patient was in oculogyric crisis. Movements in the second case were quite subtle but nonetheless problematic for the patient. In each case, discontinuation of GBP led to rapid resolution of the movements, although a single dose of lorazepam was used in the first case. Although formal electrophysiologic studies have not been performed, the movements associated with GBP use appear to be dystonic or myoclonic. Discontinuation of GBP led to rapid resolution of the movements. In severe cases, as in patients with oculogyric crisis, small doses of a benzodiazepine (BZD) appear to be efficacious and safe." }, { "id": "pubmed23n0762_5616", "title": "Antiepileptics other than gabapentin, pregabalin, topiramate, and valproate for the prophylaxis of episodic migraine in adults.", "score": 0.009174311926605505, "content": "Some antiepileptic drugs but not others are useful in clinical practice for the prophylaxis of migraine. This might be explained by the variety of actions of these drugs in the central nervous system. The present review is part of an update of a Cochrane review first published in 2004, and previously updated (conclusions not changed) in 2007. To describe and assess the evidence from controlled trials on the efficacy and tolerability of antiepileptic drugs other than gabapentin, pregabalin, topiramate, and valproate (which are the subjects of separate Cochrane reviews) for preventing migraine attacks in adult patients with episodic migraine. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2012, Issue 12), PubMed/MEDLINE (1966 to 15 January 2013), MEDLINE In-Process (current week, 15 January 2013), and EMBASE (1974 to 15 January 2013) and handsearched Headache and Cephalalgia through January 2013. Studies were required to be prospective, controlled trials of antiepileptic drugs other than gabapentin, pregabalin, topiramate, and valproate taken regularly to prevent the occurrence of migraine attacks, to improve migraine-related quality of life, or both. Two review authors independently selected studies and extracted data. For headache frequency data, we calculated mean differences (MDs) between antiepileptic drugs and comparators (placebo, active control, or same drug in a different dose) for individual studies and pooled these across studies. For dichotomous data on responders (patients with ≥ 50% reduction in headache frequency), we calculated odds ratios (ORs) and numbers needed to treat (NNTs). We also summarised data on adverse events from placebo-controlled trials and calculated risk differences (RDs) and numbers needed to harm (NNHs). Eleven papers describing 10 unique trials met the inclusion criteria. The 10 trials reported results for nine antiepileptic drugs other than gabapentin, pregabalin, topiramate, and valproate. Six of the eight drugs investigated in placebo-controlled trials were not better than placebo in reducing headache frequency per 28-day period during treatment (clonazepam, lamotrigine, oxcarbazepine, and vigabatrin) and/or in the proportion of responders (acetazolamide, carisbamate, lamotrigine, oxcarbazepine). One prospective, randomised, double-blind, single cross-over trial of 48 patients demonstrated a significant superiority of carbamazepine over placebo in the proportion of responders (OR 11.77; 95% confidence interval (CI) 3.92 to 35.32). The NNT was 2 (95% CI 2 to 3). In a small prospective, randomised, double-blind, parallel-group trial, levetiracetam 1000 mg was significantly superior to placebo in reducing headache frequency per 28-day period during treatment (MD -2.40; 95% CI -4.52 to -0.28; 26 patients), as well as in the proportion of responders (OR 26.07; 95% CI 1.30 to 521.91; 26 patients). The NNT was 2 (95% CI 1 to 4). The same trial examined levetiracetam 1000 mg versus topiramate 100 mg and found a small but significant difference favouring topiramate in headache frequency per 28-day period during treatment (MD 1.40; 95% CI 0.14 to 2.66; 28 patients). There was no significant difference between levetiracetam and topiramate in the proportion of responders (OR 0.71; 95% CI 0.16 to 3.23; 28 patients). Finally, one trial with 75 participants examined zonisamide versus topiramate (200 and 100 mg, respectively) and found no significant difference between them in reduction of headache frequency from baseline during the third month of treatment. Adverse events for active treatment versus placebo were available for all investigated drugs except levetiracetam, vigabatrin, and zonisamide. A high prevalence of adverse events was noted for carbamazepine, with a NNH of only 2 (95% CI 2 to 4). Available evidence does not allow robust conclusions regarding the efficacy of antiepileptic drugs other than gabapentin, pregabalin, topiramate, and valproate in the prophylaxis of episodic migraine among adults. Acetazolamide, carisbamate, clonazepam, lamotrigine, oxcarbazepine, and vigabatrin were not more effective than placebo in reducing headache frequency. In one trial each, carbamazepine and levetiracetam were significantly superior to placebo in reducing headache frequency, and there was no significant difference in proportion of responders between zonisamide and active comparator. These three positive studies suffer from considerable methodological limitations." }, { "id": "pubmed23n0528_13046", "title": "A comparative study of vigabatrin vs. carbamazepine in monotherapy of newly diagnosed partial seizures in children.", "score": 0.009174311926605505, "content": "Carbamazepine (CBZ) is a drug of choice for the treatment of simple or complex partial seizures and secondary generalized seizures in adults and children. Vigabatrin (VGB) is a relatively new second line antiepileptic drug and was first registered for use in Poland more than ten years ago. Few reports have been published on the comparison of efficacy of VGB in children with epilepsy. The objective of this study is to evaluate the safety, efficacy and EEG effects of initial VGB monotherapy compared with initial CBZ monotherapy in children with newly diagnosed epilepsy. We present results of a prospective, outpatient and open study carried out in the University Hospital Center in Białystok. Twenty-six children with partial epilepsy treated with VGB and 28 patients treated with CBZ were studied. The evaluation of the efficacy of the two drugs did not reveal any significant differences. Very good (reduction &gt; 75%) seizure control was achieved in 22 out of 26 patients (84.6%) in the VGB group. One patient had a 50-75% decrease of seizures (good effect), similarly one child had a 25-50% reduction of seizures (mild effect). In two patients, we observed increased seizures (myoclonic jerks). Very good seizure control was achieved in 17 out of 28 patients (60.7%) in the CBZ group. Good seizure control was achieved in 5 out of 28 patients (17.8%) and mild control was seen in two children. No improvement was observed in 4 (14%) of the patients. The EEG background activity was improved in VGB-treated patients. No effect on the EEG background activity was observed in CBZ-treated children. VGB seems to be a safe and effective antiepileptic drug as primary monotherapy for epilepsy in children with similar proportion of side effects as CBZ." }, { "id": "pubmed23n0387_23718", "title": "[Two siblings with eyelid myoclonia with absences].", "score": 0.00909090909090909, "content": "We report two siblings with eyelid myoclonia with absences. Patient 1, a 7-year-old boy, visited us because of eyelid blinking resembling a tic. He had experienced the movements since 2 years old. The diagnosis of a simple motor tic was initially made, however, the episodes worsened gradually. Patient 2, a younger brother of patient 1, was a 5-year-old boy. His eyelid blinking also began at age of 2 years. Additionally, the mother's aunt and her cousin had a history of grand mal on awakening, and the patient's cousin has febrile seizures. Their clinical features were as follows; (i) eyelid myoclonia, described as rapid, rhythmic eyelid fluttering with upward jerking of the eyes and head, lasting for 1-2 seconds; (ii) it occurred frequently each day; (iii) when it lasted for more than 2-3 seconds, it was associated with absences; (iv) both hyperventilation and photic stimulation on 18 f/c induced clinical seizures; and (v) ictal EEG revealed 3-4 c/s generalized irregular spike-waves with a duration of 1-3 seconds. Based on these characteristics, a diagnosis of eyelid myoclonia with absences was made. The present cases are the first sibling cases reported in Japan and, according to their family history, a genetic predisposition should be considered." }, { "id": "pubmed23n0402_10475", "title": "A 5-year-old boy with recurrent mania successfully treated with carbamazepine.", "score": 0.00909090909090909, "content": "In the present paper the clinical symptomatology and treatment of childhood mania that was first seen in a child at 5 years of age and which re-emerged at age 7, is reported. The patient presented at the child and adolescent psychiatric outpatient clinic of Istanbul Medical University with the typical symptoms of mania such of hyperactivity, euphoria, irritability, dangerous and risky behavior, decreased sleep, and age-inappropriate sexual behavior. He was treated with carbamazepine safely and effectively without any major side-effects. Clinical phenomenology and treatment of the condition are discussed with relevant literature." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 89, 145 ] ], "word_ranges": [ [ 16, 24 ] ], "text": "Hypophonesis in a hemithorax + tympanism = pneumothorax." }, "3": { "exist": true, "char_ranges": [ [ 146, 193 ] ], "word_ranges": [ [ 24, 31 ] ], "text": "If there is dullness on percussion: hemothorax." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Traumatic cardiac tamponade.", "2": "Right tension pneumothorax.", "3": "Massive right hemothorax.", "4": "Pulmonary contusion.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0955_18458", "title": "A shocking bike accident.", "score": 0.016677089847821555, "content": "CLINICAL INTRODUCTION: A man in his late 40s presented with severe chest pain and progressive dyspnoea after hitting a tree at high speed during a bike ride in the woods. On admission, the patient appeared agitated, pale and sweaty. Core temperature was 35.5°C, respiratory rate 35/min and blood pressure 90/50 mm Hg with a regular pulse at 110 beats/min. Physical examination revealed multiple sternal bruises, distended jugular veins and muffled heart sounds (figure 1A). Lactate level was 4.4 mmol/L (normal &lt;2.0 mmol/L) and high-sensitivity cardiac troponin T 0.142 mcg/L (normal &lt;0.005 mcg/L). An ECG and a total body CT scan were performed (figure 1B,C).heartjnl;104/20/1706/F1F1F1Figure 1(A) Multiple sternal bruises. (B) ECG on admission. (C) Thoracic CT. QUESTION  WHAT IS THE MOST LIKELY DIAGNOSIS?: Inferior myocardial infarction with right ventricular involvement.Cardiac contusion with tamponade.Commotio cordis.Aortic laceration." }, { "id": "pubmed23n0756_4182", "title": "[Factors affecting mortality in blunt thoracic trauma].", "score": 0.01660465757199945, "content": "Blunt thoracic trauma is usually associated with extra-thoracic injuries, but the effect of blunt thoracic trauma on mortality is not known. Patients with blunt thoracic trauma were evaluated with regard to clinical findings and factors affecting mortality. There were 76 patients (37.2±15 years) in the study group. Traffic accidents (63%) were the most common cause of trauma. Pneumothorax (54%), rib fracture (42%), hemothorax (22%) and lung contusion (22%) were common thoracic injuries. Extra-thoracic injuries were most commonly seen in the extremities (46%) and abdomen (40%). Glasgow Coma, Injury Severity and Revised Trauma Scores were 14±2.6, 19±13 and 7.4±1.5, respectively. Non-operative management was effective in 37 (48.7%) patients, tube thoracotomy and thoracotomy were performed in 37 (48.7%) and 2 (2.6%) patients, respectively. Mortality rate was 10.5%. Systolic blood pressure lower than 90 mmHg and superficial and apneic respiration at the first admission, and values of trauma scoring systems were significantly associated with mortality (p&lt;0.05). The effect of thoracic trauma on mortality with regard to thoracic pathology is not shown, although it is usually associated with extra-thoracic injuries. There was a close relationship between the pattern of respiration, values of systolic blood pressure and trauma scoring systems, and mortality. Non-operative management and tube thoracotomy were effective in most of the cases." }, { "id": "pubmed23n0955_12454", "title": "Blunt rupture of the thoracic duct after severe thoracic trauma.", "score": 0.01625226625226625, "content": "A 53-year-old man was admitted to our trauma center after sustaining thoracoabdominal injuries, secondary to a rear-end motor vehicle collision. As he stepped out of his vehicle, he was struck by a tractor trailer at 55 mph. The following were the initial vital signs on his arrival: heart rate 140 beats/min, blood pressure 142/80 mm Hg, respiratory rate 28 breaths/min, temperature 36.8°C, and oxygen saturation 93%. The Glasgow Coma Scale score was 15 and the Injury Severity Score was 59. He was evaluated and resuscitated per the advanced trauma life support protocols. The focused assessment with sonography for trauma examination was negative. Initial findings included bilateral chest wall and thoracic spine tenderness, subcutaneous emphysema in the chest and neck, and an unstable pelvis. He required bilateral chest tubes and a pelvic binder. CT imaging revealed a left temporal epidural hematoma, multiple facial fractures, a sternal fracture, a left scapula fracture, acromioclavicular fractures, bilateral hemopneumothoraces, pulmonary contusions, extensive pneumomediastinum compressing the right atrium, multiple rib fractures (2-10 on the left with a flail segment and 2-8 on the right) (figure 1), an unstable open-book pelvic fracture which included bilateral superior and inferior pubic rami fractures, sacral and left iliac wing fractures, and symphysis pubis diastasis.Figure 1Three-dimensional CT scan reconstruction demonstrating left-sided flail chest.The patient developed hypotension and severe respiratory distress, and was intubated. ECG revealed no dysrhythmias. Echocardiogram revealed significant left ventricular wall dysfunction consistent with myocardial contusion and right atrial compression. His troponins were also significantly elevated. He required significant resuscitation with crystalloids, blood products and vasopressors. He underwent bronchoscopy, esophagram and upper endoscopy to exclude tracheoesophageal injury, and these were negative. On hospital day 2, the patient was hemodynamically stable, and pressors were discontinued. His pelvic fractures were repaired using external fixation and sacral screws. Given his extensive left flail chest, he underwent reconstruction of his left chest wall on hospital day 5. Open reduction and internal fixation of his left ribs, 3 to 6 anteriorly and 4 to 7 posteriorly, with titanium plates was performed (figure 2). He had an epidural catheter inserted for analgesia. On postoperative day 2 after chest wall reconstruction, the patient was extubated and resumed enteral feeds. Overnight, the output from the left-sided chest tube changed from serosanguinous to milky. A sample was sent for triglycerides and lymphocyte counts confirming the diagnosis of chylothorax. His chest tube output increased to approximately 2000 mL/day. A lymphangiogram was performed with Lipiodol to diagnose the location of the chylous leak. It revealed contrast extravasation at the level of T3 to T4. An MRI was also performed to better define the anatomic course of the thoracic duct.Figure 2Postoperative chest X-ray demonstrating left chest wall reconstruction. Conservative management: placing the patient nulla per os (NPO), and starting total parenteral nutrition (TPN), octreotide and midodrine.Thoracic duct embolization by interventional radiology.CT-guided thoracic duct disruption.Thoracotomy with thoracic duct ligation." }, { "id": "pubmed23n0753_3228", "title": "Case 1/2013: 69-year-old male patient with sudden back and lower right limb pain and shock.", "score": 0.016133162612035852, "content": "The patient, MSM, a 69-year-old man, sought medical care due to left dorsal and right lower limb pain. The chest x-ray showed mediastinal enlargement. He was undergoing examination when he lost consciousness and went into shock. Subcutaneous emphysema was observed in the left hemithorax, as well as abolition of breath sounds at auscultation. Tracheal intubation was performed with draining of blood-tinged fluid from the left hemithorax. Echocardiography showed left ventricle with 44/29 mm; septum, 12 mm; posterior wall, 13 mm; mild aortic root dilation, dissection of the lamina and periaortic hematoma. The valves and pericardium were normal. The patient was transferred to Instituto do Coraçao - InCor. Physical examination (21 Oct 2004: 10:45) showed that the patient was sedated with tracheal intubation, pale, heart rate at 90 bpm, blood pressure 130 x 80 mmHg, bloody drainage in the chest tube. Electrocardiogram - frequency 90 bpm, sinus rhythm, low voltage in the frontal plane and decreased voltage in left leads (Fig. 1). Computed tomography showed bilateral subcutaneous emphysema, thoracic aorta with inaccurate borders in its descending portion (from the subclavian artery to the middle portion), collapsed left lung and extensive collection of hematic characteristics in same hemithorax and middle and posterior mediastinum. Small right pneumothorax; small right pleural effusion with underlying parenchymal alterations. The analysis of the heart was impaired by the presence of hemothorax. While undergoing computed tomography, the patient showed no pulse, mydriasis, with asystole unresponsive to resuscitation and died (21 Oct 2011; 15:00 h)." }, { "id": "pubmed23n0322_20444", "title": "[Blunt thoracic injury].", "score": 0.014638792800922444, "content": "Of 161 patients with blunt thoracic injury, 135 were male (83.9%) and 26 were female. The most common cause of injury was traffic accidents (130 patients, 80.7%), followed by falls (22 patients), and crushing (7 patients). There were 46 third decade and 36 second decade patients. Thirty-two patients had single thoracic injury and the other had multiple organ injury. The most common associated injury was head injury (65 patients). Most traffic accidents involved motor cycle accident. Forty-four patients died, 32 within 24 hours, and 4 died to thoracic injury. These 4 patients were shock on arrival and died within 24 hours. The injury severity score, which was under 30 in 78.3% of patients, correlated to the mortality rate. Rib fracture was the most common thoracic injury in 96 patients followed by hemothorax in 91, pulmonary contusion in 79, and pneumothorax in 64. Most of the thoracic injuries were treated conservatively. Thoracotomy was performed in 6 patients. Other than one patient with rupture of the left pulmonary vein, 5 patients recovered. Continued bleeding at a rate of more than 200 ml/h from the chest drainage tube or no recovery from shock and large air leakage preventing re-expansion of the lung are indications for emergency thoracotomy. Thoracotomy should also be considered after conservative treatment in patients with continued air leakage or intrabronchial bleeding negatively affecting respiration. Indications for thoracotomy should be determined individually based on evaluating of vital sign." }, { "id": "wiki20220301en057_46147", "title": "Advanced trauma life support", "score": 0.012895434003428394, "content": "Breathing and ventilation The chest must be examined by inspection, palpation, percussion and auscultation. Subcutaneous emphysema and tracheal deviation must be identified if present. The aim is to identify and manage six life-threatening thoracic conditions as Airway Obstruction, Tension Pneumothorax, Massive Haemothorax, Open Pneumothorax, Flail chest segment with Pulmonary Contusion and Cardiac Tamponade. Flail chest, tracheal deviation, penetrating injuries and bruising can be recognized by inspection. Subcutaneous emphysema can be recognized by palpation. Tension Pneumothorax and Haemothorax can be recognized by percussion and auscultation." }, { "id": "pubmed23n1133_22546", "title": "Attention: Cardiac contusion.", "score": 0.012594268476621418, "content": "The objective of the study is to investigate diagnostic and clinical processes performed for cardiac contusion in patients with blunt thoracic trauma. This study was conducted retrospectively on 65 patients admitted with isolated blunt thoracic trauma to the Emergency Medicine Department. The CT images, the cardiac enzyme levels, the periodic 4-h follow-up electrocardiography (ECGs) in the emer-gency department, and the results of echocardiography, performed at admission and when required according to the clinical status, were investigated. The 1-h and 4-h high-sensitivity troponin I levels were studied, and values above 0.04 ng/ml were considered as positive. Sixty-five patients with isolated thoracic trauma were included in the study, 23 (35.38%) had pulmonary and cardiac contu-sions both. In 23 (35.38%) patients, pulmonary contusion had been present, and cardiac contusion had not been identified at the initial evaluation. However, during clinical follow-up, troponin became positive, dysrhythmia developed, and the trauma affected the heart in four of these patients. In six (9.24%) patients, cardiac contusion was identified without pulmonary contusion. In 13 (20%) patients, no cardiac or pulmonary contusion was identified. troponin elevation was detected in 10 patients without a diagnosis of cardiac contusion who had a pulmonary contusion, hemothorax, and/or pneumothorax at the time of hospital admission and then with normal troponin levels at 4-h control. We found that there was a statistical agreement between cardiac contusion and troponin-ECG results at 4th h. We advise that all blunt thoracic trauma patients should be screened for cardiac contusion by continuous ECG monitoring and troponin levels." }, { "id": "pubmed23n0075_9220", "title": "Blunt traumatic cardiac rupture. A 5-year experience.", "score": 0.012272895810159437, "content": "Blunt traumatic cardiac rupture is associated with a high rate of mortality. A review of the computerized trauma registry (1983 to 1988) identified 32 patients with this injury (ages 19 to 65 years; mean age, 39.5 years; 21 men and 11 women). Twenty-one patients (65.6%) were injured in vehicular crashes, 3 (9.4%) in pedestrian accidents, 3 (9.4%) in motorcycle accidents; 3 (9.4%) sustained crush injury; 1 (3.1%) was injured by a fall; and 1 (3.1%) was kicked in the chest by a horse. Anatomic injuries included right atrial rupture (13[40.6%]), left atrial rupture (8 [25%]), right ventricular rupture (10[31.3%]), left ventricular rupture (4[12.5%]), and rupture of two cardiac chambers (3 [9.4%]). Diagnosis was made by thoracotomy in all 20 patients presenting in cardiac arrest. In the remaining 12 patients, the diagnosis was established in seven by emergency left anterolateral thoracotomy and in five by subxyphoid pericardial window. Seven of these 12 patients (58.3%) had clinical cardiac tamponade and significant upper torso cyanosis. The mean Injury Severity Score (ISS), Trauma Score (TS), and Glasgow Coma Scale (GCS) score were 33.8, 13.2, and 14.3, respectively, among survivors and 51.5, 8.3, and 7.0 for nonsurvivors. The overall mortality rate was 81.3% (26 of 32 patients), the only survivors being those presenting with vital signs (6 of 12 patients [50%]). All patients with rupture of two cardiac chambers or with ventricular rupture died. The mortality rate from myocardial rupture is very high. Rapid prehospital transportation, a high index of suspicion, and prompt surgical intervention contribute to survival in these patients." }, { "id": "pubmed23n0554_11667", "title": "[Penetrating thoracic injury].", "score": 0.01227106227106227, "content": "To clarify the clinical aspects of penetrating thoracic injury. Eighteen patients with penetrating thoracic injury treated from 1987 to 2005 were evaluated. There were 13 men and 5 women. The age distribution was 8 to 69 years, with an average of 36.7 years. There were 14 patients with stab wound and 4 with impalement injury. Five patients with stab wound were those who attempted suicide. In 4 patients with impalement injuries, the cause was fall in 2, traffic accident in 1 and sports injury in 1. The calculated injury severity score (ISS) was over 15 in 4 patients, 6 to 14 in 12, and under 5 in 2. Thoracotomy was performed in 2 patients with cardiac tamponade, 3 with massive hemothorax and 1 with an impalement injury caused by an iron bar. All of them were rescued and got well. In the other cases, after cleansing and debridement, the wound was closed and thoracic drainage was performed. Only 1 patient with cardiac arrest on arrival died within 24 hours after reviving. Emergent thoracotomy is indicated for patients with massive bleeding including shock, continuous air leakage and cardiac tamponade. Since cardiac arrest is difficult to cure, appropriate cooperation with the rescue team is necessary to avoid preventable trauma death." }, { "id": "wiki20220301en089_35250", "title": "Traumatic asphyxia", "score": 0.012118437118437119, "content": "Traumatic asphyxia, or Perthes's syndrome, is a medical emergency caused by an intense compression of the thoracic cavity, causing venous back-flow from the right side of the heart into the veins of the neck and the brain. Signs and symptoms Traumatic asphyxia is characterized by cyanosis in the upper extremities, neck, and head as well as petechiae in the conjunctiva. Patients can also display jugular venous distention and facial edema. Associated injuries include pulmonary contusion, myocardial contusion, hemo/pneumothorax, and broken ribs. Causes Traumatic asphyxia occurs when a powerful compressive force is applied to the thoracic cavity. This is most often seen in motor vehicle accidents, as well as industrial and farming accidents. However, it can be present anytime a significant pressure is applied to the thorax." }, { "id": "pubmed23n1144_12364", "title": "Left atrial appendage rupture: A rare complication of right-sided haemothorax: A case report.", "score": 0.011143677108139464, "content": "Cardiac injury accounts for less than 10 % of all traumas and it is a fatal condition associated with cardiac tamponade or massive haemothorax, which requires immediate intervention, such as resuscitative thoracotomy. However, in case of haemothorax without the findings suggestive of cardiac damage such as pericardial effusion, it is difficult to determine the complications of cardiac injury, because injury of the lung or intercostal arteries is usually considered first. We describe a rare case of left atrial appendage rupture with a right-sided massive haemothorax with slight cardiac effusion. A 47-year-old man with no significant medical history was transferred to our emergency department after crashing his motorcycle into a car. A right resuscitative thoracotomy for massive haemothorax was performed, followed by hilarious clamping and pericardial drainage. We found continuous bleeding from a right dorsal pericardial injury which indicated cardiac injury. Soon after the patient was referred to the operating room, left atrial appendage rupture was found, and ligated. The postoperative course was uneventful, and he was discharged on 15th postoperative day without complication. Left atrial appendage rupture is caused by a direct external force to the left atrium, so the pericardial injury is usually ipsilateral to the left side of the pericardium, resulting in perforation of the left thoracic cavity. Therefore, left atrial appendage rupture with a right-sided massive haemothorax is rare. In addition, when a cardiac injury is associated with a pericardial injury, most of the pericardial effusion drains into the thoracic cavity, resulting in a small amount of pericardial effusion, which make it difficult to recognize the cardiac injury. In conclusion, in blunt trauma, even in the case of a right-sided haemothorax, the possibility of cardiac injury in addition to pulmonary contusion should be considered and explored, because cardiac injury could be fatal." }, { "id": "pubmed23n0903_20949", "title": "Emergency room thoracotomy for acute traumatic cardiac tamponade caused by a blunt cardiac injury: A case report.", "score": 0.010502232758145432, "content": "Traumatic blunt cardiac injuries have a high mortality rate, and prompt diagnosis and treatment can be lifesaving in cardiac tamponade. A 62-year-old man was transferred to the emergency department after a motor vehicle accident. He was hemodynamically unstable. A focused assessment with sonography in trauma (FAST) showed pericardial fluid with right ventricular collapse consistent with cardiac tamponade in the subxiphoid view. He collapsed despite a subxiphoid pericardiotomy. Owing to the ongoing hemodynamic instability, we performed a left anterolateral thoracotomy. Direct incision of the pericardium showed blood and clots within the pericardial space, indicating hemopericardium. The heart stroke and hemodynamic status recovered on removing the clot. Although the physical findings of cardiac tamponade are not always apparent in life-threatening acute cardiac tamponade after blunt trauma, FAST is a reliable tool for diagnosing and following cardiac tamponade. A median sternotomy is a standard approach for evaluating cardiac injury in hemodynamically stable patients with or without cardiopulmonary bypass. However, a left anterior thoracotomy was the fastest, simplest life-saving procedure considering the need for open-chest cardiac massage given our patient's life-threatening condition. A prompt diagnosis using FAST and treatment can be lifesaving in traumatic acute cardiac tamponade. A pericardiotomy via a thoracotomy is mandatory for lifesaving cardiac decompression in acute traumatic cardiac tamponade in cases of ineffective drainage due to clot formation within the pericardial space." }, { "id": "wiki20220301en397_28573", "title": "Transmediastinal gunshot wound", "score": 0.010484684397727876, "content": "Unstable patients The criteria to define a patient as stable or unstable could have variations from institution to institution. For example, Burack et al. used a list of 6 criteria in his paper that defined an unstable hemodynamic state: Traumatic cardiac arrest or near arrest and an EDT Cardiac tamponade Persistent ATLS class III shock despite fluid resuscitation (blood loss 1500–2000 mL, pulse rate greater than 120, blood pressure decreased) Chest tube output greater than 1500 mL of blood on insertion Chest tube output greater than 500 mL/hour for the initial hour Massive hemothorax after chest tube drainage One common criteria found in literature is a sustained systolic blood pressure of less than 100 mmHg, but this can be an oversimplification. Patients with clinical evidence of possible TMGSW that are considered unstable receive no further evaluation and are taken to surgery immediately. Management" }, { "id": "wiki20220301en036_7649", "title": "Traumatic cardiac arrest", "score": 0.009900990099009901, "content": "Hemothorax Hemothorax occurs when injury to the chest results in bleeding into the thoracic cavity. Similar to tension pneumothorax, increasing pressure prevents the return of blood from circulation to the heart. Cardiac tamponade In the setting of trauma, cardiac tamponade results from an acute pericardial effusion, the accumulation of blood within the sac that surrounds the heart. As this sac is filled with fluid, the pressure on the heart is increased, and the chambers of the heart are unable to fill with blood. Hypoxia Inability to maintain oxygenation in trauma patients may be a result of airway compromise due to mechanical injury or obstruction or due to loss of the respiratory drive from cervical spine or peripheral nerve injury. These conditions result in the hypoxia that may lead to cardiac arrest. Signs and symptoms" }, { "id": "pubmed23n0265_10271", "title": "[2 cases of the tension pneumopericardium following blunt chest trauma resulting in the cardiac tamponade].", "score": 0.009900990099009901, "content": "A 63-year-old man (case 1) was brought to our emergency unit following a high speed collision. He developed fatal cardiopulmonary arrest shortly after arrival despite resuscitation efforts. Tension pneumopericardium was revealed by chest X-ray and CT examination. An 18-year-old man (case 2) was admitted after a motorcycle accident. Pneumopericardium was noted on admission chest X-ray and CT examination. He developed cardiac tamponade after the examination. He was intubated and mechanically ventilated after the subxiphoid pericardial drainage. Pneumopericardium following blunt chest trauma is realized with tracheobronchial, pulmonary or esophageal injury. The clinical significance of pneumopericardium is the development of tension pneumopericardium resulting into cardiac tamponade. In a patient with traumatic pneumopericardium who requires mechanical ventilatory support, continuous pericardial drainage should be considered. In addition, tension pneumopericardium may occur in patients with breathing spontaneously as in our cases. In these cases, careful observation and immediate subxiphoid pericardial drainage are required." }, { "id": "pubmed23n0658_5536", "title": "[Blunt trauma to the intrapericardial inferior vena cava with concomitant rupture of the pericardium].", "score": 0.00980392156862745, "content": "We report a rare case of blunt trauma to the intrapericardial inferior vena cava with concomitant rupture of the pericardium, which was successfully managed by surgical treatment. A 77-year-old male was transferred to our hospital for treatment of trauma by a traffic accident. The patient presented with the sign of shock and there were no external injuries. After admission, right-sided traumatic hemothorax and left-sided traumatic pneumothorax were drained with chest tubes. Although an echocardiography and chest computed tomography (CT) demonstrated no pericardial fluid collection and cardiovascular injuries, his blood pressure dropped suddenly with massive hemorrhage from right thoracic cavity after starting continuous suction drainage of bilateral chest tubes. Thus, we decided to perform emergency operation, while assuming that cardiovascular injuries were the source of the bleeding. A right-sided thoracotomy revealed that a small laceration of intrapericardial inferior vena cava with the pericardial tear was the site of the bleeding. Repair for that injury was done with interrupted sutures without cardiopulmonary bypass. He recovered gradually, and moved to department of orthopaedic surgery in a stable condition on the 25th hospital day." }, { "id": "pubmed23n0316_9279", "title": "[Aortic rupture after blunt chest trauma. Rapid diagnosis using transesophageal echocardiography when radiographic and computed tomographic findings are unclear].", "score": 0.00980392156862745, "content": "A 37-year-old woman who was not wearing a seat-belt while driving a car had a head-on collision at 70 km/h. On arrival of the emergency physician she was awake and responsive but complained of pain with bruising over the sternum and the epigastrium. Pressure on the sternum was painful. Arterial pressure was 95/60 mm Hg, heart rate 112/min. On admission the heart sounds were unremarkable and peripheral pulses normal. Vesicular sounds were heard over both lungs. In addition to multiple facial abrasions voluntary movements were impaired and the right knee-joint was swollen. The ECG showed sinus tachycardia (103 beats/min) with left axis deviation, but was otherwise unremarkable. Initially the haemoglobin was 12.6 g/dl with normal white cell and platelet counts. Clotting tests, serum transaminases, creatine kinase, lactate dehydrogenase and other routine laboratory tests were within normal limits. Because the haemoglobin level had fallen to 7.7 g/dl within the first 4 hours erythrocytes concentrate was infused. The chest radiogram and subsequent computed tomography showed a mediastinal and paraaortic haematoma of unclear origin. Transoesophageal echocardiography (TEE) demonstrated rupture of the descending aorta with free floating intraluminal parts of the intima in the isthmal region, just distal to the origin of the left subclavian artery, which was not occluded. Colour Doppler echocardiography revealed abnormal flow into mediastinal and paraaortic tissues. At operation the echocardiographic findings were confirmed and part of the descending aorta was replaced by a 3 cm dacron tube during an aortic crossclamping time of 37 min. The patient was discharged after a postoperative stay of average length, during which her other injuries were treated. After blunt thoracic or deceleration trauma earliest possible TEE is indicated, because it can at once provide details of extent and degree of injury to heart and/or aorta." }, { "id": "pubmed23n0712_25048", "title": "An evidence-based approach to emergency ultrasound.", "score": 0.009708737864077669, "content": "Paramedics bring into the ED an elderly man who is complaining of right-sided chest and abdominal pain. Earlier this morning, a friend had arrived at the patient's home and found him on the floor at the bottom of the stairs. The patient is in pain, somewhat altered, and unable to provide further details about what happened. After numerous attempts, the paramedics were only able to place a 22-gauge peripheral line. On examination, his blood pressure is 98/55 mm Hg, heart rate is 118 beats per minute, respiratory rate is 32 breaths per minute, oxygen saturation is 94% on a nonrebreather, and temperature is 36.0 degrees C (96.8 degrees F). His Glasgow Coma Scale score is 12 (eyes 3, verbal 4, motor 5). Given the unclear events surrounding his presentation and the concern for trauma, the patient is boarded and collared. His chest is stable but tender, and because of noise in the resuscitation room, you have difficulty auscultating breath sounds. The abdominal examination is notable for marked tenderness over the right upper quadrant and right flank, with some guarding. There is also mild asymmetric swelling of his right lower extremity. The patient is critically ill, his history is limited, and at this point the differential is quite broad. You consider the possibility of a syncopal episode followed by a fall, with a closed head injury, blunt thoracic trauma, and blunt abdominal trauma. His hypotension could be secondary to hypovolemia (dehydration or blood loss due to a ruptured aortic aneurysm), heart failure (left- or right-sided dysfunction), cardiac tamponade, tension pneumothorax, or sepsis. Your ED recently purchased an ultrasound machine, you wonder whether bedside ultrasound can help narrow the differential and guide your resuscitation. You call over one of your new faculty members who just finished resident training; a fortunate decision for both you and the patient." }, { "id": "pubmed23n0291_7035", "title": "[Successful repair of right atrial rupture due to nonpenetrating trauma of the chest].", "score": 0.009708737864077669, "content": "A 24-year-old male was brought to our hospital after being injured in a traffic accident. On arrival, his blood pressure was 70/44 mmHg and his pulse rate was 135/min and regular. Chest X-p revealed cardiomegaly but there was no pleural effusion or bone fracture. Echocardiogram revealed cardiac tamponade and he was diagnosed as cardiac rupture due to non penetrating trauma. Under midline sternotomy, right atrial rupture was repaired. The patient developed cardiac arrest lasting approximately 8 minutes during anesthetic induction, so he needed to be ventilated for 8 days. However his postoperative course was not so eventful and he was discharged 38 days after surgery without any neurophysiological disturbance." }, { "id": "wiki20220301en084_63787", "title": "Chest injury", "score": 0.009615384615384616, "content": "Classification Chest injuries can be classified as blunt or penetrating. Blunt and penetrating injuries have different pathophysiologies and clinical courses. Specific types of injuries include: Injuries to the chest wall Chest wall contusions or hematomas. Rib fractures Flail chest Sternal fractures Fractures of the shoulder girdle Pulmonary injury (injury to the lung) and injuries involving the pleural space Pulmonary contusion Pulmonary laceration Pneumothorax Hemothorax Hemopneumothorax Injury to the airways Tracheobronchial tear Cardiac injury Pericardial tamponade Myocardial contusion Traumatic arrest Hemopericardium Blood vessel injuries Traumatic aortic rupture Thoracic aorta injury Aortic dissection And injuries to other structures within the torso Esophageal injury (Boerhaave syndrome) Diaphragm injury" }, { "id": "pubmed23n0846_14832", "title": "Outcome of Patients Underwent Emergency Department Thoracotomy and Its Predictive Factors.", "score": 0.009615384615384616, "content": "Emergency department thoracotomy (EDT) may serve as the last survival chance for patients who arrive at hospital in extremis. It is considered as an effective tool for improvement of traumatic patients' outcome. The present study was done with the goal of assessing the outcome of patients who underwent EDT and its predictive factors. In the present study, medical charts of 50 retrospective and 8 prospective cases underwent emergency department thoracotomy (EDT) were reviewed during November 2011 to June 2013. Comparisons between survived and died patients were performed by Mann-Whitney U test and the predictive factors of EDT outcome were measured using multivariate logistic regression analysis. P &lt; 0.05 considered statistically significant. Fifty-eight cases of EDT were enrolled (86.2% male). The mean age of patients was 43.27±19.85 years with the range of 18-85. The mean time duration of CPR was recorded as 37.12±12.49 minutes. Eleven cases (19%) were alive to be transported to OR (defined as ED survived). The mean time of survival in ED survived patients was 223.5±450.8 hours. More than 24 hours survival rate (late survived) was 6.9% (4 cases). Only one case (1.7%) survived to discharge from hospital (mortality rate=98.3%). There were only a significant relation between ED survival and SBP, GCS, CPR duration, and chest trauma (p=0.04). The results demonstrated that initial SBP lower than 80 mmHg (OR=1.03, 95% CI: 1.001-1.05, p=0.04) and presence of chest trauma (OR=2.6, 95% CI: 1.75-3.16, p=0.02) were independent predictive factors of EDT mortality. The findings of the present study showed that the survival rate of trauma patients underwent EDT was 1.7%. In addition, it was defined that falling systolic blood pressure below 80 mmHg and blunt trauma of chest are independent factors that along with poor outcome." }, { "id": "wiki20220301en423_14927", "title": "List of medical mnemonics", "score": 0.009523809523809525, "content": "Imobilisation/surgery in the last 4 weeks (1.5) Previous DVT/PE Blood in sputum (haemoptysis) (1) Active cancer (1) Two tier score: PE likely > 4 Causes of life-threatening chest pain PET-MAC P = Pulmonary embolism E = Esophageal rupture T = Tension pneumothorax M = Myocardial infarction A = Aortic dissection C = Cardiac tamponade GCS intubation Under 8, intubate. Ipecac: contraindications 4 C's: Comatose Convulsing Corrosive hydrocarbon JVP: raised JVP differential PQRST(EKG waves): Pericardial effusion Quantity of fluid raised (fluid over load) Right heart failure Superior vena caval obstruction Tricuspid stenosis/tricuspid regurgitation/tamponade (cardiac) MI: immediate treatment DOGASH: Diamorphine Oxygen GTN spray Aspirin 300 mg Streptokinase Heparin PEA/asystole (ACLS): cause ITCHPAD Infarction Tension pneumothorax Cardiac tamponade Hypovolemia/hypothermia/hypo-,hyperkalemia/hypomagnesmia/hypoxemia Pulmonary embolism Acidosis" }, { "id": "pubmed23n0649_8024", "title": "Diagnosis and treatment of deep pulmonary laceration with intrathoracic hemorrhage from blunt trauma.", "score": 0.009523809523809525, "content": "Blunt chest trauma resulting in massive hemothorax requires immediate attention. We investigated the diagnostic and prognostic utility of various clinical factors in patients with deep pulmonary laceration caused by blunt chest trauma with a view toward interventional treatment. We reviewed 42 patients with deep pulmonary laceration resulting from blunt chest trauma who were treated between 1988 and 2008. Various clinical factors were compared between survivors and nonsurvivors. Of the 42 patients, 29 (69%) survived. Median (25th, 75th percentile) systolic blood pressure at arrival was 102 (76, 121) mm Hg for survivors and 70 (60, 90) mm Hg for nonsurvivors (p = 0.015). The median heart rate at arrival was 107 (98, 120) beats/min for survivors and 130 (120, 140) beats/min for nonsurvivors (p = 0.014). Respiratory rate, Glasgow Coma Scale score, and arterial blood gas values did not affect prognosis. Blood loss through the chest tube at insertion was 500 (400, 700) mL for survivors and 700 (500, 1000) mL for nonsurvivors (p = 0.147) and within 2 hours of arrival was 850 (590, 1100) mm Hg and 1600 (1400, 2000) mL, respectively (p &lt; 0.001). Blood loss during thoracotomy was 1170 (600, 1790) mL and 3500 (2000, 6690), respectively (p &lt; 0.001). In patients with deep pulmonary laceration, hemorrhagic shock with systolic blood pressure less than 80 mm Hg and heart rate more than 120 beats/min leads to a poor prognosis. Emergency thoracotomy and pulmonary lobectomy should be performed before the intrathoracic hemorrhage reaches 1200 mL." }, { "id": "wiki20220301en155_16126", "title": "Gunshot wound", "score": 0.009433962264150943, "content": "Chest Important anatomy in the chest includes the chest wall, ribs, spine, spinal cord, intercostal neurovascular bundles, lungs, bronchi, heart, aorta, major vessels, esophagus, thoracic duct, and diaphragm. Gunshots to the chest can thus cause severe bleeding (hemothorax), respiratory compromise (pneumothorax, hemothorax, pulmonary contusion, tracheobronchial injury), cardiac injury (pericardial tamponade), esophageal injury, and nervous system injury." }, { "id": "pubmed23n1089_17394", "title": "Thoracoscopic diagnosis of traumatic pericardial rupture with cardiac hernia: A case report.", "score": 0.009433962264150943, "content": "Pericardial rupture caused by blunt chest trauma is rare in clinical practice. Because of its atypical clinical symptoms, and because surgeons are often unfamiliar with the clinical and radiological manifestations of the injury, preoperative diagnosis is difficult; it is easily misdiagnosed and causes serious consequences. A 60-year-old man, previously healthy, was transported to the emergency room after falling from a great height. Upon arrival, his vital signs were stable. Electrocardiography and echocardiography were performed, and there was no sign of cardiac injury or ischemia. Chest and abdomen computerized tomography revealed pneumopericardium, hemopneumothorax, lung contusion, multiple rib fractures on the right side (Figure 1), and right scapula and clavicle fractures. He was admitted to the inpatient department for further observation after tube thoracostomy. The next day, the patient suddenly experienced rapid arrhythmia (the ventricular rate reached 150-180 beats/min) when turning onto his right side, accompanied by a blood pressure drop to 70/45 mm Hg and a chief complaint of palpitation. Thoracoscopy was performed urgently, and a large vertical tear (8 cm × 6 cm) was found in the pericardium. The defect was successfully repaired using a heart Dacron patch. His postoperative condition was uneventful without any fluctuations in vital signs, and he was transferred to the orthopedics department for further surgery on postoperative day 8. Although the possibility of pericardial rupture combined with cardiac hernia is extremely low, it is one of the causes of cardiogenic shock following blunt trauma. Therefore, clinicians need to be more familiar with its characteristic manifestations and maintain a high degree of vigilance against such injuries to avoid disastrous consequences." }, { "id": "pubmed23n1086_24931", "title": "[Traumatic Right Atrial Rupture with Left Hemothorax but without Hemopericardium:Report of a Case].", "score": 0.009345794392523364, "content": "Traumatic cardiac rupture is mostly accompanied by tamponade and/or hemopericardium. We experienced a rare case of traumatic right atrial rupture with left hemothorax, but without hemopericardium. A 36-year-old male had a traffic accident, and was transported to our hospital. He was in a state of shock caused by massive hemothorax. He underwent emergency operation through median sternotomy. No blood was seen in the pericardium nor injury of any major vessels or lungs. When the heart was exposed, massive bleeding occurred. A tear of 30 mm in length was found in the right atrium at the junction of the superior vena cava. The tear was repaired under cardiopulumonary bypass. Even after surgery, however, he remained unconscious." }, { "id": "pubmed23n0845_21551", "title": "Simple pneumopericardium due to blunt trauma progressing to tension pneumopericardium during transportation.", "score": 0.009345794392523364, "content": "Patients with simple pneumopericardium due to blunt thoracic trauma occasionally progressed to tension pneumopericardium, although pneumopericardium is believed to be benign in general. A 65-year-old man had both arms caught in a grinding machine and his face struck hard at work. He was diagnosed with bilateral degloving injuries of both arms and mediastinal emphysema on computed tomography. He required transfer to an advanced emergency medical service center for treatment. Although he was hemodynamically stable then, the patient's condition deteriorated during transportation. The patient returned to the local hospital as cardiopulmonary resuscitation continued, repeat computed tomography was performed, which showed a substantial pneumopericardium and exacerbation of mediastinal and subcutaneous emphysema. After then, cardiopulmonary resuscitation was discontinued because there was no response. For the patient to be rescued in this situation, thoracotomy is required, although it should be reserved for patients with evidence of hemodynamic compromise attributable to cardiac tamponade." }, { "id": "wiki20220301en012_131376", "title": "Cardiac tamponade", "score": 0.00933075933075933, "content": "Differential diagnosis Initial diagnosis of cardiac tamponade can be challenging, as there is a broad differential diagnosis. The differential includes possible diagnoses based on symptoms, time course, mechanism of injury, patient history. Rapid onset cardiac tamponade may also appear similar to pleural effusions, shock, pulmonary embolism, and tension pneumothorax. If symptoms appeared more gradually, the differential diagnosis includes acute heart failure. In a person with trauma presenting with pulseless electrical activity in the absence of hypovolemia and tension pneumothorax, the most likely diagnosis is cardiac tamponade." }, { "id": "article-30078_9", "title": "Thoracic Trauma -- History and Physical", "score": 0.009302495257551438, "content": "The initial evaluation of a trauma patient is based on the ATLS protocol. This begins with an assessment of the patient's airway, breathing, and circulation (ABCs) during the primary survey, typically in that order. The initial evaluation of the patient who has sustained blunt or penetrating thoracic trauma is similar and geared toward the rapid identification of immediately life-threatening conditions, namely tension pneumothorax, cardiac tamponade, aortic injury, massive hemothorax, and tracheobronchial disruption. The clinician must pay careful attention to the patient's appearance on arrival to the trauma bay. Signs of respiratory distress, agitation, diaphoresis, or unwillingness to lay flat suggest underlying cardiopulmonary injuries, such as tension pneumothorax or cardiac tamponade, in which case the breathing or circulation portions of the primary survey would need to be addressed and intervened upon first, as indicated. Intubating such patients may exacerbate the pneumothorax or hypotension and lead to cardiovascular collapse due to the increased intrathoracic pressure generated by positive pressure ventilation. Therefore, if time and personnel allow, these interventions should be performed while the patient is prepared for intubation. However, assessment of the airway is generally performed first to establish patency and evaluate the need for intubation. The assessment of breathing begins at the trachea, which is inspected and palpated to ensure that it is midline and not deviated. The chest wall in then inspected for asymmetry, auscultated for breath sounds, and palpated for tenderness, crepitus, and to detect flail segments. In assessing circulation, hypotension in the setting of thoracic trauma should raise suspicion for tension pneumothorax or tamponade, which need urgent intervention before further evaluation of the patient can proceed." }, { "id": "wiki20220301en157_24152", "title": "Penetrating trauma", "score": 0.009284878646636088, "content": "Chest Most penetrating injuries are chest wounds and have a mortality rate (death rate) of under 10%. Penetrating chest trauma can injure vital organs such as the heart and lungs and can interfere with breathing and circulation. Lung injuries that can be caused by penetrating trauma include pulmonary laceration (a cut or tear) pulmonary contusion (a bruise), hemothorax (an accumulation of blood in the chest cavity outside of the lung), pneumothorax (an accumulation of air in the chest cavity) and hemopneumothorax (accumulation of both blood and air). Sucking chest wounds and tension pneumothorax may result." }, { "id": "pubmed23n0686_15300", "title": "A case of traumatic cardiac tamponade showing sudden spontaneous disappearance of the pericardial fluid.", "score": 0.009259259259259259, "content": "Traumatic cardiac tamponade must be treated by pericardial drainage as soon as possible. We recently encountered a rare case of traumatic cardiac tamponade in which the pericardial fluid disappeared spontaneously immediately before the planned drainage. This case is reported in this paper. The patient was a 22-year-old male who was transported to our hospital after he sustained injuries in a traffic accident. The patient was diagnosed to have a facial bone fracture, bilateral lung contusions, myocardial contusion (suspected), injury to the spinal cord at the L3-L4 level, injury to the left kidney and pelvic fracture. After TAE was performed to deal with the bleeding from the injured pelvis, the patient was immediately hospitalized. About 6 hours after the injury, pericardial fluid accumulation began to be noted, and about 18 hours after the injury, the patient went into shock, responding poorly to fluid resuscitation and treatment with pressor agents. At this time, a diagnosis of cardiac tamponade was made and emergency operation was arranged for. However, just before this could be executed, the patient's blood pressure showed a sharp rise, accompanied by disappearance of the pericardial fluid. He continued to show steady improvement and could eventually be discharged from the hospital." }, { "id": "pubmed23n0395_17138", "title": "A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma.", "score": 0.009174311926605505, "content": "We sought to determine the prevalence of thoracic injuries in children sustaining blunt torso trauma and to develop a clinical prediction rule to identify children with these injuries. We prospectively enrolled pediatric patients (&lt;16 years) who presented to the emergency department of a Level I trauma center with blunt torso trauma and underwent chest radiography. Clinical findings were recorded in a standardized fashion by the ED faculty physician. Thoracic injuries included the following: pulmonary contusion, hemothorax, pneumothorax, pneumomediastinum, tracheal-bronchial disruption, aortic injury, hemopericardium, pneumopericardium, cardiac contusion, rib fracture, sternal fracture, or any injury to the diaphragm. Multiple logistic regression and recursive partitioning analyses were performed to generate a clinical prediction rule for identifying children with these injuries. Nine hundred eighty-six patients with a mean age of 8.3+/-4.8 years were enrolled. Eighty (8.1%; 95% confidence interval [CI] 6.5% to 10.0%) patients sustained thoracic injuries. Multiple logistic regression and recursive partitioning analyses identified the following predictors of thoracic injuries: low systolic blood pressure (14% with injury versus 2% without injury; adjusted odds ratio [OR] 4.6), elevated age-adjusted respiratory rate (51% versus 16%; adjusted OR 2.9), abnormal results on examination of the thorax (68% versus 36%; adjusted OR 3.6), abnormal chest auscultation findings (14% versus 1%; adjusted OR 8.6), femur fracture (13% versus 5%; adjusted OR 2.2), and a Glasgow Coma Scale (GCS) score of less than 15 (61% versus 26%; adjusted OR 3.3). Seventy-eight (98%; 95% CI 91% to 100%) of the 80 patients with thoracic injuries had at least 1 of these predictive factors. Three hundred thirty-six (37%) children had none of these predictive factors, including 2 (0.6%; 95% CI 0.1% to 2.1%) with thoracic injuries. These 2 injuries, however, did not require any intervention. Predictors of thoracic injury in children sustaining blunt torso trauma include low systolic blood pressure, elevated respiratory rate, abnormal results on thoracic examination, abnormal chest auscultation findings, femur fracture, and a GCS score of less than 15. These predictors can be used to create a sensible clinical decision rule for the identification of children with thoracic injuries." } ] } } }

{ "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": [ [ 0, 102 ] ], "word_ranges": [ [ 0, 17 ] ], "text": "They are undoubtedly describing the typical lesions (both on skin and oral mucosa) of a lichen planus" } }

{ "1": "Pityriasis versicolor.", "2": "Mycosis fungoides.", "3": "Psoriasis in drops.", "4": "Pityriasis rosea of Gibert.", "5": "Lichen planus." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0715_21227", "title": "Segmental lesions in pityriasis rosea: a rare presentation.", "score": 0.018362533692722373, "content": "A 34-year-old nonpregnant woman noted a mildly pruritic skin lesion on her right breast for 1 week following an episode of coryza, malaise, and low-grade fever of 3 days' duration. The latter symptoms subsided without any treatment. Ketoconazole cream prescribed by her family physician did not resolve the breast eruption after 1 week, so was stopped. A week later, multiple skin lesions erupted suddenly on her right chest wall starting near the herald patch in midaxillary line and spread distally until the midback. She then consulted the authors. She denied a history of abrasion or trauma to the affected areas. Travel, contact, sexual, and drug histories were unremarkable. She categorically denied past or family history of eczema, psoriasis, contact dermatitis, and drug eruptions. On examination, the initial lesion was an annular and well-demarcated erythematous plaque on her right breast in the upper outer quadrant. Multiple small oval scaly plaques were noted, extending distally along the ribs to the midline on her back, not crossing the midline, predominantly over the distribution of right T4 dermatome (Figure 1). Peripheral collarette scaling was noted (Figure 2). A few scattered small lesions were also noted in the vicinity of this dermatome. Three isolated small plaques were also present on the trunk, one in the supramammary area and the other two on the abdomen and back, respectively. Palmoplantar and mucosal surfaces were uninvolved. The rest of the skin and systemic examination revealed no abnormalities. Complete blood cell counts, fasting glucose, and urinalysis were normal. Venereal Disease Research Laboratory (VDRL) results were nonreactive and human immunodeficiency virus (HIV) antibodies were negative. Repeat testing ofVDRL in serial dilutions and HIV antibodies after 3 months were also nonreactive and negative, respectively. Scrapings from the initial large lesion and subsequent smaller eruptions did not show any evidence of fungal infection on potassium hydroxide smear examination. The patient declined skin biopsy; however, we thought that the most diagnostic label for this condition was pityriasis rosea. Hence, we treated her with triamcinolone acetonide ointment 0.025% to be applied twice daily and desloratadine tablet 5 mg daily for 10 days. The patient demonstrated complete resolution, leaving postinflammatory hypopigmentation. There was no recurrence until 1 year after complete remission." }, { "id": "pubmed23n0211_11035", "title": "[Follicular psoriasis with cicatricial alopecia. Piccardi-Lassueur-Graham Little syndrome of a psoriatic nature].", "score": 0.01743750935488699, "content": "The case of a 21 years old female patient is reported who has had scaly lesions on the scalp since the age of 3, alopecia (later scarring alopecia) since the age of 5, and erythematous and squamous lesions on the trunk and limbs since the age of 14. More recently she developed grouped follicular papules on the trunk, back of the neck and upper limbs. Seven biopsies from the scalp, trunk and sole of foot were performed which showed typical psoriatic changes in all but one, from the scalp, where only scarring alopecia changes could be found. In one lesion from the trunk pseudogranulomatous features were observed in some papillae which were probably due to ectasia, tortuosity and endothelial proliferation of papillary blood vessels. The oral administration of RO 10-9359 was followed by a good remission of the lesions with exception of the scalp alopecia. The differential diagnosis, particularly with pityriasis rubra pilaris and lichen planus, is discussed and the similarities of our case with the Piccardi-Lassueur-Graham Little syndrome emphasised. If one accepts multiple diseases as the cause of the syndrome psoriasis could be admitted as one of them." }, { "id": "pubmed23n0771_3902", "title": "Hyperkeratotic Palmoplantar Lichen Planus in a child.", "score": 0.017424242424242425, "content": "Lichen planus (LP) is a common idiopathic inflammatory disorder that affects the flexor aspect of the wrists, the legs, and the oral and genital mucosa. Depending upon the site of involvement, LP can be divided into mucosal, nail, scalp, or palmoplantar types. Palmoplantar LP can pose a diagnostic problem to the clinician as it resembles common dermatoses like psoriasis, verruca, corn, calluses, lichenoid drug eruption, and papular syphilide of secondary syphilis. In this case report, we describe a 4-year-old male child who presented with highly pruritic erythematous to violaceous hyperkeratotic papules and plaques on his palms and soles. Typical LP papules were noted on the upper back. Histopathology of the papular lesion showed features of LP. Dermatoscopy of a papule from the back showed the characteristic Wickham striae. We report this rare involvement of palm and soles in a case of childhood LP. " }, { "id": "pubmed23n0961_20010", "title": "Annular Lesions: Diagnosis and Treatment.", "score": 0.016748366013071895, "content": "Annular lesions can present in a variety of diseases. Knowledge of the physical appearance and history of presentation of these skin findings can help in the diagnosis. A pruritic, annular, erythematous patch that grows centrifugally should prompt evaluation for tinea corporis. Tinea corporis may be diagnosed through potassium hydroxide examination of scrapings. Recognizing erythema migrans is important in making the diagnosis of Lyme disease so that antibiotics can be initiated promptly. Plaque psoriasis generally presents with sharply demarcated, erythematous silver plaques. Erythema multiforme, which is due to a hypersensitivity reaction, presents with annular, raised lesions with central clearing. Lichen planus characteristically appears as planar, purple, polygonal, pruritic papules and plaques. Nummular eczema presents as a rash composed of coin-shaped papulovesicular erythematous lesions. Treatment is aimed at reducing skin dryness. Pityriasis rosea presents with multiple erythematous lesions with raised, scaly borders, and is generally self-limited. Urticaria results from the release of histamines and appears as well-circumscribed, erythematous lesions with raised borders and blanched centers. Annular lesions occur less commonly in persons with fixed drug eruptions, leprosy, immunoglobulin A vasculitis, secondary syphilis, sarcoidosis, subacute cutaneous lupus erythematosus, and granuloma annulare." }, { "id": "pubmed23n1126_23416", "title": "Dermoscopy of Gottron's papules and other inflammatory dermatoses involving the dorsa of the hands.", "score": 0.016465494620834426, "content": "Several inflammatory dermatoses, including dermatomyositis (DM), may present as erythematous papules or plaques on the dorsal aspects of the hands over the joints. Limited skin involvement in these entities may pose a diagnostic challenge. (Video)dermoscopy is being utilized more frequently to aid in the differential diagnosis of inflammatory skin conditions. To describe the dermoscopic findings in Gottron's papules and compare them with dermoscopic features of other dermatoses involving the dorsal aspects of the hands. Videodermoscopic images from patients presenting with erythematous papules or plaques on the dorsal surface of the hands were retrospectively analysed for the presence of standardized dermoscopic parameters. Dermoscopic images from patients with DM (n = 12), psoriasis (n = 19), chronic dermatitis (n = 16), mycosis fungoides (n = 7), lichen planus (n = 5) and pityriasis rubra pilaris (n = 3) were included. Gottron's papules were characterized by pleomorphic vessels (dotted vessels accompanied by thick or thin linear vessels with branches or linear curved vessels) in 66.7% of cases, arranged in an unspecified pattern (91.7%), and accompanied by white or pink structureless areas (75.0%). Psoriatic plaques were characterized by dotted vessels arranged in a uniform pattern (94.7%). Vessels arranged in a ring pattern were nearly exclusively observed in psoriasis, while yellow structureless areas and erosions were more frequently present in chronic dermatitis. White lines, corresponding to Wickham striae, were specific for lichen planus. Videodermoscopy might be of value in differentiating Gottron's papules from other dermatoses involving dorsa of the hands." }, { "id": "pubmed23n1032_24239", "title": "Dermoscopy in differential diagnosis of inflammatory dermatoses and mycosis fungoides.", "score": 0.01569676181617348, "content": "The use of dermoscopy for the evaluation of various inflammatory dermatoses has witnessed a gradual increase in recent years. The present study describes and highlights the importance of dermoscopic findings in the differential diagnosis of plaque psoriasis (PP), lichen planus (LP), mycosis fungoides (MF), pityriasis rosea (PR), and nummular dermatitis (ND) that mostly involve the trunk. The study included 150 cases (PP:50, LP:30, MF:20, PR:30, ND:20). The lesions were inspected using a polarized dermoscope. The dermoscopic findings of each lesion were evaluated for background color, type, and distribution of vessels, color and distribution of scales, and other additional findings. When the patient groups were evaluated for background color, yellow color was prominent in PR, and light and dull red color was prominent in other groups. Dotted vessels were prominent in PP, PR, and ND, and dotted + linear vessels were significantly more prominent in MF and LP. In the evaluation of the distribution pattern of vessels, PP showed regular, LP showed peripheral, and PR, MF, and ND showed patchy distribution patterns. White scales were prominent in PP, PR, and MF, and yellow-white scales were prominent in LP and ND. Only PR had a predominant peripheral distribution of scales, while other groups had a patchy distribution. In conclusion, it was observed that PP, LP, MF, PR, and ND exhibited specific dermoscopic patterns that might be useful in clinical diagnosis." }, { "id": "pubmed23n0833_16919", "title": "The practical usefulness of dermoscopy in general dermatology.", "score": 0.015233362143474503, "content": "Beside to traditional use, dermoscopy is more and more used in the assessment of other \"general\" dermatologic conditions, namely scalp and hair disorders (trichoscopy), nails abnormalities (onychoscopy), skin infections and infestations (entomodermoscopy), and cutaneous inflammatory diseases (inflammoscopy). Among the list of new applications of dermoscopy, the study of inflammatory dermatoses is probably the most promising topic in terms of development and usefulness, considering the large number of such disorders and the frequent problems in their differential diagnosis which the dermatologist encounters in own daily clinical practice. In this paper, we report selected relatively common clinical differential diagnosis issues concerning inflammatory dermatoses (and some clinically related noninflammatory conditions), analysing them by a dermoscopic point of view in order to assist their noninvasive resolution according to the available literature data and our personal experience, including papulosquamous dermatoses (guttate psoriasis, pityriasis lichenoides chronica, pityriasis rosea, lichen planus, lymphomatoid papulosis, classic pityriasis rubra pilaris, papulosquamous sarcoidosis, disseminated forms of porokeratosis and papulosquamous chronic GVHD), dermatoses presenting with erythematous-desquamative patches/plaques (plaque psoriasis, eczematous dermatitis, pityriasis rosea, mycosis fungoides, subacute cutaneous lupus erythematosus), palmar psoriasis vs. chronic hand eczema, scalp psoriasis vs. seborrheic dermatitis, erythematous-desquamative disorders typically involving the elbows (psoriasis vulgaris, circumscribed juvenile pityriasis rubra pilaris, dermatomyositis/Gottron's sign), itchy papulonodular dermatoses (hypertrophic lichen planus, prurigo nodularis, nodular scabies and acquired perforating dermatosis), common facial inflammatory skin diseases (rosacea, seborrheic dermatitis and demodicidosis), lichen sclerosus vs. morphea, urticaria vs. urticarial vasculitis and common inflammatory cicatricial alopecia (discoid lupus erythematosus, lichen planopilaris and folliculitis decalvans). " }, { "id": "pubmed23n0717_1668", "title": "Accuracy of dermoscopic criteria for the diagnosis of psoriasis, dermatitis, lichen planus and pityriasis rosea.", "score": 0.01471304159679775, "content": "Dermoscopy is useful in evaluating skin tumours, but its applicability extends also to the field of inflammatory skin disorders. Plaque psoriasis (PP), dermatitis, lichen planus (LP) and pityriasis rosea (PR) are common inflammatory skin diseases, but little is currently known about their dermoscopic features. To determine and compare the dermoscopic patterns associated with PP, dermatitis, LP and PR and to assess the validity of certain dermoscopic criteria in the diagnosis of PP. Patients with PP, dermatitis, LP and PR were prospectively enrolled. The single most recently developed lesion was examined dermoscopically and histopathologically. Variables included vascular morphology, vascular arrangement, background colour, scale colour, scale distribution and presence of Wickham striae. Univariate and adjusted odds ratios were calculated. Discriminant functions were used to plot receiver-operator characteristic curves. Eighty-three patients with PP and 86 patients with either dermatitis, LP or PR were included in the study. Dotted vessels in a regular arrangement over a light red background and white scales were highly predictive for the diagnosis of PP, whereas dermatitis more commonly showed yellow scales and dotted vessels in a patchy arrangement. PR was characterized by yellowish background, dotted vessels and peripheral scales; whitish lines (Wickham striae) were seen exclusively in LP. PP, LP, PR and dermatitis show specific dermoscopic patterns that may aid their clinical diagnosis. Certain combinations of dermoscopic features can reliably predict the diagnosis of PP." }, { "id": "article-24254_11", "title": "Lichen Planus -- History and Physical", "score": 0.014467253176930596, "content": "Lichen planus can display a variety of lesion types, but the most common presentation is an area of polygon-shaped, itchy, violaceous, flat-topped papules a few millimeters wide. This classic presentation is known as The Six Ps of LP: purple, polygonal, planar, pruritic papules, and plaques. The lesions have a shiny surface covered in fine white lines known as Wickham striae and are firm on palpation. They may be seen as a few individual lesions, found scattered widely, grouped in plaques, or arranged in annular, linear, or actinic (sun-exposed) patterns. The isomorphic response (i.e., Koebner phenomenon) can be seen in LP wherein new lesions arise in lines where scratching occurs, just as is seen in psoriasis. The most common areas of involvement include the flexor wrists, dorsal hands, lower back, ankles, and shins. Frequently a grayish-brown hyperpigmentation can be found after lesions resolve due to deposition of melanin in the superficial dermis. [5] [10]" }, { "id": "pubmed23n0975_22643", "title": "Hypertrophic Lichen Planus Mimicking Verrucous Lupus Erythematosus.", "score": 0.013722424874066354, "content": "Lichen planus is an inflammatory skin condition that can affect the hair, mucous membranes, nails, and skin. Cutaneous lichen planus typically presents as papules that are planar, polygonal, pruritic, and purple. Subtypes of lichen planus include actinic, annular, atrophic, eruptive, follicular, hypertrophic, inverse, linear, palmoplantar, pemphigoides, pigmentosus, ulcerative, vesiculobullous, and vulvovaginal. The various clinical presentations of lichen planus can mimic other dermatologic conditions. A 63-year-old woman, who presented with pruritic, hyperkeratotic plaques on the lower legs of two years duration, is described; her lesions were morphologically suggestive of verrucous lupus erythematosus. However, an examination also revealed purple papules on the wrists and white, reticulated patches on the bilateral buccal mucosa. Biopsies demonstrated lichenoid dermatitis while laboratory studies for systemic lupus erythematosus were negative. A correlation of the clinical presentation, pathology, and laboratory studies established a diagnosis of hypertrophic lichen planus. The clinical mimickers of hypertrophic lichen planus are reviewed and the therapeutic treatments for this condition discussed." }, { "id": "pubmed23n0877_13961", "title": "Clinicopathological Study of Non-Infectious Erythaematous Papulosquamous Skin Diseases.", "score": 0.013653766317634576, "content": "Papulosquamous diseases are characterized by scaly papules and plaques with similar clinical picture which amounts to confusion and hence, a definitive histopathological diagnosis goes a long way in treatment of such diseases. The aim of the study was to study the histomorphology of non-infectious, erythaematous, papulosquamous lesions of skin with clinicopathological correlation. Skin biopsies from 150 clinically diagnosed/suspected non-infectious erythaematous, papulosquamous skin diseases were received in the Department of Pathology. The specimens obtained were subjected to formalin fixation and paraffin embedding, stained with haematoxylin and eosin and studied. The lesions were classified as psoriasis, lichen planus, lichen nitidus, lichen striatus, pityriasis rosea and pityriasis rubra pilaris and clinicopathological correlation was done. Papulosquamous lesions were common in the elderly. Males were commonly affected except in pityriasis rosea. Among the 150 cases studied, 72 cases (48%) were histopathologically confirmed to be papulosquamous lesions. Psoriasis was the most common lesion. Key histopathological features and clinicopathological correlation gives a conclusive diagnosis. The importance of specific histomorphological diagnosis lies in distinguishing these lesions as the treatment and prognosis varies widely." }, { "id": "pubmed23n0658_12338", "title": "Profile of lichen planus in Bangladesh.", "score": 0.013351360486733143, "content": "Lichen planus is one of the common inflammatory disorders of skin, mucous membrane, nail and hair characterized by violaceous, polish, pruritic, polygonal, flat-topped papules usually distributed bilaterally symmetrically over the extremities. Our objectives in this study were to explore the prevalence of lichen planus in large area of Dhaka in Bangladesh and to establish the clinical characteristics of lichen planus. This descriptive type of cross sectional study was carried out from September 2006 to August 2008 in the Department of Dermatology and Venereology of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka Medical College Hospital (DMCH) and Combined Military Hospital (CMH) in Dhaka. Patients suffering from lichen planus were selected as study population. By face to face interview and clinical observations, data were collected from sample. A total 120 patients of lichen planus were selected, on the basis of age, 30(25%) were 10-30 years of age, 75(62.56%) were 30-50 years and 16(13.33%) were over 50 years of age. The mean age of the patient was 40+/-4 years. Out of 120 patients, 80(66.66%) were male and 60(33.33%) were female and eight patients (6.67%) had positive family history among highest age group (30 to 50 years). In case of duration of disease, highest percentage (68%) of cases was 15 days to 6 months and considering clinical sign, koebnerization was present 45(37.5%) cases and Wickhams striae 22(18.33%) cases. Regarding site of onset of lesion, lesions were highest 100(83.33%) in upper limbs, next lower limbs, trunk, oral mucosa etc. The distribution of clinical pattern of lichen planus showing classic pattern (68.33%) was the most common type, followed by hypertrophic, actinic, ashy dermatoses, lichen plano-pilaris, erosive or ulcerative etc. This clinico-epidemiological study of lichen planus attending in the different hospital in Dhaka, Bangladesh has shown that lichen planus is usually associated with 30 to 50 years of age group, with higher male prevalence than female, 15 days to 6 months are mainly duration of disease, koebnerization and Wickhams striae are common clinical signs, upper limbs is mainly the site of onset of lesion, and classic pattern is the most common clinical type in lichen planus." }, { "id": "wiki20220301en035_39770", "title": "Pityriasis rosea", "score": 0.012574525745257453, "content": "Diagnosis Experienced practitioners may make the diagnosis clinically. Classical symptoms are usually straightforward to recognize, but the wide range of atypical forms may cause difficulty for the clinician in diagnosing some cases. Misdiagnosis by nondermatologists is not uncommon. If the diagnosis is in doubt, tests may be performed to rule out similar conditions such as Lyme disease, ringworm, guttate psoriasis, nummular or discoid eczema, drug eruptions, other viral exanthems. The clinical appearance of pityriasis rosea in some cases is similar to that of secondary syphilis, and rapid plasma reagin testing should be performed if there is any clinical concern for syphilis. A biopsy of the lesions will show extravasated erythrocytes within dermal papillae and dyskeratotic cells within the dermis. A set of validated diagnostic criteria for pityriasis rosea is as follows: A patient is diagnosed as having pityriasis rosea if:" }, { "id": "article-28811_27", "title": "Seborrheic Dermatitis -- Differential Diagnosis -- Trunk", "score": 0.012347625052543085, "content": "Psoriasis - sharply-defined red plaques with a loose, silvery lamella scale Pityriasis rosea - herald spot; collarette scale; Christmas tree distribution Pityriasis versicolor - not symmetrical; hypo/hyperpigmentation Subacute lupus erythematosus - photosensitive distribution Eczema (nummular) - intense pruritus Tinea corporis - raised leading edges and central clearing; uncommon in infants Erythema annulare centrifugum - recurrent polycyclic lesions that slowly expand and disappear Darier disease - Greasy wart-like papules and plaques Grover disease (transient acantholytic dermatosis) - acanthosis Drug reaction - drug history (neuroleptic; immunosuppressant; PUVA; lithium) Parapsoriasis - elderly; very slow growing; resistant to treatment Pemphigus foliaceus - fragile, painful blisters - Nikolsky sign is positive Secondary syphilis - lesions on the palms and soles; a history of chancre" }, { "id": "wiki20220301en589_21494", "title": "Histopathologic diagnosis of dermatitis", "score": 0.012021690198485778, "content": "Interface dermatitis with lichenoid inflammation Interface dermatitis with lichenoid inflammation, not otherwise specified, can be caused by lichen planus-like keratosis, lichenoid actinic keratosis, lichenoid lupus erythematosus, lichenoid GVHD (chronic GVHD), pigmented purpuric dermatosis, pityriasis rosea, and pityriasis lichenoides chronica. Unusual conditions that can be associated with a lichenoid inflammatory cell infiltrate are HIV dermatitis, syphilis, mycosis fungoides, urticaria pigmentosa, and post-inflammatory hyperpigmentation. In cases of post-inflammatory hyperpigmentation, it is important to exclude potentially harmful mimics such as a regressed melanocytic lesion or lichenoid pigmented actinic keratosis. Psoriaform dermatitis Examining multiple deeper levels is recommended if initial cuts do not correlate well with the clinical history." }, { "id": "pubmed23n0724_22015", "title": "Vesicular palmoplantar pityriasis rosea.", "score": 0.011996848589027359, "content": "A 16-year-old young man presented with intensely itchy erythematous dermatitis on the body for 1 week and vesicular lesions on the palms and soles for 4 to 5 days. Lesions on the palms and soles were accompanied by severe burning and itching. The patient gave a history of sore throat and fever, 1 week prior to the onset of lesions. A general physical examination was normal, and cutaneous examination revealed multiple, well-defined erythematous scaly plaques with collaret scaling on the trunk and extremities (Figure 1). Vesicular lesions were seen on the palms and soles (Figure 2). The differential diagnoses we considered were pityriasis rosea and secondary syphilis. The possibility of dermatophytid, vesicular pityriasis rosea, and pompholyx was limited to the palms and sole lesions. Complete blood cell count was within normal limits. Results from antistreptolysin O titer, potassium hydroxide mount, and venereal disease research laboratory were negative. Skin biopsies were taken from the back and left palm. The biopsy specimen from the back revealed focal spongiosis, lymphocyte exocytosis, vacuolar changes in the basal layer, and perivascular lymphocytic infiltrate in the dermis (Figure 3). The biopsy obtained from the vesicular lesion on the left palm revealed an intraepidermal vesicle with no evidence of acantolytic process (Figure 4). A diagnosis of pityriasis rosea was made and the patient was started on clarithromycin 500 mg once a day for 7 days, along with antihistamines and emollients. The lesions faded dramatically in a very short period, and there was significant involution of almost all of the lesions after 7 days of clarithromycin. During the 6 months of follow-up, no recurrence was observed." }, { "id": "article-24253_8", "title": "Lichen Nitidus -- History and Physical", "score": 0.011926480599046971, "content": "Lichen nitidus usually presents as asymptomatic, shiny, flat-topped, fleshy pink to dark brown papules. They are typically 1 to 2 mm in diameter. In patients with darker skin lesions can appear as light spots. Lesions commonly present on the neck, trunk, limbs, abdomen, and penile shaft. The involvement of mucous membranes, palms, soles, and nails are rare, but there are reports. [2] [3] [4] If lichen nitidus is symptomatic, the patient mainly complains of mild sporadic pruritus. [3] Koebner phenomenon is a hallmark of lichen nitidus, as seen in lichen planus, but is not present in all cases. [3] [4] Rarely lichen nitidus will present only on the palms and soles and will usually present with lichen nitidus lesions in other locations. [11] If lesions present in the oral mucosa, they will be flat, greyish papules. [3] [12]" }, { "id": "wiki20220301en030_5171", "title": "Lichen planus", "score": 0.01185295464956482, "content": "Signs and symptoms Although lichen planus can present with a variety of lesions, the most common presentation is as a well defined area of purple-coloured, itchy, flat-topped papules with interspersed lacy white lines (Wickham's striae). This description is known as the characteristic \"6 Ps\" of lichen planus: planar (flat-topped), purple, polygonal, pruritic, papules, and plaques. This rash, after regressing, is likely to leave an area of hyperpigmentation that slowly fades. That said, a variety of other lesions can also occur. Skin" }, { "id": "wiki20220301en040_69473", "title": "Papule", "score": 0.011802721088435374, "content": "Papules with scale on the palms and soles may occur in secondary syphilis, psoriasis, eczema, tinea manuum, mycosis fungoides. In lichen planus papules may be itchy, flat-topped, polygonal, purplish with white streaks, and can be solitary, or occur in clusters or in a line. See also List of cutaneous conditions References External links Dermatologic terminology" }, { "id": "InternalMed_Harrison_3986", "title": "InternalMed_Harrison", "score": 0.011673414304993253, "content": "CHAPTER 71 Eczema, Psoriasis, Cutaneous Infections, Acne, and Other Common Skin Disorders Psoriasis Sharply demarcated, erythematous plaques with mica-like scale; predominantly on elbows, knees, and scalp; atypical forms may localize to intertriginous areas; eruptive forms may be associated with infection Lichen planus Purple polygonal papules marked by severe pruritus; lacy white markings, especially associated with mucous membrane lesions Pityriasis rosea Rash often preceded by herald patch; oval to round plaques with trailing scale; most often affects trunk; eruption lines up in skinfolds giving a “fir tree–like” appearance; generally spares palms and soles Dermatophytosis Polymorphous appearance depending on dermatophyte, body site, and host response; sharply defined to ill-demarcated scaly plaques with or without inflammation; may be associated with hair loss May be aggravated by certain drugs, infection; severe forms seen in association with HIV" }, { "id": "article-24666_23", "title": "Malassezia Furfur -- Differential Diagnosis", "score": 0.011586142973004285, "content": "Several dermatologic disorders may mimic PV. SD may occur on the trunk as PV does, but lesions are more erythematous with thicker scaling, and other locations, including the scalp, are usually involved. Pityriasis rosea may be differentiated from PV by the appearance of a herald patch before the onset of symptoms, \"Christmas tree\" distribution, and erythematous, scaling macules and patches. Whereas PV causes hypopigmented skin lesions, those seen in vitiligo are depigmented. The eczematous lesions of pityriasis alba also may appear as hypopigmented macules and patches; however, the face is primarily affected, and affected children typically have a history of atopy. Secondary syphilis must be ruled out in a patient with generalized hyperpigmented macules involving the palms and soles. Mycosis fungoides may present as hypopigmented lesions on the trunk and extremities, but scaling, erythema, and plaques are more characteristic. [17]" }, { "id": "wiki20220301en190_9891", "title": "Papulosquamous disorder", "score": 0.01158008658008658, "content": "A papulosquamous disorder is a condition which presents with both papules and scales, or both scaly papules and plaques. Examples include psoriasis, lichen planus, and pityriasis rosea. See also List of cutaneous conditions References Further reading http://www.emedicine.com/derm/index.shtml#papulosquamous External links Dermatologic terminology Papulosquamous disorders" }, { "id": "wiki20220301en248_42840", "title": "Pityriasis amiantacea", "score": 0.01134606890459364, "content": "Diagnosis Pityriasis amiantacea can easily be misdiagnosed due to its close resemblance to other scalp diseases such as psoriasis, seborrhoeic dermatitis or lichen planus. However, in pityriasis amiantacea the scales are attached to both the hair shaft and the scalp. Pityriasis amiantacea may be present with other inflammatory conditions such as atopic dermatitis or seborrhoeic dermatitis and sebaceous scales and alopecia can occur. According to Bolognia's textbook \"Dermatology,\" this rare condition is most often combined with psoriasis, but it may also develop as secondarily infected atopic dermatitis, seborrheic dermatitis, and/or tinea capitis. Treatment" }, { "id": "wiki20220301en149_46689", "title": "Epidermodysplasia verruciformis", "score": 0.010989280545539284, "content": "Signs and symptoms Clinical diagnostic features are lifelong eruptions of pityriasis versicolor-like macules, flat wart-like papules, one to many cutaneous horn-like lesions, and development of cutaneous carcinomas. Patients present with flat, slightly scaly, red-brown macules on the face, neck, and body, recurring especially around the penial area, or verruca-like papillomatous lesions, seborrheic keratosis-like lesions, and pinkish-red plane papules on the hands, upper and lower extremities, and face. The initial form of EV presents with only flat, wart-like lesions over the body, whereas the malignant form shows a higher rate of polymorphic skin lesions and development of multiple cutaneous tumors. Generally, cutaneous lesions are spread over the body, but some cases have only a few lesions which are limited to one extremity." }, { "id": "wiki20220301en004_124247", "title": "Psoriasis", "score": 0.010959190063667676, "content": "Diagnosis A diagnosis of psoriasis is usually based on the appearance of the skin. Skin characteristics typical for psoriasis are scaly, erythematous plaques, papules, or patches of skin that may be painful and itch. No special blood tests or diagnostic procedures are usually required to make the diagnosis. The differential diagnosis of psoriasis includes dermatological conditions similar in appearance such as discoid eczema, seborrheic eczema, pityriasis rosea (may be confused with guttate psoriasis), nail fungus (may be confused with nail psoriasis) or cutaneous T cell lymphoma (50% of individuals with this cancer are initially misdiagnosed with psoriasis). Dermatologic manifestations of systemic illnesses such as the rash of secondary syphilis may also be confused with psoriasis." }, { "id": "pubmed23n0771_3916", "title": "Palmar lichen planus mimicking tinea nigra.", "score": 0.01095192990764859, "content": "Lichen planus (LP) is a chronic inflammatory skin disease characterized by polygonal, violaceous papules commonly involving flexural areas of the wrists, legs, and oral and genital mucous membranes. This report describes a patient who presented with asymptomatic black colored patches on both palms simulating Tinea nigra, a superficial fungal infection. She was previously diagnosed as allergic contact dermatitis and was being treated with potent topical steroid i.e. clobetasol propionate 0.05% and white soft paraffin. Dermatoscopy of the lesion showed brownish pigmentation along ridges of the dermatoglyphics. A biopsy from the lesional skin showed findings of lichen planus. Our case highlights the potential diagnostic confusion that can occur with unusual variants of palmoplantar lichen planus and importance of histopathology in diagnosis of such unusual lesions. " }, { "id": "wiki20220301en030_5168", "title": "Lichen planus", "score": 0.01032925757212499, "content": "Lichen planus (LP) is a chronic inflammatory and immune-mediated disease that affects the skin, nails, hair, and mucous membranes. It is not an actual lichen, and is only named that because it looks like one. It is characterized by polygonal, flat-topped, violaceous papules and plaques with overlying, reticulated, fine white scale (Wickham's striae), commonly affecting dorsal hands, flexural wrists and forearms, trunk, anterior lower legs and oral mucosa. Although there is a broad clinical range of LP manifestations, the skin and oral cavity remain as the major sites of involvement. The cause is unknown, but it is thought to be the result of an autoimmune process with an unknown initial trigger. There is no cure, but many different medications and procedures have been used in efforts to control the symptoms." }, { "id": "wiki20220301en111_27496", "title": "Pemphigoid", "score": 0.010038986354775828, "content": "Presentation Primary lesions of small and large blisters, known as vesicles and bullae, are found on the skin and sometimes on the mucous membranes. Non-bullous pemphigoid In some patients, pemphigoid starts off with cutaneous manifestations of BP without bullae, as the only sign of the disease. Pruritic eczematous, papular, or urticaria-like skin lesions may also persist for weeks to months. Bullous phase The bullous stage of BP shows vesicles and bulla, appearing on apparently normal or erythematous skin, predominantly at the flexural aspects of the extremities and the lower trunk. Mucosal lesions, which typically are erosions of the oral mucosa, are present in 10 to 30 percent of patients. Occasionally, the blister fluid becomes blood-tinged. The blisters are tense, about 1–4 cm in diameter, leaving eroded and crusted areas, together with urticarial and infiltrated papules and plaques in an annular or figurate pattern." }, { "id": "InternalMed_Harrison_3996", "title": "InternalMed_Harrison", "score": 0.009933774834437087, "content": "Lichen planus (LP) is a papulosquamous disorder that may affect the skin, scalp, nails, and mucous membranes. The primary cutaneous lesions are pruritic, polygonal, flat-topped, violaceous papules. Close examination of the surface of these papules often reveals a network of gray lines (Wickham’s striae). The skin lesions may occur anywhere but have a predilection for the wrists, shins, lower back, and genitalia (Fig. 71-5). Involvement of the scalp (lichen planopilaris) may lead to scarring alopecia, and nail involvement may lead to permanent deformity or loss of fingernails and toenails. LP commonly involves mucous membranes, particularly the buccal mucosa, where it can present on a spectrum ranging from a mild, white, reticulate eruption of the mucosa to a severe, erosive stomatitis. Erosive stomatitis may persist for years and may be linked to an increased risk of oral squamous cell carcinoma. Cutaneous eruptions clinically resembling LP have been observed after administration of" }, { "id": "pubmed23n0880_19088", "title": "Dermoscopy in General Dermatology: A Practical Overview.", "score": 0.009900990099009901, "content": "Over the last few years, dermoscopy has been shown to be a useful tool in assisting the noninvasive diagnosis of various general dermatological disorders. In this article, we sought to provide an up-to-date practical overview on the use of dermoscopy in general dermatology by analysing the dermoscopic differential diagnosis of relatively common dermatological disorders grouped according to their clinical presentation, i.e. dermatoses presenting with erythematous-desquamative patches/plaques (plaque psoriasis, eczematous dermatitis, pityriasis rosea, mycosis fungoides and subacute cutaneous lupus erythematosus), papulosquamous/papulokeratotic dermatoses (lichen planus, pityriasis rosea, papulosquamous sarcoidosis, guttate psoriasis, pityriasis lichenoides chronica, classical pityriasis rubra pilaris, porokeratosis, lymphomatoid papulosis, papulosquamous chronic GVHD, parakeratosis variegata, Grover disease, Darier disease and BRAF-inhibitor-induced acantholytic dyskeratosis), facial inflammatory skin diseases (rosacea, seborrheic dermatitis, discoid lupus erythematosus, sarcoidosis, cutaneous leishmaniasis, lupus vulgaris, granuloma faciale and demodicidosis), acquired keratodermas (chronic hand eczema, palmar psoriasis, keratoderma due to mycosis fungoides, keratoderma resulting from pityriasis rubra pilaris, tinea manuum, palmar lichen planus and aquagenic palmar keratoderma), sclero-atrophic dermatoses (necrobiosis lipoidica, morphea and cutaneous lichen sclerosus), hypopigmented macular diseases (extragenital guttate lichen sclerosus, achromic pityriasis versicolor, guttate vitiligo, idiopathic guttate hypomelanosis, progressive macular hypomelanosis and postinflammatory hypopigmentations), hyperpigmented maculopapular diseases (pityriasis versicolor, lichen planus pigmentosus, Gougerot-Carteaud syndrome, Dowling-Degos disease, erythema ab igne, macular amyloidosis, lichen amyloidosus, friction melanosis, terra firma-forme dermatosis, urticaria pigmentosa and telangiectasia macularis eruptiva perstans), itchy papulonodular dermatoses (hypertrophic lichen planus, prurigo nodularis, nodular scabies and acquired perforating dermatosis), erythrodermas (due to psoriasis, atopic dermatitis, mycosis fungoides, pityriasis rubra pilaris and scabies), noninfectious balanitis (Zoon's plasma cell balanitis, psoriatic balanitis, seborrheic dermatitis and non-specific balanitis) and erythroplasia of Queyrat, inflammatory cicatricial alopecias (scalp discoid lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia and folliculitis decalvans), nonscarring alopecias (alopecia areata, trichotillomania, androgenetic alopecia and telogen effluvium) and scaling disorders of the scalp (tinea capitis, scalp psoriasis, seborrheic dermatitis and pityriasis amiantacea)." }, { "id": "pubmed23n0633_12685", "title": "Genitogluteal porokeratosis: 10 years to make the diagnosis!", "score": 0.009900990099009901, "content": "Genitogluteal porokeratosis, a relatively rare presentation of porokeratosis of Mibelli, often manifests in an atypical way due to its verrucous appearance that may obscure the characteristic annular keratotic rim. For this reason, misdiagnosis as other common papulosquamous diseases is not uncommon. We report a 44-year-old man with a 10-year-history of slowly progressive pruritic psoriasiform/lichenified plaques over the buttocks. Despite multiple skin biopsies, the lesions were misdiagnosed as psoriasis, lichen simplex chronicus, pityriasis rubra pilaris, and mycosis fungoides, until the last biopsy revealed findings characteristic of porokeratosis. Dermatologists and dermatopathologists should be aware of this rare and unique variant of porokeratosis, which, in addition to the atypical clinical presentation and the occasional misleading histology, may portend a better prognosis in terms of malignant degeneration." }, { "id": "InternalMed_Harrison_4037", "title": "InternalMed_Harrison", "score": 0.009878437672333183, "content": "(Table 72-1) When an eruption is characterized by elevated lesions, either papules (<1 cm) or plaques (>1 cm), in association with scale, it is referred to as papulosquamous. The most common papulosquamous diseases—tinea, psoriasis, pityriasis rosea, and lichen planus—are primary cutaneous disorders (Chap. 71). When psoriatic lesions are accompanied by arthritis, the possibility of psoriatic arthritis or reactive arthritis (formerly known as Reiter’s syndrome) should be considered. A history of oral ulcers, conjunctivitis, uveitis, and/or urethritis points to the latter diagnosis. Lithium, beta blockers, HIV or streptococcal infections, and a rapid taper of systemic glucocorticoids are known to exacerbate psoriasis. Comorbidities in patients with psoriasis include cardiovascular disease and metabolic syndrome." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 275, 410 ] ], "word_ranges": [ [ 39, 60 ] ], "text": "If enteral nutrition is considered to be of short duration, the route of choice is the nasogastric or nasoduodenal- nasojejunal tube..." }, "2": { "exist": true, "char_ranges": [ [ 275, 410 ] ], "word_ranges": [ [ 39, 60 ] ], "text": "If enteral nutrition is considered to be of short duration, the route of choice is the nasogastric or nasoduodenal- nasojejunal tube..." }, "3": { "exist": true, "char_ranges": [ [ 411, 495 ] ], "word_ranges": [ [ 60, 73 ] ], "text": "If prolonged nutrition is anticipated the route of choice is gastrostomy (option 3)," }, "4": { "exist": true, "char_ranges": [ [ 496, 591 ] ], "word_ranges": [ [ 73, 90 ] ], "text": "with jejunostomy being reserved for cases in which it is not possible to use the gastric route." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Enteral nutrition by nasogastric tube.", "2": "Enteral nutrition by nasoduodenal tube.", "3": "Enteral nutrition by gastrostomy.", "4": "Enteral nutrition by jejunostomy.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0476_8962", "title": "Percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients with stroke.", "score": 0.019232547387887194, "content": "The use of percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients admitted for stroke is difficult, varying and needs specific consideration. There is therefore need for more data on this patient group. We examined the indications, survival, tube removal and time with PEG in stroke patients and in other patients with PEG with the aim of providing guidance for the management of enteral nutrition via PEG in stroke patients. Retrospective assessment of data from all stroke patients and patients with other diseases (control group) who had received PEG for enteral nutrition during a period of 8.5 years. Eighty-three stroke patients with dysphagia received PEG after unsuccessful use of nasogastric tubes or long-term tube feeding. Early mortality rate was 19% in the stroke group, 26% in the older group (&gt;74 years) and 12% in the younger group (60-74 years). The PEG tubes were later removed due to swallowing recovery in 20% of the older group and in 31% of the younger group. At 90 days, 50%-60% still needed PEG. The stroke patients were older compared to the control group (n = 115); 30-day mortality was similar but more patients recovered the ability to swallow. Stroke patients are older than other patients who receive PEG; 27% have swallowing recovery and more than 75% have long-term need for PEG. Nasogastric tubes often fail, and the need for early PEG placement (within 2 weeks) must be assessed in appropriate patients. The patient's prognosis, the objective of nutritional treatment, duration of dysphagia, age and comorbidity should all be taken into consideration." }, { "id": "pubmed23n0801_25280", "title": "[Nutritional support in stroke patients].", "score": 0.018268268268268266, "content": "Stroke is a public health problem of the first order. In developed countries is one of the leading causes of death, along with cardiovascular disease and cancer. In addition, stroke is the leading cause of permanent disability in adulthood. Many of the patients who survive do so with significant sequelae that limit them in their activities of daily living. Most strokes (80-85%) are due to ischemia, while the rest are hemorrhagic. We have identified many modifiable risk factors, some with an important relationship with dietary factors or comorbidities in wich the diet has a significant impact. The incidence of malnutrition in stroke patients is not well known, but most likely impacts on patient prognosis. Furthermore, the nutritional status of patients admitted for stroke often deteriorates during hospitalization. It is necessary to perform a nutritional assessment of the patient in the early hours of admission, to determine both the nutritional status and the presence of dysphagia. Dysphagia, through alteration of the safety and efficacy of swallowing, is a complication that has an implication for nutritional support, and must be treated to prevent aspiration pneumonia, which is the leading cause of mortality in the stroke patient. Nutritional support should begin in the early hours. In patients with no or mild dysphagia that can be controlled by modifying the texture of the diet, they will start oral diet and oral nutritional supplementation will be used if the patient does not meet their nutritional requirements. There is no evidence to support the use of nutritional supplements routinely. Patients with severe dysphagia, or decreased level of consciousness will require enteral nutrition. Current evidence indicates that early nutrition should be initiated through a nasogastric tube, with any advantages of early feeding gastrostomy. Gastrostomy will be planned when the enteral nutrition support will be expected for long-term (4 weeks). Much evidence points to the importance of glycemic control during hospitalization for stroke. Hyperglycemia at diagnosis and during the first hours of admission impact on patient prognosis. The goal of glycemic control necessary to modify this bad prognosis without adding risk by iatrogenic hypoglycemia is still matter of debate." }, { "id": "pubmed23n1152_6403", "title": "Laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy for superior mesenteric artery syndrome with dysphagia: a case report.", "score": 0.017216117216117217, "content": "Superior mesenteric artery (SMA) syndrome denotes a mechanical duodenal obstruction between the SMA and aorta. Total parenteral or enteral nutrition is the treatment of choice. However, surgical intervention is indicated if the patient's condition does not improve with conservative treatment. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy. A 64-year-old man was admitted to another hospital because of appetite loss and vomiting. There, he was diagnosed as having superior mesenteric artery (SMA) syndrome after appropriate investigation. He had had a cerebral infarction at age 57 years, since which he had lived in social housing because of complications of that infarction. A nasogastric tube was inserted into the third portion of the duodenum beyond the constricted section. He was discharged 2 months after admission his condition having improved. He was subsequently referred to our hospital for gastrostomy because the nasogastric tube had been in place for a long time and his condition had not improved. Additionally, gastrostomy was needed as a route for enteral nutrition because he had dysphagia, which had persisted despite attempts at rehabilitation, restricting his food intake to small amounts. Computed tomography (CT) revealed compression of the third portion of the duodenum between the SMA and aorta. After obtaining informed consent, we planned an operative procedure. We performed laparoscopic gastrojejunostomy under general anesthesia, followed by laparoscopic-assisted percutaneous endoscopic gastrostomy. The operation time was 156 min and there was little blood loss. Contrast radiography on postoperative day 3 revealed no evidence of leakage or stenosis. Enteral nutrition via the gastrostomy was started. He was discharged from our hospital on the 27th postoperative day. The gastrostomy was well tolerated and there has been no evidence of recurrence of SMA syndrome during follow-up. Gastrostomy is often performed to provide a route for administering enteral nutrition in patients with dysphagia. Development of SMA syndrome in patients with dysphagia necessitates operative management of the obstruction. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy." }, { "id": "pubmed23n0573_21406", "title": "Is looped nasogastric tube feeding more effective than conventional nasogastric tube feeding for dysphagia in acute stroke?", "score": 0.016960114983830397, "content": "Dysphagia occurs in up to 50% of patients admitted to hospital with acute strokes with up to 27% remaining by seven days. Up to 8% continue to have swallowing problems six months after their stroke with 1.7% still requiring enteral feeding. Nasogastric tubes (NGT) are the most commonly used method for providing enteral nutrition in early stroke, however they are easily and frequently removed leading to inadequate nutrition, early PEG (Percutaneous Endoscopic Gastrostomy) insertion or abandoning of feeding attempts. Looped nasogastric tube feeding may improve the delivery of nutrition to such patients. Three centre, two arm randomised controlled trial, with 50 participants in each arm comparing loop (the intervention) versus conventional nasogastric tube feeding. The primary outcome measure is proportion of intended feed delivered in the first 2 weeks. The study is designed to show a mean increase of feed delivery of 16% in the intervention group as compared with the control group, with 90% power at a 5% significance level. Secondary outcomes are treatment failures, mean volume of feed received, adverse events, cost-effectiveness, number of chest x-rays, number of nasogastric tubes and tolerability. ISRCTN Number: ISRCTN61174381." }, { "id": "pubmed23n0926_9734", "title": "Continuation of Enteral Nutrition and Relief from Vomiting by Administration of a New Formula: a Case Report.", "score": 0.016382868937048503, "content": "Gastro-esophageal reflux (GER) is a common and serious complication in patients receiving enteral nutrition, making continuation of enteral nutrition difficult. Semi-solid enteral nutrients were developed to prevent feeding-related GER. Semi-solid enteral nutrients have high viscosity and, therefore, are typically administered through a large-diameter percutaneous endoscopic gastrostomy (PEG) tube. Recently, a new formula (Mermed<sup®</sup, Mermed Plus<sup®</sup) was introduced that uses alginate, which behaves like a gelatin in acidic conditions. This formula improved GER during enteral feedings. Our case report shows that this new formula enables the continuation of enteral nutrition via a nasogastric tube (NGT) in patients with difficulty tolerating enteral nutrition secondary to vomiting. An 86-year-old woman with an atherothrombotic cerebral infarction vomited during tube feeding, resulting in aspiration pneumonia. After 1 week, we introduced a viscosity regulator and restarted enteral feeding using a 100 mL liquid diet, but vomiting persisted. Because of the continued difficulty in tolerating enteral nutrition, the patient was transferred to our hospital. From hospital day 4, Mermed Plus<sup®</sup (300 mL/225 kcal, administered for 1 hour, 3 times a day) was started, eventually increasing to 535 mL/400 kcal at hospital day 5. After this, vomiting ceased. Mermed Plus<sup®</sup was easily administered via NGT, and its effects were immediate. This treatment appeared to improve the patient's quality of life while reducing the burden on medical staff." }, { "id": "pubmed23n0104_14108", "title": "[Percutaneous endoscopic gastrostomy--a possibility for enteral feeding of patients with severe cerebral dysfunctions].", "score": 0.016312244089288074, "content": "Patients who are unable to be adequately nourished owing to cerebral dysfunction do not tolerate nasogastric tubes for enteral nutrition well. They are threatened by active or passive dislocation of the tube into the oesophagus with subsequent aspiration. Although these risks are minimized by percutaneous gastrostomy (PEG), aspiration cannot be completely prevented even when this method of feeding is employed. Enteral nutrition was provided by PEG in 33 patients with different cerebral disorders. PEG was indicated when adequate oral intake of food and fluids proved impossible 8 to 12 days after an acute hypoxaemic cerebrovascular event. 3 of 23 patients who had suffered a stroke, 2 of 8 patients with hypoxaemic brain damage and 3 of 5 patients with decompensated cerebral sclerosis regained the ability to eat between the 21st and 50th day of treatment, so that the gastrostomy could be dispensed with. The other patients died of their severe underlying disease. 6 patients aspirated. In 2 cases this complication occurred during acute aggravation of the underlying disease after several weeks of satisfactory enteral tube feeding. 2 patients aspirated after returning to oral nutrition, whereby feeding was certainly implicated in 1 patient and probable in the other patient. PEG enables adequate enteral nutrition of patients with severe neurological impairment. The advantages of PEG over parenteral nutrition are fewer complications, lower costs and, above all, its superiority in meeting physiological requirements." }, { "id": "pubmed23n0962_23771", "title": "Long-Term Nasogastric Versus Percutaneous Endoscopic Gastrostomy Tube Feeding in Older Asians With Dysphagia: A Pragmatic Study.", "score": 0.015407061569886197, "content": "A barrier to gastrostomy feeding exists among Asian clinicians and caregivers due to negative perceptions regarding complications. We compared clinical and nutrition outcomes in older dysphagic Asian patients with nasogastric (NG) or gastrostomy tube feeding using a pragmatic study design. The choice of enteral tube access was determined by managing clinicians and patients/caregivers. Comparisons of tube feeding methods were made during a 4-month period, adjusting statistically for inherent confounders. A total of 102 participants (NG: n = 52, gastrostomy: n = 50) were recruited over 2 years from 2013 to 2015. Subjects on long-term NG tube feeding were older (82.67 ± 7.15 years vs 76.88 ± 7.37 years; P &lt; .001) but both groups had similar clinical indications (stroke: 63.5% NG vs 54% gastrostomy; P = .33). After adjustment for confounders, gastrostomy feeding was associated with fewer tube-related complications (adjusted odds ratio [aOR] = 0.19; 95% confidence interval [CI] = 0.06-0.60) and better complication-free survival rate (aOR = 0.32; 95% CI = 0.12-0.89) at 4-month follow-up. Anthropometric and biochemical nutrition parameters improved significantly in both groups at 4 months, but no significant differences were observed at the end of the study. Gastrostomy feeding is associated with a greater 4-month complication-free survival and lower tube-related complications compared with long-term NG feeding in older Asians with dysphagia. However, no differences in nutrition outcomes were observed between NG and gastrostomy feeding at 4 months." }, { "id": "pubmed23n0070_17389", "title": "Indications for tube feedings in elderly patients.", "score": 0.014989517819706498, "content": "Tube feedings are utilized in elderly patients with acute and chronic problems. Inadequate oral intake with malnutrition, comatose state, neurologic disorders with severe dysphagia, extensive burns, massive gastrointestinal resection, and oropharyngeal and upper gastrointestinal malignancies are the commonly encountered conditions requiring tube alimentation. Dysphagia with frequent aspiration is the most common indication for use of tube feedings in the elderly. Nasogastric tube is preferred for short-term feeding, while gastrostomy or jejunostomy is indicated for long-term or permanent nutritional support. Nutritional assessment should be done initially and on a regular basis. Specific formulas are available to calculate height, weight, and caloric needs of bedbound elderly patients. Various enteral feeding formulas are available for a specific clinical condition and are preferably administered by continuous drip using a pump. Parenteral nutrition is also indicated for certain situations in which enteral feeding cannot meet the patient's nutritional requirement, and in particular situations where enteral feeding is contraindicated and not feasible. Optimal patient care is dependent on adequate nutritional support." }, { "id": "pubmed23n0820_20344", "title": "Enteral tube feeding for dysphagic stroke patients.", "score": 0.014819237867766802, "content": "Enteral feeding tubes, a nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG), are commonly used to provide nutrition, hydration and essential medications to stroke patients who cannot swallow. Early tube feeding is associated with improved survival after stroke and it is recommended that patients start tube feeding within 24 hours of hospital admission. NGT feeding is the preferred method for short-term feeding in the acute phase of stroke as it has the advantage of being easily placed at the bedside. However, there are often difficulties inserting the NGT and it can be easily dislodged by agitated and confused patients, leading to potentially fatal complications. A PEG tube is considered a more secure method of feeding stroke patients who require longer-term nutritional support, but it is an invasive procedure that can result in complications that are associated with an increased risk of morbidity and mortality after stroke. The aim of this article is to review the complications associated with enteral feeding tubes and discuss their prevention and management for stroke patients. " }, { "id": "pubmed23n0401_5510", "title": "[Dysphagia in patients with disorders of the nervous system--comparison of a nasogastric tube with percutaneous endoscopic gastrostomy].", "score": 0.014744944977503116, "content": "Dysphagia is frequently encountered in patients with acute affections of the nervous system (cerebrovascular attacks, craniocerebral injuries) and in chronic nervous diseases (amyotrophic lateral sclerosis, Parkinson s disease, dementia). To these patients enteral nutrition must be administered. If the perspective of dysphagia is short (several days) then nutrition by a nasogastric tube is fully indicated and sufficient. In cases of more prolonged dysphagia and in patients with a long perspective of dysphagia percutaneous endoscopic gastrostomy (PEG) is indicated. Both these methods of enteral nutrition have their advantages and disadvantages which are manifested in different ways in patients with disorders of the nervous system. The authors compared 62 patients hospitalized in the course of 4.5 years at the neurological department who had PEG with 72 patients who had nasogastric tubes and were hospitalized at the neurological intensive care unit in the course of one year. The authors evaluated the different indications for application, the incidence of complications and the advantages and disadvantages of the two methods." }, { "id": "pubmed23n0285_3745", "title": "A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke.", "score": 0.014345794392523363, "content": "To compare percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. Randomised prospective study of inpatients with acute stroke requiring enteral nutrition. One university hospital (Nottingham) and one district general hospital (Derby). 30 patients with persisting dysphagia at 14 days after acute stroke: 16 patients were randomised to gastrostomy tube feeding and 14 to nasogastric tube feeding. Six week mortality; amount of feed administered; change in nutritional state; treatment failure; and length of hospital stay. Mortality at 6 weeks was significantly lower in the gastrostomy group with two deaths (12%) compared with eight deaths (57%) in the nasogastric group (P &lt; 0.05). All gastrostomy fed patients (16) received the total prescribed feed whereas 10/14 (71%) of nasogastric patients lost at least one day's feed. Nasogastric patients received a significantly (P &lt; 0.001) smaller proportion of their prescribed feed (78%; 95% confidence interval 63% to 94%) compared with the gastrostomy group (100%). Patients fed via a gastrostomy tube showed greater improvement in nutritional state, according to several different criteria at six weeks compared with the nasogastric group. In the gastrostomy group the mean albumin concentration increased from 27.1 g/l (24.5 g/l to 29.7 g/l) to 30.1 g/l (28.3 g/l to 31.9 g/l). In contrast, among the nasogastric group there was a reduction from 31.4 g/l (28.6 g/l to 34.2 g/l) to 22.3 g/l (20.7 g/l to 23.9 g/l) (P &lt; 0.003). In addition, there were fewer treatment failures in the gastrostomy group (0/16 versus 3/14). Six patients from the gastrostomy group were discharged from hospital within six weeks of the procedure compared with none from the nasogastric group (P &lt; 0.05). This study indicates that early gastrostomy tube feeding is greatly superior to nasogastric tube feeding and should be the nutritional treatment of choice for patients with acute dysphagic stroke." }, { "id": "pubmed23n0419_10086", "title": "[Home enteral nutrition: analysis of efficiency in a Health District].", "score": 0.014143920595533498, "content": "Studies on the analysis of direct costs generated by household enteral nutrition (HEN) have been scant. The objective of our study was to carry out a direct costs analysis of household enteral nutrition using both the biochemical and nutritional monitoring values of the nutritional state as a point of reference. Since January 1999 until December 2001, we studied a total sample of 102 consecutive patients with indication of household nutritional support. The following epidemiological data were obtained in all patients: age, sex, and primary condition for which enteral nutrition was prescribed; we carried out an anthropometric assessment and a biochemical nutritional assessment quarterly. We recorded also the number of episodes of diarrhea, vomiting, aspiration pneumonia, and death during the treatment. Average age of the patients was 58.7 13.3 years. The number and proportion of patients according to primary conditions were the following: 71 (69.3%) with head and neck cancer, 14 (13.9%) with a neurological condition with swallowing disturbance (stroke and/or dementia), 6 (5.9%) with tumors in other locations, and 11 (10.9%) with a group of diseases associated with dysphagia or anorexia. HEN was administered by oral route in 81 patients (79.4%), by nasogastric tube (NGT) in 15 patients (14.7%), by PEG in 5 patients (4.9%) and by yeyunostomy in 1 patient (1%). Average duration of HEN was 101 46.9 days. We showed a significant improvement of biochemical and anthropometric parameters in patients with HEN. The economic analysis of direct costs generated by enteral nutrition showed that the total average cost of nutritional formulas and expendable equipment utilized (holders, probes and nutritional tubes) was 300,033 599,203 pesetas/full treatment/patient (1,803 3,601 euros), or a daily average cost of 2,970 5,932 pesetas/day/patient (17.8 35.6 euros). In the analysis of costs acording to different items, the expendable equipment (nutritional tubes, nasogastric tubes and nutritional formula holders) were an average of 1,284 4,571 pesetas/full treatment/patient (7.7 27.4 euros) (5% in total), and the nutritional preparations were an average of 231,313 399,756 pesetas/full treatment/patient (1,390.2 2,402 euros) (95%). The patients with greater resources expenditure were those with tumors of head and neck. In order to analyze the efficiency of this treatment an analysis of costs was carried out for each objective parameter indicating nutritional status improvement; that way, the increase of 1 g/dl of albumin was an average cost of 103,817 2,897 pesetas (623.9 17.4 euros), while the increase of 1 kg of weight was an average cost of 857,237 25,097 pesetas (5,152.1 150.8 euros). CONCLUSIONS. In summary, nutrition enteral household was an effective therapy for nutritional status improvement in different groups of ambulatory patients. The cost of the nutritional support was superior in the group of patients with tumors of the upper aereodigestive system because of the greater duration of the treatment and the complex access route." }, { "id": "article-23776_44", "title": "Ischemic Stroke -- Treatment / Management -- Nutrition", "score": 0.014133516625139616, "content": "Early enteric feeding should be encouraged. For patients with dysphagia, use a nasogastric tube to promote enteric feeding. If there is concern that the patient may have swallowing difficulties for a prolonged period (more than 2 to 3 weeks), placing a percutaneous gastrostomy tube is recommended. Early feeding has been demonstrated to have an absolute reduction in the risk of death [24] ." }, { "id": "pubmed23n0891_3599", "title": "The Use of Enteral Nutrition in the Management of Stroke.", "score": 0.013910060975609756, "content": "This article discusses the use of enteral nutrition in the management of stroke. Stroke is a major source of disability, including dysphagia. The clinical manifestation of swallowing difficulties in stroke patients may lead to malnutrition which has implications for health status and clinical outcomes including morbidity, mortality and cost to the health service. The prevalence of malnutrition following an acute stroke could range from 8% to 34%. Therefore, the need to develop and implement the use of enteral nutrition support in stroke patients becomes pertinent. A range of enteral feeding tubes and feeding methods may be used to support stroke patients who are unable to meet their nutritional requirements through oral intake alone, although each of these approaches has its merits and limitations. Based on this review, there is evidence that enteral nutrition support is a useful method of providing nutrition for patients with dysphagia following a stroke in order to enhance their nutritional status and promote their health. However, there are challenges in the use of enteral tube feeding in these patients." }, { "id": "wiki20220301en037_67326", "title": "Percutaneous endoscopic gastrostomy", "score": 0.013736263736263736, "content": "PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many stroke patients, for example, are at risk of aspiration pneumonia due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition. PEGs may also be inserted to decompress the stomach in cases of gastric volvulus. Indications Gastrostomy may be indicated in numerous situations, usually those in which normal (or nasogastric) feeding is impossible. The causes for these situations may be neurological (e.g. stroke), anatomical (e.g. cleft lip and palate during the process of correction) or other (e.g. radiation therapy for tumors in head & neck region)." }, { "id": "article-25555_6", "title": "Nasogastric Tube -- Indications", "score": 0.013667907921462424, "content": "Less commonly, nasogastric tubes can be placed to administer medications or nutrition in patients who have a functional gastrointestinal tract but are unable to tolerate oral intake. This is most common in patients who have suffered a stroke or other malady, which has left them unable to swallow effectively. [3] Nasogastric tubes may be placed for nutritional support while waiting to see how much function the patient will recover, and if the patient does not recover their swallowing ability or will otherwise require long term nutritional support, then a more permanent feeding tube should be placed such as gastrostomy or jejunostomy feeding tube." }, { "id": "wiki20220301en010_101523", "title": "Dysphagia", "score": 0.01292664289353031, "content": "Oral vs. nonoral feeding Adequate nutrition and hydration must be preserved at all times during dysphagia treatment. The overall goal of dysphagia therapy is to maintain or return the patient to, oral feeding. However, this must be done while ensuring adequate nutrition and hydration and a safe swallow (no aspiration of food into the lungs). If oral feeding results in increased mealtimes and increased effort during the swallow, resulting in not enough food being ingested to maintain weight, a supplementary nonoral feeding method of nutrition may be needed. In addition, if the patient aspirates food or liquid into the lungs despite the use of compensatory strategies, and is therefore unsafe for oral feeding, nonoral feeding may be needed. Nonoral feeding includes receiving nutrition through a method that bypasses the oropharyngeal swallowing mechanism including a nasogastric tube, gastrostomy, or jejunostomy." }, { "id": "pubmed23n0695_1460", "title": "Nutrition in the stroke patient.", "score": 0.012916666666666667, "content": "Malnutrition is common both before and after stroke, with dysphagia adding to nutrition risk. Many patients require specialized nutrition support in the acute phase and beyond when swallowing function does not improve or return to allow for nutrition autonomy. When neurologic deficits improve, assessment of the swallowing function, introduction of dysphagia diets, and specialized swallowing techniques are used to transition away from enteral feeding tubes to oral diets. This article reviews the evaluation and treatment of dysphagia, use of specialized nutrition support, strategies for weaning enteral tube feedings, and the impact of nutrition on quality of life in the stroke patient population." }, { "id": "pubmed23n0801_5410", "title": "[The use of percutaneous endoscopic gastrostomy for provision of the long-term enteral nutrition].", "score": 0.012857142857142857, "content": "Percutaneous endoscopic gastrostomy for provision of the long-term enteral nutrition is well established in clinical practice because unlike from traditional gastrostomy and jejunostomy allowed to avoid many complications. The technique is used for enteral tube feeding in the absence of real positive predictive recovery of consciousness and swallowing function. During presented study from 387 patients with a gastrostomy imposed by percutaneous endoscopic technique, observed only 1,8% of suppurative complications and in 1% of cases - uncontrolled removal of the tube by the patient. Our experience allows us to recommend this technique for wide implementation in practice of medical institutions in case when it is necessity in enteral feeding more than 3 weeks of patients with impaired" }, { "id": "pubmed23n0509_21326", "title": "[Percutaneous endoscopic gastrostomy: prospective experience at a national private center].", "score": 0.012824510797536447, "content": "Percutaneous endoscopic gastrostomy tube feeding is a safe and effective method of providing long-term enteral nutrition in patients who are unable to swallow and offers important advantages over nasogastric tub feeding. The indications of this procedure have been received and over 7 years of practice on 103 patients and 128 procedures have been experienced with Ponsky pull techniques. All patients were given vitamin K and a prophylactic antibiotic (chephalotine) prior to testing. 1.56% of major deadly complications have been reports both for reflux and aspiration at 48 and 72 hours post treatment. The most common minor complication was wound infection in 8.9% of patients. There was no further mortality during testing or while undergoing treatment in the following 30 days. All patients were suffering from post heart attack dementia and stroke (CVA) at a rate of 23.3% and 21.4%, respectively. Percutaneous endoscopic gastrostomy has become the method of choice to sustain long-term enteral nutrition." }, { "id": "wiki20220301en025_24692", "title": "Feeding tube", "score": 0.012717891507460605, "content": "Product types Medical nutrition companies make flavored products for drinking and unflavored for tube feeding. These are regulated as medical foods, which are defined in section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee (b) (3)) as \"a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.\" Types The most common types of tubes include those placed through the nose, including nasogastric, nasoduodenal, and nasojejunal tubes, and those placed directly into the abdomen, such as a gastrostomy, gastrojejunostomy, or jejunostomy feeding tube. Nasogastric feeding tube" }, { "id": "pubmed23n0627_9491", "title": "Clinical outcomes and complications of enteral nutrition among older adults.", "score": 0.01039136302294197, "content": "Several reviews or clinical trials published in the last years have not demonstrated that tube feeding can improve outcomes, including inhalation pneumonia, survival, pressure sores. Further, high rate of risks are recognized. Therefore, this practice should be discouraged for severely demented patients. The aim of this study was to assess the validity of these findings in a sanitary district in the Venetian Region, Italy, characterized by a fully integrated program of territorial-hospital care and where enteral nutrition (EN) is supervised by a specialized nutritional team (NT). A distinctive aspect of this study concerns the fact that all patients with tube feeding were followed at home, in hospital, in nursing home by the same NT. The team controls the selection of patients and supports the follow-up, according to the guidelines of the Italian Society of Parenteral and Enteral nutrition. The study provides a prospective evaluation including 108 patients, mean age 78.2 years, followed for 12 months. Each patient underwent multidimensional tests, including activities of daily living, instrumental activities of daily living, Norton, Pfeiffer and Karnofsky scales, and anthropometric and biochemical indicators of nutritional status. The main diagnoses were dementia (72 patients), stroke (23 patients), malignancy (5 patients), amyotrophic lateral sclerosis (3 patients) and miscellaneous disease (5 patients). EN was delivered by PEG (62 patient), NGT (45 patient), jejunostomy in one patient. The main complications of nasogastric tube versus PEG have been inhalation 15.5% and 7.9%, respectively, tube displacement 62.2%, and 4.7%, tube clogging 11.1% and 7.9 %. The first month mortality rate was 7.4% and 23.1% at one year. The mean survival was 674 days. Almost all complications have been mild and could be managed throughout adequately. Their prevalence is low, with reference to the long period of follow-up, for a whole of 39420 days. Tube displacement is frequent with NGT but not with PEG and may be a cause of physical restraint, compromising in this way patient's quality of life. In this study, survival was nearly three times higher than reported in literature. These positive outcomes may be the result of two factors. First, the selection and follow-up program was supervised by the same nutritional team. Second, the network of integrated services of continuing care, including nursing homes, hospital and home care." }, { "id": "pubmed23n1031_11067", "title": "A Descriptive Study of enteral tube feeding among adults in an acute care tertiary hospital-patient selection, characteristics and complications.", "score": 0.009928553830992856, "content": "It is vital to develop a better understanding of the use of different modalities for enteral feeding and its associated complications, given differences in funding support, community resources and infrastructure available to support home enteral feeding in an acute care tertiary hospital. To provide a description of the clinical characteristics of patients on long-term enteral feeding and incidence of associated complications. A retrospective case records review study design was adopted. Medical records of patients discharged from a tertiary hospital with long-term nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG) feeding for the first time during the period of January 2010 to June 2017 were reviewed. Data collected include patient's demographics, reason for enteral feeding, morbidity and nutritional status upon initiation of NGT and PEG feeding, readmission episodes and documented complications (associated with enteral feeding) within one-year post discharge. Records of 120 NGT and 118 PEG patients were analysed. Significant age and gender differences were found with older patients being more likely to be placed on NGT [NGT (Mean 79.1, SD 11.3) vs. PEG (Mean 67.1, SD 12.6)] and higher number of females in the NGT group as compared to the PEG group (NGT 59.2% vs. PEG 31.4%). Majority of patients were fed by caregivers in the NGT (99.2%) as compared to the PEG (51.7%) group. Patients with cancer were more likely to be on PEG feeding (NGT 5%, PEG 70.3%), whereas patients with stroke-related diagnoses were more likely to be on NGT feeding (NGT 48% vs. PEG 8.5%). The total Charlson Comorbidity score was also significantly different between the NGT (mean = 5.7; SD = 1.5) and PEG (mean = 4.5; SD = 2.0) groups. A higher number of patients with PEG feeding had no complications (47.5%) as compared to the NGT group (8.3%). Patients who received NGT feeding were more likely experience tube blockage [OR 0.03, 95% CI (0.001-0.72), p = 0.03], secondary displacement of tube [OR 0.04, 95% CI (0.002-0.72), p = 0.03] and accidental tube removal [OR 0.03, 95% CI (0.004-0.21), p &lt; 0.001]. Overall, patients who received NGT feeding experienced more complications than those who had PEG feeding. The choice for NGT or PEG feeding may be influenced by patient related factors as well as the presence of caregivers, which need to be considered in the improvement of enteral nutrition services in the local context." }, { "id": "pubmed23n1088_23919", "title": "Medical decision making about long-term artificial nutrition after severe stroke: a case report.", "score": 0.009900990099009901, "content": "Choosing to use a percutaneous endoscopic gastrostomy (PEG tube) for long term artificial nutrition in the setting of inadequate oral intake after stroke is complex because the decision must be made in a relatively short amount of time and prognosis is often uncertain. This case study utilized interviews with attending and resident neurologists, and surrogate medical decision makers in order to examine how neurologists and surrogate medical decision makers approached the decision to either receive a PEG tube or pursue comfort measures after severe stroke in two patients. Although these two patients presented with similar clinical characteristics and faced similar medical decisions, different decisions regarding PEG tube placement were made. Major challenges included physicians who did not agree on prognosis and surrogates who did not agree on whether to place a PEG tube. These cases demonstrate the importance of the role of the surrogate medical decision maker and the necessity of physicians and surrogate medical decision makers approaching the complex decision of PEG tube placement after stroke together. Additionally, these cases highlight the differing views on what defines a good quality of life and show the vital importance of high-quality goals of care conversations about prognosis and quality of life when deciding whether to place a PEG tube after severe stroke." }, { "id": "wiki20220301en369_23981", "title": "Physician Orders for Life-Sustaining Treatment", "score": 0.009869767217929275, "content": "Artificially Administered Nutrition This section comes with options of “no artificial nutrition by tube”, “defined trial period of artificial nutrition by tube” and “long-term artificial nutrition by tube”. If the person is able to chew and swallow, the food will be taken by mouth. Studies have found that orders to withhold artificial nutrition such as feeding tubes are usually executed by the providers." }, { "id": "pubmed23n0416_1838", "title": "Enteral nutrition delivery technique.", "score": 0.00980392156862745, "content": "Ingestion and absorption of a nutritionally adequate diet is necessary to maintain normal body composition and organ function. Patients with all kinds of diseases are at increased risk of developing nutritional abnormalities from anorexia, dietary restriction, malabsorption, increased intestinal losses or altered nutrient requirements. Therefore, it is important for doctors to understand the general principles of clinical nutrition for optimal management of patients with various disorders. The purpose of this review is to highlight an important aspect of nutrition: methods for enteral nutrient delivery. Enteral feeding is the preferred method to provide nutritional support in patients who cannot or will not eat but who have a functional gastrointestinal tract. The placement of a small-diameter nasogastric or nasoduodenal tube is the simplest technique for feeding patients who are unlikely to require tube feeding for more than 6 weeks. Gastrostomy, gastrojejunostomy and jejunostomy tubes placed by using endoscopic, radiologic, or surgical techniques should be considered in patients who require long-term feeding. With newer endoscopic feeding techniques replacing more conventional surgical techniques, this review proposes to discuss the newer developments in techniques of enteral feeding. This review will briefly discuss the principles governing nasoenteral feeding and will describe in detail the endoscopic assisted methods for placing enteral feeding tubes. These include percutaneous endoscopic gastrostomy, jejunal extension through a percutaneous endoscopic gastrostomy or direct endoscopic jejunostomy. It will also discuss the procedural complications and long term results of these methods of enteral feeding. Lastly the latest innovation in enteral feed - the one step button - is also discussed. Percutaneous endoscopic gastrostomy placement is an appropriate method for providing nutrition in ill patients if no contraindication to enteral feeding exists. In certain situations, percutaneous endoscopic gastrostomy placement may even be used to make the life of a terminally ill patient comfortable." }, { "id": "pubmed23n0767_546", "title": "Percutaneous endoscopic gastrostomy tube placement in left versus right middle cerebral artery stroke: effects of laterality.", "score": 0.009615384615384616, "content": "Prolonged dysphagia after middle cerebral artery (MCA) territory strokes may require percutaneous endoscopic gastrostomy (PEG) tube feeding. We examined the predictors of PEG placement among patients with MCA stroke. It was hypothesized that stroke laterality was a predictor. A retrospective cohort study of existing data from Hartford Hospital Stroke Database was done. A total of 157 patients with acute ischemic MCA stroke were included. Patients were divided into the \"PEG\" group (n = 24) and \"no PEG\" group (n = 133). Existing demographic, clinical and swallowing data were compared between the 2 groups. Demographic data were similar between the groups. The \"PEG\" group had a higher admission National Institute of Health Stroke Scale (NIHSS) score, higher proportion of patients who had thrombolytic administration, in- hospital aspiration pneumonia and inability to be assessed on first swallow evaluation. Multivariate analysis revealed that all, except thrombolytic administration may predict PEG placement. Admission NIHSS score, in-hospital aspiration pneumonia and inability to undergo first swallow evaluation may predict PEG placement in patients with acute MCA stroke. Stroke laterality was not associated. This knowledge facilitates early identification of patients that may require PEG tube placement for early nutrition provision and discharge to rehabilitation." }, { "id": "pubmed23n0622_17079", "title": "Predicting the chance of weaning dysphagic stroke patients from enteral nutrition: a multivariate logistic modelling study.", "score": 0.009433962264150943, "content": "The aim of this article was to develop a simple predictive model of dysphagia outcome for stroke patients. The study enrolled patients recovering from first-ever stroke (supratentorial lesions) staying in a long-term rehabilitation hospital. On admission, all patients were being fed via nasogastric or percutaneous endoscopic gastrostomy (PEG) tube. Functional Independence Measure (FIMTM) scores were assessed on admission. FIM-motor and cognition score, age, days after onset on admission were set as explanatory variables. Target criteria were defined as dichotomous categories; completely oral feeding or any need for nutrition via tube feeding. Multivariate logistic analysis was performed on these data. Thirty patients were enrolled: age range was 50-94 (median 75) years; FIM-motor scores spanned 13 to 17 (median 13), FIM-cognition scores spanned 5 to 19 (median 9); and days from stroke onset to transfer to long-term rehabilitation care ranged from 15 to 64 (median 43.5) days. Of these patients, 12 were weaned back to oral feeding and 18 were not. Multivariate logistic regression modelling was successful on these data (P=0.0003, R2=0.518; Logit=0.770xFIM-motor+0.089xFIM-cognition 0.070xdays after onset 0.255xage+10.222). Estimated probability for return to oral feeding is nearly 10% when logit equals -2, 50% when logit equals 0, nearly 90% when logit equals 2. A logit formula factoring in age, FIM scores, and days after stroke onset can readily predict oral feeding outcome. Further studies are needed to assess external validation to establish wide clinical applicability of this prediction model." }, { "id": "wiki20220301en028_8473", "title": "Malabsorption", "score": 0.009345794392523364, "content": "Management Treatment is directed largely towards management of underlying cause: Replacement of nutrients, electrolytes and fluid may be necessary. In severe deficiency, hospital admission may be required for nutritional support and detailed advice from dietitians. Use of enteral nutrition by naso-gastric or other feeding tubes may be able to provide sufficient nutritional supplementation. Tube placement may also be done by percutaneous endoscopic gastrostomy, or surgical jejunostomy. In patients whose intestinal absorptive surface is severely limited from disease or surgery, long term total parenteral nutrition may be needed. Pancreatic enzymes are supplemented orally in pancreatic insufficiency. Dietary modification is important in some conditions: Gluten-free diet in coeliac disease. Lactose avoidance in lactose intolerance. Antibiotic therapy to treat Small Bowel Bacterial overgrowth." }, { "id": "pubmed23n0379_14684", "title": "[Endoscopic gastrostomy in patients with complicated heart diseases].", "score": 0.009259259259259259, "content": "Complicated cardiologic patients with brain ischemia and heart failure need long term enteral nutrition. Long term nasoenteral tube feeding may cause complications that could be avoided with percutaneous endoscopic gastrostomy. The aim of this study was to evaluate the indications for percutaneous endoscopic gastrostomy and its main complications. Twelve patients were submitted to percutaneous endoscopic gastrostomy (eight male) with main age of 62.42 +/- 22.10 years old. Brain ischemia was the main indication of percutaneous endoscopic gastrostomy and occurred after 35.58 +/- 26.79 days, after initiated enteral nutrition. There were no complications during procedure. On late post operatory period there were local infection in one cases, treated with local care. In conclusion, percutaneous endoscopic gastrostomy is a secure technique with low incidence of complications and its indication should be earlier." }, { "id": "wiki20220301en037_67325", "title": "Percutaneous endoscopic gastrostomy", "score": 0.009174311926605505, "content": "Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia or sedation). This provides enteral nutrition (making use of the natural digestion process of the gastrointestinal tract) despite bypassing the mouth; enteral nutrition is generally preferable to parenteral nutrition (which is only used when the GI tract must be avoided). The PEG procedure is an alternative to open surgical gastrostomy insertion, and does not require a general anesthetic; mild sedation is typically used. PEG tubes may also be extended into the small intestine by passing a jejunal extension tube (PEG-J tube) through the PEG tube and into the jejunum via the pylorus." }, { "id": "pubmed23n0063_17807", "title": "Safe and effective tube feeding of bedridden elderly.", "score": 0.009174311926605505, "content": "An increasing number of patients with swallowing disorders due to stroke, head trauma, degenerative neurologic diseases, and other causes are surviving for prolonged periods with tube feeding of commercial formulas as their sole source of nutritional support. Reviewed in this article are the indications, methods, strategies for formula selection, complications, and outcomes of tube feeding in the long-term care patient." } ] } } }

{ "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, 170 ] ], "word_ranges": [ [ 0, 32 ] ], "text": "These are typical adverse effects of ACEIs, in the case of cough it is usually dry and irritative and appears in up to 3% of patients. Hyperkalemia may also appear in 1%." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Hydrochlorothiazide.", "2": "Bisoprolol.", "3": "Furosemide.", "4": "Enalapril.", "5": "Hydralazine." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0347_9959", "title": "Hypersensitivity myocarditis associated with ephedra use.", "score": 0.016950369891546364, "content": "Ephedrine has previously been described as a causative factor of vasculitis but myocarditis has not yet been associated with either ephedrine or its plant derivative ephedra. A 39-year-old African American male with hypertension presented to Rush Presbyterian St. Luke's Medical Center with a 1-month history of progressive dyspnea on exertion, orthopnea, and dependent edema. He was taking Ma Huang (Herbalife) 1-3 tablets twice daily for 3 months along with other vitamin supplements, pravastatin, and furosemide. Physical examination revealed a male in mild respiratory distress. The lung fields had rales at both bases without audible wheezes. Internal jugular venous pulsations were 5 cm above the sternal notch. Medical therapy with intravenous furosemide and oral enalapril was initiated upon admission. Cardiac catheterization with coronary angiography revealed normal coronary arteries, a dilated left ventricle, moderate pulmonary hypertension, and a pulmonary capillary wedge pressure of 34 mm Hg. The patient had right ventricular biopsy performed demonstrating mild myocyte hypertrophy and an infiltrate consisting predominantly of lymphocytes with eosinophils present in significantly increased numbers. Treatment for myocarditis was initiated with azothioprine 200 mg daily and prednisone 60 mg per day with a tapering course over 6 months. Anticoagulation with warfarin and diuretics was initiated and angiotensin-converting enzyme inhibition was continued. Hydralazine was added later. One month into therapy, an echocardiogram demonstrated improved left ventricular function with only mild global hypokinesis. A repeat right ventricular biopsy 2 months after the first admission showed no evidence of myocarditis. At 6 months, left ventricular ejection fraction was normal (EFN 50%) and the patient asymptomatic. Ephedra (Ma Huang) is the suspected cause of hypersensitivity myocarditis in this patient due to the temporal course of disease and its propensity to induce vasculitis." }, { "id": "wiki20220301en166_44933", "title": "WHO Model List of Essential Medicines", "score": 0.016523506655301293, "content": "Antianginal medicines Bisoprolol Glyceryl trinitrate Isosorbide dinitrate Verapamil Antiarrhythmic medicines Bisoprolol Digoxin Epinephrine (adrenaline) Lidocaine Verapamil Amiodaroneα Antihypertensive medicines Amlodipine Bisoprolol Enalapril Hydralazine Hydrochlorothiazide Lisinopril/amlodipine (lisinopril + amlodipine) Lisinopril/hydrochlorothiazide (lisinopril + hydrochlorothiazide) Losartan Methyldopa Telmisartan/amlodipine (telmisartan + amlodipine) Telmisartan/hydrochlorothiazide (telmisartan + hydrochlorothiazide) Sodium nitroprussideα Medicines used in heart failure Bisoprolol Digoxin Enalapril Furosemide Hydrochlorothiazide Losartan Spironolactone Dopamineα Antithrombotic medicines Anti-platelet medicines Acetylsalicylic acid (aspirin) Clopidogrel Thrombolytic medicines Alteplaseα Streptokinaseα Lipid-lowering agents Simvastatin Dermatological medicines (topical)" }, { "id": "pubmed23n0421_19610", "title": "Epidemiology, pathophysiology, prognosis, and treatment of systolic and diastolic heart failure in elderly patients.", "score": 0.016312244089288074, "content": "American College of Cardiology/American Heart Association class I recommendations for treating patients with heart failure (HF) and abnormal left ventricular ejection fraction are diuretics in patients with fluid retention, an angiotensin-converting enzyme (ACE) inhibitor unless contraindicated, a beta-blocker unless contraindicated, digoxin for the treatment of symptoms of HF, and withdrawal of drugs known to precipitate or aggravate HF such as nonsteroidal anti-inflammatory drugs, calcium channel blockers, and most antiarrhythmic drugs. Class II(a) recommendations for treating HF with abnormal left ventricular ejection fraction are spironolactone in patients with class IV symptoms, preserved renal function, and normal serum potassium; exercise training as an adjunctive approach to improve clinical status in ambulatory patients; an angiotensin receptor blocker in patients who cannot be given an ACE inhibitor because of cough, rash, altered taste sensation, or angioedema; and hydralazine plus nitrates in patients being treated with diuretics, a beta-blocker, and digoxin who cannot be given an ACE inhibitor or an angiotensin receptor blocker because of hypotension or renal insufficiency. Patients with diastolic HF should be treated with cautious use of diuretics and with a beta-blocker. An ACE inhibitor should be added if HF persists or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioedema, rash, or altered taste sensation. Isosorbide dinitrate plus hydralazine should be added if HF persists. A calcium channel blocker should be added if HF persists. Digoxin should be avoided in diastolic HF if sinus rhythm is present." }, { "id": "Pharmacology_Katzung_1764", "title": "Pharmacology_Katzung", "score": 0.015874015748031496, "content": "During a routine check and on two follow-up visits, a 45-year-old man was found to have high blood pressure (160–165/95–100 mm Hg). His physician initially prescribed hydrochlorothiazide, a diuretic commonly used to treat hyper-tension. His blood pressure was reduced by hydrochloro-thiazide but remained at a hypertensive level (145/95 mm Hg), and he was referred to the university hypertension clinic. Because the patient had elevated plasma renin activity and aldosterone concentration, hydrochlorothiazide was replaced with enalapril, an angiotensin-converting enzyme inhibitor. Enalapril lowered his blood pressure to almost normotensive levels. However, after several weeks on enalapril, the patient returned complaining of a persistent cough. In addition, some signs of angioedema were detected. How does enalapril lower blood pressure? Why does it occasionally cause coughing and angioedema? What other drugs could be used to inhibit the renin-angiotensin system and decrease blood pressure," }, { "id": "pubmed23n0584_10591", "title": "Treatment of heart failure with normal left ventricular ejection fraction.", "score": 0.01505193979224083, "content": "Underlying causes and precipitating causes of heart failure (HF) should be treated when possible. Persons with HF and normal left ventricular ejection fraction (LVEF) should have maintenance of sinus rhythm, treatment of hypertension, myocardial ischemia, dyslipidemia, and anemia, slowing of the ventricular rate below 90 bpm, and reduction of salt overload. First-line drug treatment in the management of these persons is the use of loop diuretics combined with beta blockers and angiotensin-converting enzyme (ACE) inhibitors. If persons are unable to tolerate ACE inhibitors because of cough, angioneurotic edema, rash, or altered taste sensation, angiotensin II type I receptor antagonists (ARBs) should be given. If HF persists despite diuretics, beta blockers, and ACE inhibitors or ARBs, isosorbide dinitrate plus hydralazine should be administered. Beta blockers, verapamil, diltiazem, and digoxin may be used to slow a rapid ventricular rate in persons with supraventricular tachyarrhythmias. Digoxin should not be used in persons with HF in sinus rhythm with normal LVEF. Exercise training should be encouraged in persons with mild to moderate HF to improve functional status and to decrease symptoms." }, { "id": "pubmed23n0084_22159", "title": "Angiotensin-converting enzyme inhibitor-induced cough.", "score": 0.014988290398126464, "content": "A 65-year-old woman started taking enalapril 2.5 mg daily for hypertension. Twelve days later she complained of a persistent, dry cough. Due to the coughing and a preexisting cystocele, she developed stress incontinence and a marked decline in her functional status. The coughing and incontinence resolved with the discontinuation of enalapril. During a subsequent hospitalization the patient received captopril 6.25 mg twice daily for congestive heart failure. Within 24 hours the dry cough recurred. It resolved with the discontinuation of the drug. Cough is a symptom that is generally not recognized as a drug side effect. However, increasing numbers of case reports document angiotensin-converting enzyme inhibitor-induced cough. Although the actual frequency and mechanism are currently unknown, the dry cough typically begins early in the course of therapy. It may be specific to this pharmacologic class rather than to one individual agent. Age and sex may be contributing factors. While cough has been considered a minor side effect, unnecessary hospitalizations and inappropriate treatments may easily result. Even minor adverse reactions may have an impact on a patient's quality of life." }, { "id": "pubmed23n0375_10801", "title": "Left ventricular diastolic heart failure with normal left ventricular systolic function in older persons.", "score": 0.014932126696832578, "content": "Underlying causes and precipitating causes of congestive heart failure (CHF) should be treated when possible. Older persons with CHF and normal left ventricular (LV) ejection fraction should have maintenance of sinus rhythm, treatment of hypertension and myocardial ischemia, slowing of the ventricular rate below 90 beats/minute, and reduction of salt overload. First-line drug treatment in the management of these persons is the use of loop diuretics combined with beta blockers as tolerated. Angiotensin-converting enzyme (ACE) inhibitors should be administered if CHF persists despite diuretics and beta blockers. If persons are unable to tolerate ACE inhibitors because of cough, rash, or altered taste sensation, angiotensin II type 1 receptor antagonists should be given. If CHF persists despite diuretics, beta blockers, and ACE inhibitors or the person is unable to tolerate beta blockers, ACE inhibitors, and angiotensin II type 1 receptor antagonists, isosorbide dinitrate plus hydralazine should be administered. Calcium channel blockers should be used if CHF persists despite administration of diuretics and the person is unable to tolerate beta blockers, ACE inhibitors, angiotensin II type 1 receptor antagonists, and isosorbide dinitrate plus hydralazine. Digoxin, beta blockers, verapamil, and diltiazem may be used to slow a rapid ventricular rate in persons with supraventricular tachyarrhythmias. Digoxin should not be used in persons with CHF in sinus rhythm with normal LV ejection fraction." }, { "id": "pubmed23n0979_5797", "title": "When a Diuretic Causes Pulmonary Oedema.", "score": 0.014488146062312654, "content": "Hydrochlorothiazide (HCTZ) is one of the most popular drugs for the treatment of hypertension and heart failure. Most of its side effects are harmless and predictable, but some studies report a few life-threatening reactions to this drug, one of the most dangerous being acute pulmonary oedema. A 73-year-old woman was admitted to the Emergency Department with acute respiratory failure due to pulmonary oedema. Her past medical history included long-lasting hypertension with permanent atrial fibrillation and mitral stenosis. Her blood pressure control had been suboptimal, so her cardiologist had changed amlodipine to combination therapy with ramipril and HCTZ. However, 20 min after taking the new drug, the patient experienced fever, vomiting and diarrhoea immediately followed by acute onset of dyspnoea. Since HCTZ is one of the most popular drugs for hypertension treatment and millions of patients take it every day, it is important to keep in mind both the common adverse reactions as well as the dangerous, although rare, ones. Pulmonary oedema is a very unusual adverse reaction to hydrochlorothiazide, and a rare presentation of a common condition.Pulmonary oedema is not always due to heart problems.It is important to keep in mind that hypersensitivity reactions may have many different presentations." }, { "id": "wiki20220301en062_55695", "title": "Hydralazine", "score": 0.014170733795701686, "content": "Medical use Hydralazine is not used as a primary drug for treating hypertension because it elicits a reflex sympathetic stimulation of the heart (the baroreceptor reflex). The sympathetic stimulation may increase heart rate and cardiac output, and in people with coronary artery disease may cause angina pectoris or myocardial infarction. Hydralazine may also increase plasma renin concentration, resulting in fluid retention. To prevent these undesirable side effects, hydralazine is usually prescribed in combination with a beta blocker (e.g., propranolol) and a diuretic. Beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol. Hydralazine is used to treat severe hypertension, but is not a first-line therapy for essential hypertension. Hydralazine is often used to treat hypertension in pregnancy, though, with either labetalol and/or methyldopa." }, { "id": "pubmed23n0534_8267", "title": "Treatment of systolic and diastolic heart failure in the elderly.", "score": 0.014141414141414142, "content": "Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Drugs known to precipitate or aggravate HF should be stopped. Patients with HF and an abnormal left ventricular ejection fraction (LVEF) (systolic heart failure) or normal LVEF (diastolic HF) should be treated with diuretics if fluid retention is present; with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation; and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/mL. A multidisciplinary approach should be used with nurse monitoring of the condition. In a home-bound patient, a homemaker should be hired." }, { "id": "pubmed23n0102_5224", "title": "Captopril. An update of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in hypertension and congestive heart failure.", "score": 0.014100420300989742, "content": "Captopril is an orally active inhibitor of angiotensin-converting enzyme (ACE) and has been widely studied in the treatment of patients with mild to moderate essential hypertension, severe hypertension not responsive to conventional diuretic/beta-adrenoceptor blocker/vasodilator regimens, and patients with chronic congestive heart failure refractory to treatment with a diuretic and digitalis. In patients with mild or moderate essential hypertension, titrated low doses of captopril used alone or in conjunction with a diuretic are similar in efficacy to usual doses of hydrochlorothiazide, chlorthalidone, or beta-adrenoceptor blocking drugs, as well as to the other ACE inhibitors. In addition, captopril improved well-being to a greater extent than methyldopa or propranolol in a study designed specifically to determine the effect of treatment on the quality of life of patients with mild or moderate essential hypertension. The earlier demonstrated efficacy of captopril, used with a diuretic and often also with a beta-adrenoceptor blocking drug, in the treatment of severe hypertension refractory to conventional 'triple therapy' has been confirmed in more recent trials which illustrate the generally marked antihypertensive effect of captopril-containing regimens in such patients. Results of initial trials in patients with scleroderma are promising, with control of hypertension and stabilization of renal function in these patients when treated at an early stage of the disease. Several comparative and long term trials of captopril in patients with chronic congestive heart failure refractory to treatment with a diuretic/digitalis regimen clearly demonstrate that initial haemodynamic improvement is maintained and correlates with clinical benefit. A tendency for overall clinical response to captopril to be better than the response to prazosin, hydralazine, nisoldipine or enalapril has been reported. Results of a multicentre comparison with digoxin and placebo indicate that captopril is a suitable alternative to digoxin in patients with mild to moderate heart failure who are receiving maintenance diuretic therapy. The tolerability of captopril has now been studied in many thousands of patients involved in formalized trials and the early impression of poor tolerability can no longer be justified. The use of generally lower dosages of captopril in patients with normal or slightly impaired renal function has resulted in a generally low incidence of rash (0.5 to 4%), dysgeusia (0.1 to 3%), proteinuria (0.5%), neutropenia (0.3% during first 3 months) and symptomatic hypotension (0.1 to 3%). Cough is an infrequent but troublesome effect resulting from ACE inhibition.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0534_16627", "title": "Drug treatment of systolic and of diastolic heart failure in elderly persons.", "score": 0.01406926406926407, "content": "Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Patients with HF and an abnormal left ventricular ejection fraction (systolic HF) or normal left ventricular ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/ml. Cardiac synchronized pacing should be considered in patients with severe systolic HF despite optimal medical therapy, with sinus rhythm, and with ventricular dyssynchrony." }, { "id": "pubmed23n0724_13203", "title": "Therapeutic challenges and management of heart failure during pregnancy (part I).", "score": 0.01401689708141321, "content": "Therapeutic management in pregnant patients with heart failure still remains a challenge, even though in most pregnant women with cardiac diseases an outcome is good. A 32-year-old woman, 17 weeks pregnant, was admitted to hospital with heart failure (HF) NYHA class III/IV. Echocardiography revealed enlarged LV, LVEF 13%, significant mitral insufficiency and pulmonary hypertension. The patient wished to continue the pregnancy. In a life-threatening condition, metoprolol, enalapril, spironolactone (for 5 days), furosemide, and digitalis were administered. Enalapril was continued for 42 days. Then the patient was switched to a dihydralazine and isosorbide mononitrate regimen. The fetus was controlled ultrasonographically. In the 19th week of pregnancy, the patient's condition improved (NYHA class II, LVEF 23%). The patient experienced 2 more episodes of HF exacerbation. In the 26th week of pregnancy, in a primary prevention of sudden cardiac death and because of 2nd-degree AV block, an ICD was implanted. In the 32nd week of pregnancy a cesarean section was performed. A male infant was delivered. The patient made a good recovery and was discharged on the 7th postoperative day. The newborn was discharged after 4 weeks, in good general condition. At 1-year follow-up the patient presented NYHA class II.&lt;br /&gt;" }, { "id": "wiki20220301en600_20051", "title": "Enalapril/hydrochlorothiazide", "score": 0.013544393202875067, "content": "Enalapril/hydrochlorothiazide, sold under the brand name Vaseretic among others, is a fixed-dose combination medication used for the treatment of hypertension (high blood pressure). It contains enalapril, an angiotensin converting enzyme inhibitor, and hydrochlorothiazide a diuretic. It is taken by mouth. The most frequent side effects include dizziness, headache, fatigue, and cough. History Enalapril/hydrochlorothiazide was approved for medical use in the United States in October 1986. References Further reading External links ACE inhibitors Antihypertensive agents Diuretics Prodrugs" }, { "id": "pubmed23n0085_11109", "title": "Enalapril-induced cough.", "score": 0.013172110030748774, "content": "A retrospective analysis of records from an outpatient medical practice was undertaken to determine the incidence and features of cough resulting from the use of enalapril maleate. Of 209 patients taking enalapril, 22 (10.5%) required discontinuation of therapy because of an intractable, dry cough. Cough was more than twice as common in women; 16 (14.6%) of 109 women and 6 (6%) of 100 men stopped taking enalapril because of cough. The cough resolved in 21 of 22 patients within 2 weeks of discontinuation of enalapril therapy. When the patients with cough were compared with the others, there was no significant difference in age, smoking status, creatinine levels, enalapril dosage, associated cardiopulmonary disease, or concomitant administration of medications. Among the 187 study patients who did not discontinue taking enalapril because of cough, many developed a persistent, dry cough that to date has not been severe enough to require discontinuation of therapy, after a mean follow-up period of 16 months. The enalapril-induced cough is insidious, dry, persistent, benign, and reversible on discontinuation of therapy. It is important to distinguish enalapril-induced cough from cough resulting from acute illness, reactive airway disease, and congestive heart failure. Optimal clinical application of enalapril in the treatment of hypertension and congestive heart failure will require increased awareness of this incessant cough, which requires discontinuation of the therapy in about 10% of patients." }, { "id": "pubmed23n0541_1770", "title": "Epidemiology, pathophysiology, prognosis, and treatment of systolic and diastolic heart failure.", "score": 0.013121693121693121, "content": "Underlying causes, risk factors, and precipitating causes of heart failure (HF) should be treated. Drugs known to precipitate or aggravate HF such as nonsteroidal antiinflammatory drugs should be stopped. Patients with HF and a low left ventricular ejection fraction (systolic heart failure) or normal ejection fraction (diastolic HF) should be treated with diuretics if fluid retention is present, with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, and with a beta blocker unless contraindicated. If severe systolic HF persists, an aldosterone antagonist should be added. If HF persists, isosorbide dinitrate plus hydralazine should be added. Calcium channel blockers should be avoided if systolic HF is present. Digoxin should be avoided in men and women with diastolic HF if sinus rhythm is present and in women with systolic HF. Digoxin should be given to men with systolic HF if symptoms persist, but the serum digoxin level should be maintained between 0.5 and 0.8 ng/mL." }, { "id": "pubmed23n0346_1251", "title": "Quinapril in patients with congestive heart failure: controlled trial versus captopril.", "score": 0.012604709973131026, "content": "After two weeks of a wash-out run-in period with placebo, 131 patients with congestive heart failure (New York Heart Association [NYHA] class II to III) and left ventricular ejection fraction &lt;/=40% were randomly assigned to a treatment period of 4 weeks with 10 mg quinapril once daily or 12.5 mg captopril twice daily. At the end of this period, doses were titrated to 20 mg quinapril once daily or 25 mg captopril twice daily on the basis of physician judgment if there were no major adverse reactions and if blood pressure was not below 110/70 mm Hg. Clinical symptoms of heart failure were significantly relieved by both drugs at the end of a 12-week treatment period. At the beginning of the study, 23 (35%) of the 65 patients taking quinapril and 27 (41%) of the 66 patients taking captopril were in NYHA functional class III, whereas, at the end of the trial, only 4 (6%) of the patients in the quinapril group and 14 (22%; p &lt; 0.05 versus quinapril) patients in the captopril group were classified as NYHA class III. Both drugs had a positive effect on echocardiographic parameters. There was a statistically significant increase in exercise duration in both treatment groups (quinapril, 6.2 +/- 1.8 versus 7.8 +/- 1.9 minutes, p &lt; 0.001; captopril, 5.9 +/- 1.9 versus 7.1 +/- 2.3 minutes, p &lt; 0.001). One patient in the quinapril group died suddenly during the study and two patients in the captopril group dropped out of the study due to persistent dry cough. No patient in the quinapril group reported side effects. Three patients in the captopril group suffered from moderate dry cough, one from taste-blindness, and another from unstable angina. The safety of the tested drugs was confirmed by laboratory tests. Quinapril was as effective as captopril in reducing signs and symptoms of heart failure and in improving the left ventricular function and the exercise capacity with few side effects." }, { "id": "wiki20220301en055_62432", "title": "Acute coronary syndrome", "score": 0.012559589292262559, "content": "Heart failure Heart failure (HF) is defined as the incapacity of the heart to function properly, pumping insufficient blood towards the tissues and leading to fluid accumulation within the lungs, liver and peripheral tissues. Oral manifestations Most if not all patients with heart failure will be undergoing drug treatments for their condition and these drugs can produce a series of oral manifestation. In this context, angiotensin-converting enzyme (ACE) inhibitors such as captopril and enalapril can produce burning mouth sensation lichenoid reactions and a loss of taste sensation, while diuretics like furosemide can produce xerostomia." }, { "id": "pubmed23n0974_9461", "title": "[Severe and rare adverse reaction to hydrochlorothiazide].", "score": 0.011784686839277667, "content": "The immune mechanism involved in the reaction to hydrochlorothiazide, which is widely used to control hypertension, is unknown. The short latency period between the take of the drug and the onset of symptoms suggests immediate hypersensitivity. 63-year-old woman with arterial hypertension who, on three occasions, experienced nausea, vomiting, general malaise, shivering, arthralgias, dysthermic sensation, back pain of mechanical characteristics and mild non-productive cough, as well as fever and chest tightness with increased dyspnea and desaturation of up to 88 %, after taking hydrochlorothiazide. Clinical presentation in the patient was similar to a septic shock, which is a rare allergic reaction. The diagnosis has to be clinical. This type of reaction might be due to type III hypersensitivity owing to the formation of immune complexes. Avoiding of the culprit drug is key to a good evolution." }, { "id": "pubmed23n0812_18983", "title": "A One-Two Punch: Hydralazine-Induced Liver Injury in a Recovering Ischemic Hepatitis.", "score": 0.011063700091435539, "content": "A 77-year-old woman presented to the emergency department with a 2-day history of nausea and vomiting. Her medical history included diabetes mellitus, hypertension, atrial fibrillation, dilated cardiomyopathy, and coronary artery disease. Her home medications included aspirin, clopidogrel, warfarin, digoxin, metoprolol, losartan, simvastatin, isosorbide dinitrate, furosemide, and spironolactone. Initial physical examination showed blood pressure of 170/80 mm Hg with a heart rate of 69 beats per minute, otherwise unremarkable. Initial laboratory workup was significant for INR of 3.6, with slightly elevated troponin I and creatinine of 0.06 ng/mL and 1.4 mg/dL, respectively. The patient was admitted to the medicine floor. However, a few hours later, her atrial fibrillation went into rapid ventricular response, associated with hypotension. Cardiac enzymes began to trend up along with worsening of her renal function tests and hepatic enzymes. Her INR remained supratherapeutic despite holding coumadin and giving vitamin K. The patient was transferred to the medical intensive care unit for closer monitoring. During day 1 of the medical intensive care unit stay, losartan, simvastatin, and diuretics were held, whereas aspirin, clopidogrel, and isosorbide dinitrate were continued. In the following 2 days, there was worsening of tissue perfusion, and laboratory workup showed AST 514 IU/L, ALT 391 IU/L, INR &gt;9, creatinine 3.8 mg/dL, and troponin I 0.19 ng/mL; therefore, digoxin was also held. Once the patient achieved hemodynamic stability, she was started on hydralazine. On day 4, renal function, cardiac, and hepatic enzymes improved significantly. However, 24 hours later, transaminases began to trend up again reaching a maximum of AST and ALT of 359 and 525 IU/L, respectively. Other possible causes were ruled out because her viral hepatitis markers, antihistone antibody, antinuclear antibody, and anti-double-stranded DNA were all negative. After thorough review of all medications, hydralazine was held with subsequent improvement in transaminases. The patient was seen a month later after her discharge, and all her laboratory workup improved to baseline. " }, { "id": "pubmed23n0203_8126", "title": "Overall tolerance and safety of enalapril.", "score": 0.010899910899910902, "content": "To date, more than 5000 patients have had experience with enalapril. Over 1000 subjects have been exposed to the drug for more than one year and approximately 600 for over two years. In controlled trials, 2249 subjects, who included normal volunteers and patients with hypertension and congestive heart failure, have received enalapril alone or concomitantly with hydrochlorothiazide or other antihypertensive agents. There have been no deaths attributed to enalapril. The incidence of serious adverse experiences in controlled trials was similar to placebo, and was not higher in the elderly. The incidence of adverse experiences was not dose-related. Drug discontinuation due to adverse experiences was 3.5%, similar to placebo, and approximately half that of control drugs. Serious laboratory adverse experiences were rare. Enalapril attenuated the adverse metabolic effects of hydrochlorothiazide, particularly hypokalaemia. Skin rash occurred in approximately 1.0% of patients. One case of transient taste loss occurred on enalapril, and one on enalapril in combination with hydrochlorothiazide. Neutropenia and agranulocytosis were not encountered. Mean white blood cell counts did not change overall. Most patients (approximately equal to 80%) show no change or an improvement in renal function on enalapril. Discontinuation of concomitant hydrochlorothiazide usually normalized renal function. Enalapril is well tolerated in renal insufficiency. Azotaemia may occur in bilateral renovascular hypertension. Proteinuria was rarely seen and often improved on enalapril. Compassionate use protocols have been available to patients either resistant or intolerant to captopril. Of 68 patients admitted for captopril-related skin rashes, only five recurred on enalapril.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en024_709", "title": "Antihypertensive drug", "score": 0.010854000801878688, "content": "ARBs happens to be the favorable alternative to ACE inhibitors if the hypertensive patients with the heart failure type of reduced ejection fraction treated with ACEis was intolerant of cough, angioedema other than hyperkalemia or chronic kidney disease. Adrenergic receptor antagonists Beta blockers acebutolol atenolol bisoprolol betaxolol carteolol carvedilol labetalol metoprolol nadolol nebivolol oxprenolol penbutolol pindolol propranolol timolol Alpha blockers: doxazosin phentolamine indoramin phenoxybenzamine prazosin terazosin tolazoline urapidil Mixed Alpha + Beta blockers: bucindolol carvedilol labetalol" }, { "id": "InternalMed_Harrison_19588", "title": "InternalMed_Harrison", "score": 0.009907110398289228, "content": "Diuretics Thiazides Hydrochlorothiazide 6.25–50 mg (1–2) Diabetes, dyslipidemia, hyperuricemia, gout, hypokalemia Chlorthalidone 25–50 mg (1) Loop diuretics Furosemide 40–80 mg (2–3) CHF due to systolic dysfunc-Diabetes, dyslipidemia, hypertion, renal failure uricemia, gout, hypokalemia Aldosterone antagonists Spironolactone 25–100 mg (1–2) CHF due to systolic dysfunc-Renal failure, hyperkalemia tion, primary aldosteronism Renal failure, hyperkalemia Triamterene 50–100 mg (1–2) Beta blockers Asthma, COPD, 2ndor 3rd-degree heart block, sick- Cardioselective Atenolol 25–100 mg (1) Angina, CHF due to systolic sinus syndrome dysfunction, post-MI, sinus tachycardia, ventricular tachyarrhythmias Metoprolol 25–100 mg (1–2) Nonselective Propranolol 40–160 mg (2) Propranolol LA 60–180 (1) Combined alpha/beta Labetalol 200–800 mg (2) ?Post-MI, CHF Carvedilol 12.5–50 mg (2) Alpha antagonists" }, { "id": "pubmed23n0596_19977", "title": "Cough induced by losartan with resolution after substitution with enalapril.", "score": 0.009708737864077669, "content": "Cough is an adverse event associated with the angiotensin-converting enzyme (AA inhibitor drugs. ACE inhibitor-induced cough is believed to be related to the accumulation of bradykinin,substance P,and prostaglandins resulting from the inhibition of ACE.Angiotensin-receptor blockers (AARBs) do not have any effect on ACE and theoretically might not cause cough. Therefore, a proposed option in patients suffering with ACE inhibitor-induced cough is to try an ARB. However,this report describes the reverse: a case of losartan-induced cough th hat co om completely resolved after it was substituted with an ACE inhibitor, enalapril. A 23-year-old, nonsmoking white woman, weighing 73.55 kg, ACE inhibitor naive (before admission), presented to the emergency department at Imam Referral Hospital, Tehran, Iran,with hypertension,proteinuria, and hyperlipidemia. The patient was admitted to the nephrology ward. She was prescribed hydrochlorothiazide 12.55 mg/d, furosemide 20 mg BID, and simvastatin 20 mg/d. The patient had no respiratory illnesses. The patient experienced cough 3 days following the initiation of losartan treatment. The cough continued in this patient for the 2-week duration of losartan treatment; however, 1 week after substitution of losartan with enalapril (22.5 mg/d),the cough resolved completely. This report describes a young woman who developed cough while receiving losartan treatment,which resolved after substitution with the ACE inhibitor enalapril." }, { "id": "pubmed23n0778_15548", "title": "Lump in the throat - a case study.", "score": 0.009708737864077669, "content": "Jack, aged 66 years, presented to his general practitioner with a foreign body sensation in his throat and altered voice, which developed over 30 minutes. He was otherwise well, having no other new symptoms or recent alterations to medication. He had not eaten anything unusual. He had hypertension, type 2 diabetes, stable ischaemic heart disease, urolithiasis and benign prostatic hypertrophy. His regular medication was metformin, rosuvastatin, carvedilol, candesartan (last 5 years) and saxagliptin (last 6 months). He had no allergies but was intolerant of ramipril due to cough. There was no family history of note. On examination he had no itch or rash, or swelling of the tongue, lips, cheek or neck. However, there was oedema of the soft palate and uvula. He was maintaining his airway, saturating at 98%, and his chest was clear. He was afebrile and systemically well." }, { "id": "wiki20220301en025_92716", "title": "Enalapril", "score": 0.009654191891396074, "content": "Enalapril, sold under the brand name Vasotec among others, is an ACE inhibitor medication used to treat high blood pressure, diabetic kidney disease, and heart failure. For heart failure, it is generally used with a diuretic, such as furosemide. It is given by mouth or by injection into a vein. Onset of effects are typically within an hour when taken by mouth and last for up to a day. Common side effects include headache, tiredness, feeling lightheaded with standing, and cough. Serious side effects include angioedema and low blood pressure. Use during pregnancy is believed to result in harm to the baby. It is in the angiotensin-converting-enzyme (ACE) inhibitor family of medications." }, { "id": "wiki20220301en503_4143", "title": "ACE inhibitor and thiazide combination", "score": 0.009615384615384616, "content": "An ACE inhibitor and thiazide combination is a drug combination used to treat hypertension (high blood pressure). They are given by mouth. ACE inhibitors reduce the activity of angiotensin-converting enzyme (ACE) which produces angiotensin II, a hormone that constricts blood vessels. Thiazides are a class of diuretics that inhibit the thiazide receptor, thereby increasing urine production and reducing excess water and salt in the body. Several organizations recommend combination therapy for hypertension in cases of failure of a single drug to achieve target blood pressure, or even as a first line treatment for some patients. Examples Enalapril/hydrochlorothiazide (trade name Enalapril comp), wherein enalapril is the ACE inhibitor and hydrochlorothiazide is the thiazide. Quinapril/hydrochlorothiazide (trade name Accuretic) Lisinopril/hydrochlorothiazide is marketed as Prinzide, Zestoretic, and many others. Fosinopril/hydrochlorothiazide" }, { "id": "pubmed23n1070_21182", "title": "A 49-Year-Old Man With Postcoital Hemoptysis.", "score": 0.009615384615384616, "content": "A 49-year-old man was seen in the pulmonary clinic for evaluation of postcoital hemoptysis. His medical history was significant for nonischemic cardiomyopathy and hypertension. He had red-yellow sputum with streaks of blood associated with dyspnea and wheezing for 5 years. He noted his symptoms occurred only with sexual intercourse while horizontal, but not while upright. He did not have any symptoms with other exertional activities, including heavy weight lifting. He did not have other symptoms. He had a remote history of less than 10 pack years of smoking. He had no personal or family history of pulmonary disease. He worked as a construction worker in the past, and currently as a driver. He had been incarcerated in the past but denied direct contact with TB. He was born in the United States, had always lived in the Northeastern region, and denied international travel. He had no constitutional symptoms or symptoms concerning for malignancy or autoimmune disease, including joint or skin complaints. His medications included aspirin, atorvastatin, carvedilol, furosemide, lisinopril, and spironolactone, and he endorsed adherence. He denied herbal or over-the-counter drugs use and denied illicit drug use." }, { "id": "pubmed23n0296_22439", "title": "Effects of long-term treatment with enalapril or hydralazine on the renin-angiotensin-aldosterone system and fluid balance in dogs with naturally acquired mitral valve regurgitation.", "score": 0.009433962264150943, "content": "To study long-term effects of enalapril, an angiotensin-converting enzyme inhibitor, and hydralazine, an arteriodilator, on renin-angiotensin-aldosterone system and fluid balance before and after administration of furosemide. 22 dogs with clinical signs of congestive heart failure (CHF) attributable to mitral regurgitation. After initial examination, 12 dogs received enalapril and 10 received hydralazine. Dogs were re-examined 3 weeks and 6 months after initial examination. Furosemide was added after the 3-week examination, and at 6 months, dogs had received furosemide for at least 4 months. Angiotensin II and aldosterone plasma concentrations were low before treatment, and only aldosterone became significantly decreased after enalapril monotherapy. Concentrations of both hormones and heart rate increased in dogs receiving hydralazine monotherapy, and fluid retention was evident. After long-term treatment with either of the 2 drugs together with furosemide, angiotensin II and aldosterone values increased in both groups. Natriuresis and kaliuresis developed in all dogs, with greatest effect in those receiving enalapril and furosemide. These dogs had decreased plasma sodium concentration, whereas potassium concentration was equally decreased in both groups. After 6 months, the enalapril group, but not the hydralazine group, had increased cardiac size. All dogs had moderate reduction of weight and were azotemic, although changes were more pronounced in those of the hydralazine group. The 2 drugs have different effects on the renin-angiotensin-aldosterone system and fluid balance in dogs with CHF." }, { "id": "pubmed23n0063_8585", "title": "[Dry cough in the elderly patients treated with angiotensin converting enzyme inhibitor].", "score": 0.009345794392523364, "content": "Since dry cough has recently been recognized as a side effect of angiotensin converting enzyme (ACE) inhibitors employed in the treatment of hypertension or congestive heart failure, the incidence of dry cough in elderly patients receiving ACE inhibitors was investigated. There were 237 out-patients on either captopril, enalapril, or delapril, in August and November 1989. Questionnaires concerning dry cough and smoking were completed by 184 patients. Patients either less than 50 years of age, or with chronic pulmonary disease were excluded. The remaining 168 patients, 63 males, 105 females, with a mean age of 73 years were analyzed for the incidence of a dry cough in relation to age, sex, smoking, and type of drugs. The overall incidence of a dry cough was 21/168 (12.5%), 7/63 (11.1%) for males and 14/105 (13.3%) for females, and was less frequent with advancing age; in the 51-60 age group 4/11 (36.4%), in the 61-70 age group 5/39 (12.8%), in the 71-80 age group 9/75 (12.0%), in the 81-90 age group 3/40 (7.5%), in the 91- age group 0/3 (0%). Enalapril showed significantly higher incidence of dry cough than captopril (16/93, 17.2% vs 7/88, 8.0%, p less than 0.05). Delapril showed an incidence 4/11, 36.4%, however, 9 out of the 11 patients who were given delapril had had a history of a dry cough with captopril or enalapril, and in 4 out of these 9 patients the dry cough disappeared by replacement of captopril or enalapril by delapril.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n1019_2148", "title": "Ranolazine Induced Bradycardia, Renal Failure, and Hyperkalemia: A BRASH Syndrome Variant.", "score": 0.009345794392523364, "content": "Ranolazine is a well-known antianginal drug, that was first licensed for use in the United States in 2006. It was objectively shown to improve exercise capacity and to lengthen the time to symptom onset in patients with coronary artery disease. The most commonly reported side effects of ranolazine include dizziness, headache, constipation, and nausea. Here, we describe a case of bradycardia, hyperkalemia, and acute renal injury in the setting of ranolazine use. Our patient is an 88-year-old female who presented with abdominal pain, nausea, and vomiting. Her medical comorbidities included hypertension, diabetes, CAD, heart failure with preserved ejection fraction, paroxysmal atrial fibrillation, hypothyroidism, and a history of cerebrovascular accident without any residual deficits. Her prescription regimen included amlodipine, furosemide, isosorbide mononitrate, levothyroxine, metformin, omeprazole, and ranolazine. Physical examination was remarkable for bradycardia and decreased breath sounds in the left lower lung field. Laboratory studies were significant for a serum potassium level of 6.8 mEq/L and a serum creatinine level of 1.6 mg/dL. She was given insulin with dextrose, sodium polystyrene, and calcium gluconate in addition to fluids. Her bradycardia and renal function worsened over the next 24 hours. Ranolazine was discontinued. Metabolic derangements were treated appropriately. After 48 hours from presentation, potassium and renal function returned to baseline and her heart rate improved to a range of 60-100 bpm. She was discharged with an outpatient cardiology follow-up. Ranolazine treatment was not continued upon discharge. In summary, our case illustrates an association between ranolazine and renal failure induced hyperkalemia, leading to conduction delays in the myocardium. Though further studies are warranted, we suspect that this is a variant of the recently described BRASH syndrome. We propose that in cases such as ours, along with treatment of the hyperkalemia, medication review and removal of any offending agent should be considered." }, { "id": "pubmed23n0993_1438", "title": "Chronic Cough in a 70-Year-Old Woman.", "score": 0.009259259259259259, "content": "A 70-year-old lifelong nonsmoking woman with a past medical history of hypertension was referred to the respiratory clinic for evaluation of chronic cough. She presented with a 5-month history of dry cough, night sweats, fatigue, and a 4.5-kg weight loss. Her cough tended to be worse while lying flat. She denied having shortness of breath, chest pain, wheeze, or hemoptysis. She was taking amlodipine for her blood pressure as well as omeprazole for indigestion. She denied having any reflux symptoms or heartburn. She worked as a receptionist for an optician. She did not have any pets at home and had no family history of asthma or allergic conditions. She had not been abroad recently." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 541, 615 ] ], "word_ranges": [ [ 88, 99 ] ], "text": "We should not prescribe treatment without first ruling out organic causes." }, "2": { "exist": true, "char_ranges": [ [ 25, 191 ] ], "word_ranges": [ [ 5, 32 ] ], "text": "We are dealing with a case of postmenopausal metrorrhagia, whose most frequent cause is genital atrophy in the first place and endometrial cancer in the second place." }, "3": { "exist": true, "char_ranges": [ [ 387, 444 ] ], "word_ranges": [ [ 63, 73 ] ], "text": "she provides a normal cytology, which rules out option 3." }, "4": { "exist": true, "char_ranges": [ [ 445, 540 ] ], "word_ranges": [ [ 73, 88 ] ], "text": "The hormonal evaluation is not opportune, since we understand that the patient is in menopause." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Prescribe cyclic progesterone.", "2": "Endometrial biopsy.", "3": "Random cervical biopsies.", "4": "Hormonal evaluation with FSH, LH and estradiol.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0356_10102", "title": "Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: is it always necessary to perform an endometrial biopsy?", "score": 0.017721320473614053, "content": "This study was undertaken to evaluate whether it was possible to abstain from performing an endometrial biopsy when endometrial thickness according to transvaginal ultrasonography was &lt;/=4 mm in women with postmenopausal bleeding or irregular bleeding during hormone replacement therapy. Transvaginal ultrasonography was performed in 361 women aged &gt;/=50 years who were referred because of postmenopausal bleeding or irregular bleeding during hormone replacement therapy. If endometrial thickness was &lt;/=4 mm, a Papanicolaou cervical smear was performed and the woman was reexamined with transvaginal ultrasonography after 4 and 12 months. Subjects were also instructed to return if they had recurrent bleeding, in which case transvaginal ultrasonography was performed and an endometrial biopsy specimen was obtained. Women with an endometrial thickness &gt;/=5 mm underwent either curettage or endometrial biopsy. One hundred sixty-three women had an endometrial thickness &lt;/=4 mm. In this group one endometrial cancer that was missed by ultrasonography was diagnosed by cervical cytologic examination and two adnexal malignancies were diagnosed by ultrasonography. Endometrial malignancy was diagnosed in 0.6% of the women with an endometrial thickness &lt;/=4 mm. Endometrial biopsy was performed because of recurrent bleeding in 6.1% of cases and because of endometrial thickening in 8.1%. No cancer or hyperplasia was subsequently diagnosed among the women with an endometrial thickness &lt;/=4 mm. Endometrial cancer was diagnosed in 18.7% of the women with an endometrial thickness &gt;/=5 mm. The corresponding figure when atypical hyperplasia and endometrial metastases were included was 20. 2%. If the false-negative rate of endometrial biopsy techniques is taken into account, then the combination of transvaginal ultrasonography and cervical cytologic examination is an adequate form of management for women with postmenopausal bleeding or irregular bleeding during hormone replacement therapy as long as endometrial thickness is &lt;/=4 mm. A randomized prospective study is necessary to verify this finding." }, { "id": "pubmed23n0391_1186", "title": "Atypical complex endometrial hyperplasia treated with the GyneLase system.", "score": 0.016050333846944015, "content": "A 47-year-old premenopausal, para 1, gravida 1 woman complained of menometrorrhagia. She had no risk factors for endometrial hyperplasia or cancer, and office endometrial biopsy indicated focal, nonatypical endometrial hyperplasia. Seven months later the patient was scheduled for hysteroscopic endometrial resection. Instead she was treated by hysteroscopy, curettage, and the GyneLase system. The curetting indicated atypical, complex endometrial hyperplasia. The woman refused hysterectomy and salpingo-oophorectomy and adjunctive therapy with progesterone. She agreed to close surveillance and further treatment if she had any vaginal bleeding. At 13 months she remains amenorrheic, the endometrial echo is 2 mm, and follicle-stimulating hormone level is 63 IU/L. Based on the patient's amenorrhea and ultrasound uterine measurement, it is tempting to assume that GyneLase treatment may have cured her atypical hyperplasia. However, at this time, we have no evidence to substantiate this assumption." }, { "id": "pubmed23n0013_9950", "title": "A prospective, controlled trial of six forms of hormone replacement therapy given to postmenopausal women.", "score": 0.014040630073274538, "content": "This study was undertaken to investigate the effect of various forms of hormone replacement therapy (HRT) upon postmenopausal women while controlling as many variables as possible. It was felt that the age, duration of amenorrhoea and the general health of the patients should be as comparable as possible and that each patient should provide her own pretherapy and post-therapy control data. In addition, it was felt that any placebo effect should be investigated and the patients were therefore randomly allocated to placebo tablets or one of six available forms of HRT. The age/sex registers of two large general practices were scrutinized and all women between 49 and 54 years of age were asked to cooperate; for a variety of reasons only 56 women were suitable and willing to take part in the project, yielding 8 women for each of the seven possible therapy groups. Blood samples were taken at 7-day intervals three times before therapy was given and the mean of the three values was used as the control value. The women returned on day 21 of each subsequent therapy cycle for six consecutive months and finally three months after discontinuing therapy. From the data the following broad conclusions can be drawn: (i) some women have classic symptoms of hot flushes and sweating despite high endogenous oestrogen concentrations; (ii) vaginal cytology is a relatively poor indicator of endogenous oestrogen status; (iii) while follicle stimulating hormone (FSH) and luteinizing hormone (LH) concentrations are reduced on HRT neither is decreased to anywhere near premenopausal values while prolactin is unaffected; (iv) plasma cholesterol levels are reduced on HRT, the pulse rate is slower and both systolic and diastolic blood pressure are reduced to a small but significant extent; (v) there is no adverse effect upon blood clotting; and (vi) most women experience significant or complete relief of symptoms on all forms of HRT as do some women taking a placebo. The combined preparations containing an oestrogen and progestogen produced vaginal bleeding in only 80 per cent of the women. Thus protection by regular endometrical shedding may not be afforded to all women. As vaginal bleeding is unacceptable to most women if they can achieve the same symptomatic relief without inducing menstruation, it is suggested that women have a low dose oestrogen preparation prescribed cyclically for 6 to 12 months. If therapy is to be maintained for a longer time, uterine curretage should be undertaken at regular intervals to exclude the possibility of endometrial carcinoma developing." }, { "id": "article-21104_28", "title": "Endometrial Hyperplasia -- Treatment / Management -- Treatment duration and follow up:", "score": 0.011148373062630291, "content": "In order to induce the regression of the hyperplasia, treatment should be for at least six months. Endometrial surveillance with office endometrial biopsy is recommended at six-monthly intervals. Before discharging the patient, two consecutive 6 – monthly negative biopsies should be obtained. Women who have a BMI of more than 35 and who were treated with oral progestogens are at a higher risk of relapse and should be advised annual follow -up. All women should be advised to come for a follow -up if they experience the symptoms of abnormal uterine bleeding.[2]" }, { "id": "First_Aid_Step2_819", "title": "First_Aid_Step2", "score": 0.010346146490724803, "content": "First step: Obtain a β-hCG to rule out ectopic pregnancy. Second step: Order a CBC to rule out anemia. Third step: Pap smear to rule out cervical cancer (which can present with bleeding). TFTs to rule out hyper-/hypothyroidism and hyperprolactinemia. Obtain platelet count, bleeding time, and PT/PTT to rule out von Willebrand’s disease and factor XI def ciency. Order an ultrasound to evaluate the ovaries, uterus, and endometrium. Look for uterine masses, polycystic ovaries, and thickness of the endometrium. If the endometrium is ≥ 4 mm in a postmenopausal woman, obtain an endometrial biopsy. An endometrial biopsy should also be obtained if the patient is > 35 years of age, obese (BMI > 35), and diabetic. Heavy bleeding: Since heavy or prolonged uterine bleeding has likely denuded the endometrial cavity, estrogen is needed to rapidly promote endometrial growth." }, { "id": "Gynecology_Novak_2049", "title": "Gynecology_Novak", "score": 0.009978101494811006, "content": "Endometrial Sampling Endometrial sampling should be performed to evaluate abnormal bleeding in women who are at risk for endometrial pathology, including polyps, hyperplasia, or carcinoma. Such sampling is mandatory in the evaluation of anovulatory bleeding in women older than 35 to 40 years of age, in younger women who are obese, and in those who do not respond to medical therapy or those with a history of prolonged anovulation (143). The technique of D&C, which was used extensively for the evaluation of abnormal bleeding, was largely replaced by endometrial biopsy in the office. The classic study in which a D&C was performed before hysterectomy with the conclusion that less than one-half of the endometrium was sampled in more than one-half of the patients led to questioning the use of D&C for endometrial diagnosis (176,177). Hysteroscopy, either diagnostic or operative, with endometrial sampling, can be performed either in the office or operating room (178)." }, { "id": "pubmed23n0769_20667", "title": "Management of hypogonadism in adolescent girls and adult women with Prader-Willi syndrome.", "score": 0.009900990099009901, "content": "Prader-Willi syndrome (PWS) is a neurodevelopmental disorder characterized by an insatiable appetite, dysmorphic features, cognitive and behavioral difficulties, and hypogonadism. The heterogeneous reproductive hormone profiles indicate that some PWS women may have symptoms of hypoestrogenism, while others may potentially be fertile. We describe our experience in the assessment and treatment of hypogonadism in adolescents and adult females with PWS. The study population consisted of 20 PWS females, age ≥16 years (27.3 ± 7.9 years), followed in our clinic (12 deletion, 7 uniparental disomy, 1 imprinting-center defect). General physical examination, pubertal assessment, body mass index (BMI), gynecological examination, ultrasonography, bone densitometry, and hormonal profiles [FSH, LH, inhibin B, estradiol, prolactin, and TSH] were performed. The relevant assessed factors were: FSH and inhibin B, menstrual cycles (oligo/amenorrhea or irregular bleeding), ultrasound findings (endometrial thickness, uterine/ovarian abnormalities), BMI, bone densitometry, and patient/caregivers attitude. We classified seven women with inhibin B &gt;20 ng/ml as potentially fertile. Following the assessment of the above factors, we recommended the individual-specific treatment; contraceptive pills, intra-uterine device, estrogen/progesterone replacement, and cyclic progesterone, in 3, 1, 4, and 1 patients, respectively. Four patients did not follow our recommendations due to poor compliance or family refusal. We recommended contraception pills for one 26-year-old woman with inhibin B and FSH levels 53 ng/ml and 6.4 IU/L; however, she refused treatment, conceived spontaneously and had an abortion. Guidelines for hormonal replacement therapy in PWS need to be tailored individually depending on physical development, hormonal profiles, bone density, and emotional and social needs of each PWS adolescent and adult." }, { "id": "pubmed23n0507_19555", "title": "[Women's opinion on hormone pills and the main sources of information].", "score": 0.009900990099009901, "content": "The aim of this paper was to analyze and to evaluate women's opinion on hormone pills and the influence on hormone pill usage and reveal the main sources of information. Women who came for pregnancy termination (Group A) and women who came for consultation on further usage of contraception (Group K) have been interrogated. Interrogation according the special questionnaire has been performed at four consultation centers and three gynecologic clinics of Kaunas city. It was find out that due to the wrong information 25.1% of women in group A and 35% of women in group K thought that hormone pills cause irregular bleeding (p=0.01). Another myth - the possibility to become pregnant when taking pills - was indicated by 17% of women in group A and 32.4% of women in group K (p=0.01). Nine percent in group A and 12% in group K were confident that when taking hormone pills for some period of time one will not be able to become pregnant in the future. Seventy three percent of group A women and 80% of group K women indicated that the use of hormone pills increases the body weight (p=0.01). This research showed that the women that used hormone pills were properly informed about their treatment and side effects. Fifty four percent of group A women and 36% of group K women indicated that hormone pills were not suitable in case of several diseases (p=0.01). Eighty three percent of group A women and 71% of group K knew that hormone pills did not protect from cervical cancer (p=0.01). This information was mainly obtained from medical workers. The main reason why women of fertile age who took part in our research used little of hormone pills was false information received from insufficiently skilled persons and accordingly the negative opinion about hormone pills. Women's opinion on hormone pills is a very important factor for its usage. This opinion depends on sources of information, whether women received correct or false information on hormone pills. The most reliable source of information indicated by investigated women was medical personnel." }, { "id": "Gynecology_Novak_1988", "title": "Gynecology_Novak", "score": 0.009882047876545553, "content": "3. If this hormonal therapy is not effective, the patient should be reevaluated and the diagnosis should be reassessed. The failure of hormonal management suggests that a local cause of bleeding is more likely. In this event, consideration should be given to a pelvic ultrasonographic examination to determine any anatomic causes of bleeding (such as uterine leiomyomas, endometrial polyps, or endometrial hyperplasia) and to assess the presence of intrauterine clots that may impair uterine contractility and prolong the bleeding episode. Although anatomic causes of heavy menstrual bleeding are rare in adolescents, they become increasingly common in women of reproductive age. 4. If intrauterine clots are detected, evacuation of the clots (suction curettage or D&C) is indicated. Although a D&C will provide effective immediate control of the bleeding, it is unusual to reach this step in adolescents." }, { "id": "pubmed23n0930_19913", "title": "Menstrual restoration in severe panhypopituitarism many years after cranial irradiation for suprasellar germinoma.", "score": 0.00980392156862745, "content": "We report a very rare case showing menstrual restoration in severe pan-hypopituitarism many years after cranial irradiation for suprasellar germinoma. A 30-year-old, almost primarily amenorrheic woman with severe panhypopituitarism presented with cyclic genital bleeding for the previous five months. She had menstruated once, when she was 13 years old. When she was 14 years old, she was diagnosed with a suprasellar germinoma measuring 10 mm in diameter, which led to diabetes insipidus. Cranial irradiation with a total dose of 24 Gy and chemotherapy resulted in complete tumor remission. She developed severe hypopituitarism [luteinizing hormone (LH) = 0.4 mIU/mL, follicle-stimulating hormone (FSH) = 1.7 mIU/mL, and serum estradiol (E2) level &lt; 10 pg/mL]. She had received multiple hormone replacement therapies for many years. When she was 29 years old, she expressed a desire to become pregnant. Serum gonadotropin and E2 levels increased (LH = 5.8 mIU/mL, FSH = 5.9 mIU/mL, and E2 = 58 pg/mL). She conceived with clomiphene therapy, and then delivered a healthy baby. Eight months after parturition, her basal body temperature and serum progesterone levels indicated recovery of ovulatory cycles. Ten months after parturition, she also spontaneously conceived. Menstrual restoration is very rare in severe panhypopituitarism after cranial irradiation. A relatively low dose of irradiation and small tumor size may have contributed to the recovery of menstruation in our patient." }, { "id": "pubmed23n0389_9120", "title": "[Evaluation of weight and morphotype of French women in gynecological consultation].", "score": 0.00980392156862745, "content": "Weight and morphology change with age in proportions which depend on numerous environmental factors. This French study on 3,000 women age between 40 and 70, seeing their gynecologist, has shown that the average body mass index of this population is 23.97 kg/m2, and that the waist hip ratio is 0.81. Those two parameters increase with age and are reduced when women have a physical activity for more than 2 hours a week and are on oral contraception or hormone replacement therapy. Women on percutaneous hormone replacement therapy have a lower body mass index and a lower waist hip ratio. Cigarette smoking goes with a lower body mass index. When it dates back to more than 5 years, menopause is associated with a body mass index increase. In this population, the proportion of women under hormone replacement therapy is 69%, mostly percutaneous estrogenotherapy on a discontinuous sequential rhythm." }, { "id": "Gynecology_Novak_2127", "title": "Gynecology_Novak", "score": 0.009745968484686103, "content": "Table 14.16 Etiology of Postmenopausal Bleeding From Hacker NF, Moore JG. Essentials of obstetrics and gynecology, 3rd ed. Philadelphia: WB Saunders, 1998:635, with permission. Endometrial sampling is indicated for any unexpected bleeding that occurs with hormonal therapy. A significant change in withdrawal bleeding or breakthrough bleeding (e.g., absence of withdrawal bleeding for several months followed by resumption of bleeding or a marked increase in the amount of bleeding) should prompt endometrial sampling. Patient adherence to hormonal regimens is a significant issue with hormone therapy, with the challenges of oral therapy mitigated by nonoral routes of administration (247). Missed doses of oral medication and failure to take the medication in the prescribed fashion can lead to irregular bleeding or spotting that is benign in origin but that can result in patient dissatisfaction (248)." }, { "id": "pubmed23n1080_739", "title": "Estrogen-secreting adrenocortical tumor in a postmenopausal woman: a challenging diagnosis.", "score": 0.009708737864077669, "content": "Adrenocortical carcinoma (ACC) is a malignant disorder with rapid evolution and severe prognosis in adults and most produce cortisol and androgen. Estrogen-secreting adrenocortical carcinomas are extremely rare, especially in women, tend to be larger and have worse prognosis compared with other types of ACCs. We report the case of a 58-year-old woman who presented with bilateral breast enlargement and postmenopausal genital bleeding. She presented high estradiol (818 pg/mL - 25 times above upper normal limit for postmenopausal women) and testosterone (158 ng/dL - 2 times above upper normal limit) levels and no suppression of cortisol after overnight 1 mg dexamethasone test (12.5 µg/dL; normal reference value: &lt; 1.8 µg/dL). The patient had no clinical features of cortisol excess. MRI showed a 12 cm tumor in the right adrenal. Clinical findings of bilateral breast enlargement and postmenopausal genital bleeding with no signs of hypercortisolism associated with hormonal findings of elevated estradiol and testosterone levels would indicate either an ovarian etiology or an adrenal etiology; however, in the context of plasma cortisol levels non-suppressive after dexamethasone test and the confirmation of an adrenal tumor by MRI, the diagnosis of an adrenal tumor with mixed hormonal secretion was made. The patient underwent an open right adrenalectomy and pathological examination revealed an ACC with a Weiss' score of 6. Estradiol and testosterone levels decreased to normal range soon after surgery. She was put on mitotane treatment as adjuvant therapy, but due to side effects, we were unable to up-titrate the dose and she never achieved serum mitotane dosage above the desired 14 µg/mL. The patient remained in good health without any local recurrence or metastasis until 5 years after surgery, when increased levels of estradiol (81 pg/mL - 2.5 times above upper normal limit) and testosterone (170 ng/dL - 2.1 times above upper normal limit) were detected. MRI revealed a retroperitoneal nodule measuring 1.8 × 1.2 cm. The pathological finding confirmed the recurrence of the estrogen-secreting ACC with a Weiss' score of 6. After the second procedure, patient achieved normal estrogen and androgen serum levels and since then she has been followed for 3 years. The overall survival was 8 years after the diagnosis. In conclusion, although extremely rare, a diagnosis of an estrogen-secreting ACC should be considered as an etiology in postmenopausal women presenting with bilateral breast enlargement, genital bleeding and increased pure or prevailing estrogen secretion. Estrogen-secreting adrenocortical carcinomas are exceedingly rare in adults and account for 1-2% of adrenocortical carcinomas. Estrogen-secreting adrenal tumors can be present in females, but are even more rare, we found few cases described in the literature. In women, they present with precocious puberty or postmenopausal bleeding. Feminization in the context of an adrenal tumor is considered almost pathognomonic of malignancy. Feminizing ACCs tend to be larger and with worse prognosis compared with nonfeminizing ACCs." }, { "id": "pubmed23n0363_22476", "title": "[Guideline for the diagnosis of postmenopausal bleeding. PMPB Working Group of the SGGG].", "score": 0.009708737864077669, "content": "2.1. History and clinical-gynecological investigation including a Pap smear are the first step in the clarification. The history should make sure if there is in fact bleeding from the genital and not from the urological or the intestinal region. Drug intake should be recorded, and risk factors for the development of endometrial carcinoma should be considered. This will not affect further investigation. The clinical-gynecological investigation should prove the source of postmenopausal bleeding according to the anatomical site--uterine, infra-, or suprauterine. The causes of infrauterine bleeding may easily be diagnosed by means of inspection of the external genitalia and further by using a speculum. The causes of uterine bleeding are of major importance. Cytology and colposcopy, supported by bimanual investigation, exclude cervical carcinoma as a cause of bleeding. Atypical endometrial cells on the cytological smear arouse suspicion of endometrial carcinoma. 2.2. Transvaginal sonography (TVS) is the next step if the above-mentioned investigations are negative. Both adnexa should always be investigated and the findings sonographically documented, so that solid cystic masses in the adnexal area can be better identified as suprauterine causes of postmenopausal bleeding. Then the uterus should be investigated. Further procedures are decided from the results of measurement of the longitudinal section of the endometrium at the level of maximum endometrial thickness. If the endometrial thickness is _&lt;4 mm, an observant attitude can be assumed. After 3 months the patient should be controlled against using TVS. If bleeding recurs or the endometrial thickness is &gt;4 mm on TVS, the procedure given in subparagraph 2.3 should be followed. In case the endometrial thickness is &gt;4mm or not measurable, a histomorphological investigation according to subparagraph 2.3 should be performed. In such cases, saline infusion sonohysterography(SIS) is useful as a simple method to supplement TVS. It can aid in the decision making as to which further, more invasive measures should be taken (endometrial biopsy/hysteroscopic resection). Computerized tomography or magnetic resonance imaging are, as a rule, not indicated in patients with postmenopausal bleeding. 2.3. A definite diagnosis is possible only on the basis of a histological investigation. If TVS or SS show evidence of a polypoid state, removal under hysteroscopic control is the diagnostic method of choice. In cases of symmetrical or asymmetrical thickening of the endometrium on SIS, a less invasive biopsy may be sufficient. If the biopsy specimen does not yield representative diagnostic material, one should proceed as described above. A fractionated curettage should as a rule not be performed solely, but in combination with hysteroscopy." }, { "id": "pubmed23n1107_13669", "title": "Cyclic Progesterone Therapy in Androgenic Polycystic Ovary Syndrome (PCOS)-A 6-Month Pilot Study of a Single Woman's Experience Changes.", "score": 0.009615384615384616, "content": "<iBackground and Objectives:</i Women with androgenic Polycystic Ovary Syndrome (PCOS) have increased endometrial cancer risk that cyclic progesterone will prevent; it may also reverse PCOS's neuroendocrine origins. This pilot study's purpose was to document 6-month <iexperience changes</i in a woman with PCOS taking cyclic progesterone therapy because she was intolerant of combined hormonal contraceptive therapy, the current PCOS standard of care. A 31-year-old normal-weight woman with PCOS had heavy flow, irregular cycles, and was combined hormonal contraceptives-intolerant. She was prescribed cyclic oral micronized progesterone (OMP) (300 mg/<ih.s.</i cycle days 14-27). She kept Menstrual Cycle Diary© (Diary) records, starting with the 1st treatment cycle for six cycles; she was on no other therapy. Statistical analysis <ia priori</i hypothesized progesterone decreases high estradiol (E2) experiences (flow, cervical mucus, fluid retention, front-of-the-breast tenderness and anxiety); analysis focused on these. Our objectives: (1) changes from cycles 1 to 6 in E2-related experiences; and (2) follicular phase E2-related changes from cycle 1 (no therapy) to cycles 3 and 6. <iMaterials and Methods:</i Data from consecutive Diaries were entered into an SPSS database and analyzed by Wilcoxon Signed Rank Test (Objective #1) within-person whole cycle ordinal data, and (Objective #2 follicular phase) repeated measures ANOVA. <iResults:</i Cyclic OMP was associated with regular, shorter cycles (±SD) (28.2 ± 0.8 days). Comparison of cycles 1-6 showed decreased fluid retention (<ip</i = 0.001), breast tenderness (<ip</i = 0.002), and cervical mucus (<ip</i = 0.048); there were no changes in flow or anxiety. Fluid retention in the follicular phase also significantly decreased over time (F (1.2, 14.7) = 6.7, <ip</i = 0.017). <iConclusions:</i Pilot daily Diary data suggest women with PCOS have improved everyday experiences on cyclic progesterone therapy. Larger prospective studies with more objective outcomes and randomized controlled trials of this innovative PCOS therapy are needed." }, { "id": "pubmed23n0667_14440", "title": "Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause.", "score": 0.009615384615384616, "content": "Normal menstrual periods last 3-6 days and involve blood loss of up to 80ml. Menorrhagia is defined as menstrual periods lasting more than 7 days and/or involving blood loss greater than 80ml. The prevalence of abnormal uterine bleeding (AUB) is estimated at 11-13% in the general population and increases with age, reaching 24% in those aged 36-40 years. A blood count for red cells+platelets to test for anemia is recommended on a first-line basis for women consulting for AUB whose history and/or bleeding score justify it. A pregnancy test by an hCG assay should be ordered. A speculum examination and Pap smear, according to the French High Health Authority guidelines should be performed early on to rule out any cervical disease. Pelvic ultrasound, both abdominal (suprapubic) and transvaginal, is recommended as a first-line procedure for the etiological diagnosis of AUB. Hysteroscopy or hysterosonography can be suggested as a second-line procedure. MRI is not recommended as a first-line procedure. In idiopathic AUB, the first-line treatment is medical, with efficacy ranked as follows: levonorgestrel IUD, tranexamic acid, oral contraceptives, either estrogens and progestins or synthetic progestins only, 21 days a month, or NSAIDs. When hormone treatment is contraindicated or immediate pregnancy is desired, tranexamic acid is indicated. Iron must be included for patients with iron-deficiency anemia. For women who do not wish to become pregnant in the future and who have idiopathic AUB, the long-term efficacy of conservative surgical treatment is greater than that of oral medical treatment. Placement of a levonorgestrel IUD (or administration of tranexamic acid by default) is recommended for women with idiopathic AUB. If this fails, a conservative surgical technique must be proposed; the choices include second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency), or, if necessary, first-generation techniques (endometrectomy, roller-ball). A first-line hysterectomy is not recommended in this context. Should a hysterectomy be selected for functional bleeding, it should be performed by the vaginal or laparoscopic routes." }, { "id": "wiki20220301en002_113881", "title": "Menopause", "score": 0.009523809523809525, "content": "The stages of the menopause transition have been classified according to a woman's reported bleeding pattern, supported by changes in the pituitary follicle-stimulating hormone (FSH) levels. In younger women, during a normal menstrual cycle the ovaries produce estradiol, testosterone and progesterone in a cyclical pattern under the control of FSH and luteinizing hormone (LH), which are both produced by the pituitary gland. During perimenopause (approaching menopause), estradiol levels and patterns of production remain relatively unchanged or may increase compared to young women, but the cycles become frequently shorter or irregular. The often observed increase in estrogen is presumed to be in response to elevated FSH levels that, in turn, is hypothesized to be caused by decreased feedback by inhibin. Similarly, decreased inhibin feedback after hysterectomy is hypothesized to contribute to increased ovarian stimulation and earlier menopause." }, { "id": "pubmed23n0396_12308", "title": "[Endometrial hyperplasias resistant to progestins: alternatives to traditional treatments].", "score": 0.009523809523809525, "content": "Endometrial hyperplasias are mainly regarded as a response to unopposed endogenous estrogenic stimulation and concern 12% of perimenopausal women. They are usually diagnosed because of irregular bleeding. They are divided into two categories based on the presence or absence of cytological atypia and further classified as simple or complex according to the extent of architectural abnormalities. Endometrial hyperplasias with cytological atypia are classically treated by hysterectomy. Endometrial hyperplasias without cytological atypia are classically treated by progestins. The bad observance (25% spontaneously stopping), the 30% recurrence rate after stopping progestin and the 12-53% resistance rate to treatment lead to propose a second-line therapy after endocrinological check-up, exploration of haemostasis, pelvic ultrasonography, hysteroscopy and endometrial biopsies. Standard treatments include uterine curettage which is not very effective and hysterectomy. Medical alternatives (gonadotropin-releasing hormone agonists, levonorgestrel-releasing intrauterine device) and surgical alternatives (endometrial resection, thermal balloon endometrial ablation) were developed to avoid treating functional pathology radically. These conservative procedures correct 80% of endometrial hyperplasia symptoms with a low rate of lateral effects. However, these results need to be confirmed by long-term studies. Some economical, legal or material factors can also limit carrying out the procedures. Clinical trials need to be performed to better define the place of medical and surgical alternatives to hysterectomy in the treatment of endometrial hyperplasias resistant to progestins." }, { "id": "pubmed23n0226_936", "title": "The effect of a synthetic progestogen, ethylnorgestrienone, on hypothalamic-pituitary-ovarian function, cervical mucus, vaginal cytology, and endometrial morphology.", "score": 0.009433962264150943, "content": "The antifertility mechanism of a new progestin preparation, ethylnorgestrienone (13 beta-ethyl-17 alpha-ethynyl-17-hydroxy-gona-4,9,11-triene-3-one) (R2323), was evaluated. The compound was administered orally in doses of 5 mg weekly to seven subjects for a total of nine treatment cycles. Each woman served as her own control and was studied during a normal menstrual cycle followed by a cycle in which she received R2323. Serum concentrations of luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, and progesterone, as well as cervical mucus properties, were studied serially during the control and treatment cycles. Results indicated that all control cycles were ovulatory. Ovulatory gonadotropin patterns were observed in four treated cycles, but preovulatory FSH and LH peaks and progesterone production during the luteal phase were suppressed significantly. Estradiol levels showed an early increase during the follicular phase and a significantly decreased preovulatory peak. Cervical mucus properties were altered and sperm penetration in cervical mucus was inhibited in all treatment cycles. These findings suggest that at least two different factors might be involved in the contraceptive mechanism of R2323: (1) alteration of the ovulatory process and progesterone production, and (2) cervical mucus changes leading to inhibition of sperm migration." }, { "id": "Gynecology_Novak_2126", "title": "Gynecology_Novak", "score": 0.009433962264150943, "content": "Differential Diagnosis The causes of postmenopausal bleeding and the percentage of patients who seek treatment for different conditions are presented in Table 14.16. Hormone therapy may be used to manage troublesome menopausal symptoms; it is recommended to treat with the lowest effective dose with the risks versus benefits regularly reviewed by a woman and her doctor (246). Women who are taking hormone therapy during menopause may be using a variety of hormonal regimens that can result in bleeding (see Chapter 34). Because unopposed estrogen therapy can result in endometrial hyperplasia, various regimens of progestins are typically added to the estrogen regimen; they are given in a continuous fashion, although they may be given in a sequential fashion for women within 1 year of menopause (246). Table 14.16 Etiology of Postmenopausal Bleeding From Hacker NF, Moore JG. Essentials of obstetrics and gynecology, 3rd ed. Philadelphia: WB Saunders, 1998:635, with permission." }, { "id": "wiki20220301en013_90829", "title": "Anorgasmia", "score": 0.009345794392523364, "content": "Women suffering from anorgasmia with no obvious psychological cause would need to be examined by their GP to check for absence of disease. Blood tests would also need to be done (full blood count, liver function, oestradiol/estradiol, total testosterone, SHBG, FSH/LH, prolactin, thyroid function, lipids and fasting blood sugar) to check for other conditions such as diabetes, lack of ovulation, low thyroid function or hormone imbalances. The normal thresholds for these tests and timing in a woman's menstrual cycle is detailed in Berman et al., 2005. They would then need to be referred to a specialist in sexual medicine. The specialist would check the patient's blood results for hormonal levels, thyroid function and diabetes, evaluate genital blood flow and genital sensation, as well as giving a neurological work-up to determine the degree (if any) of nerve damage." }, { "id": "pubmed23n1026_22092", "title": "A Case of Uterine Cervical Adenocarcinoma in Which Initial Total Laparoscopic Hysterectomy Was Performed for Suspected Atypical Endometrial Hyperplasia.", "score": 0.009259259259259259, "content": "The patient was a 69-year-old multiparous female (gravida/para, 3/3) who had hypertension and arrhythmia. Her history included cerebral infarction treated with conservative therapy. She visited our hospital for atypical genital bleeding. She was diagnosed with atypical glandular cells (AGC) based on cervical cytology, atypical cells in endometrial cytology, and atypical endometrial hyperplasia on preoperative endometrial biopsy, and underwent total laparoscopic hysterectomy. However, in a postoperative pathologic examination, she was diagnosed with stage IB1 cervical adenocarcinoma without endometrial abnormality. AGC appeared in cervical cytology before surgery, but a surgical plan was not made with consideration of cervical adenocarcinoma." }, { "id": "pubmed23n0727_22359", "title": "Postmenopausal bleeding should be referred urgently.", "score": 0.009259259259259259, "content": "Postmenopausal bleeding is an episode of bleeding 12 months or more after the last menstrual period. It occurs in up to 10% of women aged over 55 years. All women with postmenopausal bleeding should be referred urgently. Endometrial cancer is present in around 10% of patients; most bleeding has a benign cause. The peak incidence for endometrial carcinoma is between 65 and 75 years of age. Causes of postmenopausal bleeding include: endometrial carcinoma; cervical carcinoma; vaginal atrophy; endometrial hyperplasia +/- polyp; cervical polyps; hormone-producing ovarian tumours; haematuria and rectal bleeding. The aim of assessment and investigation of postmenopausal bleeding is to identify a cause and exclude cancer. Assessment should start by taking a detailed history, with identification of risk factors for endometrial cancer, as well as a medication history covering use of HRT, tamoxifen and anticoagulants. Abdominal and pelvic examinations should be carried out to look for masses. Speculum examination should be performed to see if a source of bleeding can be identified, assess atrophic changes in the vagina and look for evidence of cervical malignancy or polyps. Ultrasound scan and endometrial biopsy are complementary. Ultrasound scan can define endometrial thickness and identify structural abnormalities of the uterus, endometrium and ovaries. Endometrial biopsy provides a histological diagnosis. The measurement of endometrial thickness aims to identify which women with postmenopausal bleeding are at significant risk of endometrial cancer. If the examination is normal, the bleeding has stopped and the endometrial thickness is &lt; 5 mm on transvaginal ultrasound scan, no further action need be taken." }, { "id": "pubmed23n0268_8086", "title": "[A \"no-bleeding\" substitute hormone treatment with an oral microdose progesterone. A prospective multicenter study].", "score": 0.009174311926605505, "content": "Study of influence of different sequences of oral micronized progesterone (Pg) on endometrial morphology and the incidence of bleeding. Prospective comparative multicentric study conducted in 101 post-menopausal patients. 98 patients who did not wish any regular withdrawal bleeding were given percutaneous oestradiol 17-beta (E2) (1.5 mg/d) associated with micronized Pg (100 mg/d) at bedtime during either 21 out of 28 days (group I), or 25 days per calendar month (group III), during a minimum of 6 months. For those wishing withdrawal bleeding (n = 3), E2 (3 mg/d) during 25 days was associated with Pg (300 mg/d) from the 16th to the 25th day of the month (group III). Endometrial biopsies were performed after 6 months of the same treatment and blindly analysed; transvaginal ultrasonography (measurement of endometrial mucosa thickness) was done in case of insufficient amount of tissue. Groups I and II: 61% of the endometrium were quiescent without mitosis, 23% were slightly active with rare mitoses, 8% partly secretory and 4% subatrophic. Sampling was inadequate in the remaining 4%. Mitotic activity of glands was low on the overall samplings (average &lt; 0.53/1,000 cells). The average mucosa thickness was at 3.9 mm. No bleeding (spotting or withdrawal bleeding) occurred in 73.3% and 82.1% of cycles at the 3rd and 6th months of administration, respectively. Group III: endometrium were quiescent or slightly active and combined with frequent withdrawal bleeding. A relatively low dose of oral progesterone (100 mg/d) combined with E2 during 21d/28d or 25 d/month efficiently controls proliferation, induces a very low endometrial cyclic activity--while reducing spottings--and maintains an amenorrhea in the majority of women. This simple treatment is likely to improve compliance." }, { "id": "wiki20220301en558_21966", "title": "Pharmacodynamics of estradiol", "score": 0.00909090909090909, "content": "Generally, estrogens are antigonadotropic and inhibit gonadotropin secretion. However, in women, a sharp increase in estradiol levels to about 200 to 500 pg/mL occurs at the end of the follicular phase (mid-cycle) during the normal menstrual cycle and paradoxically triggers a surge in LH and FSH secretion. This occurs when estradiol concentrations reach levels of about 250 to 300 pg/mL. During the mid-cycle surge, LH levels increase by 3- to 12-fold and FSH levels increase by 2- to 4-fold. The surge lasts about 24 to 36 hours and triggers ovulation, the rupture of the dominant ovarian follicle and the release of the egg from the ovary into the oviduct. This estrogen-mediated gonadotropin surge effect has also been found to occur with exogenous estrogen, including in transgender women on hormone therapy and pre-hormone therapy transgender men acutely challenged with a high dose of an estrogen, but does not occur in men, pre-hormone therapy transgender women, or transgender men on" }, { "id": "pubmed23n0573_47", "title": "[The effect of postmenopausal hormone replacement therapy on endometrial bleeding].", "score": 0.00909090909090909, "content": "The aim of this study was to determine the effect of postmenopausal hormone replacement therapy (exclusively oestrogen or sequential/continuous combined oestrogen-progestogen treatment) on endometrial bleeding, including the histological alteration of the endometrium. From January 2000 to December 2005, 5893 women were treated by the authors in the menopause unit of their department. They examined the frequency of menopausal bleeding in treated and control groups. In case of bleeding, dilatation and fractional curettage was always carried out and the tissues were histologically evaluated. In menopausal patients who did not obtain hormone replacement therapy, bleeding occurred twice as frequently as in the treated group. Proliferating or hyperplastic endometrium was observed mainly among the treated patients, suggesting that in due time, even before the age of menopause, hormonal treatment might decrease hyperplasia and indirectly the chance of occurrence of adenocarcinoma. Hyperplasia was found more frequently in patients obtaining only oestrogen. According to the authors' view, unbalanced oestrogen treatment might further aggravate the existing hyperplasia of the endometrium. In the group treated with hormonal therapy, only simplex hyperplasia was observed. No case of complex hyperplasia with atypia was found among these patients. In the majority of patients on continuous balanced hormonal therapy, the myometrium underwent atrophy and the frequency of hyperplasia, including the chance of bleeding, mostly decreased. Endometrial polyps most frequently were found under hormonal therapy, but no acceptable explanation can be provided. The rate of cervical polyps was also higher in this group. According to the observations of the authors, hormone replacement therapy does not increase the risk of endometrial carcinoma. Combined preparations decrease the frequency of hyperplasia and consequently the chance of occurrence of adenocarcinoma." }, { "id": "wiki20220301en514_32772", "title": "Estradiol (medication)", "score": 0.009009009009009009, "content": "Medical uses Hormone therapy Menopause Estradiol is used in menopausal hormone therapy to prevent and treat moderate to severe menopausal symptoms such as hot flashes, vaginal dryness and atrophy, and osteoporosis (bone loss). As unopposed estrogen therapy (using estrogen alone without progesterone) increases the risk of endometrial hyperplasia and endometrial cancer in women with intact uteruses, estradiol is usually combined with a progestogen like progesterone or medroxyprogesterone acetate to prevent the effects of estradiol on the endometrium. This is not necessary if the woman has undergone a hysterectomy (surgical removal of the uterus). A 2017 meta-analysis found that estradiol had no effect on depressive symptoms in peri- and postmenopausal women." }, { "id": "pubmed23n0016_4466", "title": "[A histological and hormonal study of 399 women near the menopause or with confirmed menopause (author's transl)].", "score": 0.009009009009009009, "content": "This work is concerned with 399 women who were either near the menopause or had had the menopause and on whom 476 hormone levels and 169 examinations of the endometrium had been carried out. It is possible to put the women into three groups. 13 p. 100 showed a diphasic cycle, with more or less normal ovarian function. Among the group of women whose cycle was not diphasic an appreciable number had normal oestrogenic activity, or were indeed hyperoestrogenic. The others were hypo-oestrogenic. Several facts can be derived from this study. Raised levels of E.2 can be found even when there is no cyclical activity and even in women who have raised levels of FSH. Normal ovarian function may be resumed several months after the menopause, although when the levels of FSH are raised the occurrence of the postmenopausal state would seem to be confirmed. The presence of hot flushes does not seem to correspond to a particular hormonal state. Marked differences seem to exist between the levels of the plasma hormones and the endometrial biopsy results. It is possible to have an atrophic endometrium with a raised level of oestradiol-17 beta, or on the other hand a polypoidal endometrium in women who are hypo-oestrogenic. The presence of levels of progesterone such as are found in a normal luteal phase does not indicate that the endometrium will necessarily be secretory. These contradictions cannot be resolved by studying the intra-cellular concentrations of the hormone receptors. The approach of the menopause is not always characterized by a progressive and continuous state of oestrogen deficiency or by hypophysial overactivity. This classical picture can be heavily shaded. All kinds of hormone profiles and responses by the receptor organs may be met and the clinician should be aware of these facts when he chooses therapy." }, { "id": "pubmed23n1071_16833", "title": "Endometriosis presenting as vaginal polyps: outpatient vaginoscopic treatment.", "score": 0.008928571428571428, "content": "To demonstrate an outpatient vaginoscopic technique for treating multiple vaginal polyps. Demonstration of surgical technique using slides, pictures, and video. Private hospital. Thirty-two-year-old nulligravid woman presenting to the gynecology clinic with one episode of intermenstrual bleeding, regular menstrual cycles with normal flow, and no history of dysmenorrhoea or dyspareunia. The genital local examination was normal, and speculum examination showed multiple vaginal lesions like polyps in the proximal posterior two-thirds and right lateral vaginal walls. Her transvaginal ultrasound read a normal uterus with a right ovarian simple cyst. The surgeon performed an outpatient operative vaginoscopy using a 5-mm continuous flow office hysteroscope with a 2.9-mm rod lens optical system and a 5F working channel. Distension of the vagina was achieved with a normal saline solution, and an intrauterine pressure of 50 to 60 mm Hg was maintained by an irrigation and aspiration electronic pump. An inspection of the vaginal walls, fornices, and the external cervical os (Fig. 1) revealed 10 vaginal lesions like polyps in the proximal two-thirds of the posterior and right lateral vaginal wall. The vaginal lesions (Fig. 2) varied in size from 0.5 cm to 4 cm. An excisional biopsy was performed and the sample sent for histopathologic evaluation. The vaginal lesions &lt;2 cm in length were excised by cutting the base with scissors or using a bipolar vaporization electrode, which was connected to an electrocautery unit by a bipolar high-frequency cord. Vaginal lesions &gt;2 cm were excised with the TruClear 5C Hysteroscopic Tissue Removal System (HTRS) with a zero-degree scope using the 2.9-mm incisor with a 5-mm cutting window at one end attached to a reusable handpiece with two connectors-one to the motor unit and second to the suction bottle with a collection bag. The overall diameter of TruClear 5C is 5.7 mm, and the optic size is 0.8 mm. The same irrigation pump is compatible with HTRS, and the pressure was increased to 150 mm Hg to maintain vaginal distension. Three factors influenced our decision to use the HTRS intraoperatively: the number and size of the vaginal lesions and the surgical time in the outpatient setting. A mechanical system that works on the principle of excising and aspirating tissue, the HTRS incisor has a rotatory action with the excising window placed against the most distal part of the vaginal lesions. The cutting action is controlled via a foot pedal attached to a motor control with 800 rotations per minute. The handpiece remains stationary while the polyp is excised and aspirated through the window into the collection bag. Minimal bleeding occurred and stopped spontaneously. The institutional ethics committee exempted this case report from review, and we obtained informed written consent from the patient. All vaginal lesions excised in an outpatient setting via vaginoscopy technique without anesthesia. The operative time with the Bettocchi hysteroscope was 14 minutes, and HTRS was 6 minutes. The patient did not complain of pain but did describe minimal discomfort, rated on the visual analog scale as 2 (where ≥5 is severe pain). She was discharged 1 hour later. The histopathology was reported as vaginal endometriosis (ectopic presentation of endometriosis is rare, accounting for 0.02% of cases). After surgery, she was started on cyclical oral contraceptive pills (OCP) in the combination of 30 mg of ethinyl estradiol + 2 mg of dienogest because she desired to delay pregnancy by 1 year. She remained asymptomatic for 6 months. These contraceptive hormones are available in the form of oral pills, vaginal rings, and transdermal patches, and a physician can provide OCP continuously or cyclically. Continuous OCP is more efficacious for control of dysmenorrhoea, but cyclical OCP is preferred because it is affordable, tolerable, effective, produces no unpredictable bleeding, and slows the progression of the disease. (A cohort study found the contraceptive vaginal ring to be more effective for symptom-control in rectovaginal endometriosis with higher patient satisfaction than the transdermal patch; vaginal rings or transdermal patches are not available in some countries.) CONCLUSION(S): Vaginoscopy allows a more in-depth visualization of the vagina with complete inspection and removal of all polyps. Vaginoscopy is feasible in the outpatient setting and allows a comfortable, ergonomic position for the surgeon. Vaginoscopy or no-touch technique avoids the use of a speculum or tenaculum and results in minimal pain during the outpatient procedure." }, { "id": "pubmed23n0211_10370", "title": "[Endometrial biopsy in hormonal imbalance].", "score": 0.008928571428571428, "content": "Despite the new techniques of biochemical evaluation of steroid hormones in the plasma and urines, the endometrial biopsy remains an easy valuable method of evaluation of ovarian activity. The clinical indications of the endometrial biopsy are mainly a history of sterility or an abnormal uterine bleeding if we exclude the diagnosis of cancer. Different technical procedures should be followed carefully in order to get a valuable answer. The biopsy should be taken at the right time of the cycle which means 10 to 12 days after ovulation. The danger of interrupting a pregnancy is minimal but in a case of sterility, the biopsy can be performed 4 to 6 days after ovulation to prevent any interference with a early pregnancy. Proper fixation, embedding and staining must be the rule. A fragment of the middle layer of the functionalis must be present to evaluate accurately the hormonal stimulation. Isthmic or cervical tissues are unsuited for functional diagnosis. The existence of an endometritis or the administration of steroid hormones are clinical circumstances which prevent any functional evaluation. The normal menstrual cycle can be divided into different functional phases: the early, the middle and the late proliferative phases, and the early and late secretory phases followed by the menstruation period. The different cellular components of the endometrial mucosa will exhibit various changes corresponding to each of the phases. The interpretation of the endometrial biopsy lies in the correlation between the observed image and the image corresponding to that date of the cycle. The functional disturbances are associated with absent, deficient or excessive function of the ovarian hormonal secretion. The endometrial mucosa will reflect these anomalies revealing atrophic, hypoplastic or hyperplastic conditions of the glandular and stromal components. It is essential to obtain the clinical informations including the knowledge of any hormone administration to provide a valuable diagnosis. Properly interpreted, the endometrial biopsy remains a very useful technique in the study of hormonal ovarian disturbances." }, { "id": "wiki20220301en118_17538", "title": "Dydrogesterone", "score": 0.008849557522123894, "content": "Estrogen promotes endometrial cell growth and in postmenopausal women with an intact uterus, estrogen monotherapy results in continued endometrial development without the physiological secretory changes normally brought on by progesterone. This action is associated with an increased incidence of endometrial hyperplasia and carcinoma. Additional protection with progestogens is therefore important in patients with an intact uterus who receive estrogen therapy. Dydrogesterone counters the proliferative effect of estrogens on the endometrium and ensures the transition to a secretory pattern and cyclical shedding of the endometrium in serial menopausal hormone therapy regimes. Dydrogesterone effectively protects against the ontogenesis of endometrial hyperplasia. Unlike androgenic progestogens, dydrogesterone does not reverse the benefits brought on by estradiol on lipid profiles and carbohydrate metabolism. In a continuous, combined menopausal hormone therapy regimen, dydrogesterone" }, { "id": "pubmed23n0588_3672", "title": "What is the recurrence rate of postmenopausal bleeding in women who have a thin endometrium during a first episode of postmenopausal bleeding?", "score": 0.008849557522123894, "content": "To determine the incidence and significance of recurrent postmenopausal bleeding among women diagnosed with an endometrial thickness &lt; or =4 mm after a first episode of postmenopausal bleeding. Consecutive patients not using hormone replacement therapy (HRT) presenting with a first episode of postmenopausal bleeding and an endometrial thickness &lt; or =4 mm at transvaginal ultrasonography (TVU) were managed expectantly. In case of recurrent bleeding, the patient was evaluated according to the hospital's local policy with TVU, office endometrial sampling, hysteroscopy or dilatation and curettage (D&amp;C) or a combination of these tests. We evaluated the incidence of recurrent bleeding, potential risk factors for recurrent bleeding, and the diagnosis made after recurrent bleeding. A total of 607 patients were registered with a first episode of postmenopausal bleeding, of whom 249 had an endometrial thickness &lt; or =4 mm. Follow-up took place with a median of 174 weeks (range: 4-250 weeks). During follow-up, 25 of the 249 patients (10%; 95% CI: 6.6-14%) had recurrent bleeding. Median time until recurrence of bleeding was 49 weeks (range: 9-186 weeks). Two patients with recurrent bleeding turned out to have an endometrial carcinoma (8%; 95% CI: 2.2-25%), and 1 patient had a malignant melanoma. Time since menopause, age, body mass index, hypertension, diabetes and anticoagulants were not predictive for recurrent bleeding. The recurrence rate after a first episode of postmenopausal bleeding managed expectantly is low and cannot be predicted by patient characteristics. Patients with recurrent bleeding should be re-evaluated, as they bear a considerable risk of carcinoma." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 356, 448 ] ], "word_ranges": [ [ 62, 80 ] ], "text": "Ischemic ASD... I do not deny that it exists, but it does not even appear in the guidelines." }, "2": { "exist": true, "char_ranges": [ [ 129, 207 ] ], "word_ranges": [ [ 24, 37 ] ], "text": "A ventricular aneurysm depresses LVEF, but does not suddenly put you into PAD." }, "3": { "exist": true, "char_ranges": [ [ 221, 355 ] ], "word_ranges": [ [ 39, 62 ] ], "text": "a VSD sharply increases flow to the pulmonary bed, causing pulmonary edema, and is also one of the most frequent complications of AMI." }, "4": { "exist": true, "char_ranges": [ [ 356, 448 ] ], "word_ranges": [ [ 62, 80 ] ], "text": "Ischemic ASD... I do not deny that it exists, but it does not even appear in the guidelines." }, "5": { "exist": true, "char_ranges": [ [ 453, 503 ] ], "word_ranges": [ [ 81, 88 ] ], "text": "endocarditis would not require so many saddlebags." } }

{ "1": "Acute post-infarction mitral insufficiency.", "2": "Left ventricular aneurysm.", "3": "Acute ventricular septal defect.", "4": "Postinfarction atrial septal defect.", "5": "Dysfunction of the bioprosthesis due to probable acute endocarditis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1069_5645", "title": "Closure of a Prosthetic Mitral Valve Paravalvular Leak Using a Ventricular Septal Defect (VSD) Amplatzer Occluder Device.", "score": 0.016964924838940586, "content": "BACKGROUND Paravalvular leaks (PVL) are becoming more commonly experienced in clinical practice due to the increasing number of mitral valve replacements performed. There are about 182 000 valve replacements performed annually, with a 5-15% prevalence rate of paravalvular leaks. Due to increased mortality associated with surgical repair, percutaneous transcatheter closure procedures are increasingly being performed as an alternative to repeat surgery. CASE REPORT We present the case of a 52-year-old woman with past medical history of mitral valve endocarditis who developed worsening acute heart failure 1 month after surgical bioprosthetic mitral valve replacement. Transesophageal echocardiography at the time revealed dehiscence of the bioprosthetic mitral valve and severe mitral regurgitation. She subsequently had emergent surgical bioprosthetic mitral valve replacement and annular reconstruction. The post-operative course was complicated by increasing dyspnea and lower-extremity edema, with recurrent pericardial tamponade requiring placement of a pericardial window. Based on her multiple comorbidities, most notably the concomitant right ventricular failure with severe pulmonary hypertension and prior pericardial patch repair with compromise of her mitral valve annulus, she was deemed inoperable for re-do surgery and eventually underwent a successful percutaneous closure of the mitral paravalvular leak with a ventricular septal defect (VSD) Amplatzer occluder device. The patient made good recovery and was discharged home a few days after the procedure. CONCLUSIONS Although use of the Amplatzer VSD occluder device for this indication currently remains off-label, our report supports the use of the VSD occluder device in this subset of patients considering the high mortality rates associated with repeat surgical procedure." }, { "id": "pubmed23n0080_2287", "title": "Are there indications for reconstructive surgery in severe mitral regurgitation after acute myocardial infarction?", "score": 0.014470642625982431, "content": "From 1972 to 1988, early surgery were performed in 26 patients with acute mitral regurgitation (MR) unresponsive to medical management complicating a recent acute myocardial infarction (AMI). The indication was acute pulmonary oedema (11), major left ventricular insufficiency (5), cardiogenic shock (10). Surgery was performed within 3 weeks following AMI. Mitral lesions were as follows: rupture of chordae tendinae (9) of papillary muscle (6), haemorrhagic necrosis of one (17) or two (9) papillary muscles. The mitral annulus was never found to be enlarged. The LV posterior wall was necrotic in 23, with a septal rupture in 3 and a giant aneurysm in 5. Valve replacement was performed in all but one patient. The 30-day mortality included 8 patients (31%). The cause of death was myocardial insufficiency in 5, early thrombosis of a disk valve in 1 and unrelated complications in 2. One patient deteriorated rapidly and had a Jarvik device implanted. Late results (1 month-15 years) showed 4 cardiac related deaths within the first year. One patient had to be transplanted after 1 year. Two patients died of non-cardiac problems at 3 months and 5 years. The probability of survival at 5 years is 43% and at 10 years 22%. In conclusion, there are still indications for early surgery in MR post AMI. Anatomical lesions of both papillary muscles and ventricular wall do not allow conservative surgery and new non-invasive technics provide a more promising strategy in such desperately ill patients." }, { "id": "wiki20220301en082_56744", "title": "Intra-aortic balloon pump", "score": 0.013680425265791121, "content": "Indications The following situations may benefit from this device. Cardiogenic shock when used alone as treatment for myocardial infarction. 9–22% survive the first year. Reversible intracardial mechanical defects complicating infarction, i.e. acute mitral regurgitation and septal perforation. Unstable angina pectoris benefits from counterpulsation. Post cardiothoracic surgery—most common and useful is counterpulsation in weaning patients from cardiopulmonary bypass after continued perioperative injury to myocardial tissue. Preoperative use is suggested for high-risk patients such as those with unstable angina with stenosis greater than 70% of main coronary artery, in ventricular dysfunction with an ejection fraction less than 35%. Percutaneous coronary angioplasty In high risk coronary artery bypass graft surgery where cardiopulmonary bypass time was shortened, as well as during intubation period and hospital stay. Thrombolytic therapy of acute myocardial infarction." }, { "id": "wiki20220301en245_33081", "title": "Acute decompensated heart failure", "score": 0.013429631075541675, "content": "Surgery Certain scenarios will require emergent consultation with cardiothoracic surgery. Heart failure due to acute aortic regurgitation is a surgical emergency associated with high mortality. Heart failure may occur after rupture of ventricular aneurysm. These can form after myocardial infarction. If it ruptures on the free wall, it will cause cardiac tamponade. If it ruptures on the intraventricular septum, it can create a ventricular septal defect. Other causes of cardiac tamponade may also require surgical intervention, although emergent treatment at the bedside may be adequate. It should also be determined whether the patient had a history of a repaired congenital heart disease as they often have complex cardiac anatomy with artificial grafts and shunts that may sustain damage, leading to acute decompensated heart failure." }, { "id": "pubmed23n0583_4390", "title": "Mitral valve surgery with surgical embolectomy for mitral valve endocarditis complicated by septic coronary embolism.", "score": 0.012865579302587176, "content": "Acute myocardial infarction (AMI) complicated by septic coronary embolism due to active infective endocarditis is rare but usually fatal. We report a case of successful mitral valve surgery with surgical embolectomy in a 27-year-old man with an AMI complicated by septic coronary embolism due to mitral valve endocarditis. A chest radiograph revealed cardiomegaly and marked pulmonary edema. A transthoracic echocardiogram disclosed severe mitral regurgitation with highly mobile vegetations and hypokinesia of the left ventricular apex. The electrocardiographic findings of ST segment elevation in leads V2-4 and elevated cardiac enzyme levels were strongly suggestive of an acute anterolateral AMI. Nevertheless, emergent cardiac surgery was needed without selective coronary angiography because of intractable heart failure and life-threatening ventricular tachyarrhythmia requiring cardiopulmonary resuscitation. A total occlusion of the distal left anterior descending artery caused by embolic vegetation and thrombus, which was incidentally detected intraoperatively, was successfully recanalized by surgical embolectomy and thrombectomy using a direct coronary incision. The mitral valve endocarditis was managed with wide debridement and mechanical valve replacement. Three years after the surgery a follow-up echocardiogram showed no abnormalities of the regional wall, motion in the left ventricle and the patient is living an active life without any complications." }, { "id": "pubmed23n0091_2256", "title": "Postinfarction ventricular septal defect--surgical strategies and results.", "score": 0.012633587786259542, "content": "Twenty consecutive patients with postinfarction ventricular septal defect (VSD) were subjected to surgery: there were 8 females and 12 males with a mean age of 67 +/- 9 years. Nine acute patients developed cardiogenic shock, and intra-aortic balloon pump was started before surgery (with IABP). Eight acute patients showed preoperatively relatively stable hemodynamics, and surgery was feasible without previous use of the intra-aortic balloon pump (without IABP). The interval between myocardial infarction and surgery was 13 days for 17 acute cases. In the group with IABP the interval was 8 +/- 5 days versus 19 +/- 11 days in the group without IABP (p less than 0.025). VSD patch closure was performed in 20/20, resection of infarct in 10/20, transventricular approach without resection of infarct in 3/20, patch enlargement of the left ventricle in 2/20, plicature of an aneurysm in 3/20, aorto-coronary bypass in 10/20 (number of bypasses: 2.1 +/- 1.3) and mitral annuloplasty in 1/20. The perioperative 30 days mortality was 5/20 (25%) for the whole series. In the group with IABP mortality was 4/9 (44%) versus 1/8 (13%) in the group of acute patients without IABP (p less than 0.05). Mean follow-up for the 15 surviving patients was 1.7 +/- 1.0 years. Two patients died during the first year, one of them due to carcinoma. After 1 year, mean NYHA functional class was assessed 1.5 +/- 0.6. One patient showed a residual VSD which was closed surgically. Immediate closure of a postinfarction ventricular septal defect is the therapy of choice of this complication of acute myocardial infarct with a natural history showing an extremely high mortality." }, { "id": "pubmed23n0277_9736", "title": "[The recurrence of an atrial myxoma in a patient with a mechanical mitral prosthesis--apropos a case].", "score": 0.012138092290764046, "content": "Recurrence of cardiac myxoma after surgery is an uncommon situation, particularly if a wide excision of the tissue under the tumour has been done. The authors report a case of a 54-year-old male presenting with a left atrial myxoma near the mitral valve, which had to be replaced by a mechanical prosthetic valve during the removal of the tumour. One year later, he was admitted to hospital with persistent fever, weight loss, and congestive heart failure. After a positive hemoculture, intravenous antibiotherapy was initiated, and twice modified because of relapsing fever. Six weeks later, he was transferred to our institution, after an episode of severe acute pulmonary edema. 2D-Doppler echocardiography suggested the possibility of prosthesis dysfunction, revealing a transprothetic diastolic flow with a high peak velocity and moderately elevated pressure half-time. No intra-atrial masses were visualized. Computed tomography was also inconclusive, because of multiple artifacts produced by the prosthesis. These results led to the performance of a cardiac catheterization with contrast ventriculography, which revealed the presence of a transprothetic gradient, and mild mitral regurgitation. The patient was submitted to cardiac surgery, which revealed a recurrent pedunculated left atrial myxoma, with mechanical obstruction of the mitral prosthetic valve. No signs of endocarditis were found. Recurrent cardiac myxomas are reviewed and discussed, as well as the specific problems of the present case, namely the presence of a mechanical prosthetic mitral valve and the initial hemoculture results, with consequent diagnostic delay." }, { "id": "wiki20220301en024_39610", "title": "Mitral stenosis", "score": 0.012037037037037037, "content": "With careful patient pre-selection, percutaneous balloon mitral valvuloplasty (PBMV) is associated with good success rates and a low rate of complications. By far the most serious adverse event is the occurrence of acute severe mitral regurgitation. Severe mitral regurgitation usually results from a tear in one of the valve leaflets or the subvalvular apparatus. It can lead to pulmonary edema and hemodynamic compromise, necessitating urgent surgical mitral valve replacement. Other serious complications with PBMV usually relate to the technique of trans-septal puncture (TSP). The ideal site for TSP is the region of the fossa ovalis in the inter-atrial septum. Occasionally, however, the sharp needle used for TSP may inadvertently traumatize other cardiac structures, leading to cardiac tamponade or serious blood loss." }, { "id": "pubmed23n0207_5196", "title": "Surgical and mechanical support of the failing heart.", "score": 0.011858797573083286, "content": "The surgical treatment of acute heart failure is limited to cases of pressure or volume overload. Acute valvular regurgitation due to active endocarditis or to prosthetic dysfunction is a classic example of failure which can be cured by restoring valvular competence. Acute pressure load is mostly caused by prosthetic dysfunction or pulmonary embolism; therapy is aimed at removal of the causative agent. Coronary heart disease can cause heart failure by volume overload: acute mitral incompetence or ventricular septal defect lend themselves to surgical correction. In the surgical treatment of acute heart failure maximal attention is devoted to optimal timing of surgery, anesthetic management and postoperative care. Careful attention to the function of the right and left ventricle and combination of catecholamines, afterload reducing agents and volume loading together with respirator support have considerably improved the surgical results. Acute pump failure due to coronary insufficiency and infarction is less amenable to surgical treatment, with rare exceptions of emergencies during coronary angiography and percutaneous dilatation. The intra-aortic balloon pump is the only method of mechanical circulatory assistance which has reached widespread clinical acceptance. The best results are achieved in conjunction with surgery: either as cardiac support in inherently reversible postoperative heart failure or as the means of circulatory stabilization prior to surgery. Ventricular assist devices are still in the experimental stage: their use has been sharply curtailed by the virtual disappearance of the postoperative low output syndrome. In selected cases of end-stage cardiomyopathy cardiac transplantation is nowadays performed with acceptable survival (70% at one year after surgery). Both orthotopic and heterotopic transplantation (transplanted heart in parallel with the natural one) give comparable results, but the procedure is still very restricted due to the lack of donors, multiple contraindications and lack of suitable heart preservation techniques." }, { "id": "wiki20220301en324_29404", "title": "Myocardial infarction complications", "score": 0.01181844250542788, "content": "Rupture is usually a catastrophic event that may result a life-threatening process known as cardiac tamponade, in which blood accumulates within the pericardium or heart sac, and compresses the heart to the point where it cannot pump effectively. Rupture of the intraventricular septum (the muscle separating the left and right ventricles) causes a ventricular septal defect with shunting of blood through the defect from the left side of the heart to the right side of the heart, which can lead to right ventricular failure as well as pulmonary overcirculation. Rupture of the papillary muscle may also lead to acute mitral regurgitation and subsequent pulmonary edema and possibly even cardiogenic shock. Arrhythmia" }, { "id": "wiki20220301en100_5616", "title": "List of MeSH codes (C14)", "score": 0.011382401509790044, "content": "– endocarditis – endocarditis, bacterial – endocarditis, subacute bacterial – heart aneurysm – heart arrest – death, sudden, cardiac – heart defects, congenital – aortic coarctation – arrhythmogenic right ventricular dysplasia – cor triatriatum – coronary vessel anomalies – crisscross heart – dextrocardia – kartagener syndrome – ductus arteriosus, patent – ebstein's anomaly – eisenmenger complex – heart septal defects – aortopulmonary septal defect – endocardial cushion defects – heart septal defects, atrial – lutembacher's syndrome – trilogy of fallot – heart septal defects, ventricular – hypoplastic left heart syndrome – leopard syndrome – levocardia – marfan syndrome – tetralogy of fallot – transposition of great vessels – double outlet right ventricle – tricuspid atresia – truncus arteriosus, persistent – heart failure, congestive – cardiomyopathy, dilated – dyspnea, paroxysmal – edema, cardiac – heart neoplasms" }, { "id": "pubmed23n0755_10680", "title": "[Giant thrombus in the left atrium after mitral bioprosthesis implantation: is standard oral anticoagulation always sufficient?].", "score": 0.011017822948887906, "content": "We present a case of 70-year old male after coronary by-pass surgery and mitral bioprosthesis implantation due to infective endocarditis, with continuous atrial fibrillation, who was admitted to the hospital due to the worsening of the heart failure. He was on oral antivitamine K agents with therapeutic value of INR. On echocardiography we found enlargement of all cavities with extremely big left atrium (9.5 cm) and poor contractile left ventricular function (EF 25%). An enormously big old thrombus was found in the left atrium. The patient was disqualified from surgical treatment. Treatment with unfractionated heparin was unsuccessful. We discuss if standard antithrombotic treatment is always sufficient in such unusual cases." }, { "id": "wiki20220301en293_12445", "title": "List of circulatory system conditions", "score": 0.009900990099009901, "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": "pubmed23n0075_8813", "title": "[Prosthesis-endocarditis in the aortic position in a 22-year case load. Surgical versus conservative treatment].", "score": 0.009900990099009901, "content": "During the period 1965-1986, a total of 852 patients underwent isolated aortic valve replacement. With 4,875 patients-years at risk, 24 patients developed prosthetic valve endocarditis (PE; 0.49% per patient-year). The five, ten and fifteen year cumulative freedoms from PE were 98.2%, 95.4% and 93.0%, respectively. PE was unrelated to pre- or intraoperative data. No patients submitted to operation for acute/subacute bacterial endocarditis of the native aortic valve developed PE. Out of the 12 episodes of PE within two years of the operation, seven (58%) were caused by Staphylococcus albus compared with two out of 12 (17%; p less than 0.05) subsequent episodes of PE. Seven of the nine infections with Staphylococcus albus were caused by a highly resistant nosocomial variant. Ten of the PE patients underwent replacement of the prosthesis while 14 were treated conservatively. The two therapeutic groups were comparable, although the surgically treated patients tended to be younger and to have more impaired cardiac status. All surgically treated patients and all patients treated conservatively and in whom post mortem verification was possible had paravalvular defects, annular abscesses and/or vegetations on the prosthesis. The thirty-day, one year and ten year cumulative survivals were 80%, 80% and 50%, respectively, after replacement of the prosthesis and 64%, 21% and 7%, respectively, after conservative treatment (p = 0.02). A Cox regression analysis identified conservative treatment, infection with Escherichia coli or Haemophilus influenzae and the need to intensify digitalis/diuretic treatment for congestive heart failure as independent risk factors. It is concluded that replacement of the prosthesis early in the course of the disease should be considered as the treatment of choice." }, { "id": "wiki20220301en042_8521", "title": "Pulmonary artery catheter", "score": 0.00980392156862745, "content": "Indications General indications are: Management of complicated myocardial infarction Hypovolemia vs cardiogenic shock Ventricular septal rupture (VSR) vs acute mitral regurgitation Severe left ventricular failure Right ventricular infarction Unstable angina Refractory ventricular tachycardia Assessment of respiratory distress Cardiogenic vs non-cardiogenic pulmonary edema Primary vs secondary pulmonary hypertension Assessment of types of shock Assessment of therapy Afterload reduction Vasopressors Beta blockers Intra-aortic balloon counter-pulsation Assessment of fluid requirement in critically ill patients Hemorrhage Sepsis Acute kidney injury Burns Management of postoperative open heart surgical patients Assessment of valvular heart disease Assessment of cardiac tamponade/constriction" }, { "id": "pubmed23n0936_4941", "title": "Primary percutaneous coronary intervention during ST elevation myocardial infarction in prosthetic valve endocarditis: a case report.", "score": 0.00980392156862745, "content": "Infective endocarditis (IE) is still a condition with high mortality and morbidity, especially in the elderly, and in patients with prosthetic valves. The concept of \"time-to-therapy\" plays a key role for the prompt management of IE and related complications, and the currently available multimodality imaging may play a key role in this setting. Myocardial ischemia due to extrinsic coronary compression from an aortic abscess is an extremely rare condition where the optimal therapeutic strategy has not been defined yet. We present herein the first case of a patient with ST elevation myocardial infarction caused by an aortic root abscess treated with percutaneous stent implantation. An 82-year-old woman with a history of atrial fibrillation, chronic renal failure, anemia and a bioprosthetic aortic valve replacement performed in 2014, was admitted to hospital with profound asthenia and a pyrexia of unknown origin. Because of high clinical suspicion of endocarditis, a trans-esophageal echocardiogram was performed. Empirical broad-spectrum antimicrobial therapy was initiated, followed by targeted treatment based on the results of blood cultures (Staphylococcus aureus). The echocardiogram did not show vegetations and the patient was managed conservatively. She suddenly deteriorated, due to an acute coronary syndrome (ACS) with anterior ST segment elevation. An urgent angiogram was performed, and extrinsic compression of the left coronary system, due to an aortic root abscess, was suspected. After discussion with the surgical team, percutaneous revascularization was attempted, aiming to restore satisfactory hemodynamics, in order to plan surgery. Unfortunately, the patient rapidly developed cardiogenic shock, with multi organ failure, and died in less than 24 h. Patients with fever, and significant risk factors for endocarditis, who develop ACS, need a prompt diagnostic work up, including trans-esophageal echocardiography. At present, the specific timing of echocardiographic follow-up and surgical intervention is still a matter of debate, and our case aims to highlight the importance of this aspect in the management of endocarditis, in order to avoid severe complications that adversely affect patient prognosis." }, { "id": "wiki20220301en293_12446", "title": "List of circulatory system conditions", "score": 0.009656015365811071, "content": "Ischemic heart diseasesSee also :Category:Ischemic heart diseases Angina pectoris Acute coronary syndrome Acute myocardial infarction Valvular heart diseaseSee also :Category:Valvular heart disease Aortic insufficiency Mitral stenosis Tricuspid valve stenosis Pulmonary valve stenosis Mitral insufficiency/regurgitation Tricuspid insufficiency/regurgitation Pulmonary insufficiency/regurgitation Vascular surgerySee also :Category:Vascular surgery'' Aortic aneurysm References Lists of diseases" }, { "id": "pubmed23n0307_11302", "title": "[Replacement of the aortic valve with a pulmonary autograft: experience at the University of Verona].", "score": 0.009615384615384616, "content": "Early and long term results after surgical replacement of the aortic valve depend to a large degree on the type of valve substitute used. Pulmonary autograft offers many theoretical advantages, particularly in young patients. Between July 1994 and August 1996, 15 patients (12 male) with a mean age of 28 +/- 6 years (range 14 to 36 years) were selected for aortic valve replacement with a pulmonary autograft. The aortic valve disease was isolated insufficiency in 7 cases (47%), stenosis in 3 (20%) and mixed lesion in 5 (33%). One patient in the last group had bacterial endocarditis (Streptococcus mitis). Seven patients (47%) had a bicuspid aortic valve. In 3 cases (20%) the autograft was inserted as a scalloped subcoronary implant. Twelve patients (80%) had total aortic root replacement with re-implantation of the coronary ostia. The right ventricular outflow tract was reconstructed with a cryopreserved homograft (13 pulmonary; 2 aortic). The aortic cross-clamp time was 156 +/- 18 minutes with a total bypass time of 221 +/- 26 minutes. All patients survived the operation. Three postoperative bleeding (20%) necessitated re-exploration. Mean post-operative hospital stay was 10 +/- 2 days. All patients were discharged on aspirin for the period of three months. One patient (7%) with moderate neo-aortic valve insufficiency died suddenly 11 months post-operatively. All survivors are asymptomatic, in NYHA FC 1 at a mean follow-up time of 15.7 months. Freedom from reoperation, valve related complication and endocarditis is 100%. Two-dimensional (2-D) echocardiography six months postoperatively showed a mean left ventricular outflow gradient of 13 +/- 4 mmHg with no evidence of aortic regurgitation in 11 cases (78.5%) and trivial in 3 (21.5%). Although the Ross operation is technically more challenging and requires a longer operating time than standard procedures, this does not seem to affect early mortality and morbidity. Clinical and haemodynamic results appear to be gratifying. Continued patients evaluation particularly with regard to evidence of valve degeneration and arrhythmias in the long term is warranted." }, { "id": "wiki20220301en133_43049", "title": "Myocardial rupture", "score": 0.009523809523809525, "content": "Classification Myocardial ruptures can be classified as one of three types. Type I myocardial rupture is an abrupt slit-like tear that generally occurs within 24 hours of an acute myocardial infarction. Type II is an erosion of the infarcted myocardium, which is suggestive of a slow tear of the dead myocardium. Type II ruptures typically occur more than 24 hours after the infarction occurred. Type III ruptures are characterized by early aneurysm formation and subsequent rupture of the aneurysm. Another method for classifying myocardial ruptures is by the anatomical portion of the heart that has ruptured. By far the most dramatic is rupture of the free wall of the left or right ventricles, as this is associated with immediate hemodynamic collapse and death secondary to acute pericardial tamponade. Rupture of the interventricular septum will cause a ventricular septal defect. Rupture of a papillary muscle will cause acute mitral regurgitation." }, { "id": "pubmed23n0214_12178", "title": "[Results of singular valve replacement with a mechanical prosthesis or bioprosthesis in valve diseases with advanced myocardial failure].", "score": 0.009523809523809525, "content": "Surgery may prolong survival in some patients in advanced cardiac failure due to valvular heart disease refractory to digitalo-diuretic and vasodilator therapy. The operative risk is high and myocardial dysfunction after surgery is also a problem. However, in some cases, surprising improvement is observed. An analysis of the principal publications in the literature on the natural history of valvular heart disease and the results of surgery in the last ten years show that: In chronic aortic valve disease complicated by congestive heart failure, the natural prognosis does not exceed 2 to 3 years in either aortic stenosis or regurgitation. On the other hand, prosthetic valve replacement is associated with a 57% 4 years survival in aortic regurgitation, and a 70% 5 years survival in aortic stenosis, but with an operative mortality of 20 to 27%. Surgery is even more valuable in acute aortic regurgitation due to endocarditis, leading to a 60% 2 years survival compared to only 6% with medical therapy alone. In chronic mitral valve disease with advanced cardiac failure, the natural prognosis does not exceed 4.5 years in mitral regurgitation, 8 years in mitral stenosis and an intermediate period in mixed mitral valve disease. On the other hand, prosthetic valve replacement with an operative risk of 21 to 26% is associated with a life expectancy of 56 to 60% at 5 years, and 46% at 10 years, operative mortality included. The surgical results depend on good myocardial protection and intensive pre-, per- and post-operative care using positive inotropic agents, vasodilators and, when necessary, intra aortic balloon pumping.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0606_4995", "title": "[Late postinfarction rupture of the interventricular septum].", "score": 0.009433962264150943, "content": "Postinfarction ventricular septal rupture complicates 1 to 2% of cases of acute myocardial infarction and accounts for 5% of early mortality. This severe complication usually occurs within two weeks after acute myocardial infarction, and the elderly are more susceptible. We present a case of late rupture of the septum. In a 75-year-old man, a ventricular septal defect developed more than two months after an extensive inferoseptal myocardial infarction due to occlusion of the right coronary artery. After more than two months of no symptoms he was referred to hospital due to symptoms of right ventricle failure. The diagnosis was made by echocardiography, pulmonary artery catheterization and ventriculography. Coronarography was also performed. Intraaortic balloon pump was introduced and the patient was transferred to the operating room. The defect was repaired using a circular polytetrafluoroethylene patch supported by buttressed interrupted sutures from both sides. Due to significant mitral valve regurgitation mechanical bileaflet mitral valve was implanted with preservation of the entire mitral apparatus and the left descending artery was revascularized using a saphenous graft. This case is reported to emphasize that later postinfarction rupture of the ventricular septum may occur with symptoms of right ventricle failure dominating the clinical course." }, { "id": "pubmed23n1079_15170", "title": "[Elective Mitral Valve Repair for Acute Mitral Regurgitation Due to Anterior Papillary Muscle Rupture:Report of a Case].", "score": 0.009433962264150943, "content": "An 83-year-old woman with congestive heart failure due to severe mitral regurgitation was referred to our department. Because acute coronary syndrome was suspected, the patient underwent emergent coronary artery angiography, which showed 75% stenosis of segment 2 and 90% stenosis of segment 11. Subsequently, segment 11 was treated by percutaneous coronary intervention. Additionally, transesophageal echocardiography findings showed a prolapse of P2 due to papillary muscle rupture. After management of heart failure, a scheduled operation was performed under the diagnosis of acute mitral regurgitation due to papillary muscle rupture. Intraoperative findings demonstrated a rupture of the anterior papillary muscle, prolapse of P2, and no evidence of infection. The patient underwent mitral valve repair with artificial chordae through median sternotomy. Her postoperative course was uneventful." }, { "id": "wiki20220301en101_49425", "title": "Pulmonary wedge pressure", "score": 0.009345794392523364, "content": "Noninvasive estimation techniques have been proposed. Clinical significance Because of the large compliance of pulmonary circulation, it provides an indirect measure of the left atrial pressure. For example, it is considered the gold standard for determining the cause of acute pulmonary edema; this is likely to be present at a PWP of >20mmHg. It has also been used to diagnose severity of left ventricular failure and mitral stenosis, given that elevated pulmonary capillary wedge pressure strongly suggests failure of left ventricular output. Traditionally, it was believed that pulmonary edema with normal PWP suggested a diagnosis of acute respiratory distress syndrome (ARDS) or non cardiogenic pulmonary edema (as in opiate poisoning). However, since capillary hydrostatic pressure exceeds wedge pressure once the balloon is deflated (to promote a gradient for forward flow), a normal wedge pressure cannot conclusively differentiate between hydrostatic pulmonary edema and ARDS." }, { "id": "pubmed23n0366_20603", "title": "Duromedics original prosthesis: what do we really know about diagnosis and mechanism of leaflet escape?", "score": 0.009345794392523364, "content": "The Edwards-Duromedics (ED) is a bileaflet pyrolitic carbon mechanical valve introduced by Hemex Scientific Inc in 1982, subsequently acquired by Baxter Healthcare Corp, withdrawn from the market in 1988, and modified and reintroduced in 1990. From 1982 to date, 46 cases of leaflet escape have been registered by the manufacturer of an estimated total of 20,000 valves implanted. Disc embolization 12 years after an ED mitral prosthesis implantation is reported in a 45-year-old man operated on when he was in cardiogenic shock because a preliminary transthoracic Doppler echocardiography did not show malfunction of the valve. A correct diagnosis was made four days after the onset of the symptoms by transesophageal echocardiography. During the operation, the posterior leaflet of the ED valve was not found, a 29 mm St Jude Medical bileaflet mechanical prosthesis was implanted and the patient died in the intensive care unit because of low cardiac output syndrome. Cavitation damage is generally considered the most frequent mechanism in cases of such fracture. Thus, any patient with a mechanical valve presenting with acute pulmonary edema must be immediately transferred to a surgical unit; cinefluoroscopy or transesophageal echocardiography may be performed rapidly to achieve successful management of patients with leaflet embolization." }, { "id": "pubmed23n0113_13752", "title": "[Obstacle to left ventricle ejection after mitral valvular replacement with a Carpentier-Edwards bioprosthesis. Apropos of 2 cases].", "score": 0.009259259259259259, "content": "Impairment of the left ventricular ejection induced by a mitral prosthesis remains an infrequent complication, perhaps because it often is unrecognized. This complication would mainly be seen with ball prostheses or standard bioprosthesis used in mitral valve replacements with a small ventricle. Two cases have been recently reported during mitral valve replacement. The two patients were successfully re-operated upon, one after five weeks and the second immediately after the first procedure. A review of the literature enable to specify the etiology and diagnostic criteria with the assistance of Doppler-sonocardiography. Early re-operation may prevent death, often due to a post-operative myocardial dysfunction." }, { "id": "pubmed23n0858_11072", "title": "Effective percutaneous \"edge-to-edge\" mitral valve repair with mitraclip in a patient with acute post-MI regurgitation not related to papillary muscle rupture.", "score": 0.009174311926605505, "content": "A 65-year-old woman was admitted to our institution for rest dyspnea and hypotension. EKG showed sinus tachycardia with signs of infero-posterior STEMI. 2D-echocardiogram showed severe left ventricular systolic dysfunction with a- diskynesia of the inferior and posterior walls and severe functional mitral regurgitation (MR). The patient underwent urgent coronary angiography that showed 3-vessels disease with total occlusion of both first obtuse marginal (OM) branch of the left circumflex artery and right coronary artery (RCA) and critical stenosis of left anterior descending (LAD). Because of extremely high surgical risk, we performed a staged totally percoutaneous approach. First, we reopened the presumed culprit vessels (RCA and OM) and then, after 48 hr, we performed angioplasty of the LAD. Since revascularization provided no significant improvement in respiratory and hemodynamic parameters we performed a percutaneous mitral repair with Mitraclip. MR grade was reduced from severe to trivial with rapid improvement of the respiratory and hemodynamic parameters. The post-procedural course was uneventful and the patient was discharged 7 days later. At the 30-day and 6-month follow-up the patient remained asymptomatic in NYHA I functional class with no recurrence of MR. Acute MR due to post-AMI mechanical complications is generally considered a contraindication to MitraClip implantation for several reasons. However, the present report shows that, in selected cases, the Mitraclip system may be successfully used to reduce the severity of acute MR secondary to AMI and may allow to reverse cardiogenic shock and/or refractory pulmonary congestion related to the acute regurgitation. © 2016 Wiley Periodicals, Inc." }, { "id": "pubmed23n0929_14420", "title": "Extracorporeal membrane oxygenation system as a bridge to reparative surgery in ventricular septal defect complicating acute inferoposterior myocardial infarction.", "score": 0.00909090909090909, "content": "Post-infarction ventricular septal defect (VSD) is a rare but potentially lethal complication of acute myocardial infarction. Medical management is usually futile, so definitive surgery remains the treatment of choice but the risk surgery is very high and the optimal timing for surgery is still under debate. A 55-year-old man with no previous medical history attended the emergency-room for 12 h evolution of oppressive chest pain and strong anginal pain 7 days ago. On physical examination, blood pressure was 96/70 mmHg, pansystolic murmur over left sternal border without pulmonary crackles. An electrocardiogram revealed sinus rhythm 110 bpm, elevation ST and Q in inferior-posterior leads. Transthoracic echocardiogram showed inferoposterior akinesia, posterior-basal septal rupture (2 cm × 2 cm) with left-right shunt. Suspecting VSD in inferior-posterior acute myocardial infarction evolved, we performed emergency coronarography with 3-vessels disease and complete subacute occlusion of the mid segment of the right coronary artery. Left ventriculography demonstrated shunting of contrast from the left ventricule to the right ventricule. He was rejected for heart transplantation because of his age. Considering the high surgical risk to early surgery and his hemodynamic and clinical stability, delayed surgical treatment is decided, and 4 days after admission the patient suffered hemodynamic instability so venoarterial extracorporeal membrane oxygenation system (ECMO) is implanted as a bridge to reparative surgery. The 9th day after admission double bypass, interventricular defect repair with pericardial two-patch exclusion technique, and ECMO decannulation were performed. The patient's postoperative course was free of complications and was discharged 10 days post VSD repair surgery. Follow-up 3-month later revealed the patient to be in good functional status and good image outcome with intact interventricular septal patch without shunt. ECMO as a bridge to reparative surgery in postinfarction VSD is an adequate option to stabilize patients until surgery." }, { "id": "wiki20220301en000_122200", "title": "Down syndrome", "score": 0.009009009009009009, "content": "Heart The rate of congenital heart disease in newborns with Down syndrome is around 40%. Of those with heart disease, about 80% have an atrioventricular septal defect or ventricular septal defect with the former being more common. Mitral valve problems become common as people age, even in those without heart problems at birth. Other problems that may occur include tetralogy of Fallot and patent ductus arteriosus. People with Down syndrome have a lower risk of hardening of the arteries. Cancer Although the overall risk of cancer in Down syndrome is not changed, the risk of testicular cancer and certain blood cancers, including acute lymphoblastic leukemia (ALL) and acute megakaryoblastic leukemia (AMKL) is increased while the risk of other non-blood cancers is decreased. People with Down syndrome are believed to have an increased risk of developing cancers derived from germ cells whether these cancers are blood- or non-blood-related." }, { "id": "pubmed23n0688_17727", "title": "[Effectiveness of transesophageal echocardiography in diagnosing complete rupture of the papillary muscle after acute myocardial infarction].", "score": 0.009009009009009009, "content": "We reviewed a case undergoing emergency surgery for acute post-infarction papillary muscle rupture. The patient was a 79-year-old woman transferred to our hospital with cardiogenic shock who required endotracheal intubation. The acute myocardial infarction diagnosis was based on the electrocardiographic findings. She had developed progressively worsening pulmonary edema. No heart murmur was detected. Transthoracic echocardiography demonstrated hyperdynamic cardiac motion and an intracardiac massive turbulent color Doppler signal, but neither mitral regurgitation nor the ruptured papillary muscle head was demonstrated. Her deteriorating condition precluded cardiac catheterization. We performed transesophageal echocardiography (TEE), which demonstrated massive mitral regurgitation and the ruptured anterior papillary muscle connected to normal chordae tendineae and anterior and commissural leaflets. During systole, the head of the ruptured papillary muscle moved like a whip in the left atrium. Emergency surgery was performed. Complete rupture of the anterior papillary muscle head was found, and the mitral valve was replaced with a porcine bioprosthesis (Mosaic #25). Postoperatively, she was weaned from intra-aortic balloon pumping after 2 days and recovered uneventfully. Postoperative coronary angiography demonstrated no significant coronary arterial stenosis. To make the diagnosis of post-infarction papillary muscle rupture, we recommend immediate TEE." }, { "id": "pubmed23n0278_18852", "title": "[Myocardial infarction in pregnancy].", "score": 0.008928571428571428, "content": "We report two cases of pregnant women who developed an acute myocardial infarction. The proposed cause of massive myocardial anterior and interventricular wall infarction of the first patient appears to be bacterial intracoronary thrombus during the course of bacterial endocarditis. Acute insufficiency of the mitral valve caused by rupture chordae tendineae of the anterior mitral left was another complication. Labor contractions occurred on the 13th day of treatment. On the next day the patient gave birth to a healthy child by elective cesarean section. She was also qualified for an operation because of increased signs of left ventricular heart failure. Preoperative coronary angiography revealed occlusion of the anterior descending branch and reconstruction of its periphery. Other vessels were not changed. The patient was subjected to implantation of artificial valve, an aortocoronary by-pass and repair of atrial septal defect. Eighteen months follow up was uneventful. The second case was a 29 year-old pregnant woman who had previously undergone mitral commissurotomy admitted because of an acute myocardial infarction in the II trimester. No complication of the disease was observed." }, { "id": "wiki20220301en082_40256", "title": "List of ICD-9 codes 390–459: diseases of the circulatory system", "score": 0.008907624633431085, "content": "Heart failure Congestive heart failure unspecified Left heart failure Pulmonary edema, acute Systolic heart failure Diastolic heart failure Heart failure, combined, unspec. Ill-defined descriptions and complications of heart disease Myocarditis unspecified Myocardial degeneration Cardiovascular disease unspecified Cardiomegaly Functional disturbances following cardiac surgery Rupture of chordae tendineae Rupture of papillary muscle Certain sequelae of myocardial infarction not elsewhere classified Certain sequelae of myocardial infarction not elsewhere classified acquired cardiac septal defect Certain sequelae of myocardial infarction not elsewhere classified other Other ill-defined heart diseases Other disorders of papillary muscle Hyperkinetic heart disease Takotsubo syndrome Other ill-defined heart diseases Heart disease unspecified" }, { "id": "wiki20220301en563_1338", "title": "List of cardiology mnemonics", "score": 0.008849557522123894, "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" } ] } } }

{ "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": [ [ 317, 444 ] ], "word_ranges": [ [ 57, 78 ] ], "text": "all the adenopathies at this level that I have seen have ended up corresponding to carcinomas of the upper aerodigestive tract." } }

{ "1": "Scalp.", "2": "Parotid.", "3": "Lung.", "4": "Esophagus.", "5": "Larynx." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0319_14999", "title": "Metastatic laryngeal basaloid squamous cell carcinoma simulating primary small cell carcinoma of the lung on fine needle aspiration lung biopsy. A case report.", "score": 0.013585968738640493, "content": "First described in 1986, the basaloid squamous variant of laryngeal carcinoma is an uncommon, aggressive neoplasm with early presentation of metastatic disease and widespread dissemination. It is characterized primarily by its biphasic morphologic appearance. A 64-year-old female smoker presented with left hilar and right lower lung lobe masses. The fine needle aspiration cytologic findings were consistent with features of primary undifferentiated small cell carcinoma. The basaloid squamous cell carcinoma of head and neck region is a highly malignant neoplasm with frequent metastatic disease at the time of diagnosis. Metastatic deposits may consist of basaloid and/or squamous carcinoma cells. The basaloid component of this biphasic neoplasm is poorly differentiated and demonstrates cytologic features that mimic undifferentiated small cell carcinoma. Previous reports of cervical lymph node metastases from basaloid squamous carcinoma indicate frequent misdiagnosis as small cell carcinoma. Pulmonary metastases are more problematic since they introduce the possibility of a second primary lesion in these patients who have a frequent history of cigarette and/or ethanol abuse. Immunohistochemistry is useful in the distinction of metastatic basaloid squamous carcinoma from a second primary cell carcinoma of the lung." }, { "id": "pubmed23n0845_107", "title": "Thyroid metastasis from small cell lung carcinoma: a case report and review of the literature.", "score": 0.01213235294117647, "content": "Small cell lung carcinoma frequently metastasizes to lymph nodes, liver, adrenal glands, bone, brain and pleura. Metastasis of small cell lung cancer to the thyroid gland is extremely rare. A 55-year-old Turkish man presented with a mediastinal mass intermingled with mediastinal lymphadenopathy, measuring 11cm in total, and encasing superior vena cava and deviating his trachea, esophagus and vascular structures. He had superior vena cava syndrome. His thyroid appeared normal on computed tomography of his chest. A bronchoscopic biopsy showed small cell lung carcinoma. Chemotherapy with cisplatin and etoposide and external radiotherapy was given. Six months after the presentation, multiple brain metastases were detected on magnetic resonance imaging. Chemotherapy was changed to topotecan and cranial irradiation was performed. At the same time, a right thyroid nodule was detected on computed tomography of his chest and showed growth in size in the following 4 months. A palpable right thyroid nodule came to our attention at that time, the 10th month of presentation. Free thyroxine, free triiodothyronine, thyroid-stimulating hormone, antithyroglobulin and antithyroid peroxidase antibodies were within normal limits. Thyroid ultrasonography showed a right thyroid lobe 26.2×16.8×15.7mm hypoechoic solid nodule with irregular borders. Ultrasonography-guided thyroid fine-needle aspiration biopsy showed metastasis from small cell lung carcinoma. His cranial metastases worsened. He developed right cervical lymph node, hepatic, pancreatic and meningeal metastases and died 15 months after the initial presentation and 9 months after the detection of thyroid metastasis by computed tomography of his chest. Our case and two previously reported cases were male, 55-years old or older and had history of more than 40 pack-years of cigarette smoking. All had metastatic disease elsewhere, when the thyroid metastasis was diagnosed by fine-needle aspiration biopsy. All had poor survival, between 9 and 18 months, after thyroid metastasis was diagnosed. We conclude that in a patient with a known history of malignant disease, the finding of a new thyroid mass should be promptly evaluated with a thyroid fine-needle aspiration biopsy to search for metastatic disease. The clinical features of our and two previously reported cases were summarized." }, { "id": "pubmed23n0721_24687", "title": "Primary squamous cell carcinoma of thyroid: a case report and review of literature.", "score": 0.011577760084925691, "content": "Thyroid gland lacks squamous epithelium (except in some rare situations like embroyonic remnants or in inflammatory processes); for that reason the primary squamous cell carcinoma (SCC) of thyroid is extremely rare entity, seen only in less than 1% of all thyroid malignancies and is considered almost fatal. So, far, only few case reports have been published in literature. Herein we present a 54 years old Saudi female with 3 months history of progressive neck swelling and hoarse voice, who was referred to us by her primary care physician as suspected case of anaplastic carcinoma of thyroid for radical external beam radiation therapy (EBRT). Fine Needle aspiration cytology (FNAC) revealed squamous cell carcinoma. Computed tomography (CT) neck showed 10 × 10 cm mass in left lobe of thyroid invading trachea and skin. Extensive staging work up ruled out the possibility of any primary site of SCC other than thyroid gland. Tumor was found unresectable and was referred to radiation oncology. She received palliative EBRT 30 Gy in 10 fractions. After completion of EBRT, there was progression of disease and patient died 3 months after completion of EBRT by airway compromise. Primary SCC of thyroid is rare and aggressive entity. FNAC is reliable and effective tool for immediate diagnosis. Surgery is a curative option, but it is not always possible as most of cases present as locally advanced with adjacent organs involvement. EBRT alone was found ineffective. Aggressive combined modality (debulking surgery, radiation and chemotherapy) shall be considered for such cases." }, { "id": "pubmed23n1030_2408", "title": "Sebaceous lymphadenoma of parotid gland: A case report of a unique presentation in an immunocompromised patient.", "score": 0.009900990099009901, "content": "Sebaceous lymphadenoma is a rare, benign tumor of the parotid gland accounting for only 0.196% of all adenomas of the parotid gland. Our aim is to present a case of sebaceous lymphadenoma, which has been rapidly enlarging over a period of few months in an immunocompromised patient. This presentation is unusual for a benign salivary gland neoplasm. A 55-year-old female who is a known case of systemic lupus erythromatous, antiphospholipid syndrome, and lupus nephritis, which have been treated by cyclophosphamide, presented with a 2-year complaint of fluctuating painless right parotid swelling, over the last 3 months the swelling started to progressively increasing in size. Physical examination showed a 4 × 3 cm firm, nontender mass in the right parotid gland. The facial nerve was intact and no cervical lymphadenopathy. Fine-needle aspiration cytology (FNAC) revealed marked chronic inflammation and was not helpful for diagnosis. Right superficial parotidectomy was performed without complications and there was no recurrence after 24 months of careful follow-up. In patients presenting with a rapidly enlarging parotid mass associated with an intact facial nerve, the possibility of sebaceous lymphadenoma should be considered as an important differential diagnosis in addition to other benign tumors of the parotid gland. The role of FNAC in this neoplasm is controversial." }, { "id": "pubmed23n0295_16085", "title": "Non-squamous malignancy in lymph nodes: the occult primary.", "score": 0.009900990099009901, "content": "The present study presents 105 patients seen at a head and neck specialist clinic with a neck gland which subsequently proved to be a non-squamous malignancy. Of the 105 patients, 50 patients were eventually found to have a tumour in the head and neck region, 30 to have a distant primary and in 25 no primary site was ever found. The majority of patients were diagnosed in the clinic after careful examination and most of the remainder were diagnosed during endoscopy/biopsy. Chest radiography was the most useful investigation for diagnosing primary tumours of the lung. The 5-year-survival for the whole group of 105 patients was 28% (95% CI 17-39). The 5-year-survival for the head and neck primary tumour group was 44% (95% CI 25-60). The median survival of patients with a distant primary tumour was only a 6 months, there was one 5-year-survivor. The median survival for those in whom the primary was never discovered was 18 months. However, a reasonable proportion of these patients survived, five being alive at 5 years. The difference between survival for the three groups was statistically significant (P &lt; 0.001). The most common histological type was undifferentiated/anaplastic tumours (37 out of 105) and this was followed by adenocarcinoma (33 out of 105). There was a significant difference in the survival between these two groups (chi 2 = 2.02, d.f. = 1, P = NS). Multi-variate analysis suggested that survival was better in the older age group and was affected by histology (P = 0.0093, P = 0.0332 respectively). The present study suggests that the treatment of patients in whom the primary site is eventually found to be in the head and neck region is rewarding with the same survival as a similar group of patients with squamous cell carcinoma. Sixty of the group of 105 patients had excision biopsies of the neck node and this did not affect survival." }, { "id": "pubmed23n0758_18855", "title": "Primary squamous cell carcinoma of the parotid gland: a rare entity.", "score": 0.00980392156862745, "content": "Primary squamous cell carcinoma of the parotid gland is a rare aggressive malignancy. It is a rapidly advancing lesion which, if not recognised and treated early, results in high morbidity and mortality. Despite radical surgery and adjuvant radiotherapy, prognosis of this cancer continues to be poor. Careful clinical and histological examination is mandatory to differentiate this tumour from metastatic squamous cell carcinoma and other primary malignancies of the parotid. The authors hereby report the case of a 50-year-old male patient who presented with a progressively increasing, painless mass in parotid region of 6 months duration. An initial fine-needle aspiration cytology and subsequent histopathological examination confirmed that the tumour was squamous cell carcinoma. As no other primary source could be demonstrated in the patient, a final diagnosis of primary squamous cell carcinoma of parotid was offered. Currently the patient is on regular follow-up without any signs of recurrence." }, { "id": "pubmed23n0025_7038", "title": "[Primary bronchogenic and pharyngo-laryngeal carcinomas (author's transl)].", "score": 0.00980392156862745, "content": "The study of 112 case histories of lung cancers, both primary and secondary, has allowed the authors to determine as being of 5% the incidence of primary bronchogenic carcinoma associated with treated pharyngo-laryngeal cancer. One out of three such primaries was a solitary lung opacity. Bronchogenic primaries appeared be almost as frequent as lung, pleura and mediastine secondarie. They can be diagnosed at any moment of the treatment or follow-up of pharyngo-laryngeal cancer, and appear to occur later than pulmonary metastases. Their symptoms are more \"bronchopulmonary\" in nature. They are more frequently associated with endolarynx and chorda carcinomas. They are possibly more frequent in cases of smaller primaries without lymph-node involvement. Solitary lung opacities should be considered as independent primaries and constitute the best candidates for efficient pulmonary treatment. Treated pharyngo-laryngeal patients should undergo regularly spaced lung roentgenograms and frequent tracheal sputum cytology." }, { "id": "pubmed23n0725_22017", "title": "Correct diagnosis of Warthin tumor in the parotid gland with dynamic MRI.", "score": 0.009708737864077669, "content": "Warthin tumor (WT) is a benign tumor of the salivary gland primarily affecting middle-aged men. WT is almost exclusively located in the parotid gland and tend to grow slowly without symptoms. Although fine needle aspiration cytology (FNAC) often correctly diagnoses these tumors, they are occasionally misdiagnosed as malignant. Our study sought to distinguish between WT and non-WT using dynamic MRI. In dynamic MRI, a series of images are taken over time measuring the intensity of gadolinium uptake by the parotid. We examined two patients for this study. The first was a 53-year old male, heavy smoker, experiencing manic-depressive episodes. He received a brain MRI at which time his parotid tumor was discovered. Parotid FNAC indicated a squamous cell carcinoma. The second patient was a 76-year old male, moderate smoker and drinker, who had been complaining about swelling in the neck. FNAC of the parotid indicated acinic cell carcinoma and gadolinium-enhanced MRI suggested the tumor was malignant. Prior to surgically extracting of these masses, we performed dynamic MRI on each patient. Both tumors exhibited a pattern consisting of rapid enhancement and rapid attenuation, the pattern of which is characteristic of WT. The surgical specimens confirmed that both were WTs without malignant transformation. Our findings indicate that dynamic MRI is a useful tool for preoperative diagnosis of WT, where other examinations indicate malignancy. Early and correct diagnosis of WT can minimize the use of invasive procedures, and eliminate the stress placed on the patient from a diagnosis of cancer." }, { "id": "pubmed23n1132_4324", "title": "Esophageal myoepithelial carcinoma: Four case reports.", "score": 0.009708737864077669, "content": "Myoepithelial carcinoma (MC) is a rare malignant neoplasm that mainly occurs in the salivary gland. MC can be confused with many other tumors when arising outside the salivary glands because it presents with a wide spectrum of cytomorphological and immunohistochemical features. To the best of our knowledge, esophageal MC has not been previously reported. The purpose of this study was to describe the imaging and clinicopathological features of esophageal MC to improve the understanding of the disease. Three men and one woman diagnosed with esophageal MC were enrolled in this study. The primary clinical symptom was dysphagia. The mass was mainly located in the middle esophagus. Laboratory tests revealed that two patients who underwent tumor abnormal protein were positive. Radical resection was performed for all patients with no adjuvant therapy. Hematoxylin-eosin staining showed infiltrative growth of epithelial cells with hyperchromatic and pleomorphic nuclei toward the periphery. Immunohistochemistry showed that all patients were positive for P63, and most patients were positive for SOX-10, AE1/AE3, P40, and calponin. The Ki-67 values were all higher than 60%. Patient one died one month after discharge from an unknown cause. Patient two lost to follow-up. At patient three's four-month review, enhanced computed tomography (CT) showed anastomosis recurrence and bilateral lung metastases. He abandoned treatment and lost to follow-up. Patient four attended review appointments regularly and remained in a good general condition. Here, we present the first report of esophageal MC and review the relevant literature. Esophageal MC is more likely to occur in the middle esophagus in older patients with male dominance. A fungating type observed on CT scanning may help narrow down the differential diagnosis. Cystic change or necrosis may occur in larger lesions. The final diagnosis should be made according to the pathological examination. The treatment for MC is surgical resection, and the efficacy of chemotherapy needs to be determined with future studies." }, { "id": "pubmed23n1008_6663", "title": "Warthin-like mucoepidermoid carcinoma of the parotid gland: a diagnostic and therapeutic dilemma.", "score": 0.009615384615384616, "content": "Mucoepidermoid carcinoma (MEC) is the most common malignant salivary gland tumor. Although the parotid gland is the most common site of involvement, other major salivary glands and the minor salivary glands-most commonly of the palate-also can be involved. The management of mucoepidermoid carcinoma depends on the grade of the tumor and the adequacy of resection. We present the case of a 56-year-old female presenting a painless progressive cheek mass over 2 months. Imaging and fine-needle aspiration cytology provided the diagnosis of Mucoepidermoid carcinoma. A superficial parotidectomy was done, and the histopathology revealed a predominantly cystic tumor with a bilayered epithelium of oncocytic and basal cells. Moderate nuclear pleomorphism with infiltration of atypical squamous cells in few glandular cysts was seen. Special staining revealed the presence of intracellular mucin. A diagnosis of Warthin-like variant of MEC was made, based on these findings. After the surgical procedures, the patient is disease-free at 8 months of follow-up. The Warthin-like variant is a rare variant of MEC with fewer than 10 cases described in the English literature. Various differential diagnoses include the malignant transformation of Wartin tumor (WT), squamous metaplasia of WT, and metastasis from a distant primary. We emphasize the role of routine microscopy in identifying rare variants of common malignancies. Even though translocation studies are helpful in diagnosis, the typical histopathological findings should confirm it." }, { "id": "pubmed23n0843_2885", "title": "Second primary tumours in head and neck cancer.", "score": 0.009615384615384616, "content": "Head and neck cancer patients have a higher risk of second primary tumours than the general population. The most frequent locations are head and neck, lung and oesophagus, decreasing long-term survival. The aim of this work was to analyse the incidence, location according to index tumour and stage, chronology, patient age, and survival after diagnosis. Retrospective study on 579 patients with head and neck squamous cell carcinoma, treated with curative intent, with a minimum 24-month follow-up. Early stages (I/II) were 42.4%, and 57.6% were stages III and IV. Second primary tumour incidence was 15% (87/579), with 9.2% (8/97) developing a third tumour. The most frequent locations of the second tumours were head and neck, 37.9% (33/87); lung, 36.8% (32/87); oesophagus, 5.7% (5/87); and colon, 5.7% (5/87). Five- and 10-year survival in patients without a second tumour was 65.1% and 52.7% respectively, versus 58.7% and 40.2% in those who developed one. The incidence of second primary tumours increased in the last decade, having a negative effect on survival. Since no specific early diagnosis tool is available, alcohol and tobacco avoidance along with scheduled follow-up are suggested procedures to reduce its incidence." }, { "id": "pubmed23n0626_15381", "title": "Cytologic features of metastatic lymphoepithelial carcinoma in pleural fluid: a case report.", "score": 0.009523809523809525, "content": "Lymphoepithelial carcinoma of the salivary gland is a rare undifferentiated or poorly differentiated squamous cell carcinoma associated with abundant inmphocytes. Only a handful of reports descibe the cytologic features of fine needle aspiration in lymphoepithelial carcinoma of the salivary gland and lymph nodes. A 29-year-old man presented with a painless mass in his right parotid gland. After the surgical specimen was evaluated, the mass was diagnosed as a lymphoepithelial carcinoma, which extended to the periglandular soft tissue with lymph node metastasis. Despite radiation and chemotherapy, multiple mediastinal lymph node metastases, including in the right hilar lymph nodes, occurred. Pulmonary atelectasis of the right upper lobe and a right pleural effusion developed. Aspiration cytology of metastatic lymph nodes and pleural effusion cytology both demonstrated strongly cohesive clusters of tumor cells. These cells had vesicular nuclei and prominent nucleoli admixed with benign lymphoid cells. Pleural effusion cytopathology ofmetastatic lymphoepithelial carcinoma is similar to that of primary tumor fine needle aspiration. Therefore, a specific diagnosis of lymphoepithelial carcinoma is possible on the basis of body fluid with these cytologic features." }, { "id": "pubmed23n0355_21764", "title": "[Metastatic squamous cell carcinoma of hilar lymph node with unknown primary site].", "score": 0.009523809523809525, "content": "An abnormal shadow was observed on chest X-ray films of a 63-year-old man presenting with cough and sputum. Chest computed tomographic scans disclosed enlargement of the right hilar lymph nodes, but no obvious primary lesion was found in the lung field. Bronchoscopic examination revealed a slightly widened second carina, but no malignant cells were detected by transbronchial aspiration cytology. At surgery, a tumor was found between the truncus superior and the truncus intermedius. The pathologic diagnosis was a metastatic lymph node of poorly differentiated squamous cell carcinoma. Because the tumor severely adhered to the bronchus and pulmonary arteries, we performed a right pneumonectomy with mediastinal node dissection. Pre- and postoperative examinations did not detect the primary lesion, and no recurrence had been observed 76 months after surgery. This was thought to be a very rare case of T0 N1 M0 lung cancer. In general, the prognosis is poor for patients with metastatic carcinoma of unknown primary site. However, patients with T 0 lung cancer, as in this case, might enjoy a better prognosis if complete resection and dissection of metastatic lymph nodes are performed." }, { "id": "pubmed23n0493_7452", "title": "Unilateral, multicentric Warthin's tumor mimicking a tumor metastatic to a lymph node. A case report.", "score": 0.009433962264150943, "content": "Warthin's tumor may be associated with false positive diagnoses of malignancy on fine needle aspiration. The most common cause of error is markedly atypical squamous metaplasia mimicking metastatic cystic squamous carcinoma. The common location of Warthin's tumors within periparotid nodes may add to the clinical suspicion of metastasis. We report a case of unilateral, multicentric Warthin's tumor arising in periparotid and intraparotid glands, leading to a strong clinical and cytologic suspicion of malignancy. A 60-year-old female presented with a 3-month history of several enlarged lymph nodes in the right side of the neck. Fine needle aspiration, performed at the right upper neck lymph node, suggested the possibility of metastatic tumor. On computed tomography and ultrasonography there were 4 nodular lesions in the right retromandibular area and lateral aspect of the neck, 1-1.5 cm in diameter. A thyroid scan revealed diffuse enlargement of the thyroid gland and a nodular lesion in the right lobe. Right thyroid lobectomy and modified radical neck dissection, including right superficial parotidectomy, were performed for evaluation of occult malignancy. Histologically we confirmed that the tumor was a synchronous, multicentric Warthin's tumor arising in the parotid gland and intraparotid and paraparotid lymph nodes. Clinicians and pathologists should consider an extraparotid Warthin's tumor in the differential diagnosis of multiple cervical masses." }, { "id": "pubmed23n0558_14710", "title": "[Clinical report of 81 cases of multiple primary cancers in laryngeal carcinoma].", "score": 0.009433962264150943, "content": "To explore the clinical characteristics and the survival status of the patients with laryngeal squamous cell carcinoma in the multiple primary cancers (MPC). Follow-up and clinical data were analyzed retrospectively in 81 laryngeal squamous cell cancer patients with MPC among 1101 patients with laryngeal carcinoma. Survival analysis and every influencing factor on survival rate were performed by Kaplan-Meier method. The occurrence rate of MPC in the patients with laryngeal squamous cell cancer was 7.4% (81/1101) in this report. Oral cavity carcinoma and nasopharyngeal carcinoma were the most common MPC in 29 cases (35.8%) in head and neck regions. MPC in head and neck regions were more often seen among patients who had treated with radiotherapy (chi2 = 5.7, P = 0.017). Lung carcinoma (25.9%, 21/81) and esophageal carcinoma (22.2%, 18/81) were the most common MPC in remote organs in 52 cases (64.2%). Thirty seven MPC cases (45.7%) were occurred in aerodigestive tract and 32 cases(39.5%) in respiratory tract in this series. Fourteen cases (17.3%) were synchronous MPC, the median time interval was 2 months. Other 67 cases (82.7%) were metachronous MPC, the median time interval was 28 months. The squamous cell carcinoma (66.7%) was the most common pathologic type among all MPC in 81 cases, which was more often seen among patients who had smoked and drunk (P = 0.007). The MPC of esophageal carcinoma and oropharyngeal carcinoma were more often seen among patients of supraglottic index cancer presentation (P = 0.04). The MPC of oral cavity cancers and nasopharyngeal carcinoma and lung carcinoma were more often seen among patients of glottic index cancer presentation (P = 0.006). The total three-and five-year survival rates were 45.2% and 29.7% respectively of all MPC patients, the five-year survival rate for patients (53 cases) who received actively different therapies for their MPC was 45.5%, obviously higher than that of untreated patients (28 cases) whose three-year survival rate was zero (P = 0.000). Lung carcinoma and esophageal carcinoma were the most common multiple primary cancers among MPC of the laryngeal cancer. MPC of the laryngeal cancer in head and neck regions were more often seen among patients who had treated with radiotherapy. The pathologic type of squamous carcinomas of MPC was more often seen among patients who had smoked and drunk. MPC affected the prognosis of patients in laryngeal cancer largely. Treating effectively and in time could help to improve the survival rate of patients with MPC in laryngeal squamous cell carcinomas." }, { "id": "pubmed23n0900_20736", "title": "Bilateral Basaloid Squamous Cell Carcinoma of the Parotid Gland: A Case Report and Review of the Literature.", "score": 0.009345794392523364, "content": "We describe the first known case of bilateral basaloid squamous cell carcinoma of the parotid gland, and we review existing literature. A previously healthy, 70-year-old white man presented with a 2-cm enlarging mass in the tail of the right parotid gland. Magnetic resonance imaging and computed tomography showed ipsilateral pathologic adenopathy. Results of fine-needle aspiration revealed a high-grade malignancy with squamous features. The patient underwent a right total parotidectomy and modified radical neck dissection. Final pathologic findings revealed a basaloid squamous cell carcinoma. Four years after the initial resection, the patient presented with an enlarging left parotid mass. Findings of fine-needle aspiration and imaging were similar to those 4 years earlier. The patient received a left total parotidectomy and modified radical neck dissection. Postoperative radiation therapy was performed after each surgical intervention. He remains disease free at 4-year follow-up after the second mass was resected. Squamous cell carcinoma with basaloid features is a rare and aggressive type of squamous cell carcinoma. To our knowledge, this is the first case report of bilateral parotid basaloid squamous cell carcinoma." }, { "id": "pubmed23n0243_6331", "title": "Panendoscopy for second primaries in head and neck cancer.", "score": 0.009345794392523364, "content": "Four hundred patients with biopsy-proven squamous cell carcinoma of the upper aerodigestive tract were studied for evidence of a synchronous second primary tumor. The protocol of study included in most cases direct laryngoscopy, metal tube bronchoscopy, and esophagoscopy. Chest x-ray studies were performed on all patients and many had barium swallow x-ray studies. Asymptomatic second head and neck primary tumors were found only in the vallecula and esophagus among this series of patients. Metachronous second primary tumors were presented as early as one month after the original endoscopy and were located in areas which had been carefully examined by endoscopy and appeared asymptomatic to the examining physician at the time of the original evaluation. Based on this series of patients, we recommend careful indirect laryngoscopy and oral examination, direct laryngoscopy and esophagoscopy as well as a barium swallow for patients with clinically suspicious mucosal lesion of the upper aerodigestive tract. In view of our failure to discover a single lung carcinoma which was not evident from chest x-ray studies, we recommend bronchoscopy, which adds some morbidity to the endoscopic procedure, not be included unless a specific clinical suspicion is entertained. However, because of the important treatment implication which follow the diagnosis of a new squamous cell carcinoma of the upper aerodigestive tract, we feel it is imperative that the entire esophagus be evaluated in the course of the pretreatment exploration of the patient. Although few esophageal tumors were discovered, their implications in terms of surgical resection and debilitation without much likelihood of long-term patient survival has encouraged us to continue the above described procedure." }, { "id": "pubmed23n1042_12499", "title": "Primary parotid lymphoepithelial carcinoma: A case report and literature review of a rare pathological entity.", "score": 0.009259259259259259, "content": "Lymphoepithelial carcinoma (LEC) of the salivary glands is a rare, but distinct, poorly-differentiated neoplasm that resembles undifferentiated nasopharyngeal carcinomas (NPC). Among primary salivary gland LECs, they most commonly arise in the parotid gland. These lesions have a noticeable racial predilection, mostly occurring in Asians and Arctic region native populations. They are strongly associated with Epstein-Barr virus (EBV), and are more common in EBV-endemic areas. The most common presenting symptoms of primary parotid LEC are parotid mass development and cervical lymphadenopathy. We report an unusual case of EBV-negative LEC in a Canadian Caucasian woman. A 40-year-old female from Atlantic Canada presented with a rapidly enlarging preauricular mass and cervical lymphadenopathy. Preoperative diagnostics via radiology and fine needle aspiration alluded to an ambiguous primary parotid malignancy. She underwent a total parotidectomy with facial nerve sacrifice and ipsilateral selective neck dissection. The facial nerve was reconstructed with a lateral antecubital nerve graft. Pathology came back positive for LEC, and she began adjuvant radiotherapy. At her 1-year follow up, she was disease-free and obtained a House-Brackmann facial nerve function grade of 3. The case report highlights the importance of having a high index of suspicion and the need for interdisciplinary collaboration in reaching the diagnosis of primary parotid LEC. LEC can afflict patients of any ethnicity in non-EBV endemic areas and should therefore be considered in all patients with a painless parotid mass regardless of ethnicity. Further studies are required to elucidate the oncogenic role of EBV in these cancers." }, { "id": "pubmed23n0358_12238", "title": "[Multiple primaries of the upper aerodigestive tract, esophagus, and lung].", "score": 0.009259259259259259, "content": "The existence of multiple primary tumors of the upper aerodigestive tract, esophagus, and lung (UADT-E-L) is related with a common etiopathogenic factor (alcohol-tobacco association). In a review of 43 patients, 6.75% with a UADT-E-L tumor developed another neoplasm, 3.25% at the same site. Nine percent (8.59%) of the tumors were synchronic and 10.85% were metachronic. The most frequent association was larynx-lung. Another neoplasm was detected by physical examination and/or radiology in 44.18% of cases, with a time lapse of less than 3 years in 50%. The most frequent treatment was surgery with/without complementary radiotherapy. The most common stage was T1-T2 (62.06%) and N0-N1 (68.96%). The survival rate was 31% at 2 years and 25% at 3 years." }, { "id": "pubmed23n1090_7132", "title": "Graves disease and metastatic hormonal-active Hürthle cell thyroid cancer: A case report.", "score": 0.009174311926605505, "content": "A hormone-active metastatic Hürthle cell thyroid carcinoma (HCTC) and Graves disease (GD) present a therapeutic challenge and is rarely reported. We present a 64-year-old male patient, who had dyspnea and left hip pain lasting 4 months. He had clinical signs of hyperthyroidism and a tumor measuring 9 cm in diameter of the left thyroid lobe, metastatic neck lymph node and metastases in the lungs, mediastinum, and bones. Laboratory findings confirmed hyperthyroidism and GD. Fine-needle aspiration biopsy and cytological investigation revealed metastases of HCTC in the skull and in the 8th right rib. A CT examination showed a thyroid tumor, metastatic neck lymph node, metastases in the lungs, mediastinum and in the 8th right rib measuring 20 × 5.6 × 4.5 cm, in the left acetabulum measuring 9 × 9 × 3 cm and parietooccipitally in the skull measuring 5 × 4 × 2 cm. Histology after total thyroidectomy and resection of the 8th right rib confirmed metastatic HCTC. The region of the left hip had been irradiated with concomitant doxorubicin 20 mg once weekly. When hyperthyroidism was controlled with thiamazole, a total thyroidectomy was performed. Persistent T3 hyperthyroidism, most likely caused by TSH-R-stimulated T3 production in large metastasis in the 8th right rib, was eliminated by rib resection. Thereafter, the patient was treated with 3 radioactive iodine-131 (RAI) therapies (cumulative dose of 515 mCi). Unfortunately, the tumor rapidly progressed after treatment with RAI and progressed 10 months after therapy with sorafenib. Despite treatment, the disease rapidly progressed and patient died due to distant metastases. He survived for 28 months from diagnosis. Simultaneous hormone-active HCTC and GD is extremely rare and prognosis is dismal. Concomitant external beam radiotherapy and doxorubicin chemotherapy, followed by RAI therapy, prevented the growth of a large metastasis in the left hip in our patient. However, a large metastasis in the 8th right rib presented an unresolved problem. Treatment with rib resection and RAI did not prevent tumor recurrence. External beam radiotherapy and sorafenib treatment failed to prevent tumor growth." }, { "id": "pubmed23n0491_9803", "title": "Cervical lymph node metastases of squamous cell carcinoma from an unknown primary.", "score": 0.009174311926605505, "content": "Cervical lymph node metastases of squamous cell carcinoma from occult primary constitute about 2-5% of all patients with carcinoma of unknown primary site (CUP). Metastases in the upper and middle neck are generally attributed to head and neck cancers, whereas the lower neck (supraclavicular area) involvement is often associated with primary malignancies below the clavicles. The diagnostic procedures include physical examination with thorough evaluation of the head and neck mucosa using fiber-optic endoscopy, biopsies from all suspicious sites or blindly from the sites of possible origin of the primary, computer tomography and/or magnetic resonance. A systematic tonsillectomy in the absence of suspicious lesions is often recommended since up to 25% of primary tumors can be detected in this site. The thoracic primary (tracheal, bronchial, lung, esophagus) has to be excluded, especially in the case of lower neck involvement. Positron emission tomography (PET) with fluoro-2-deoxy-D-glucose allows detection of primary tumor in about 25% of cases, but this procedure is still considered investigational. Therapeutic approaches include surgery (lymph node excision or neck dissection), with or without postoperative radiotherapy, radiotherapy alone and radiotherapy followed by surgery. In early stages (N1), neck dissection and radiotherapy seem to have similar efficacy, whereas more advanced cases (N2, N3) necessitate combined approaches. The extent of radiotherapy (irradiation of bilateral neck and mucosa versus ipsilateral neck radiotherapy) remains debatable. A potential benefit from extensive radiotherapy should be weighted against its acute and late morbidity and difficulties in re-irradiation in the case of subsequent primary emergence. The role of other methods, such as chemotherapy and hyperthermia, remains to be determined." }, { "id": "pubmed23n1132_3246", "title": "Osteoclast-like giant cell tumor of the parotid gland; a case report with literature review.", "score": 0.00909090909090909, "content": "The osteoclast-like giant cell is a benign tumor that presents as either an isolated benign tumor or one with a carcinomatous component. This study aims to report a rare case of osteoclast-like giant cell tumor (GCT) of the parotid gland. A 67-year-old female presented with a painless left pre-auricular swelling of 2-month duration which increased in size gradually over that period. On examination, there was a firm, mobile mass with well-defined borders in the left parotid gland. Fine needle aspiration cytology showed a giant cell-rich lesion that was highly cellular and contained a large number of osteoclast-like multinucleated giant cells, with clusters of spindle and epithelioid cells. Total parotidectomy was performed. After the operation, the patient was sent for radiotherapy. The histogenesis and exact nature of this tumor are unknown although numerous ideas have been put forward. The most common clinical manifestation is a painless slow-growing tumor in the parotid area. Primary osteoclast-like GCT of the salivary gland might show concomitant benign or malignant neoplasms. There is also a \"pure form\" of the tumor that has no accompanying neoplasm. GCT of the parotid gland is a rare tumor. The histogenesis and nature of parotid gland GCT are not completely understood. The treatment of choice is total excision followed by radiotherapy." }, { "id": "pubmed23n0229_4048", "title": "Multiple primary cancers in Indian population: metachronous and synchronous lesions.", "score": 0.00909090909090909, "content": "A retrospective study of 177 patients attending Tata Memorial Hospital over a period of 40 years from 1942 through 1981 is presented. These patients who had \"primary lesions\" in the head and neck region, breast, esophagus, lung, and elsewhere as carcinoma or sarcoma developed \"second primary\" at different sites, after the treatment for the primary lesion after a variable period over years--as \"metachronous lesions\" (139 patients). Another group of patients presented with \"double primary\" at initial clinical examination and investigations, and these were \"synchronous\" lesions (38 patients). The analysis brings out the relationship of these lesions in both groups to each other with reference to habits in Indian population, viz, pan chewing, tobacco smoking, and alcohol consumption and time interval and histological variations among these lesions. An interesting relationship has been observed in certain aerodigestive tract primary lesions developing second cancer due to continued effect of \"carcinogens,\" as habits are hard to die even after developing cancer. Analysis also brings out an interesting observation of involvement of \"physiologically and anatomically\" related organs developing second cancer at an interval or concurrently. A solitary pulmonary nodule or an opacity in a patient with extrathoracic cancer should not be considered as \"metastatic\" unless proved otherwise; metachronous lesions need to be treated energetically, adequately, efficiently, and aggressively in certain clinical situations for better results and salvage." }, { "id": "pubmed23n0825_1319", "title": "[Primary squamous cell carcinoma of the breast - a case report].", "score": 0.009009009009009009, "content": "Breast cancer is the most common malignant tumor among women in Poland. According to the Center of Oncology (The National Cancer Registry) in 2010 in our country 15,784 new cases have been noted. Since 1970s worldwide growth of new cases of breast cancer have been reported. Among the well-known histological types of breast tumors, small percentage - only 0.1% - include squamous cell component. A 69-year-old female met her doctor because of the right breast tumor. After two months of observation, in the last two weeks before the visit, the tumor started to grow very rapidly. As the diagnosis from fine needle aspiration biopsy (squamous cell carcinoma) was very rare for this location, and considering the other clinical symptoms the woman reported, it was suspected to be metastatic. Finally, as the other origins of the primary tumor have been declined and as the patient's condition begun to worsen very rapidly, the urgent treatment: mastectomy (toilet mastectomy) and adjuvant chemotherapy afterward, according to the pathological report were performed. Rare histological types of the breast cancer use to suggest a metastatic origin or behave as tumors with highly malignant histological grade." }, { "id": "pubmed23n0592_4949", "title": "[Second primary tumors development in head and neck region. Case report].", "score": 0.009009009009009009, "content": "Tumours of head and neck present 12.2% of the pernicious tumours' morbidity rate in Poland. Annually, the number of new cases is around 6500. The authors of this work present a case of a 65-year-old farmer who has been smoking for 40 years and occasionally abusing alcohol. The medical history of the patient includes: arterial hypertension, ureterolithiasis, obesity. The patient's brother suffered from knee cancer. In 1998 the patient underwent ablation of carcinoma (2x2 cm) from the left auricle. The result of histopathological examination was Carcinoma planoepitheliale keratodes. In 2003, due to Carcinoma planoepitheliale laryngis, horizontal surgery of the larynx was performed. In the same year the patient had superficial lobe of the left parotid gland removed (due to Carcinoma planoepitheliale glandulae parotis sinisti). After the surgery, supplementary treatment was introduced (irradiation Co60; dose--60Gy on the treated area). Currently the patient is under systematic supervision. He is in a good clinical condition. There have been no features of local growth in the treated organs nor any remote metastasis reported." }, { "id": "pubmed23n0327_2920", "title": "Cystic lesion of the parotid gland with squamous metaplasia mistaken for squamous cell carcinoma. A case report.", "score": 0.008928571428571428, "content": "The diverse range of diseases that affect the salivary glands may lead to problems and pitfalls in cyto-diagnosis. While false negative diagnosis of cystic salivary gland tumors is well known, false positive cytodiagnosis in nonneoplastic salivary cysts is less well documented. An 85-year-old female presented with a painless left parotid gland swelling of three months' duration. Fine needle aspiration cytology yielded fluid, smears of which showed keratinizing squamous cells with nuclear atypia leading to a cytologic diagnosis of cystic squamous cell carcinoma. A total radical parotidectomy followed. Histopathologic study showed cystic dilatation of many of the salivary ducts, which were lined with metaplastic squamous epithelium that showed atypia. There was no evidence of squamous cell carcinoma. Squamous metaplasia is known to occur in benign salivary gland lesions, such as pleomorphic adenoma and Warthin's tumors, as well as in salivary duct cysts and necrotizing sialometaplasia. However, atypical squamous metaplasia of salivary duct cysts mimicking squamous cell carcinoma on cytology is unusual." }, { "id": "pubmed23n0278_5688", "title": "Squamous carcinoma presenting as an enlarged cervical lymph node.", "score": 0.008928571428571428, "content": "Patients presenting with an enlarged cervical lymph node containing squamous cell carcinoma are a difficult problem for head and neck surgeons. In most cases, the primary site lies in the head and neck region. The advent of fine-needle aspiration cytologic study means that this group of patients can be accurately identified in the clinic and investigated accordingly. The current report studies the records of 267 such patients presenting to the Head and Neck Unit at The University of Liverpool over a 29-year period. The 5-year survival rate for all patients presenting with a cervical lymph node metastasis was 27%. The 5-year survival rate for patients with a detected primary in the head and neck was 31% and the primary site was identified during the patient's life time in all but 36 patients (13%). In 53% of patients, the primary site was discovered during routine clinical examination, and in a further 16% it was discovered at panendoscopy. Most diagnostic tests proved relatively unhelpful but 10 patients in our series had the primary site discovered by radiograph and 9 of these had carcinoma of the lung. In the current study when the primary site was discovered it was in the head and neck region in 74% of patients. Primary sites other than head and neck occurred in 11% of the patients and no 5-year survivors existed. Multivariate analysis suggested that open biopsy of the lymph node metastasis appeared to have an adverse effect on survival as did advanced age and advanced N stage. The late diagnosis of the primary site, if it proved to be in the head and neck region, on the other hand, had a positive association with survival. Patients presenting with a lymph node metastasis in the head and neck region from an unknown primary have a prognosis identical to that of other patients with head and neck squamous carcinoma with neck node metastases. The prognosis for patients in whom the primary site is never discovered or in whom the primary site is not head and neck, however, is disastrous. If the primary tumor proves to be in the head and neck region, treatment is worthwhile since almost a third of patients are cured of their disease. When the primary carcinoma is not in the head and neck region, treatment must be considered palliative." }, { "id": "pubmed23n0639_13842", "title": "A rare case of paratesticular pleomorphic rhabdomyosarcoma diagnosed by fine needle aspiration: a case report.", "score": 0.008849557522123894, "content": "Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma of children and young adults. It represents 6.5% of all malignant tumors in pediatrics with an annual incidence of 4 to 7 cases per million children. Embryonal RMS arising in paratesticular region in young males is a common entity, however pleomorphic RMS in such location is quite rare. An eighteen year old male presented with painless right scrotal mass measuring 7 x 6 x 5 cm of two year duration, which was reported on ultrasonography as extratesticular tumor. Fine needle aspiration showed cellular smears comprising of pleomorphic population of mostly singly scattered cells and few cell aggregates. Few isolated large cells with whip like cytoplasmic processes and faint cross-striations were also seen. A diagnosis of paratesticular malignant mesenchymal tumor probably RMS was made. Tumor was removed surgically with right sided orchidectomy. On histopathology, it was reported as pleomorphic RMS. There was focal lymphatic invasion and involvement of rete testis. Immunostaining of tumor cells revealed myogenin and desmin positivity. The case is being presented because of diagnosis of RMS on Fine needle aspiration and rare occurrence of pleomorphic RMS in paratesticular location." }, { "id": "pubmed23n1106_24290", "title": "[Retrospective study of thyroid invasion and central lymph node metastasis in 124 patients with hypopharyngeal carcinoma].", "score": 0.008849557522123894, "content": "<bObjective:</b To investigate the characteristics of thyroid invasion and central lymph node metastasis of hypopharyngeal carcinoma, and the impact on survival rate and quality of life. <bMethods:</b A retrospective analysis of 124 cases (122 males and 2 females with age range from 36 to 78 years old) with laryngopharyngeal squamous cell carcinoma who were initially treated in the Department of Head and Neck Surgery, Beijing Tongren Hospital Affiliated to Capital Medical University from January 2014 to December 2017 was performed. The clinical data included tumor location, pathological T stage, pathological N stage, invasion of thyroid gland, central lymph node metastasis, surgical procedures and so on. Patients were grouped according to if presence of thyroid invasion and central lymph node metastasis. With follow-up, the survival was analyzed by Kaplan-Meier method, and tumor recurrence and metastasis were evaluated. <bResults:</b Of the patients, 12 patients had thyroid involvement and 5 patients had central lymph node metastasis. The incidence of thyroid involvement was 8.16% (8/98) in pyriform sinus, 1/18 in posterior pharyngeal wall and 3/8 in posterior cricoid wall, with statistically significant difference (χ<sup2</sup=15.076,<iP</i=0.008). The incidence of central lymph node metastasis was 1.02% (1/98) in pyriform sinus, 3/18 in posterior pharyngeal wall and 1/8 in posterior cricoid wall, also with statistically significant difference (χ<sup2</sup=11.205, <iP</i=0.008). There was no statistical correlation between thyroid invasion or central lymph node metastasis and gender, smoking or alcohol exposure history and tumor pathological differentiation (all <iP</i&gt;0.05). The 3-year overall survival rate was 80.65% and the 3-year recurrence free rate was 85.48%. Totally 24 patients died in 3 years, including 4 cases in thyroid invasion group and 1 case in central lymph node metastasis group. Local recurrence occurred in 18 patients, including 4 cases in thyroid invasion group and 1 case in central lymph node metastasis group. There was no significant difference in survival between patients with and without thyroid invasion and central lymph node metastasis (all <iP&gt;</i0.05). There were significantly difference in 3-year overall survival and relapse-free survival among the groups with different T stages, N stages, pathological stages and tumor pathological differentiation levels (all <iP&lt;</i0.05). There were significantly differences in the levels of serum calcium and FT3 between the groups with or without thyroid invasion and central lymph node metastasis (all <iP</i&lt;0.05). <bConclusion:</b The incidences of thyroid invasion and central lymph node metastasis of hypopharyngeal carcinoma are rare, and the risk of occurrence is related to the primary site of tumor. Comprehensive evaluation, correct decision-making and accurate treatment could be helpful to cure radically the tumor, to prevent recurrence and to improve the quality of life of patients." }, { "id": "pubmed23n0995_19384", "title": "THYROID METASTASIS FROM CLEAR CELL CARCINOMA OF THE KIDNEY 16 YEARS AFTER NEPHRECTOMY.", "score": 0.008771929824561403, "content": "The thyroid gland is one of the most vascularized organs in the body. However, metastatic disease to the thyroid gland is rare. When it does occur kidney is the most common primary tumor site, followed by melanoma, lung, breast, esophagus, uterus and colon carcinoma. We describe the case of an isolated thyroid metastasis from clear cell renal carcinoma occurring 16 years after nephrectomy. An 82 years-old woman presented for the recent growth of a right thyroid nodule, diagnosed 3 years before, when a fine needle aspiration biopsy found a benign cytology suggesting a well-differentiated follicular thyroid adenoma. Her medical history included type 2 diabetes mellitus, atrial fibrillation and a right nephrectomy for a clear cell renal carcinoma done 16 years before. The patient has lost weight but she was otherwise asymptomatic. The right lobe goiter was painless, firm, and mobile with deglutition, without signs of local compression or latero-cervical lymphadenopathy. Thyroid ultrasonography revealed an enlarged (9.9 cm) macronodular right lobe, with multiple cystic areas, with normal left lobe and a thrombus in the right internal jugular vein. Thyroid function tests were normal. The patient was suspected of thyroid carcinoma and underwent a near total thyroidectomy. Histopathological examination revealed a metastasis of clear cell renal carcinoma in the right thyroid gland lobe (8.5/5/5 cm). Further imaging showed no primary tumor or other metastases. Metastatic renal carcinoma to the thyroid should be considered in any patient presenting with a thyroid mass and a medical history of operated renal cell carcinoma, since it can occur up to 25 years after nephrectomy." }, { "id": "pubmed23n0741_5319", "title": "Nodal metastases from laryngeal carcinoma and their correlation with certain characteristics of the primary tumor.", "score": 0.008771929824561403, "content": "5O cases of carcinoma larynx were included in a prospective study to detect the incidence and pattern of nodal metastases (both clinical and occult) and to study the influence of certain characteristics of the primary tumor on the incidence of nodal metastases. In our study 66% (33 cases) of the lesions were transglottic as compared to 24% (12 cases) supraglottic and 10% (5 cases) glottic lesions. The most common age group affected in our study was 51-60 years comprising 50% of the cases. The most common symptoms were hoarseness, breathlessness and difficulty in swallowing. The incidence of clinically positive neck at the time of presentation was 42% while the incidence of occult nodal metastases was found to be 27.6%. The most common levels of lymph nodes involved in our study were levels II and III (87.5% cases). Multiple level lymph node involvement was seen in 71.4% of the eases at the time of presentation. A high incidence of cervical nodal metastases was associated with the following characteristics of the primary lesion-extralaryngeal spread, infiltrating or endophytic peripheral growth pattern, poor cellular differentiation and advanced T stage. In view of the high incidence of occult nodal metastases, use of selective lateral neck dissection is advocated in patients with a clinically negative neck at the-time of presentation (early glottic carcinomas being excluded)." }, { "id": "pubmed23n0636_16515", "title": "Papillary cystic acinic cell carcinoma with many psammoma bodies, so-called psammoma body-rich papillary cystic acinic cell carcinoma: report of a case with fine needle aspiration findings.", "score": 0.008695652173913044, "content": "Psammoma bodies are infrequent in salivary gland aspirates. We present a case of papillary cystic acinic cell carcinoma with many psammoma bodies and discuss the diagnostic pitfalls with other salivary gland tumors. A 24-year-old woman presented with a 5-month history of a gradually enlarging, painless lump in the left side of the face. Physical examination demonstrated a 2 x 2-cm, nontender, rubbery mass inferior to the auricle in the left parotid area. Sonography showed a 2-cm, cystic mass in the left parotid. Fine needle aspiration was performed and showed mainly papillary clusters and isolated cells with vacuolated cytoplasm and a round nucleus with an inconspicuous nucleolus resembling foamy histiocytes and many psammoma bodies, some of which were surrounded by cells resembling cannonballs. A preliminary diagnosis of papillary cystic salivary gland neoplasm was made and supeficial parotidectomy performed. A diagnosis of papillary cystic acinic cell carcinoma with many psammoma bodies was made. Aspiration cytology of papillary cystic acinic cell carcinoma with many psammoma bodies can be confused with more common tumors, such as cystic mixed tumor and adenoid cystic carcinoma with cannonballs, low grade mucoepidermoid carcinoma or cystic papillary carcinoma of the thyroid." } ] } } }

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{ "1": "Start treatment with inhaled bronchodilators.", "2": "Chest X-ray and spirometry with bronchodilator test.", "3": "Prescribe oral corticosteroids.", "4": "Thoracic CT scan.", "5": "Perform basal arterial blood gases." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0519_20578", "title": "Contemporary issues in the care of patients with chronic obstructive pulmonary disease.", "score": 0.016516816516816517, "content": "Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and is estimated to be responsible for 119,000 deaths in the year 2000 alone. Additionally, COPD places a tremendous burden on the health care system, with estimated annual costs of US 24 billion dollars in 2000, and it is generally expected that costs will continue to rise as more individuals are diagnosed. COPD was responsible for approximately 8 million physician outpatient visits, 1.5 million emergency department visits and 726,000 hospitalizations, also in the year 2000. The objective of this article is to review current, pertinent clinical issues in the management of patients with COPD, with estimates of their relative utility and efficacy. COPD is a disease characterized by airflow limitation that is not fully reversible. Patients with COPD may frequently experience symptoms of chronic cough with sputum production, dyspnea, and reduced exercise capacity. They may frequently experience exacerbations characterized by increased symptoms that often require medical intervention. The diagnosis of COPD is usually fairly straightforward and made in a cigarette smoker, with the aforementioned symptoms and airflow obstruction measured by spirometry. Spirometry should be performed in all patients in whom COPD is suspected, as it provides useful prognostic information and may be used to stage the disease. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has provided evidenced-based management guidelines for COPD. GOLD guidelines advocate staging COPD by spirometry and make specific treatment recommendations based on COPD stage. The most important risk factor for the development of COPD is cigarette smoking, and smoking cessation has been shown to reduce all-cause mortality and to alter the natural history of COPD. Smoking cessation strategies that employ both counseling and medications like buproprion and nicotine replacement are most effective, but relapse rates remain high. It has not been shown that medications like bronchodilators or inhaled steroids change the natural history of COPD, nor do they reduce mortality, but they can affect other important outcomes. Long-acting bronchodilators, including beta- 2-adrenergic agonists such as salmeterol and formoterol, and the anticholinergic agent tiotropium, improve lung function and exercise tolerance, reduce symptoms, and modestly reduce exacerbation rates. Long-acting bronchodilators are indicated for all COPD patients with chronic symptoms. Short-acting bronchodilators are indicated for rescue when acute symptoms occur. Inhaled corticosteroids minimally improve lung function, but, importantly, reduce exacerbation rates and are indicated in severe COPD or when exacerbations are frequent. Continuous oxygen therapy has been shown to reduce mortality when severe hypoxemia is present and can improve quality of life when moderate hypoxia is present. Finally, well-designed, multidisciplinary disease management programs and pulmonary rehabilitation can improve important disease outcomes in a cost-effective manner. COPD is a common, preventable disease that affects a significant number of people. It may be managed by utilizing various readily available medical therapies, as well as other nonpharmacologic interventions, such as pulmonary rehabilitation. Proper coordination of care is important in this disease, and efforts should be focused on improving quality of life and reduction of symptoms." }, { "id": "pubmed23n0343_15966", "title": "[Diagnostic standard for differentiation between bronchial asthma and chronic obstructive pulmonary disease].", "score": 0.01649470540320391, "content": "The aim of this study was to work out the simplified standard for distinguishing COPD from bronchial asthma. An overall sample of 150 individuals was used for statistical analysis. Sixty one were diagnosed as having COPD and 89 as suffering from asthma. For each patient the modified ATS-DLD-75-C questionnaire was filled out, and laboratory tests results were collected. Laboratory findings included: basic spirometry and flow-volume curve parameters, diurnal PEF variation, tests with bronchodilators (salbutamol, ipratropium bromide and corticosteroids), challenges with histamine and exercise, blood gas analysis, skin tests, chest X-ray, ECG, blood cell count, blood and sputum eosinophilia. Continuous variables were transformed into discrete (dichotomous) ones using commonly accepted threshold values. Then, sensitivity, specificity and accuracy indexes were calculated for each variable and for all possible sets of 2, 3 and 4 variables. Finally, 2 sets of 4 signs and symptoms were selected as the most characteristic of the diseases of interest. Asthma was diagnosed if 3 out of 4 following conditions were present: 1) episodes of shortness of breath and wheezing, 2) smoking index (cigarettes number per day x years of smoking) &lt; or = 200, 3) PC20 &lt; or = 8 mg/ml or delta FEV1 after bronchodilator &gt; or = 15% predicted, 4) diurnal PEF variation &gt; or = 20% predicted. COPD was recognised in the same way on the basis of: 1) productive cough, 2) smoking index &gt; 200, 3) signs of emphysema on the chest X-ray, 4) maximal FEV1 &lt; 80% predicted (after treatment). Diagnosis established using this model was correct in 76% and false (what was very important) in only 2.6% of cases. In the remaining 21% of patients it was uncertain (e.g. both of the diseases confirmed)." }, { "id": "pubmed23n1083_22289", "title": "Persistent Dyspnea in a 74-Year-Old Man With Normal Spirometry and Lung Volumes.", "score": 0.01601510169285105, "content": "A 74-year-old man was referred to a pulmonologist for evaluation of a 1-year history of nonproductive cough and progressive exertional dyspnea. He was initially evaluated by his primary care physician, where he had spirometry that was negative for any obstructive or restrictive lung disease. An echocardiogram showed a normal left ventricular ejection fraction, with no wall motion abnormality or valvular heart disease. He had an outpatient chest radiograph performed (Fig 1), and he was subsequently treated empirically for a COPD exacerbation with 5 days of oral prednisone and azithromycin. He was eventually referred to a pulmonologist because of a lack of clinical improvement. On seeing his pulmonary physician, he described the same exertional dyspnea and a nonproductive cough. A review of systems was negative for fever, chills, wheezing, angina, arthralgia, myalgia, rash, or leg swelling. He denied any medical illness and was not taking any medications. He was currently retired and had worked as a cashier his entire adult life. He had no occupational exposure to asbestos, coal dust, beryllium, silica dust, or dust from hard metal objects, such as cobalt. However, he had smoked approximately 1 to 2 packs of cigarettes per day and had done so for the past 50 years. His vital signs were unremarkable, aside from an oxygen saturation of 94% on room air. His physical examination revealed bibasilar \"velcro-like\" inspiratory crackles on lung examination. There was no digital clubbing, nor was there peripheral edema in his lower extremities. He had no muscle tenderness and demonstrated normal muscle strength against resistance." }, { "id": "pubmed23n0903_6343", "title": "Chronic Obstructive Pulmonary Disease: Diagnosis and Management.", "score": 0.01525900900900901, "content": "The diagnosis of chronic obstructive pulmonary disease (COPD) should be suspected in patients with risk factors (primarily a history of smoking) who report dyspnea at rest or with exertion, chronic cough with or without sputum production, or a history of wheezing. COPD may be suspected based on findings from the history and physical examination, but must be confirmed by spirometry to detect airflow obstruction. Findings that are most helpful to rule in COPD include a smoking history of more than 40 pack-years, a self-reported history of COPD, maximal laryngeal height, and age older than 45 years. The combination of three clinical variables-peak flow rate less than 350 L per minute, diminished breath sounds, and a smoking history of 30 pack-years or more-is another good clinical predictor, whereas the absence of all three of these signs essentially rules out airflow obstruction. Pharmacotherapy and smoking cessation are the mainstays of treatment, and pulmonary rehabilitation, long-term oxygen therapy, and surgery may be considered in select patients. Current guidelines recommend starting monotherapy with an inhaled bronchodilator, stepping up to combination therapy as needed, and/or adding inhaled corticosteroids as symptom severity and airflow obstruction progress." }, { "id": "pubmed23n0352_16930", "title": "Oral corticosteroid trials in the management of stable chronic obstructive pulmonary disease.", "score": 0.01476388444728707, "content": "Although recent guidelines for managing chronic obstructive pulmonary disease (COPD) recommend a trial of oral corticosteroids in the initial assessment, its prognostic value remains unclear. We prospectively studied 127 adults (64% men) with stable COPD (FEV1/FVC &lt; 60%) over 1 year. At entry, we measured lung volumes, gas transfer factor, respiratory symptoms (by questionnaire), and peripheral blood eosinophil count. Skin-prick testing was done, and spirometry after nebulized 5 mg salbutamol and, after 2 weeks, oral prednisolone. Physician A gave all patients inhaled beclomethasone dipropionate (800 mcg/day), whereas physician B prescribed this only to those with a positive oral corticosteroid trial. At 1 year, spirometry and respiratory questionnaire were repeated, with an estimate of overall symptom severity on a visual analogue scale. Follow-up data were available in 104 (82%) patients. Of these, 32 (31%) were unresponsive to salbutamol and prednisolone; 48 (46%) were responsive to beta agonists but not to corticosteroids, and 24 (23%) responded to corticosteroids and salbutamol. Patients in all groups were comparable, except that the prednisolone responders had a higher mean eosinophil count (p &lt; 0.001) and more were ex-smokers (p &lt; 0.001). Only the response to oral prednisolone correlated with the change in prebronchodilator FEV1 over 1 year. Oral prednisolone responders had higher FEV1 at 1 year (p &lt; 0.02) and significantly lower symptom scores (p &lt; 0.02). In COPD, corticosteroid trials contribute information additional to that gained from nebulized bronchodilator reversibility testing. Patients with a positive response to a corticosteroid trial are more likely to have improved symptomatically and spirometrically at 1 year." }, { "id": "wiki20220301en187_4321", "title": "Obstructive lung disease", "score": 0.014662894860914663, "content": "The diagnosis of COPD is established through spirometry although other pulmonary function tests can be helpful. A chest X-ray is often ordered to look for hyperinflation and rule out other lung conditions but the lung damage of COPD is not always visible on a chest x-ray. Emphysema, for example, can only be seen on CT scan. The main form of long term management involves the use of inhaled bronchodilators (specifically beta agonists and anticholinergics) and inhaled corticosteroids. Many patients eventually require oxygen supplementation at home. In severe cases that are difficult to control, chronic treatment with oral corticosteroids may be necessary, although this is fraught with significant side effects." }, { "id": "pubmed23n0058_10453", "title": "[Clinical study on bronchial hyperresponsiveness and development of bronchial asthma in patients with persistent cough].", "score": 0.014615770969362129, "content": "The purpose of this study was to ascertain whether in patients with persistent cough the presence of bronchial hyperresponsiveness (BH) and development of asthma could be speculated based on clinical data. Only patients who met strict criteria excluding exogenous factors that influence BH, especially smoking or respiratory infection, were included in this study. The study group included 15 males and 50 females aged 18 to 62 years (mean +/- S.D. of 44 +/- 12 years) whose physical findings, chest X-rays, spirometry results and peripheral leukocyte counts were within normal limits. Duration of cough was at least one month. The patients had no history of wheezing, dyspnea or previous bronchodilator therapy. None of them had ever been smokers. In addition, there was no history of upper respiratory tract infection in the preceding month. BH was assessed by \"Astograph\" using methacholine. Cmin and Dmir or SGrs/Grs cont. were measured as the indexes of bronchial sensitivity or reactivity respectively. A methacholine Cmin of 3, 125 micrograms/ml or less was taken as a positive indication of BH. The evaluated clinical data were age, pulmonary function (spirogram or flow volume curve), atopic factors (serum total IgE and family or personal history of atopic diseases), peripheral eosinophil count, bronchial sensitivity or reactivity, and clinical features of cough (induction by exercise or cold air and nocturnal worsening). The results were as follows. (1) Twenty-nine (45%) of 65 patients were BH-positive (BH-positive group). (2) There was no significant difference in age, %FVC, IgE, and family or personal history of atopic diseases between the BH-positive and negative group. However, the BH-positive group had significantly lower FEV1.0%, %FEV1.0, PEFR, (p less than 0.05) and V25/H (p less than 0.01) and a higher peripheral eosinophil count (p less than 0.05) than the BH-negative group. (3) Seventeen (85%) of 20 BH-positive patients prescribed bronchodilators (beta 2 agonist/theophylline) responded to therapy within a month. (4) Seven (29%) of 24 BH-positive patients available for 2 years follow-up developed clinical asthma. (5) There was no significant difference in %FVC, FEV1.0%, V25/H and peripheral eosinophil count between the patients who developed asthma (Group A) and those who did not (Group N-A). However, The patients in Group A were older than those in Group N-A.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0277_10652", "title": "Physician perceptions and management of COPD.", "score": 0.014473999520728493, "content": "To assess awareness and understanding of obstructive airway diseases by primary-care physicians, the authors surveyed a randomly selected population of 75 primary care practitioners. During one-on-one interviews, physicians were presented with a standardized case scenario and a subsequent series of open-ended questions concerning asthma and COPD. Each respondent was presented in randomized fashion with one of two versions of a case description of a hypothetical 52-year-old male smoker with a recent upper respiratory tract infection and persistent productive cough. The only difference between case descriptions was that one included explicit reference to an earlier tentative diagnosis of chronic bronchitis (CB version); the other description made no specific mention of this diagnostic term (NCB version). Chest radiographs were requested by 80 percent of physicians and sputum cultures by 50 percent, these percentages not differing significantly between CB and NCB groups. Spirometry was requested less often than either of the foregoing tests (21 percent). The CB group requested spirometry significantly more often than the NCB group (38 percent vs 5 percent, p &lt; 0.05). The most frequently mentioned primary diagnosis was bronchitis/pneumonia (33 percent), followed by bronchitis (28 percent) and chronic bronchitis (16 percent), all of which were similar in both groups. However, the diagnostic term \"COPD\" was the primary diagnosis in 16 percent of the CB group, compared with 8 percent in the NCB group (p &gt; 0.05). Oral antibiotics were the most frequently chosen first-line drug therapy (63 percent). In subsequent questions concerning the management of obstructive airway diseases, primary practitioners distinguished COPD from asthma conceptually, but their prescribed therapy for the two disorders was less distinct. beta 2-agonists were selected most frequently and similarly as initial therapy for both disorders (53 percent). Minor differences between first-line therapeutic choices included nonsignificant trends toward the more frequent mention of anticholinergic bronchodilators for COPD than for asthma (10 percent vs 0 percent) and the more frequent selection of inhaled corticosteroids for asthma (12 percent vs 5 percent). The authors conclude that to the extent that questionnaire responses reflect actual practice, primary care practitioners (1) have a low index of suspicion for obstructive airway disease, (2) markedly underutilized spirometry as a screening tool, (3) consider beta 2-agonists first-line therapy for COPD and asthma, and (4) despite considering COPD and asthma different disease processes, choose similar medications for each disorder." }, { "id": "pubmed23n0510_7051", "title": "[Survey of chest physicians regarding COPD diagnosis and treatment].", "score": 0.012333965844402276, "content": "A survey on COPD diagnostic procedures, treatment and management was conducted in a group of 517 chest physicians randomized from a list of the 1121 affiliates to the Asociación Argentina de Medicina Respiratoria. One hundred eighty-seven responses were obtained (36.2% of the questionnaires mailed). They treat an average of 53.3 COPD patients every month. Twenty-four percent of them had mild, 41.8% moderate and 33.8% severe disease (GOLD criteria). Only clinical criteria for diagnosis of COPD, clinical criteria + spirometry (S), and clinical criteria + S + chest X ray were used by 2.9, 23.4 and 73.7% of responders, respectively. Seventy percent of responders believed that chronic asthma without bronchodilator response must be included in the COPD definition. Only 14.1% of responders performed S in every office visit. Cardiac function was assessed using clinical criteria, electrocardiogram and echocardiogram by 90.6, 80.6 and 73.8% of responders, respectively, while 98.3% stated that they trained most of their patients in the inhalation technique. Metered Dose Inhaled was the first option for bronchodilators administration (64.8%) followed by nebulization (16.5%), dry powder inhalation (13.7%) and oral administration (4.8%). First option for chronic therapy in severe COPD patients was the association of anticholinergic drug (AC) + short acting beta2-agonists (SABA) (65.5%), AC alone (18.8%), long acting beta2-agonists (LABA) (9.7%), inhaled corticosteroids (IC) (3.5%) and SABA alone (2.8%). Corticosteroids and antibiotics were prescribed in severe COPD exacerbation by 92.5 and 70% of responders, respectively. First choice antibiotic formulation was beta-lactamics + beta-lactamase inhibitors in 39% of the responders followed by fluorquinolones in 23.7%, macrolides in 17.5% and beta-lactamics in 12.5%. Lastly, 12.7% of COPD patients received long-term domiciliary oxygen therapy. 59.3% of them were prescribed pulmonary rehabilitation, 94.1% vaccination against influenza and 91.4% pneumococcal vaccination. Thirty seven percent of the patients continued to smoke. Most of reponses regarding diagnosis and exacerbation treatment were in agreement with recommendations of international guidelines. For maintenance treatment the association of AC + SABA was commonly recommended as first option, whereas IC and LABA were rarely prescribed." }, { "id": "pubmed23n0077_8229", "title": "Changes in hospital management of acute severe asthma by thoracic and general physicians in Birmingham and Manchester during 1978 and 1985.", "score": 0.011886395511921458, "content": "Hospital management of acute severe asthma in 14 large hospitals in Birmingham and Manchester was audited in a random 20% of 1196 patients aged 15-45 years admitted in 1985. Of the 239 admissions randomised, 192 were suitable for study. Results were compared with those from a study in the same hospitals using the same methods in 1978. The age and sex of the patients and their smoking history, duration of asthma, and hospital attendance were similar in 1978 and 1985. A much smaller proportion of patients presented with symptoms of over seven days' duration in 1985 (8.5%) than in 1978 (26%). The inpatient management of asthma appears to have improved in both thoracic and general units, with more thorough functional assessments, more frequent performance of relevant investigations (arterial blood gases and peak expiratory flow rates) and more frequent use of recommended treatment (nebulised bronchodilators, oral and intravenous corticosteroids). Less difference was found in 1985 between units with a specialist thoracic interest and those without, though some differences remained in 1985 in monitoring of peak expiratory flow rate and arterial blood gases, outpatient prescribing, and follow up arrangements. Inhaled preventive medication was prescribed more frequently than in 1978. In 1985 there was a 56% increase in admissions for asthma. The proportion of severely ill patients was similar to that in 1978, but in the most severe functional grade mean arterial carbon dioxide tension was higher in 1985 and more patients were ventilated. Our results suggest that hospital management by thoracic and general physicians has improved over the period 1978-85. Patients presented earlier in 1985, though there seems to have been an increase in asthma of all grades of severity." }, { "id": "pubmed23n0371_17121", "title": "[Clinical examinations for COPD].", "score": 0.009900990099009901, "content": "The natural history of COPD such as pulmonary emphysema demonstrates that FEV1 rapidly declines in smokers who are susceptible to cigarette smoke. The susceptible smokers who quit smoking do not regain only a little, but the rate of the FEV1 decline is no longer steep. These have been interpreted that early detection of this obstructive impairment is the most important issue to prevent the progression to severe emphysema. Pulmonary function tests, at least a measure of FEV1, in the all middle-aged smokers have been particularly recommended. The smokers with abnormal FEV1 defect should be advised to quit smoking. In moderate and severe cases, after staging of the disease by pulmonary function and exercise tests, assessments of complicated factors such as eosinophilic bronchitis are clinically important for constructing therapeutic strategies. Asthmatic component can be assessed by eosinophil count in the sputum and/or reversibility of the pulmonary function after challenging of bronchodilater inhalations. In the severe stage of the disease, examinations such as arterial blood gas analysis and pulse oxymetric measure are critical because oxygen therapy for the patients with respiratory failure has been known to improve survival prognosis. Portable devices which can assess arterial oxygen saturation during daily activity will be useful to decide its indication or to titrate oxygen. In conclusion, clinical examination in COPD, particularly in pulmonary emphysema in this paper, should appropriately be planned in each stage of the disease, or in each clinical purpose." }, { "id": "pubmed23n0771_4414", "title": "The Changes of Pulmonary Function in COPD During Four-Year Period.", "score": 0.00980392156862745, "content": "none declared. COPD (chronic obstructive pulmonary disease) is characterized by airflow limitation that is not fully reversible. to show the changes of pulmonary function in COPD during the 4 -year evolution of illness. The research was done on patients suffering from COPD treated at the Clinic \"Podhrastovi\" during 2006 and 2007. The tested parameters were examined from the date of receiving patient with COPD to hospital treatment in 2006 and 2007 and then followed prospectively until 2010 or 2011 (the follow-up period was 4 years). There were total 199 treated patients who were chosen at random and regularly attended the control examinations. The study was conducted on adult patients of both sexes, different age group. In each patient the duration of illness was recorded so is sex, age, data of smoking habits, information about the regularity of taking bronchodilator therapy during remissions of disease, about the treatment of disease exacerbations, results of pulmonary functional tests as follows: FVC (forced vital capacity), FEV1 (forced expiratory volume in one second) and bronchodilator reversibility testing. All these parameters were measured at the beginning and at the end of each hospital treatment on the apparatuses of Clinic \"Podhrastovi\". We took in elaboration those data obtained in the beginning of the first hospitalization and at the end of the last hospitalization or at the last control in outpatient department when patient was in stable state. Patients were divided into three groups according to the number of exacerbations per year. airflow limitation in COPD is progressive; both FVC and FEV1 shows the statistically significant decrease during follow-up period of 4 years (p values / for both parameters/ =0.05) . But in patients regularly treated in phases of remission and exacerbations of illness the course of illness is slower. The fall of FVC and FEV1 is statistically significantly smaller in those received regular treatment in phases of remissions and exacerbations of illness (p values / for both parameters/ =0.01). The number of patients responding properly to bronchodilators decreased statistically significantly in patients with COPD during follow-up period (p=0.05). COPD is characterized with airflow limitation which is progressive in the course of illness, but that course may be made slower using appropriate treatment during remission and exacerbations of diseases." }, { "id": "pubmed23n1093_2276", "title": "A 75-Year-Old Woman With Pulmonary Nodules and Dyspnea.", "score": 0.009708737864077669, "content": "A 75-year-old woman was referred to the pulmonary office in January 2020 for cough and progressive worsening of shortness of breath over the years. Her medical history was significant for asthma that was diagnosed approximately 10 years earlier, when she first developed dyspnea. A pre-bronchodilator spirometry at that time showed severe airflow obstruction (Fig 1). The patient was incidentally found to have several noncalcified pulmonary nodules on a chest CT scan in 2015, which was obtained as a part of dyspnea workup. She underwent bronchoscopic evaluation with transbronchial biopsy of the largest nodule (1.6 × 1.2 cm) in the right middle lobe. She was diagnosed with low-grade neuroendocrine tumor (typical carcinoid) and had been under surveillance without any progression in the number of nodules or the size of the existing nodules. She was a lifelong nonsmoker and no family history of asthma. Over the years, she received multiple courses of systemic corticosteroids and different inhalers, without any improvement in her symptoms. The patient was frustrated by the lack of perceived benefit, and she discontinued all respiratory medications. She denied any fever, night sweats, exertional chest pain, or seasonal allergies but reported cough, wheezing, and severe exertional shortness of breath. She was unable to walk more than 20 feet at a time. She had no pets at home and did not travel outside the United States. Her only home medications were multivitamins and low-dose aspirin." }, { "id": "pubmed23n0792_22805", "title": "The changes of arterial blood gases in COPD during four-year period.", "score": 0.009708737864077669, "content": "COPD (Chronic Obstructive Pulmonary Disease) is characterized by airflow limitation that is not fully reversible and that can lead to respiratory failure. To show the changes of arterial blood gases in COPD during the 4-year evolution of illness. The research was done on patients suffering from COPD treated at the Clinic \"Podhrastovi\" during 2006 and 2007 year. The tested parameters were examined from the date of receiving patient with COPD to hospital treatment in 2006 and 2007 and then followed prospectively until 2010 or 2011 year (the follow-up period was 4 years). There were total 199 treated patients who were chosen at random and regularly attended the control examinations. The study was conducted on adult patients of both sexes, different age group. In each patient the duration of illness was recorded so is sex, age, data of smoking habits, information about the regularity of taking bronchodilator therapy during remissions of disease, about the treatment of disease exacerbations, results of blood gases analysis as follows: pH value, PaO2 (partial pressure of oxygen in arterial blood), PaCO2 (partial pressure of carbon dioxide in arterial blood). All these parameters were measured at the beginning and at the end of each hospital treatment. We took in elaboration data obtained in the beginning of the first hospitalization and at the end of the last hospitalization or at the last control in outpatient department when patient was in stable state. Patients were divided into three groups according to the number of exacerbations per year. There is the statistically significant decrease of PaO2 (p &lt; 0.01) and pH, (p &lt; 0.05) and an increase of PaCO2 (p &lt; 0.01) during follow-up period. But in patients regularly treated in phases of remission and exacerbations of illness the course of illness is slower. The decrease of pH and PaO2 and increase of PaCO2 is statistically significantly smaller in those received regular treatment in phases of remissions (P values are respectively: &lt; 0.05, &lt; 0.01 and &lt; 0.01) and exacerbations of illness (p values are respectively: &lt; 0.01, &lt; 0.01 and &lt; 0.05). COPD is characterized with airflow limitation which is progressive in the course of illness, and by the changes in arterial blood gases that can lead to respiratory failure, but that course may be made slower using appropriate treatment during remission and exacerbations of diseases." }, { "id": "wiki20220301en014_134754", "title": "Bronchiectasis", "score": 0.009615384615384616, "content": "Bronchodilators Some clinical trials have shown a benefit with inhaled bronchodilators in certain people with bronchiectasis. In people with demonstrated bronchodilator reversibility on spirometry, the use of inhaled bronchodilators resulted in improved dyspnea, cough, and quality of life without any increase in adverse events. However, overall there is a lack of data to recommend use of bronchodilators in all patients with bronchiectasis." }, { "id": "pubmed23n0146_252", "title": "Clinical and physiological follow-up of severe chronic obstructive lung disease.", "score": 0.009615384615384616, "content": "Case reports are given of 25 patients with severe chronic obstructive lung disease (COLD) and with a ventilatory capacity (MVVF) &lt; or = 35 per cent of predicted normal values. The patients were selected among persons treated 1968-1970 at the Department of Pulmonary Diseases, University Hospital, Uppsala. Clinical and physiological follow-up studies have been made. Case histories, physical and radiological findings of the heart and lungs and in 5 patients autopsy findings are given. Arterial blood gas tensions and acid-base balance in the patients' habitual state are also reported. Changes in the electrocardiograms (ECG), in lung volumes and dynamic ventilatory function and physical working capacity, measured on a bicycle ergometer, are described. In 1970-71 the patients (39-72 years of age) were admitted to hospital for 5 days in their optimal state for the following investigations: static and dynamic spirometry, total haemoglobin, ECG, vectorcardiogram (VCG), physical working capacity, pulmonary gas exchange and central haemodynamic studies. The results of the gas exchange and central haemodynamic studies, total haemoglobin and the physical working capacity are given elsewhere. Certain comparisons were made between the two groups of patients: (R) patients who had had one or several periods of manifest respiratory insufficiency with intensive treatment (n = 14) and a comparison (C) group (n = 11), with the same ventilatory impairment in regard to MVVF, but without any corresponding periods needing oxygen treatment combined with breathing assistance by a physiotherapist or respirator. Sixteen patients had chronic bronchitis with emphysema, one chronic bronchitis without emphysema, four primary emphysema, one emphysema and bronchial asthma and three emphysema and widespread bronchiectasis. The most striking difference in the clinical history of the R-and C-group patients was a greater tobacco consumption (packets/lifetime) in the R group. The ECG was typical for right ventricular hypertrophy (RVH) in one patient from each group. Slightly delayed ventricular activation and clock-wise rotation of the QRS frontal plane axis were the most common ECG findings. VCG was typical for RVH in one C-group and 4 R-group patients, and suspected to indicate RVH in 7 R- and 5 C-group patients. Biventricular hypertrophy may be one of the reasons that ECG and VCG do not more often fulfil the typical RVH criteria. The average MVVF was about 21 per cent of predicted normal values before and about 27 per cent after administration of a bronchodilating spray. The average vital capacity (VC) was 55 per cent before and 64 per cent after the use of a spray.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0956_4319", "title": "Advanced Sarcoidosis with Apparent Onset by Respiratory Failure.", "score": 0.009523809523809525, "content": "We present the case of a 14 years-old male (with poor living condition, non-smoker) hospitalized for a sudden onset of a rest dyspnea, mucopurulent cough. We found bronchial sibilant rales, wheezing, cyanosis, peripheral adenopathies, hepatosplenomegaly, purulent tonsillitis. the chest-x-ray revealed bilateral mediastinal lymphadenopathy and bilateral lung infiltrations. Spirometry: severe mixed ventilator dysfunction without reversibility. Sputum: negative microscopy and culture for Koch bacillus. Stool examination: cysts of Lamblia giardia. The patient refused bronchoscopy and mediastinoscopy, so it was performed axillary lymph node biopsy which confirmed sarcoidosis (non-caseating epithelioid granulomas). The treatment included antibiotics, antiparasites, oral and inhaled corticosteroids (CS), bronchodilators, oxygen, with clinical/functional improvement after 3 months. CS was followed 1.5 years with poor compliance. A relapse occurred after 3 years and the CS were reinserted. The computerized tomography (CT) scan revealed a diffuse interstitial fibrosis with bronchiectasis. The case particularity relies on the atypical early onset of the sarcoidosis, with respiratory failure and progression to lung fibrosis despite CS treatment. The association of proinflammatory risk factors such as multiple infections needs to be noted." }, { "id": "pubmed23n0641_14356", "title": "[Prevalence and difficulties in chronic obstructive pulmonary disease diagnosis in patients suffering from severe peripheral arterial disease].", "score": 0.009433962264150943, "content": "Cigarette smoking is the most prominent risk factor for chronic obstructive pulmonary disease (COPD) and peripheral arterial disease (PAD). Prevalence of COPD among cigarette smokers is about 23% in Poland. Effort dyspnea which develops in advanced stage of COPD is the leading cause of seeking medical advice. Physical activity among patients with PAD is reduced due to intermittent claudication. It may cause delayed COPD diagnosis in this group of patients. To estimate the prevalence of COPD among patients suffering from severe PAD who were hospitalized in surgery department due to critical limb ischemia and to evaluate difficulties during COPD diagnosis in this group of patients. We examined 64 patients suffering from severe PAD (at least IIb stage according to Fontaine's scale). Patients were asked about the typical symptoms of COPD: chronic cough, regular sputum production and dyspnea. To evaluate the intensity of dyspnea we used British Medical Research Council scale. Spirometry was performed to every patient. Patients with airways obstruction underwent spirometry after the administration of inhaled bronchodilator. Every patient who had the post-bronchodilator value of FEV,/FVC ratio below the lower limit of normal values was diagnosed with COPD. It was not possible to evaluate the dyspnea intensity using MRC scale in 44% of 34 patients who reported dyspnea. During the study we diagnosed 16 patients with COPD (9 pts had 1st stage of COPD according to GOLD classification, 7 pts--2nd). 9 patients had been formerly diagnosed with COPD (2 pts--1st stage, 5 pts--2nd, and 2 pts--3rd). Spirometry-defined COPD was present in 39% of study group. The analysis of data from patients with PAD coexistent COPD revealed that 60% of them were current cigarette smokers and 28% of them declared passive smoking exposure. The other known negative prognostic factors in patients with COPD such as BMI lower than 21 kg/mr2, FEV1% of predicted value below 65% and X-rays photograph visible emphysema were observed in 40%, 32% and 12% of patients with PAD and coexistent COPD respectively. Hypertension was present in 52% of patients with PAD and coexistent COPD, cardiac arterial disease in 52% and chronic heart failure due to cardiac arterial disease in 36%. Further analysis of laboratory tests revealed dyslipidemia and chronic kidney disease in 52% and 60% of these patients respectively. COPD diagnosis among patients suffering from severe PAD involves several difficulties such as uselessness of MRC dyspnea scale and frequent heart diseases which delay the COPD diagnosis being considered as primary dyspnea reason. Many factors which have been proven to be responsible for worse prognosis due to COPD were observed in patients with PAD and coexistent COPD. High prevalence of COPD among patients suffering from PAD suggests the spirometry as a COPD screening would be justified in that group." }, { "id": "pubmed23n0106_669", "title": "[Course and prognosis of chronic obstructive lung disease over 5 and 10 years].", "score": 0.009433962264150943, "content": "453 patients aged over 40 hospitalized with severe COPD, a mean age of 66 years and mean FEV1 of 1.24 litres (49% predicted) were prospectively followed up for 5 years (341) and 10 years (195) respectively. 5-year survival was 47%, while 10-year survival was severely limited despite uniform therapy (23%). Average survival was only 4.4 years. Of the 15 prognostic factors considered, initial FEV1, body-weight, smoking behavior, diagnosis of bronchial asthma or emphysema, finding of p pulmonale and reversibility of bronchodilation had a significant influence on survival. The average decrease in FEV1 per year was only 28 ml in the surviving patients. It was lowest in those with FEV1 reversibility of more than 105 ml after bronchodilation. A maximum increase of FEV1 of more than 485 ml during the initial hospitalization, together with stopping smoking, were the next two important factors in FEV1 decrease. Mean annual NO2 concentration at home did not correlate significantly with survival and FEV1 decrease." }, { "id": "pubmed23n0943_2039", "title": "[Bronchial adenoid cystic carcinoma masquerading as bronchial asthma: a case report].", "score": 0.009345794392523364, "content": "Here we reported a case of bronchial adenoid cystic carcinoma from Peking University Third Hospital. A 40-year-old female presented with dry cough for 1 year and nocturnal paroxysmal attacks of wheezing for 4 months. She was a non-smoker, and did not have past histories of asthma or allergy. On physical examination, no stridor, wheezing and cyanosis were present and the general appearance was good. The results of the laboratory analysis, including blood eosinophils count, immunoglobulin E level and chest X-ray were normal. Spirometry revealed reversible airflow obstruction, and post-bronchodilator forced expiratory volume in one second (FEV1) showed an increase of 12% and 230 mL from baseline. Bronchial asthma was diagnosed, however, she responded poorly despite the adequate anti-asthma therapy including high dose inhaled corticosteroid plus long-acting beta2-agonist, theophylline and montelukast. Then chest computed tomography (CT) was performed which showed a polypoid mass occupying the lumen of left main bronchus. Then the bronchoscopy revealed a polypoid endo-bronchial mass arising from the left main bronchus, causing subtotal obstruction of the lumen. Biopsy was carried out through the bronchoscopy, the pathological findings showed characteristic cribriform and tubular pattern which was formed by two-layered cells with ductal and myoepithelial phenotypes, which were consistent with adenoid cystic carcinoma. Re-examining the patient, the lung was clear without any wheeze when she was seated. However, inspiratory wheeze was heard in her left upper lung when she was supine, and disappeared after sitting up again. Subsequently the patient underwent a resection surgery. At the operational site, the tumor was seen on the anterolateral wall of the left main bronchus, without submucosally expanding histologically. Therefore, a sleeve resection surgery of the left main bronchus was performed. Following surgery, chest CT scan revealed complete resolution of the tumor. Her symptoms improved significantly, as did her pulmonary function tests, although all the medicines for asthma were stopped. Now, two years after the operation, the patient remained asymptomatic, and spirometry was performed again which showed normal completely. The presenting case report emphasizes the fact that not all wheezes and reversible airflow obstruction are asthma. It is critical to bear in mind that if a \"difficult asthma\" patient does not respond to appropriate anti-asthma therapy; localized obstructions should be differentiated." }, { "id": "pubmed23n0524_10706", "title": "World Trade Center dyspnea: bronchiolitis obliterans with functional improvement: a case report.", "score": 0.009259259259259259, "content": "Bronchiolitis obliterans is a severe, often progressive, lung disease characterized by cough, exertional dyspnea, and airflow obstruction. It has been ascribed to specific causes such as lung or bone marrow transplant, medications for rheumatoid disease, and most recently in association with exposure to environmental agents. A 42-year-old, previously healthy New York City Highway Patrol officer who arrived at the World Trade Center (WTC), \"ground zero,\" early on September 11, 2001 was evaluated. He has been followed for over 2 years with serial chest radiographs, CT scans, and pulmonary function studies. He eventually underwent an open lung biopsy. His dyspnea started on September 12, 2001 and progressed despite aggressive therapy with inhaled bronchodilator as well as oral and inhaled corticosteroids. At no time did he have any radiographic evidence of pulmonary disease. His forced vital capacity (FVC) decreased from 5.32 L in October 2001 to 2.86 L in January 2003. He underwent an open lung biopsy because of the persistent exertional dyspnea coupled with the loss of over 2 L of lung volume. The pathological findings were chronic bronchiolitis with focal obliterative bronchiolitis and rare non-necrotizing granuloma. Symptoms and pulmonary function improved after therapy with Azithromycin was added to his treatment. This process is believed to be secondary to his massive exposure to the cloud of dust that followed the collapse of the WTC. It is our conviction that many of those present at the WTC on September 11 who have persistent dyspnea and deterioration of pulmonary function may have a similar pathologic process despite absence of abnormalities on CT of the chest. In view of the many signs and symptoms seen in first responders we feel that these findings provide important information about the pathophysiology and treatment of progressive disease resulting from this exposure." }, { "id": "pubmed23n0281_4", "title": "Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone?", "score": 0.009259259259259259, "content": "The value of the history and physical examination in diagnosing chronic obstructive pulmonary disease (COPD) is uncertain. This study was undertaken to determine the best clinical predictors of COPD and to define the incremental changes in the ability to diagnose COPD that occur when the physical examination findings and then the peak flowmeter results are added to the pulmonary history. Ninety-two outpatients with a self-reported history of cigarette smoking or COPD completed a pulmonary history questionnaire and received peak flow and spirometric testing. The subjects were independently examined for 12 physical signs by 4 internists blinded to all other results. Multivariate analyses identified independent predictors of clinically significant, moderate COPD, defined as a forced expiratory volume in 1 second (FEV1) less than 60% of the predicted value or a FEV1/FVC (forced vital capacity) less than 60%. Fifteen subjects (16%) had moderate COPD. Two historical variables from the questionnaire--previous diagnosis of COPD and smoking (70 or more pack-years)--significantly entered a logistic regression model that diagnosed COPD with a sensitivity of 40% and a specificity of 100%. Only the physical sign of diminished breath sounds significantly added to the historical model to yield a mean sensitivity of 67% and a mean specificity of 98%. The peak flow result (best cutoff value was less than 200 L/min) significantly added to the models of only one of the four physicians for a mean final sensitivity of 77% and a specificity of 95%. Subjects with none of the three historical and physical variables had a 3% prevalence of COPD; this prevalence was unchanged by adding the peak flow results. Diminished breath sounds were the best predictor of moderate COPD. A sequential increase in sensitivity and a minimal decrease in specificity occurred when the quality of breath sounds was added first to the medical history, followed by the peak flow result. The chance of COPD was very unlikely with a normal history and physical examination." }, { "id": "pubmed23n0608_14407", "title": "[The realities of clinical asthma diagnosis from questionnaire results].", "score": 0.009174311926605505, "content": "We investigated the basis on which respiratory physicians establish a diagnosis of asthma in clinical practice. A questionnaire survey was conducted on physicians in charge of 1,600 asthma patients receiving outpatient treatment at the Hokkaido University General Hospital or its affiliated hospitals or clinics. The bases for diagnosis were ranked as follows: 1) recurrent paroxysmal dyspnea or symptoms such as wheezing and cough (86%); 2) detection of wheezing on auscultation (78%); 3) improvement in symptoms or auscultation findings after using bronchodilators (56%); 4) improvement in symptoms or auscultation findings after using inhaled corticosteroids (55%); 5) diagnosis of asthma by another physician (46%); and 6) spirometry findings (31%). The performance rates of each examination were as follows. Spirometry at initial visit, 47%; sputum eosinophils, 25%; improvements in FEV1 measured after inhalation of bronchodilator or after treatment as asthma, 12%; measurements of airway responsiveness, 5% and variability in peak expiratory flow, 2%. Asthma is often diagnosed by respiratory physicians based on symptoms, physical examinations and improvement in symptoms or physical findings after treatment for asthma in medical practice. The performance rates of tests used to diagnose asthma were low." }, { "id": "pubmed23n0393_3348", "title": "[The revised Dutch College of General Practitioners' standard on COPD and the first international WHO standard: differences and similarities].", "score": 0.009174311926605505, "content": "Two standards on COPD have recently been published: the revised national standard from the Dutch College of General Practitioners and the first international standard published by the World Health Organization and the US National Heart, Lung and Blood Institute. The reduced emphasis on the role of spirometry in the monitoring and evaluation of treatment is an important change in these new standards compared to previous ones. Cessation of smoking is considered to be central to the prevention and treatment of COPD. Doctors should strongly support this approach and, more than before, are urged to view COPD as a disease caused by addiction. Bronchodilators are the cornerstone of symptomatic treatment of COPD, particularly the long-acting ones due to their ease of administration and effective treatment of morning dyspnoea. Inhalation corticosteroids should only be administered as a trial treatment and only under certain conditions. Continuation of treatment with these agents is only justified if there is a demonstrated improvement in lung function, exacerbations or symptoms, although the precise area of indication is not yet clear." }, { "id": "pubmed23n0214_4373", "title": "Clinical aspects of farmer's lung: airway reactivity, treatment and prognosis.", "score": 0.00909090909090909, "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": "wiki20220301en301_24699", "title": "Eosinophilic bronchitis", "score": 0.009009009009009009, "content": "The cause of the inflammation can be associated with environmental triggers or common allergens such as dust, chloramine, latex, or welding fumes. Diagnosis Diagnosis of eosinophilic bronchitis is not common as it requires the examination of the patient's sputum for a definitive diagnosis, which can be difficult in those who present with a dry cough. In order to induce the sputum, the patient has to inhale increasing concentrations of hypertonic saline solution. If this is unavailable, a bronchoalveolar lavage can be done, and the bronchial wash fluid can be examined for eosinophils. The diagnosis is usually considered later by ruling out other life-threatening conditions or more common diagnoses such as asthma and GERD, and by seeing an improvement in symptoms with inhaled corticosteroid treatment. Chest X-rays and lung function tests are usually normal. CT scans may show some diffuse airway wall thickening. Management" }, { "id": "wiki20220301en022_69274", "title": "Pulmonology", "score": 0.008928571428571428, "content": "Procedures Clinical procedures Pulmonary clinical procedures include the following pulmonary tests and procedures: Medical laboratory investigation of blood (blood tests). Sometimes arterial blood gas tests are also required. Spirometry the determination of maximum airflow at a given lung volume as measured by breathing into a dedicated machine; this is the key test to diagnose airflow obstruction. Pulmonary function testing including spirometry, as above, plus response to bronchodilators, lung volumes, and diffusion capacity, the latter being a measure of lung oxygen absorptive area Bronchoscopy with bronchoalveolar lavage (BAL), endobronchial and transbronchial biopsy and epithelial brushing Chest X-rays CT scan Scintigraphy and other methods of nuclear medicine Positron emission tomography (especially in lung cancer) Polysomnography (sleep studies) commonly used for the diagnosis of sleep apnea" }, { "id": "pubmed23n0390_5897", "title": "Early treatment of stage II sarcoidosis improves 5-year pulmonary function.", "score": 0.008928571428571428, "content": "To evaluate the 5-year prognosis of patients with stage I and stage II newly detected (&lt; 3 months) pulmonary sarcoidosis treated immediately after diagnosis with prednisolone for 3 months followed by inhaled budesonide for 15 months. Randomized, double-blind, placebo-controlled, parallel-group study for 18 months. Thereafter, open follow-up without treatment. Twenty pulmonary medicine departments in Finland. One hundred eighty-nine adult patients, most of them with normal lung function, were randomized to treatment. One hundred forty-nine patients were followed up for 5 years: 79 patients with initial stage I disease and 70 patients with stage II disease. Oral prednisolone for 3 months followed by inhaled budesonide for 15 months (800 microg bid), or placebo tablets followed by placebo inhaler therapy. Thereafter, treatment only on an individual basis in the case of clinical deterioration. Yearly follow-up visits with chest radiographs, lung function tests (FEV(1), FVC), diffusion capacity of the lung for carbon monoxide (DLCO), serum angiotensin-converting enzyme (SACE), and serum and urinary calcium measurements. No initial differences were observed in chest radiographic findings between the active-treatment and placebo-treatment groups, either in patients with initial stage I or stage II(-III) disease. However, after the 5-year follow-up, 18 steroid-treated patients (26%) and 30 placebo-treated patients (38%) still had remaining chest radiographic changes. Placebo-treated patients more frequently required treatment with corticosteroids during the 5-year follow-up (p &lt; 0.05). Steroid-treated patients with initial stage II(-III) disease improved more in FVC and DLCO (p &lt; 0.05). No differences in reported adverse events or in SACE, serum calcium, or urinary calcium values were seen. Immediate treatment of pulmonary stage II(-III) sarcoidosis-but not stage I disease-improved the 5-year prognosis with regard to lung function variables." }, { "id": "wiki20220301en332_33600", "title": "Chronic obstructive pulmonary disease", "score": 0.008863614079811746, "content": "A CT scan is not routinely used except for the exclusion of bronchiectasis. An analysis of arterial blood is used to determine the need for oxygen supplementation, and assess for high levels of carbon dioxide in the blood; this is recommended in those with an FEV1 less than 35% predicted, those with a peripheral oxygen saturation less than 92%, and those with symptoms of congestive heart failure. WHO recommends that all those diagnosed with COPD be screened for alpha-1 antitrypsin deficiency. Differential diagnosis COPD may need to be differentiated from other conditions such as congestive heart failure, asthma, bronchiectasis, tuberculosis, obliterative bronchiolitis, and diffuse panbronchiolitis. The distinction between asthma and COPD is made on the basis of the symptoms, smoking history, and whether airflow limitation is reversible with bronchodilators at spirometry. Chronic bronchitis with normal airflow is not classified as COPD." }, { "id": "pubmed23n0627_9694", "title": "Mucoepidermoid carcinoma of the trachea mimicking asthma.", "score": 0.008849557522123894, "content": "In cases of recent asthma in which clinical control with the usual treatment (corticosteroids and bronchodilator) is unsatisfactory, it is important to consider other diagnoses, such as congestive heart failure, gastroesophageal reflux or other forms of airway obstruction. We report the case of a female patient with mucoepidermoid carcinoma of the trachea mimicking asthma. The patient presented cough and wheezing, as well as abnormal spirometry results with an obstructive pattern that was responsive to bronchodilators. One year later, the patient presented clinical and spirometric worsening. The chest X-ray revealed no abnormalities. A CT scan showed a vegetative lesion obstructing the tracheal lumen and located 1 cm from the carina. Fiberoptic bronchoscopy showed a finding similar to a bronchial carcinoid tumor. The anatomopathological diagnosis made after surgical resection was low-grade mucoepidermoid carcinoma, without lymph node involvement. Although the flow-volume curve was not suggestive of upper airway obstruction, the spirometry performed after the surgery showed a significant reduction in the degree of obstruction and greater reversibility after bronchodilator use. There was no evidence of recurrence of the disease or of the symptoms after a two-year follow-up period." }, { "id": "pubmed23n0315_19605", "title": "COPD: results of long-term treatment.", "score": 0.008849557522123894, "content": "During the last decades the life expectation of patients with COPD increased continually. Today the life expectation of these patients reach that of the normal general population. Most important for this effect is the improvement of the therapeutical possibilities. Following the experience over nearly 3 decades the treatment regime is described. Glucocorticosteroids are at first line as much as necessary and as less as possible, starting with the inhalative forms adjusted at the clinical course stabilizes the situation. Bronchodilatation around the clock and as good as possible is a further important step. These effects have to be functionally-analytically controlled. It is not enough to follow only the clinical impression. beta 2-sympathicomimetics are the overall dilators with strongest effects and increase even the clearing mechanisms of the bronchopulmonary system. Short- as long-acting medicaments are available, but the duration of the action at each of the different forms is sometimes clearly shorter as the mean values describe. Anticholinergics and theophyllines have weaker bronchodilatation power, but they show additive effects, which could be used at special situations. Combinations as Berodual (beta 2-sympathicomimetics and anticholinergics) can decrease the dosage of the beta 2-sympathicomimetics and therefore increase the therapeutic range. At the situation of exacerbation antibiotics can be very helpful, but sometimes an increase of the dosage of glucocorticosteroids is necessary and sometimes the increase of this dosage alone can control the situation. It is very important to detect the deterioration which can end with a severe life threatening exacerbation as early as possible and to control the situation already at this stage. It is shown at examples of 56 patients functionally-analytically controlled over 5 years that the function values do not deteriorate during the constant treatment regime any more. Even in spite of the constant treatment with beta 2-sympathicomimetics no signs of any kind of down regulation or of tachyphylaxis of the bronchodilatation power could be detected. A bronchodilatation test after 4.2 years of constant bronchodilatation treatment together with beta 2-sympathicomimetics showed at 25 patients the same effect as normally at acute tests without pre-treatment seen. Because after the start of this treatment regime to-day a further deterioration does not take place, it is important to detect signs of the disease as early as possible. This can be achieved as the basis of lung function values measure over a long time. The best basis for this is the individual norm known from measurement at healthy days." }, { "id": "pubmed23n0490_3245", "title": "Acute inhalation injury with evidence of diffuse bronchiolitis following chlorine gas exposure at a swimming pool.", "score": 0.008771929824561403, "content": "A previously healthy 23-year-old man with nonproductive cough and sore throat presented to the hospital a few hours after chlorine gas exposure at a fitness center swimming pool. Initial physical examination and chest radiograph were normal. Thirty-six hours later he developed worsening dyspnea and cough, with development of blood-tinged sputum. Arterial blood gas analysis showed mild hypoxemia and a subsequent chest radiograph demonstrated diffuse tiny nodular opacities. Findings on a thin-section computed tomogram of the chest were consistent with diffuse bronchiolitis. Pulmonary function tests showed a mild obstructive abnormality and he demonstrated substantial bronchodilator response. The patient was treated with oral corticosteroids and an inhaled beta(2) agonist, to which he responded well, with full clinical recovery occurring over 5 months. This manifestation of chlorine gas exposure at a swimming pool is unusual." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 193 ] ], "word_ranges": [ [ 0, 28 ] ], "text": "A picture of macroscopic hematuria and mild proteinuria with normal creatinine levels, accompanied by an upper tract catarrhal picture, is very suggestive of IgA nephropathy (option 3 correct)." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Nephropathy with minimal changes.", "2": "Postinfectious glomerulonephritis.", "3": "IgA nephropathy.", "4": "Acute interstitial nephritis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0844_9194", "title": "When Coke Is Not Hydrating: Cocaine-Induced Acute Interstitial Nephritis.", "score": 0.01951637471439452, "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": "pubmed23n0417_5268", "title": "Cases from the Osler Medical Service at Johns Hopkins University. Antiglomerular basement membrane disease.", "score": 0.018442971273159952, "content": "A 47-year-old Taiwanese man with no notable medical history was admitted with low-grade fevers and night sweats that had persisted for 5 to 6 weeks. An extensive investigation at another hospital could not determine the cause of the fevers, but documented acute renal failure with a blood urea nitrogen level of 60 mg/dL and a serum creatinine level of 5.6 mg/dL. He was admitted to the Johns Hopkins Hospital for further evaluation.The patient, who had been living in the United States for the past 20 years, reported no recent travel and no behaviors that are associated with transmission of human immunodeficiency virus. He was not taking any medications, and he denied using herbal or nutritional supplements. He had no recent weight loss. There were no specific complaints on review of systems. On physical examination, he was a thin, middle-aged man in no distress. Vital signs included a temperature of 37.5 degrees C, a blood pressure of 166/86 mm Hg, a pulse of 70 beats per minute, a respiratory rate of 16 breaths per minute, and 99% oxygen saturation on room air. Sclera were anicteric, and he had no palpable adenopathy. His lungs were clear, and his heart rate was regular without extra sounds. His abdomen was thin, nontender, and without masses or organomegaly. There was no edema or signs of embolism in the extremities. Laboratory studies revealed a white blood cell count of 14,200/mL(3), a hematocrit of 23.1%, and a platelet count of 456,000/mL(3). Blood chemistries were notable for a blood urea nitrogen level of 61 mg/dL and a serum creatinine level of 7.6 mg/dL. Levels of aminotransferases, total bilirubin, and alkaline phosphatase were within normal limits. Urinalysis revealed large hemoglobin, 1+ protein, numerous red blood cells, and 3 to 5 white blood cells. Numerous red blood cell casts were seen on microscopic examination of the urine sediment. The patient's erythrocyte sedimentation rate was &gt;130 mm/h, and his C-reactive protein level was elevated at 12.6 mg/dL. Serologies were negative for antinuclear antibodies and antineutrophil cytoplasmic antibodies; serum complement levels were normal. What is the diagnosis?" }, { "id": "pubmed23n0497_11164", "title": "[Rapidly progressive glomerulonephritis in a 68-year-old man].", "score": 0.017940466613032984, "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": "wiki20220301en012_140488", "title": "Nephrotic syndrome", "score": 0.01786843769765971, "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": "pubmed23n0053_2677", "title": "[Interstitial lupus nephritis].", "score": 0.015371127995324372, "content": "A 17-year old-male presented with a 6-week history of weight loss, lassitude and calf pains. On examination he was very pale. Laboratory tests showed a very high erythrocyte sedimentation rate (155 mm in the first hour), anaemia (haemoglobin 10.1 g/dl), and a raised serum creatinine of 1.54 mg/dl. Microhaematuria (5-10 erythrocytes/microliter) and pronounced pyuria (500 leucocytes/microliter) were present, but the urine was sterile and there was no increase in albumin excretion. The serum IgG was raised to 75.7 g/l, suggesting an autoimmune disorder. Anti-nuclear antibodies (titre 1 : 1920) and anti-double-stranded DNA antibodies (31 U/ml) were present, while the serum complement C4 was decreased to 0.11 g/l. Renal histology showed an interstitial nephritis without glomerular involvement, while the bone marrow showed vasculitis accompanied by a prominent plasma-cell infiltrate. A diagnosis of interstitial nephritis associated with systemic lupus erythematosus was made, with asymptomatic cardiac and hepatic involvement. Renal function recovered rapidly with prednisolone therapy (initial dose 2 mg/kg.d). While glomerulonephritis is the most common lupus-associated renal disorder, isolated interstitial nephritis may occur in some cases, often with an absence of proteinuria." }, { "id": "article-22283_9", "title": "Diffuse Proliferative Glomerulonephritis -- Evaluation", "score": 0.012955089024714324, "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": "pubmed23n0343_6310", "title": "An unusual manifestation of diabetes mellitus.", "score": 0.011673021606796442, "content": "Type 2 diabetes mellitus for five years; unexplained 35-lb weight loss three years ago; Bell's palsy on right side many years ago. Glipizide, 10 mg/day. Father died of leukemia at age 65; mother has kidney stones; no diabetes or neuromuscular disease. Insurance salesman; heterosexual, promiscuous, uses condoms; smokes (25 pack years); does not drink. Well-nourished, well developed, not in acute distress; had difficulty rising from a sitting position because of right lower extremity weakness. Blood pressure, 154/74; pulse, 88; temperature, 36.6 degrees C; respiratory rate, 16. Head, eyes, ears, nose, and throat: normal. Neck: normal. Heart: S4. Lungs: clear. Abdomen: mildly obese. Extremities: no cyanosis, clubbing, or edema; atrophy and weakness of right thigh and both calves; wide-based gait; able to walk on toes but not heels. Neurologic responses: cranial nerves intact; deep tendon reflexes, 1 + symmetrically; plantar reflexes, flexor bilaterally. Skin: macular rash in sun-exposed areas. Hemoglobin, 13.2 gm/dL; mean corpuscular volume, 80 micron 3; white blood cell count, 7,200/mm3 (normal differential); platelet count, 137,000/mm3. Serum: electrolytes, normal; blood urea nitrogen, 18 mg/dL; creatinine, 0.8 mg/dL; glucose, 308 mg/dL; total protein, albumin, liver enzymes, and creatine kinase, normal. Urine: 1 + glucose. Venereal disease test: nonreactive; HIV test: negative. Dermatomyositis; heavy-metal poisoning; diabetic amyotrophy. The patient was given 50 mg/day of oral amitriptyline to alleviate the painful paresthesias and was switched to 20 U/day of subcutaneously injected neutral protamine Hagedorn (NPH) insulin to normalize the blood glucose level. Histologic studies of skin and muscle showed sun damage and neuropathic changes, respectively. There was no evidence of vasculitis. Screening for heavy-metal toxins produced negative results." }, { "id": "InternalMed_Harrison_3354", "title": "InternalMed_Harrison", "score": 0.01134548529549939, "content": "AZOTEMIA Urinalysis and Renal ultrasound HydronephrosisRenal size parenchyma Urinalysis Urologic evaluation Relieve obstruction Small kidneys, thin cortex, bland sediment, isosthenuria <3.5 g protein/24 h Normal size kidneys Intact parenchyma Bacteria Pyelonephritis Chronic Renal Failure Symptomatic treatment delay progression If end-stage, prepare for dialysis Normal urinalysis with oliguria Abnormal urinalysis WBC, casts eosinophils Interstitial nephritis Red blood cells Renal artery or vein occlusion Urine electrolytes Muddy brown casts, amorphous sediment + protein RBC casts Proteinuria Angiogram FeNa <1% U osmolality > 500 mosmol FeNa >1% U osmolality < 350 mosmol Renal biopsy Prerenal Azotemia Volume contraction, cardiac failure, vasodilatation, drugs, sepsis, renal vasoconstriction, impaired autoregulation Acute Tubular Necrosis Glomerulonephritis or vasculitis Immune complex, anti-GBM disease Acute Renal Failure" }, { "id": "wiki20220301en002_229984", "title": "Albuminuria", "score": 0.010024665257223397, "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": "pubmed23n0519_1503", "title": "[Laboratory findings in patients with hemorrhagic fever with renal syndrome].", "score": 0.009900990099009901, "content": "To examine the frequency and distribution of hematologic and biochemical laboratory findings in 94 patients with hemorrhagic fever with renal syndrome (HFRS) in the epidemic year 2002. The following laboratory findings were retrospectively analyzed: erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), hemoglobin, hematocrit, leukocyte count and differential percentage (segmented neutrophils, band neutrophils, atypical lymphocytes), platelet count, coagulation tests, blood urea nitrogen (BUN), creatinine, urine, potassium, bilirubin (BIL), aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyltransferase (GT), alkaline phosphatase (ALP), and serum protein electrophoresis. The study included 94 HFRS patients treated at the Dr Fran Mihaljević University Hospital for Infectious Diseases in Zagreb during 2002. ESR increase, mostly mild to moderate, was found in 86.2% of study patients. Increased CRP was recorded in 98.9% of study patients, however, one-fourth had CRP higher than 100 mg/L. Leukocytosis was recorded in 38.3% (10.1 +/- 4.2 x 10(9)/L), thrombocytopenia in 89.4% patients (68.2 +/- 48.3 x 10(9)/L), and severe thrombocytopenia (x 10(9)/L) in six patients. Three patients had abnormal coagulation tests. Increased values of BUN and creatinine were recorded in more than a half of patients, while only four patients had mild hyperkalemia. Only three patinets required hemodialysis. Mildly to moderately increased values of aminotransferases (AST, ALT, GT) were observed in more than 2/3; hypoalbuminaemia in nearly 1/3, and elevated alpha-2 fraction in more than 2/3 of patients. The majority of patients had pathologic urine findings. First laboratory abnormalities were usually found between day 5 and 7 of the disease (increased CRP level, thrombocytopenia, leukocytosis, and elevation of hemoglobin and hematocrit). Biochemical abnormalities(elevation of cratinine and urea, increased levels of aminotransferases) usually occurred at the beginning of the second week, and ESR increase in the second week of disease. The majority of our patients had laboratory findings characteristic of HFRS. Thrombocytopenia and increased level of CRP were the most common laboratory findings during the first week of the disease. Renal and liver impairment occurred at the beginning of the second week of the disease." }, { "id": "pubmed23n0217_11873", "title": "[Asymptomatic hematuria. Features of 11 observed cases].", "score": 0.00980392156862745, "content": "The management of 11 cases of asymptomatic haematuria (E.A. in text) of which 1 macroscopic and 10 microscopic, involved a very accurate investigation on family medical history (focusing on haematuria, renal failure, deafness and atopy) as well as individual anamnesis (former events of E.A., concomitant and previous upper respiratory tract infections and allergic diseases) together with all laboratory and clinical tests on kidney functions. The first six months, the 24/hrs proteinuria, the \"minute count\" of urinary erythrocytes and the blood pressure were tested in all patients once a month, while, during the following 18 months, 3 tests only were carried out. All the subjects presented normal renal functions; for 2 of them the intravenous urography proved to be necessary because of a renal pain concomitant with haematuria while the audiogram was required for 1 subject only. After 2 years, the microscopic E.A. is still enduring in 3 patients: 2 of them recording haematuria in familial anamnesis and 1 suffering from similar episodes, long before we studied his case. None of them had to undergo the renal biopsy which the authors take into consideration only when E.A. is higher than 10,000.000 R.C./24 hrs and associated with high proteinuria and high complement decrease or when hereditary and concomitant to deafness (high frequences only)." }, { "id": "wiki20220301en012_140472", "title": "Nephrotic syndrome", "score": 0.009708737864077669, "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": "InternalMed_Harrison_1673", "title": "InternalMed_Harrison", "score": 0.009708737864077669, "content": "Fever >38.3°C (101°F) on at least two occasions 2. Illness duration of ≥3 weeks 3. 4. Diagnosis that remains uncertain after a thorough history-taking, physical examination, and the following obligatory investigations: determination of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level; platelet count; leukocyte count and differential; measurement of levels of hemoglobin, electrolytes, creatinine, total protein, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, creatine kinase, ferritin, antinuclear antibodies, and rheumatoid factor; protein electrophoresis; urinalysis; blood cultures (n = 3); urine culture; chest x-ray; abdominal ultrasonography; and tuberculin skin test (TST). The range of FUO etiologies has evolved over time as a result of changes in the spectrum of diseases causing FUO, the widespread Percentage of Cases Due to Indicated Cause" }, { "id": "pubmed23n0358_16611", "title": "A child with spider bite and glomerulonephritis: a diagnostic challenge.", "score": 0.009615384615384616, "content": "A previously healthy 7-year-old white boy presented to St. Louis Children's Hospital with a 1-day history of headache, malaise, temperature of 38.7 degrees C, and a progressively erythematous, tender calf with central dusky purpura. On the morning of admission, his mother noticed a 2-mm crust on the patient's right calf with a 3-cm x 3-cm area of surrounding erythema. No history of recent trauma or bite was obtained. He had suffered two episodes of nonbloody, nonbilious emesis during the last day. In addition, over the previous 12 h, he presented brown urine without dysuria. His mother and brother had suffered from gastroenteritis over the previous week without bloody diarrhea. On initial physical examination, there was a 6-cm x 11-cm macular tender purpuric plaque with a central punctum on the right inner calf, which was warm and tender to the touch, with erythematous streaking towards the popliteal fossa (Fig. 1). The inguinal area was also erythematous with tender lymphadenopathy and induration, but without fluctuance. Laboratory studies included an elevated white blood cell count of 20, 800/microL with 6% bands, 86% segs, and 7% lymphocytes, hemoglobin of 12.5 g/dL, hematocrit of 35.1%, and platelets of 282,000/microL. The prothrombin time/activated partial tissue thromboplastin was 10. 4/28.0 s (normal PT, 9.3-12.3 s; normal PTT, 21.3-33.7 s) and fibrinogen was 558 mg/dL (normal, 192-379 mg/dL). Urinalysis showed 1+ protein, 8-10 white blood cells, too numerous to count red blood cells, and no hemoglobinuria. His electrolytes, blood urea nitrogen (BUN), and creatine were normal. The urine culture was negative. Blood culture after 24 h showed one out of two bottles of coagulase negative Staphylococcus epidermidis. The patient's physical examination was highly suggestive of a brown recluse spider bite with surrounding purpura. Over the next 2 days, the surrounding rim of erythema expanded. The skin within the plaque cleared and peeled at the periphery. The coagulase negative staphylococci in the blood culture were considered to be a contaminant. Cefotaxime and oxacillin were given intravenously. His leg was elevated and cooled with ice packs. The patient's fever resolved within 24 h. The lesion became less erythematous and nontender with decreased warmth and lymphadenopathy. The child was discharged on Duricef for 10 days. Because the patient experienced hematuria rather than hemoglobinuria, nephritis was suggested. In this case, poststreptococcal glomerulonephritis was the most likely cause. His anti-streptolysin-O titer was elevated at 400 U (normal, &lt;200 U) and C3 was 21.4 mg/dL (normal, 83-177 mg/dL). His urine lightened to yellow-brown in color. His blood pressure was normal. Renal ultrasound showed severe left hydronephrosis with cortical atrophy, probably secondary to chronic/congenital ureteropelvic junction obstruction. His right kidney was normal." }, { "id": "article-25173_15", "title": "Minimal Change Disease -- Evaluation -- Basic labs:", "score": 0.009592848054644077, "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": 0.009523809523809525, "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": "pubmed23n0724_23685", "title": "[Glomerulonephritis and vasculitis as causes of arterial hypertension].", "score": 0.009523809523809525, "content": "The various types of glomerulonephritis, including many forms of vasculitis, are responsible for about 15% of cases of end-stage renal disease (ESRD). Arterial hypertension represents a frequent finding in patients suffering from glomerulonephritis or vasculitis and hypertension also serves as an indicator for these severe types of diseases. In addition, there are symptoms and signs like hematuria, proteinuria and renal failure. Especially, rapidly progressive glomerulonephritis (RPGN) constitutes a medical emergency and must not be missed by treating physicians. This disease can either occur limited to the kidneys or in the context of a systemic inflammatory disorder, like a vasculitis. If left untreated, RPGN can lead to a necrotizing destruction of glomeruli causing irreversible kidney damage within several months or even weeks. With respect to the immunologically caused vasculitis, there are - depending upon the severity and type of organ involved - many clinical warning signs to be recognized, such as arterial hypertension, hemoptysis, arthalgias, muscle pain, palpable purpura, hematuria, proteinuria and renal failure. In addition, constitutional signs, such as fever and loss of body weight may occur concurrently. Investigations of glomerulonephritis or vasculitis must contain a careful and complete examination of family history and medications used by the respective patient. Thereafter, a thorough clinical examination must follow, including skin, joints and measurement of arterial blood pressure. In addition, a spectrum of laboratory analyses is required in blood, such as full blood screen, erythrocyte sedimentation rate, CRP, creatinine, urea and glucose, and in urine, including urinalysis looking for hematuria, red cell casts and proteinuria. Importantly, proteinuria needs to be quantified by the utilization of a random urine sample. Proteinuria &gt; 3g/d is diagnostic for a glomerular damage. These basic tests are usually followed by more specialized analyses, such as a screening for infections, including search for HIV, hepatitis B or C and various bacteria, and for systemic inflammatory diseases, including tests for antibodies, such as ANA, anti-dsDNA, ANCA, anti-GBM and anti-CCP. In cases of membranous nephropathy, antibodies against phospholipase-A2-receptor need to be looked for. Depending upon the given clinical circumstances and the type of disease, a reasonable tumor screening must be performed, especially in cases of membranous and minimal-change nephropathy. Finally, radiological examinations will complete the initial work-up. In most cases, at least an ultrasound of the kidney is mandatory. Thereafter, in most cases a renal biopsy is required to establish a firm diagnosis to define all treatment options and their chance of success. The elimination of a specific cause for a given glomerulonephritis or vasculitis, such as an infection, a malignancy or a drug-related side-effect, remains the key principle in the management of these diseases. ACE-inhibitors, angiotensin receptor-blockers, aldosteron antagonists and renin-inhibitors remain the mainstay in the therapy of arterial hypertension with proteinuria. Only in cases of persistently high proteinuria, ACE-inhibitors and angiotensin receptor blockers can be prescribed in combination. Certain types of glomerulonephritis and essentially all forms of vasculitis require some form of more specific anti-inflammatory therapy. Respective immunosuppressive drug regimens contain traditionally medications, such as glucocorticoids (e. g. prednisone), cyclosporine A, mycophenolate mofetil, cyclophosphamide, and azathioprine. With respect to more severe forms of glomerulonephritis and vasculitis, the antibody rituximab represents a new and less toxic alternative to cyclophosphamide. Finally, in certain special cases, like Goodpasture's syndrome or severe ANCA-positive vasculitis, a plasma exchange will be useful and even required." }, { "id": "pubmed23n0558_4120", "title": "Behcet's disease and IgA nephropathy: report of this association in a patient from Brazil and literature review.", "score": 0.009345794392523364, "content": "Behcet's disease (BD) is associated with renal involvement in about one-third of the cases and a variety of renal lesions have been reported. A 27-year-old man presented a history of recurrent oral and genital ulcers, associated with pseudofoliculitis and arthritis in his left knee. The first laboratory tests revealed: urea = 53mg/dL, creatinine = 1.8 mg/dL. The urinalysis showed leukocyturia. Initial treatment with ceftriaxone, thalidomide and prednisone was instituted. He became clinically stable, with normal renal function, but presenting hematuria and proteinuria. One year later the patient presented dark urine. The new laboratory tests showed urea=58 mg/dL, creatinine = 1.4 mg/dL, and mild proteinuria (500-1000 mg/24h). Two years later the proteinuria was 2230 mg/day. The renal biopsy showed one glomerulus with severe glomerular sclerosis, mild tubular atrophy, mild interstitial fibrosis and thickening of arterial walls. Treatment with captopril was started to decrease proteinuria. Two years later, the patient presented creatinine = 1.7 mg/dL and proteinuria = 2509 mg/day. A new renal biopsy evidenced proliferative crescentic glomerulonephritis, with diffuse granullary deposits of IgA, IgM and C3. It was instituted pulsotherapy with metilprednisolone, monthly endovenous cyclophosphamide and maintenance prednisone. The patient became clinically stable, with creatinine of 1.3 mg/dL and proteinuria of 500 mg/day. BD could be one of the various causes of secondary IgA nephritis. It is important to periodically perform renal function evaluation in patients with BD, through urinalysis and measurement of serum creatinine and its clearance, in order to detect any abnormality and provide an early adequate treatment." }, { "id": "InternalMed_Harrison_1704", "title": "InternalMed_Harrison", "score": 0.009345794392523364, "content": "Fever ˜38.3° C (101° F) and illness lasting ˜3 weeks and no known immunocompromised state History and physical examination Stop antibiotic treatment and glucocorticoids Obligatory investigations: ESR and CRP, hemoglobin, platelet count, leukocyte count and differential, electrolytes, creatinine, total protein, protein electrophoresis, alkaline phosphatase, AST, ALT, LDH, creatine kinase, antinuclear antibodies, rheumatoid factor, urinalysis, blood cultures (n=3), urine culture, chest x-ray, abdominal ultrasonography, and tuberculin skin test" }, { "id": "pubmed23n0397_2230", "title": "Reversible acute renal failure and nephrotic syndrome in a Type 1 diabetic patient.", "score": 0.009259259259259259, "content": "Nephrotic syndrome is a condition commonly associated with end-stage renal disease secondary to diabetic nephropathy. It is usually associated with long-standing renal insufficiency, microalbuminuria, and overt proteinuria. We present a diabetic patient with acute oliguric renal failure and nephrotic syndrome. At presentation, he had a serum creatinine of 2.3 mg/dl, blood urea nitrogen (BUN) of 69 mg/dl, urinary protein excretion of 10.5 g/24 h, serum albumin of 1.3 g/dl, and a urine output &lt; 400 cc/24 h. A renal biopsy was done and the renal pathology was compatible with early diabetic nephropathy. Despite intense diuretic therapy, the patient's renal condition did not improve, and peritoneal dialysis was started several months after diagnosis. After 8 months of dialysis therapy, the patient's renal parameters and urinary output spontaneously restored to normal limits (serum creatinine was 1.1 mg/dl, urinary albumin excretion was 411 mg/24 h, serum albumin was 4.3 g/dl, and normal urine output) and dialysis was discontinued. His renal function did not deteriorate after discontinuation of dialysis. We conclude that this patient's reversible acute renal failure and nephrotic syndrome were associated with minimal change disease and not due to diabetic nephropathy." }, { "id": "pubmed23n0047_1231", "title": "[Clinical studies of the prognosis in cases of chance proteinuria and/or hematuria].", "score": 0.009259259259259259, "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": "wiki20220301en254_18218", "title": "Urine test strip", "score": 0.009210301893228722, "content": "Of the routine chemical tests performed on urine, the most indicative of renal disease is the protein determination. Proteinuria is often associated with early renal disease, making the urinary protein test an important part of any physical examination. Normal urine contains very little protein, usually less than 100–300 mg/L or 100 mg per 24 hours is excreted. This protein consists primarily of low-molecular-weight serum proteins that have been filtered by the glomerulus and proteins produced in the genitourinary tract. Due to its low molecular weight, albumin is the major serum protein found in the plasma, the normal urinary albumin content is low because the majority of albumin presented in the glomerulus is not filtered, and much of the filtered albumin is reabsorbed by the tubules. Other proteins include small amounts of serum and tubular microglobulins. Uromodulin produced by the renal tubular epithelial cells and proteins from prostatic, seminal, and vaginal secretions." }, { "id": "wiki20220301en001_26330", "title": "Nephrology", "score": 0.009193316104085698, "content": "Diagnosis History and physical examination are central to the diagnostic workup in nephrology. The history typically includes the present illness, family history, general medical history, diet, medication use, drug use and occupation. The physical examination typically includes an assessment of volume state, blood pressure, heart, lungs, peripheral arteries, joints, abdomen and flank. A rash may be relevant too, especially as an indicator of autoimmune disease. Examination of the urine (urinalysis) allows a direct assessment for possible kidney problems, which may be suggested by appearance of blood in the urine (hematuria), protein in the urine (proteinuria), pus cells in the urine (pyuria) or cancer cells in the urine. A 24-hour urine collection used to be used to quantify daily protein loss (see proteinuria), urine output, creatinine clearance or electrolyte handling by the renal tubules. It is now more common to measure protein loss from a small random sample of urine." }, { "id": "pubmed23n0754_1326", "title": "Acute renal failure associated with diphosphonic acid (HEDP): a case report.", "score": 0.009174311926605505, "content": "A 26-year-old man with no significant past medical history presented to emergency department 1 hr after ingesting approximately 200 ml of HEDP 2010 organophosphoric acid corrosion inhibitor. He had normal vital signs, physical examination and biochemical parameters. After 24 hr, he developed nausea with a decreased urine output. While his blood urea nitrogen, creatinine and uric acid levels increased to 36 mg/dl, 3.87 mg/dl, and 8.4 mg/dl, respectively; his serum calcium and phosphorus levels decreased to 7.4 mg/dl and 1.4 mg/dl, respectively. He had proteinuria, glucosuria, leukocyturia and high phosphorus excretion in the urine. On ultrasonographic examination, the kidneys were slightly enlarged and edematous. On the third day of hospitalization, creatinine level increased to 8.81 mg/dl and metabolic acidosis developed. He underwent to hemodialysis therapy and renal functions improved uneventfully. This case represents an example of acute renal failure developed and recovering uneventfully after unintentionally ingestion of a bisphosphonate used in industry." }, { "id": "pubmed23n0896_14500", "title": "Manifestation of paroxysmal nocturnal hemoglobinuria as repeated acute kidney injury.", "score": 0.009174311926605505, "content": "The triad of hemolytic anemia, pancytopenia, and thrombosis makes paroxysmal nocturnal hemoglobinuria (PNH) a truly unique clinical syndrome. Intravascular hemolysis in PNH can lead to a severe hemolytic episode with massive hemoglobinuria which can cause acute kidney injury (AKI) probably from acute tubular necrosis (ATN). A 15 -year-old girl was admitted with history of fever, diarrhea, vomiting followed by decreased urine output since 3 days. Urinalysis showed nil protein, no red blood cells (RBCs) on microscopy. Plasma hemoglobin level, total leukocyte count, platelet count, and serum creatinine were 6.5 gm/dl, 6440/μl, 205 000/μl, and 3.1 mg/dl, respectively. She received 3 units of packed red blood cells and the patient was discharged with normal renal function test with a diagnosis of acute gastroenteritis with recovered AKI. After 8 months she again had fever, vomiting, nausea with decreased urine output since 3 days. Laboratory investigations showed hemoglobin - 5.5 gm/dl, total leukocyte count - 1550/ μl, platelet count - 165000/μl, and serum creatinine - 4.89 mg/dl. Serum LDH level was 2188 U/l. She was managed conservatively with steroids, antibiotics and she recovered her kidney functions to normal in a week. Presentation of repeated AKI with hemolytic anemia in a short span after fever led us to perform flow cytometric analysis of peripheral blood granulocytes which revealed the presence of PNH clone. PNH may present with renal disease and anemia only even without classical history of hematuria or venous thrombosis. Thus it needs high index of suspicion as early diagnosis and treatment will help in preventing repeated episodes of AKI and thus chronic kidney disease." }, { "id": "pubmed23n1103_23217", "title": "Methimazole-Induced ANCA Vasculitis: A Case Report.", "score": 0.00909090909090909, "content": "Rapidly progressive glomerulonephritis (RPGN) is a syndrome which presents rapid loss of renal function. Vasculitis represents one of the major causes, often related to anti-neutrophil cytoplasmic antibodies (ANCA). Herein, we report a case of methimazole-induced ANCA-associated vasculitis. A 35-year-old woman complained of weight loss and fatigue for 2 weeks and attended the emergency room with alveolar hemorrhage. She had been diagnosed with Graves' disease and had been taking methimazole in the past 6 months. Her physical examination showed pulmonary wheezing, hypertension and signs of respiratory failure. Laboratory tests revealed urea 72 mg/dL, creatinine 2.65 mg/dL (eGFR CKD-EPI: 20 mL/min/1.73 m<sup2</sup), urine analysis with &gt;100 red blood cells per high-power field, 24 h-proteinuria: 1.3 g, hemoglobin 6.6 g/dL, white-cell count 7700/mm<sup3</sup, platelets 238,000/mm<sup3</sup, complement within the normal range, negative viral serological tests and ANCA positive 1:80 myeloperoxidase pattern. Chest tomography showed bilateral and diffuse ground-glass opacities, and bronchial washing confirming alveolar hemorrhage. A renal biopsy using light microscopy identified 27 glomeruli (11 with cellular crescentic lesions), focal disruption in glomerular basement membrane and fibrinoid necrosis areas, tubulitis and mild interstitial fibrosis. Immunofluorescence microscopy showed IgG +2/+3, C3 +3/+3 and Fibrinogen +3/+3 in fibrinoid necrosis sites. She was subsequently diagnosed with crescentic pauci-immune glomerulonephritis, mixed class, in the setting of a methimazole-induced ANCA vasculitis. The patient was treated with methimazole withdrawal and immunosuppressed with steroids and cyclophosphamide. Four years after the initial diagnosis, she is currently being treated with azathioprine, and her exams show creatinine 1.30 mg/dL (eGFR CKD-EPI: 52 mL/min/1.73 m<sup2</sup) and negative p-ANCA." }, { "id": "pubmed23n0496_13816", "title": "Chronic overexposure to cadmium fumes associated with IgA mesangial glomerulonephritis.", "score": 0.009009009009009009, "content": "Cadmium is a metal used in the zinc, copper and steel industries, and in the manufacture of electric batteries and solar cells. Acute cadmium poisoning is characterized by irritation of the respiratory tract, while in chronic poisoning the main target organ is the renal tubule. We report a patient with chronic work overexposure to cadmium, who presented a IgA mesangial glomerulonephritis with no respiratory or renal tubule involvement. Case report A 39-year-old patient was referred to our hospital for evaluation of a glomerular nephropathy. For the past 12 years he had worked as a welder, using cadmium electrodes. The patient had no respiratory symptoms and the chest X-ray was normal. Tests showed a proteinuria of 2 g in 24 h with microhaematuria [150 red blood cells/high power field (rbc/hpf)], with preservation of the renal function (creatinine clearance of 137 ml/min). The concentrations of cadmium in blood and urine were 45 micro g/l and 25 micro g/g creatinine, and an environmental study showed that levels of cadmium in the workplace were 52 micro g/m(3). A renal biopsy showed an IgA mesangial glomerulonephritis. The patient ceased to work with cadmium, and 1 year later cadmium levels had decreased and renal function was found to be stable. IgA mesangial glomerulonephritis is a disease of unknown aetiology which has been associated with other diseases. Chronic overexposure to cadmium may contribute to the development of this nephrophathy." }, { "id": "article-25111_27", "title": "Microscopic Polyangiitis -- Evaluation", "score": 0.008951612903225806, "content": "Lab Evaluation: It involves routine complete blood count (CBC), electrolytes, and measurement of serum titers of MPO and PR3 antibodies, which may be seen in most cases. However, low serum levels cannot be used to rule out AAV reliably. The complete blood cell count (CBC) shows leukocytosis and anemia. The erythrocyte sedimentation rate (ESR) is elevated. Blood urea nitrogen (BUN) and serum creatinine levels are elevated. Abnormal urine sediments, proteinuria, hematuria, leukocyturia, and erythrocyte casts are found on urine examination. The antineutrophil cytoplasmic antibody (ANCA) test is positive in 80% of cases. Among these, perinuclear ANCA, related to myeloperoxidase, is present in 60%, while cytoplasmic ANCA, related to proteinase-3 ANCA, is present in 40%. Blood cultures may be performed to rule out bacterial endocarditis. On complement testing, C3 and C4 levels are normal." }, { "id": "pubmed23n1076_18599", "title": "Safety of megadose of vitamin D in patients with nephrolithiasis.", "score": 0.008928571428571428, "content": "This article describes two patients with renal lithiasis who received a megadose of 25-hydroxy vitamin D (25[OH]D) and had a good outcome. The first case reports a 74-year-old man with a long-term history of renal lithiasis and about four episodes of renal crisis. He was treated once with extracorporeal shock wave lithotripsy. He also had a history of dyslipidemia, myocardial infarction, and stroke. Laboratory tests demonstrated 25(OH)D of 28 ng/mL (normal range (nr): &gt;30 ng/mL), normal lipid levels, creatinine of 1.1 mg/dL, and homocysteine of 26.6 mcmol/L (nr: 5-15 mcmol/L); parathyroid hormone (PTH) was high at 67.3 pg/mL (nr: 10-65 pg/mL), serum total calcium was 8.6 mg/dL, 24-h urinary calcium was 139 mg/d (normal range 100-300 mg/d), and urinary sediment was normal. He received 50 000 IU per week of vitamin D for 3 mo, and 25(OH)D increased to 36.6 ng/mL. Urinary calcium was 142 mg/d, PTH was 46.7 pg/mL, and serum calcium was 9.6 mg/dL. No renal crisis was perceived. He asked for an alternative form of medication since he usually would forget to take drugs. Vitamin D in a single dose of 600 000 IU intramuscular was prescribed. He was asked to increase water intake to 2 to 3 L/d. After 3 mo his 25(OH)D was 75.0 ng/mL, serum calcium was 9.2 mg/dL, urinary calcium was 148 mg/d, and PTH was 38.7 pg/mL. He had no episodes of lithiasis renal crisis. Folic acid and methylcobalamin were added, and homocysteine normalized. At follow-up 3 y later, the patient was asymptomatic, cardiologic evaluation was stable without any other renal lithiasis crises, 25(OH)D continued to be normal at 62 ng/mL, and he received a megadose of vitamin D every 6 mo. Renal ultrasound revealed only microlithiasis. The second case reports a 52-year-old man with a long-term history of renal lithiasis experienced since he was 30 y old, with three renal crisis episodes. He was treated with an extracorporeal shock wave three times. Laboratory tests demonstrated 25(OH)D 18 ng/mL, normal biochemistry, total serum calcium of 10.2 mg/dL, 24-h urinary calcium of 154 mg/d, and normal urinary sediment. He received 50 000 IU per week of 25(OH)D for 3 mo, and 25(OH)D increased to 40.3 ng/mL. Urinary calcium was 167 mg/d, PTH was 35.3 pg/mL, and serum calcium was 10.1 mg/dL. No renal crisis was perceived. He asked for an alternative form of medication, and vitamin D in a single dose of 600 000 IU intramuscular was prescribed. He was asked to increase water intake to 2 to 3 L/d. After 3 mo, his 25(OH)D was 82.0 ng/mL, serum calcium was 9.6 mg/dL, urinary calcium was 175 mg/d, and PTH was 35.3 pg/mL. The renal ultrasound was unchanged. He had no episodes of lithiasis renal crisis. At follow-up 4 y later, the patient was asymptomatic without any other renal lithiasis crises, a renal ultrasound revealed a reduction of calculi size to microlithiasis, 25(OH)D continues normal, and he received a megadose of this vitamin every 4 mo. To the best of our knowledge, this is the first description of a megadose of vitamin D used in patients with nephrolithiasis. Furthermore, this shows the safety of this strategy in patients without hypercalciuria." }, { "id": "pubmed23n0541_8108", "title": "Clinicopathological characteristics and outcome of adult patients with hematuria and/or proteinuria found during routine examination.", "score": 0.008928571428571428, "content": "Patients with hematuria and/or proteinuria found during routine examination are commonly encountered. To define the clinicopathological characteristics and outcome of these patients, 142 patients with definite pathological diagnosis were studied retrospectively. All the 142 patients were divided into three groups: pure hematuria (HU, n = 13), concomitant hematuria and proteinuria (HUPU, n = 79), and proteinuria alone (PU, n = 50). At the time of renal biopsy, 26% of the patients had renal insufficiency and 48% of the patients had hypertension. Pathologically, IgA nephropathy (n = 67) was the most common. A total of 51 patients were enrolled into the follow-up group. Finally, urinary abnormalities disappeared in 18% of the patients, 22% of HU developed proteinuria, 21% of HUPU and 23% of PU appeared to have a distinct increase of proteinuria, and 15% of PU developed hematuria. Seven patients with normal blood pressure before became hypertensive and 6% of the patients with normal renal function initially developed renal insufficiency. The renal outcome was associated with proteinuria and tubulointerstitial lesions. Because renal pathologic change does not always coincide with clinical manifestations, patients with hematuria and/or proteinuria found during routine examination do not necessarily imply a favorable outcome, so renal biopsy is quite important. Besides, early treatment and careful follow-up are helpful in these patients." }, { "id": "InternalMed_Harrison_2817", "title": "InternalMed_Harrison", "score": 0.008849557522123894, "content": "Laboratory studies should include a complete blood count to assess both the hematocrit and the platelet count as well as coagulation studies. Renal function should be evaluated and urinalysis conducted because of the possibility of pulmonary-renal syndromes presenting with hemoptysis. The documentation of acute renal insufficiency or the detection of red blood cells or their casts on urinalysis should elevate suspicion of small-vessel vasculitis, and studies such as antineutrophil cytoplasmic antibody, antiglomerular basement membrane antibody, and antinuclear antibody should be considered. If a patient is producing sputum, Gram’s and acid-fast staining as well as culture should be undertaken. If all of these studies are unrevealing, bronchoscopy should be considered. In any patient with a history of cigarette smoking, airway inspection should be part of the evaluation of new-onset hemoptysis as endobronchial lesions are not reliably visualized on CT." }, { "id": "wiki20220301en578_5312", "title": "UPCR", "score": 0.008788061501356647, "content": "The difference between urine protein/creatinine ratio and 24-hour urine collection is that former requires a urine sample to be collected only once at any time. [Creatinine(U)] is taken into account due to the notion that creatinine is normally released into the urine at a constant rate. Scientists found that the ratio of protein to creatinine roughly estimates the actual value gained from the 24-hour urine protein test. The normal urine protein/creatinine ratio is not more than 200 mg/g. References Abnormal clinical and laboratory findings for urine" } ] } } }

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{ "1": "Initial treatment should be directed to the underlying pathological process.", "2": "Treatment with diuretics should be started at high doses.", "3": "If nitrate treatment is required, it should be started at low doses.", "4": "Dyspnea can be treated by reducing neurohormonal activation with angiotensin converting enzyme inhibitors or angiotensin receptor antagonists.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0367_22090", "title": "Chronic Heart Failure.", "score": 0.015189158667419538, "content": "Physicians must aggressively treat heart failure in the early stages to prevent disease progression and improve survival. Early treatment implies early diagnosis of left ventricular (LV) dysfunction, before the onset of symptoms. Patients with risk factors for the development of heart failure, especially coronary disease or hypertension, should undergo echocardiography to evaluate LV function. Patients with LV systolic dysfunction should be further evaluated to determine the type of cardiac dysfunction, uncover correctable etiologic factors, determine prognosis, and guide treatment. Angiotensin-converting enzyme (ACE) inhibitors and beta-adrenergic blocking drugs improve survival and are integral to the treatment plan. Physicians should prescribe an ACE inhibitor as initial therapy for all patients with LV systolic dysfunction unless there are specific contraindications. The combination of hydralazine and isosorbide dinitrate is an acceptable alternative therapy for patients who cannot take ACE inhibitors. Diuretics should be used if there are signs or symptoms of volume overload. Beta-adrenergic blocking drugs should be added to therapy in stable patients with mild to moderate heart failure after optimal treatment with ACE inhibitors, diuretics, or other vasodilators. Digoxin should be used routinely in patients with severe heart failure and should be added to therapy in patients with mild to moderate heart failure who remain symptomatic despite optimal doses of ACE inhibitors and diuretics. Spironolactone should be added, but electrolytes should be closely monitored. Warfarin anticoagulation should be considered in patients with a left ventricular ejection fraction (LVEF) of 35% or less. Until survival data exist, angiotensin receptor blockers (ARBs) should not be used as initial therapy or as sole therapy but can be used for ACE-intolerant patients or can be added to standard heart failure therapy. Outpatient use of intravenous inotropic therapy should be avoided. Patients with severe heart failure should have peak oxygen consumption measured to quantify functional impairment, determine prognosis, and identify the need for advanced heart failure therapy. Patients who remain symptomatic while receiving optimal standard therapy should be referred early to a specialized heart failure center." }, { "id": "pubmed23n0584_10591", "title": "Treatment of heart failure with normal left ventricular ejection fraction.", "score": 0.014395194697597348, "content": "Underlying causes and precipitating causes of heart failure (HF) should be treated when possible. Persons with HF and normal left ventricular ejection fraction (LVEF) should have maintenance of sinus rhythm, treatment of hypertension, myocardial ischemia, dyslipidemia, and anemia, slowing of the ventricular rate below 90 bpm, and reduction of salt overload. First-line drug treatment in the management of these persons is the use of loop diuretics combined with beta blockers and angiotensin-converting enzyme (ACE) inhibitors. If persons are unable to tolerate ACE inhibitors because of cough, angioneurotic edema, rash, or altered taste sensation, angiotensin II type I receptor antagonists (ARBs) should be given. If HF persists despite diuretics, beta blockers, and ACE inhibitors or ARBs, isosorbide dinitrate plus hydralazine should be administered. Beta blockers, verapamil, diltiazem, and digoxin may be used to slow a rapid ventricular rate in persons with supraventricular tachyarrhythmias. Digoxin should not be used in persons with HF in sinus rhythm with normal LVEF. Exercise training should be encouraged in persons with mild to moderate HF to improve functional status and to decrease symptoms." }, { "id": "pubmed23n0349_4199", "title": "[Modern therapy of cardiac insufficiency].", "score": 0.014370131614289551, "content": "Heart failure is a lethal, end-stage cardiovascular disease. Recent decrease in mortality rates from cardiovascular diseases has not been accompanied by a reduced mortality from heart failure. Survival, once the heart has used up all its reserves and compensatory mechanisms, is a little better than in cancer. That makes heart failure one of the most important world health problems. This paper briefly reviews history, present and future of heart failure therapy, as a worldwide problem. Definition and diagnosis of heart failure, mechanism of deterioration of heart function, clinical use of present drugs in heart failure therapy and need for prevention of heart failure are, briefly pointed out. Results of clinical studies are presented, as well as the recommended indication for drug use. Heart failure is not readily identified, defined and evaluated. There is an absence of clear definition. To find a new definition which complies best with clinical practice is an important challenge cardiologists must face. Heart failure is a progressive disease and once the process has started it continues with further deterioration of cardiac function or ends in sudden death. In many patients changes within heart develop long before clinical symptoms occur. The left ventricle goes through a number of adaptations remodeling to compensate increased pressure or volume load or subsequent myocardial infarction. For decades therapy has been focused on relieving symptoms, whereas preventive aspects and prolonging survival received less attention. Conventional therapy with diuretics and cardiotonic glycosides causes regression of symptoms and signs of heart failure, but there is no evidence that these drugs slow down the progression of the disease and reduce mortality. Currently, angiotensin-converting enzyme inhibitors plus diuretics are considered first line therapy for all degrees of heart failure, except for heart failure with atrial fibrillation and a rapid ventricular rate. They are, currently, the only agents with proven ability to decrease mortality. There is evidence about the efficacy of angiotensin-converting enzyme inhibitors in asymptomatic left ventricular dysfunction. It is likely that not only patients with significant reduction of systolic function but also other signs of impaired left ventricular dysfunction will benefit from treatment with ACE inhibitors. However, only preventive treatment may decrease the number of patients with new onset of clinical heart failure. Therefore treatment should be introduced early, rather than waiting for heart failure to progress to a more severe stage. Based on these facts ACE inhibitors should be considered as treatment of choice, a first line therapy in most cases of heart failure. A substantial reduction in cardiovascular mortality requires detection and correction of presymptomatic left ventricular dysfunction and risk factors, which predispose to its occurrence. Major contributors to the development of cardiac failure have been delineated and quantified. Identification of high-risk individuals is difficult since signs and symptoms of heart failure are often lacking. A strategy to find these patients must use objective methods to characterize the state of the left ventricle. Despite this, methods for efficient identification presymptomatic candidates for cardiac failure for preventive measures have been developed. High-risk candidates can now be costly-effectively targeted for treatment to delay failure. Early diagnosis and subsequent aggressive medical or surgical treatment are therefore fundamental to improve adverse outcome of heart failure. It is necessary to allow a rational approach to the clinician, indicating the effectiveness of these drugs in patients with evidence of impaired ventricular function. Further reduction of morbidity and mortality from heart failure and diseases associated with heart failure is to be expected by early" }, { "id": "pubmed23n0375_10801", "title": "Left ventricular diastolic heart failure with normal left ventricular systolic function in older persons.", "score": 0.014185110663983903, "content": "Underlying causes and precipitating causes of congestive heart failure (CHF) should be treated when possible. Older persons with CHF and normal left ventricular (LV) ejection fraction should have maintenance of sinus rhythm, treatment of hypertension and myocardial ischemia, slowing of the ventricular rate below 90 beats/minute, and reduction of salt overload. First-line drug treatment in the management of these persons is the use of loop diuretics combined with beta blockers as tolerated. Angiotensin-converting enzyme (ACE) inhibitors should be administered if CHF persists despite diuretics and beta blockers. If persons are unable to tolerate ACE inhibitors because of cough, rash, or altered taste sensation, angiotensin II type 1 receptor antagonists should be given. If CHF persists despite diuretics, beta blockers, and ACE inhibitors or the person is unable to tolerate beta blockers, ACE inhibitors, and angiotensin II type 1 receptor antagonists, isosorbide dinitrate plus hydralazine should be administered. Calcium channel blockers should be used if CHF persists despite administration of diuretics and the person is unable to tolerate beta blockers, ACE inhibitors, angiotensin II type 1 receptor antagonists, and isosorbide dinitrate plus hydralazine. Digoxin, beta blockers, verapamil, and diltiazem may be used to slow a rapid ventricular rate in persons with supraventricular tachyarrhythmias. Digoxin should not be used in persons with CHF in sinus rhythm with normal LV ejection fraction." }, { "id": "pubmed23n0834_20631", "title": "[Dyspnea in left-sided heart disease].", "score": 0.014184745263571219, "content": "Shortness of breath (dyspnea) is a common symptom in left-sided heart disease but clinically, patient symptoms show a high variability. Echocardiography is the mainstay for evaluating whether left-sided heart disease is the cause of dyspnea. If left-sided heart failure is diagnosed, this symptom complex must then be subjected to further etiological evaluation. Hypertensive, ischemic and valvular heart diseases are common, as well as atrial fibrillation. If the patient does not have angina pectoris, testing for ischemic heart disease should be done non-invasively by coronary computed tomography or testing for regional myocardial ischemia. Coronary revascularization is indicated only when a prognostically relevant ischemia of more than 10 % of the left ventricle is diagnosed. Diuretics are important for the relief of dyspnea but do not improve the prognosis of patients. In patients with reduced left ventricular function, combination therapy with angiotensin-converting enzyme (ACE) inhibitors, beta blockers and aldosterone antagonists improve the symptoms and prognosis. For treatment of heart failure with preserved ejection fraction evidence-based measures are still lacking. In this case the recommended therapy consists of optimal treatment of comorbidities, regulation of heart rate and blood pressure and participation in structured exercise programs. Angiotensin receptor blockers and aldosterone antagonists can be given in patients with more severe symptoms even though the available data are very sparse. " }, { "id": "wiki20220301en245_28121", "title": "Myocardial infarction", "score": 0.013661307034038143, "content": "ACE inhibitor therapy should be started within 24 hours, and continued indefinitely at the highest tolerated dose. This is provided there is no evidence of worsening kidney failure, high potassium, low blood pressure, or known narrowing of the renal arteries. Those who cannot tolerate ACE inhibitors may be treated with an angiotensin II receptor antagonist. Statin therapy has been shown to reduce mortality and subsequent cardiac events and should be commenced to lower LDL cholesterol. Other medications, such as ezetimibe, may also be added with this goal in mind. Aldosterone antagonists (spironolactone or eplerenone) may be used if there is evidence of left ventricular dysfunction after an MI, ideally after beginning treatment with an ACE inhibitor." }, { "id": "wiki20220301en281_7516", "title": "Left axis deviation", "score": 0.013653371546851364, "content": "Treatment Left axis deviation per se does not require treatment, however the underlying cause can be treated. If left ventricular hypertrophy is the cause of LAD, treatment depends on the underlying cause of the hypertrophy. If high blood pressure is the cause of LVH, then treatment is targeted at lowering blood pressure and preventing further enlargement of the left ventricle by using medications such as angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), calcium channel blockers, diuretics, and beta-blockers. If LVH is due to valvular issues such as aortic valve stenosis, surgical repair of the valve or replacement of the valve is required. See also Right axis deviation References Cardiovascular physiology" }, { "id": "pubmed23n1103_19664", "title": "[ANMCO Position paper: Double, triple or quadruple therapy for heart failure with reduced ejection fraction. Current evidence and new strategies].", "score": 0.013614987864077669, "content": "The triple therapy (angiotensin-converting enzyme [ACE] inhibitors or angiotensin receptor blockers, beta-blockers, mineralocorticoid receptor antagonists) certificated by the 2012 guidelines for symptomatic patients with heart failure and reduced ejection fraction, reaffirmed in the following document of 2016 with the introduction of angiotensin receptor-neprilysin inhibitors (ARNI), has not yet reached an adequate implementation in clinical practice (where the majority of patients is only treated with the double treatment of ACE-inhibitors or angiotensin receptor blockers and beta-blockers). Among the reasons for this general failure, we should consider the enrollment of unselected cases from the real world, without exclusion criteria for age, comorbidity and stage of the disease, the therapeutic inertia of many cardiologists and not least the clinical and organizational complexity of the conventional scheme of implementation of therapy indicated by the guidelines. Not only the prescription of triple therapy is inadequate, but also the \"target doses\" defined by the large randomized controlled trials should be considered unrealistic in the majority of patients, who often achieve a therapeutic effect at lower doses, generally better tolerated (\"target effect\"). The new guidelines forthcoming will certify a further step forward with the quadruple therapy (sodium-glucose co-transporter 2 inhibitors, ARNI, beta-blockers and mineralocorticoid receptor antagonists), underlining how a fourfold intervention with different pharmacological mechanisms is able to determine the greatest benefits in patients with systolic heart failure. The discussion is open on the possibility of simplifying and speeding up the conventional implementation scheme of treatment, exploiting the ability of all these pharmacological principles to exert a significant and rapid favorable effect on prognosis already at a low dose in the first 4-8 weeks of treatment." }, { "id": "wiki20220301en370_36970", "title": "Heart failure with preserved ejection fraction", "score": 0.013577506474287827, "content": "Beta-blockers are the first-line therapy: they lower the heart rate and thus give more time for ventricles to fill. They may also improve survival. There is some evidence that calcium channel blockers may be of benefit in reducing ventricular stiffness. In some cases, (verapamil has the benefit lowering the heart rate). Angiotensin converting enzyme (ACE) inhibitors Likewise, treatment with angiotensin converting enzyme inhibitors, such as enalapril, ramipril, and many others, may be of benefit due to their effect on preventing ventricular remodeling but under control to avoid hypotension. ACE inhibitors do not appear to improve morbidity or mortality associated with HFpEF alone. However, they are important in the management of hypertension, a significant player in the pathophysiology of HFpEF. Angiotensin II receptor blockers (ARBs) ARB treatment results in an improvement in diastolic dysfunction and hypertension that is comparable to other anti-hypertensive medication." }, { "id": "wiki20220301en060_63067", "title": "Valsartan", "score": 0.012878015630309209, "content": "Valsartan was patented in 1990, and came into medical use in 1996. It is available as a generic medication. In 2019, it was the 154th most commonly prescribed medication in the United States, with more than 4million prescriptions. Medical uses Valsartan is used to treat high blood pressure, heart failure, and to reduce death for people with left ventricular dysfunction after having a heart attack. High blood pressure It is a reasonable initial treatment for high blood pressure as are ACE inhibitors, calcium-channel blockers, and thiazide diuretics. Heart failure There is contradictory evidence with regard to treating people with heart failure with a combination of an angiotensin receptor blocker like valsartan and an angiotensin-converting enzyme inhibitor, with two major clinical trials showing a reduction in death, and two others showing no benefits, and more adverse effects including heart attacks, hypotension, and renal dysfunction." }, { "id": "pubmed23n0310_1727", "title": "Treatment of congestive heart failure in older persons.", "score": 0.01272874852420307, "content": "To review the management of congestive heart failure (CHF), with emphasis on older adults. A computer-assisted search of the English language literature (MEDLINE database) followed by a manual search of the bibliographies of pertinent articles. Studies on the management of CHF were screened for review. Studies in older people and recent studies were emphasized. Pertinent data were extracted from the reviewed articles. Emphasis was on studies involving the older persons. Relevant articles were reviewed in depth. Available data about the management of CHF, with emphasis on studies involving older people, were summarized. Left ventricular ejection fraction (LVEF) should be measured in all older persons with CHF. Underlying causes of CHF should be treated when possible. Precipitating causes of CHF should be treated. Older persons with CHF associated with an abnormal LVEF should be treated with a low sodium diet and with diuretics plus angiotensin-converting enzyme (ACE) inhibitors. If CHF persists, digoxin should be added to the therapeutic regimen. If CHF still persists, isosorbide dinitrate plus hydralazine should be added. If CHF still persists, a beta blocker should also be used. Calcium channel blockers should not be used. Older persons with CHF associated with a normal LVEF should be treated with a low sodium diet and with diuretics plus ACE inhibitors. If CHF persists, a beta blocker or isosorbide dinitrate plus hydralazine or a calcium channel blocker should be added to the therapeutic regimen. If sinus rhythm is present, digoxin should not be used. The role of angiotensin II receptor antagonists such as losartan in the treatment of CHF is under investigation." }, { "id": "pubmed23n0387_11774", "title": "[Diastolic heart failure. Treatment].", "score": 0.012617060460013322, "content": "Many therapeutic options are proposed for the treatment of diastolic heart failure although no consensus has been established. In experimental trials, several drugs have demonstrated a potentially beneficial effect on ventricular diastolic dysfunction and could be used for diastolic heart failure: nitrate derivatives, converting enzyme inhibitors, angiotensin II antagonists, spirolactones and bradycardia agents. CLINICAL PRACTICE: In everyday clinical practice, low-dose diuretics and treatments aimed at reducing the triggering factor leading to episodes of heart failure are used alone or in combination with treatments aimed at the underlying cause of the diastolic dysfunction: betablockers, calcium inhibitors or nitrate derivatives for ischemic heart disease, drug therapy for hypertension, anti-diabetes agents, anti-arrhythmic agents for atrial fibrillation. Digitalics are not indicated. In experimental trials, converting enzyme inhibitors and angiotensin II antagonists have demonstrated interesting properties for the left ventricle but to date are not warranted for diastolic heart failure. TREATMENT OF THE CAUSE: Due to the lack of consensus on the optimal treatment for diastolic heart failure, most clinicians rely on treating the underlying heart disease and triggering factors." }, { "id": "wiki20220301en024_55495", "title": "Aortic regurgitation", "score": 0.01242297753925661, "content": "Medical treatment Medical therapy of chronic aortic regurgitation that is stable and asymptomatic involves the use of vasodilators. Trials have shown a short-term benefit in the use of ACE inhibitors or angiotensin II receptor antagonists, nifedipine, and hydralazine in improving left ventricular wall stress, ejection fraction, and mass. The goal in using these pharmacologic agents is to decrease the afterload so that the left ventricle is somewhat spared. The regurgitant fraction may not change significantly, since the gradient between the aortic and left ventricular pressures is usually fairly low at the initiation of treatment. Other rather conservative medical treatments for stable and asymptomatic cases include low sodium diet, diuretics, digoxin, calcium blockers and avoiding very strenuous activity." }, { "id": "pubmed23n0685_3725", "title": "[Drug treatment for chronic heart failure with reduced ejection fraction].", "score": 0.012211713953874234, "content": "Based on multiple randomized controlled trials performed in the last 20 years, drugs form the basis of treatment for heart failure with reduced ejection fraction (HFREF). Despite solid evidence for their efficacy and safety and publication of detailed national and international guidelines many patients with HFREF remain, who are not at all or only insufficiently treated. Treatment goals include reduction of mortality and hospitalizations, improvement of symptoms and exercise tolerance as well as prevention of disease progression. ACE-inhibitors and beta-adrenergic receptor blockers exert beneficial effects on all treatment goals and are therefore indicated in all patients with HFREF if tolerated. Diuretics allow control of fluid retention and maintenance of \"euvolemia\". Low-dose spironolactone can be considered in persistent moderate to severe (NYHA 3 - 4) HFREF despite treatment. Angiotensin receptor blockers are indicated for ACE-inhibitor intolerance or in addition to ACE-inhibitors and beta-adrenergic receptor blockers in case of persistent symptoms. Triple combination of ACE-inhibitors, angiotensin receptor blockers and aldosterone antagonists should be avoided in view of the substantial risk of hyperkalemia. In current praxis digoxin is mainly used as an adjunctive agent for rate control of atrial fibrillation in combination with beta-adrenergic receptor blockers. Titration and maintenance of heart failure treatment requires continuous control of clinical parameters, renal function and electrolytes. It is recommended to use drugs and dosest hat have been shown to be effective in clinial trials. Despite the fact that heart failure is mainly a disease of the elderly, this population is underrepresented in clinical trials. The risk of side effects and drug-drug interactions is increased in elderly patients because of physiologic changes with age and frequent comorbidities with resultant polypharmacy." }, { "id": "wiki20220301en012_66425", "title": "Heart failure", "score": 0.01204852268682056, "content": "Treatment depends on the severity and cause of the disease. In people with chronic stable mild heart failure, treatment commonly consists of lifestyle modifications such as stopping smoking, physical exercise, and dietary changes, as well as medications. In those with heart failure due to left ventricular dysfunction, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or valsartan/sacubitril along with beta blockers are recommended. For those with severe disease, aldosterone antagonists, or hydralazine with a nitrate may be used. Diuretics are useful for preventing fluid retention and the resulting shortness of breath. Sometimes, depending on the cause, an implanted device such as a pacemaker or an implantable cardiac defibrillator may be recommended. In some moderate or severe cases, cardiac resynchronization therapy (CRT) or cardiac contractility modulation may be of benefit. A ventricular assist device (for the left, right, or both ventricles), or" }, { "id": "wiki20220301en035_40478", "title": "Amiloride", "score": 0.011858079493051416, "content": "Amiloride may be used in combination with a thiazide diuretic for treatment of high blood pressure or (less commonly) in combination with a loop diuretic for treatment of heart failure. The potassium-sparing effects of amiloride offset the low blood potassium (hypokalemia) that is often induced by thiazides or loop diuretics, which is of particular importance in people for whom maintaining a normal level of potassium is critically important. For example, people that are taking Digitalis (i.e. digoxin) are at higher risk for changes in heart rhythm if their potassium levels get too high. The 2017 clinical practice guidelines of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines list amiloride as a \"secondary\" oral antihypertensive, with minimal efficacy. For people with resistant hypertension, already taking a thiazide diuretic, an angiotensin converting enzyme inhibitor (ACE-i) or an angiotensin II receptor blocker (ARB), and a" }, { "id": "wiki20220301en024_706", "title": "Antihypertensive drug", "score": 0.011818744838976053, "content": "However, ACE inhibitors (and angiotensin II receptor antagonists) should not be a first-line treatment for black hypertensives without chronic kidney disease. Results from the ALLHAT trial showed that thiazide-type diuretics and calcium channel blockers were both more effective as monotherapy in improving cardiovascular outcomes compared to ACE inhibitors for this subgroup. Furthermore, ACE inhibitors were less effective in reducing blood pressure and had a 51% higher risk of stroke in black hypertensives when used as initial therapy compared to a calcium channel blocker. There are fixed-dose combination drugs, such as ACE inhibitor and thiazide combinations. Notable side effects of ACE inhibitors include dry cough, high blood levels of potassium, fatigue, dizziness, headaches, loss of taste and a risk for angioedema. Angiotensin II receptor antagonists" }, { "id": "wiki20220301en370_36967", "title": "Heart failure with preserved ejection fraction", "score": 0.011771822073329611, "content": "Pharmacologic therapy Indications Management of HFpEF is primarily dependent on the treatment of symptoms and exacerbating conditions. The role of specific treatments for diastolic dysfunction per se is as yet unclear. Benefit Currently treatment with ACE inhibitors, calcium channel blockers, beta blockers, and angiotensin receptor blockers are employed but do not have a proven benefit in HFpEF patients. Additionally, use of diuretics or other therapies that can alter loading conditions or blood pressure should be used with caution. It is not recommended that patients be treated with phosphodiesterase-5-inhibitors or digoxin. Agents" }, { "id": "wiki20220301en024_713", "title": "Antihypertensive drug", "score": 0.011749640546369518, "content": "Sodium nitroprusside, a very potent, short-acting vasodilator, is most commonly used for the quick, temporary reduction of blood pressure in emergencies (such as malignant hypertension or aortic dissection). Hydralazine and its derivatives are also used in the treatment of severe hypertension, although they should be avoided in emergencies. They are no longer indicated as first-line therapy for high blood pressure due to side effects and safety concerns, but hydralazine remains a drug of choice in gestational hypertension. Renin inhibitors Renin comes one level higher than angiotensin converting enzyme (ACE) in the renin–angiotensin system. Renin inhibitors can therefore effectively reduce hypertension. Aliskiren (developed by Novartis) is a renin inhibitor which has been approved by the U.S. FDA for the treatment of hypertension. Aldosterone receptor antagonist Aldosterone receptor antagonists: eplerenone spironolactone" }, { "id": "wiki20220301en186_8959", "title": "First-dose phenomenon", "score": 0.011629072681704261, "content": "The cause is not clear. It occurs more commonly in patients who are salt and fluid volume depleted (as happens due to the use of diuretics), or were using beta blockers. Diuretics and beta blockers are frequently used to control hypertension. For this reason, treatment with prazosin (Minipress) should always be initiated with a low dose and should be taken at bedtime to avoid standing position. Other drug classes with observed first dose hypotension This effect is also observed after the administration of the first dose of drugs in the ACEi class (angiotensin-converting enzyme inhibitor). This may occur with the class's better known side effect of dry cough (due to decreased breakdown of bradykinin), though there is no clear relationship between the two side effects. The first dose phenomenon in ACEi is reduced and made safer by avoiding diuretics for 24 hours prior to first dose, taking first dose at night (so avoiding falls, etc) and starting on low doses and titrating upwards." }, { "id": "wiki20220301en477_24831", "title": "Management of hypertension", "score": 0.011478163493840985, "content": "The best first-line medication is disputed, but the Cochrane collaboration, World Health Organization, and US guidelines support low-dose thiazide-based diuretic as first-line treatment. The UK guidelines emphasise calcium channel blockers (CCB) in preference for people over the age of 55 years or people of African or Caribbean descent, with angiotensin-converting enzyme inhibitors (ACE-I) used as a first line for younger people. In Japan, starting with any one of six classes of medications, including CCB, ACEI/ARB, thiazide diuretics, beta-blockers, and alpha-blockers, is deemed reasonable, while in Canada and Europe all of these except alpha-blockers are recommended as options. Compared to placebo, beta-blockers have a greater benefit in stroke reduction, but no difference on coronary heart disease or all-cause mortality. However, three-quarters of active beta-blocker treatments in the randomised controlled trials included in the review used atenolol, and none used the newer" }, { "id": "wiki20220301en477_24834", "title": "Management of hypertension", "score": 0.011433536850289269, "content": "Unacceptable combinations are non-dihydropyridine calcium blockers (such as verapamil or diltiazem) and beta-blockers, dual renin–angiotensin system blockade (e.g., angiotensin converting enzyme inhibitor + angiotensin receptor blocker), renin–angiotensin system blockers and beta-blockers, and beta-blockers and centrally acting medications. Combinations of an ACE-inhibitor or angiotensin II–receptor antagonist, a diuretic, and an NSAID (including selective COX-2 inhibitors and non-prescribed medications such as ibuprofen) should be avoided whenever possible due to a high documented risk of acute kidney failure. The combination is known colloquially as a \"triple whammy\" in the Australian health industry. Tablets containing fixed combinations of two classes of medications are available and, while convenient, may be best reserved for those who have been established on the individual components. Additionally, the use of treatments with vasoactive agents for people with pulmonary" }, { "id": "wiki20220301en026_111807", "title": "Angiotensin II receptor blocker", "score": 0.010931129476584022, "content": "Angiotensin II receptor blockers (ARBs), formally angiotensin II receptor type 1 (AT1) antagonists, also known as angiotensin receptor blockers, angiotensin II receptor antagonists, or AT1 receptor antagonists, are a group of pharmaceuticals that bind to and inhibit the angiotensin II receptor type 1 (AT1) and thereby block the arteriolar contraction and sodium retention effects of renin–angiotensin system. Their main uses are in the treatment of hypertension (high blood pressure), diabetic nephropathy (kidney damage due to diabetes) and congestive heart failure. They selectively block the activation of the AT1 receptor, preventing the binding of angiotensin II compared to ACE inhibitors. ARBs and the similar-attributed ACE inhibitors are both indicated as the first-line antihypertensives in patients developing hypertension along with left-sided heart failure. However, ARBs appear to produce less adverse effects compared to ACE inhibitors." }, { "id": "wiki20220301en012_66476", "title": "Heart failure", "score": 0.010821110152430256, "content": "Vasopressin receptor antagonists can also be used to treat heart failure. Conivaptan is the first medication approved by US Food and Drug Administration for the treatment of euvolemic hyponatremia in those with heart failure. In rare cases hypertonic 3% saline together with diuretics may be used to correct hyponatremia. Ivabradine is recommended for people with symptomatic heart failure with reduced left ventricular ejection fraction who are receiving optimized guideline-directed therapy (as above) including the maximum tolerated dose of beta-blocker, have a normal heart rhythm and continue to have a resting heart rate above 70 beats per minute. Ivabradine has been found to reduce the risk of hospitalization for heart failure exacerbations in this subgroup of people with heart failure." }, { "id": "wiki20220301en003_155266", "title": "Hypertension", "score": 0.010570781793192659, "content": "Medications Several classes of medications, collectively referred to as antihypertensive medications, are available for treating hypertension. First-line medications for hypertension include thiazide-diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors (ACE inhibitors), and angiotensin receptor blockers (ARBs). These medications may be used alone or in combination (ACE inhibitors and ARBs are not recommended for use in combination); the latter option may serve to minimize counter-regulatory mechanisms that act to restore blood pressure values to pre-treatment levels. Most people require more than one medication to control their hypertension. Medications for blood pressure control should be implemented by a stepped care approach when target levels are not reached." }, { "id": "wiki20220301en370_36971", "title": "Heart failure with preserved ejection fraction", "score": 0.010230085918159312, "content": "Angiotensin II receptor blockers (ARBs) ARB treatment results in an improvement in diastolic dysfunction and hypertension that is comparable to other anti-hypertensive medication. Diuretics Diuretics can be useful if significant congestion develops, but patients must be monitored because they frequently develop low blood pressure. Experimental The use of a self-expanding device that attaches to the external surface of the left ventricle has been suggested, yet still awaits FDA approval. When the heart muscle squeezes, energy is loaded into the device, which absorbs the energy and releases it to the left ventricle in the diastolic phase. This helps retain muscle elasticity." }, { "id": "wiki20220301en226_4902", "title": "Alpha blocker", "score": 0.01019555817610063, "content": "Contraindications There is only one compelling indication for alpha blockers, which is for benign prostatic hyperplasia. Patients who need alpha blockers for BPH, but have a history of hypotension or postural heart failure, should use these drugs with caution, as it may result in an even greater decrease in blood pressure or make heart failure even worse. The most compelling contraindication is urinary incontinence and overall fluid retention. To combat such fluid retention, patients can take a diuretic in combination with the alpha-blocker. In the absence of compelling indications or contraindications, patients should take alpha blockers as a step 4 therapy to reduce blood pressure, but only if the use of ACE inhibitors, angiotensin-II receptor blockers, calcium channel blockers, or thazide diuretics (in full dose or in combinations) have not been efficacious." }, { "id": "wiki20220301en036_56607", "title": "Thiazide", "score": 0.009900990099009901, "content": "Clinical practice guidelines regarding the use of thiazides vary by geographic region. Guidelines in the United States recommend thiazides as a first-line treatment for hypertension (JNC VIII). A systematic review by the Cochrane Collaboration specifically recommended that low-dose thiazides be used as the initial pharmacological therapy for high blood pressure. Low-dose thiazides are more effective at treating hypertension than beta blockers and are similar to angiotensin-converting enzyme (ACE) inhibitors. Thiazides are a recommended treatment for hypertension in Europe (ESC/ESH). However, the UK National Institute for Health and Clinical Excellence recommends ACE inhibitor and calcium channel blockers for first-line treatment of hypertension in adults (CG127). Thiazides should be considered as initial treatment if the patient has a high risk of developing heart failure. Thiazides have also been replaced by ACE inhibitors in Australia due to the association between thaizide use" }, { "id": "pubmed23n0373_2018", "title": "[Changes in medical treatment of heart failure in the light of large clinical trials].", "score": 0.009900990099009901, "content": "In the last years, the treatment of heart failure has radically changed, as has knowledge of this complex and heterogeneous clinical syndrome. This is largely due to the results of several multicenter clinical trials, which have been undertaken since the late 80's. These trials have not only contributed to the elaboration of present-day treatment protocols, but also to a better understanding of the pathophysiologic mechanisms involved in heart failure. In the past, heart failure was generally interpreted on the basis of pathophysiologic models according to which hemodynamic abnormalities played a very important role in determining the clinical presentation and evolution of the disease. This led to the use of digitalis, diuretics, inotropic drugs and vasodilators for the treatment of heart failure. More recently, improved knowledge of the pathophysiologic mechanisms involved in the progression of this disease has highlighted the central role and the complexity of various neurohormonal mechanisms. Antagonism of these systems has proved to be the only strategy which favorably modifies the natural history of heart failure. The proved effectiveness of ACE-inhibitors and particularly of beta-blockers in patients with heart failure and left ventricular systolic dysfunction was the most convincing demonstration of the validity of this model. However, the evolution and updating of the guidelines on the treatment of heart failure should only be considered as the first step in the development of strategies aimed at extending these principles to daily clinical practice and in particular to the real patient who is different from patients typically enrolled in heart failure trials. Moreover, the development of new effective models for the management of the ever-growing number of patients with heart failure is of utmost urgency." }, { "id": "wiki20220301en024_717", "title": "Antihypertensive drug", "score": 0.009747805129970736, "content": "If lifestyle changes are ineffective, then drug therapy is initiated, often requiring more than one agent to effectively lower hypertension. Which type of many medications should be used initially for hypertension has been the subject of several large studies and various national guidelines. Considerations include factors such as age, race, and other medical conditions. In the United States, JNC8 (2014) recommends any drug from one of the four following classes to be a good choice as either initial therapy or as an add-on treatment: thiazide-type diuretics, calcium channel blockers, ACE inhibitors, or angiotensin II receptor antagonists." }, { "id": "wiki20220301en503_4143", "title": "ACE inhibitor and thiazide combination", "score": 0.009708436724565757, "content": "An ACE inhibitor and thiazide combination is a drug combination used to treat hypertension (high blood pressure). They are given by mouth. ACE inhibitors reduce the activity of angiotensin-converting enzyme (ACE) which produces angiotensin II, a hormone that constricts blood vessels. Thiazides are a class of diuretics that inhibit the thiazide receptor, thereby increasing urine production and reducing excess water and salt in the body. Several organizations recommend combination therapy for hypertension in cases of failure of a single drug to achieve target blood pressure, or even as a first line treatment for some patients. Examples Enalapril/hydrochlorothiazide (trade name Enalapril comp), wherein enalapril is the ACE inhibitor and hydrochlorothiazide is the thiazide. Quinapril/hydrochlorothiazide (trade name Accuretic) Lisinopril/hydrochlorothiazide is marketed as Prinzide, Zestoretic, and many others. Fosinopril/hydrochlorothiazide" }, { "id": "wiki20220301en038_67874", "title": "Candesartan", "score": 0.009615384615384616, "content": "Candesartan is an angiotensin receptor blocker used mainly for the treatment of high blood pressure and congestive heart failure. Candesartan has a very low maintenance dose. The metabolism for the drug is unique as it is a cascading pro-drug. Candesartan has good bioavailibility and is more potent among the AT-1 receptor antagonists. It was patented in 1990 and approved for medical use in 1997. Medical uses Hypertension As with other angiotensin II receptor antagonists, candesartan is indicated for the treatment of hypertension. Candesartan has an additive hypertensive effect when combined with a diuretic, such as chlorthalidone. It is available in a fixed-combination formulation with a low dose of the thiazide diuretic hydrochlorothiazide. Candesartan/hydrochlorothiazide combination preparations are marketed under various trade names including Atacand Plus, Hytacand, Blopress Plus, Advantec and Ratacand Plus." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 155 ] ], "word_ranges": [ [ 0, 27 ] ], "text": "They tell us about clinical symptoms of right failure, with edema and ascites. Therefore, we rule out left heart failure: EAo, dilated with DSVI and a MHO." }, "2": { "exist": true, "char_ranges": [ [ 0, 155 ] ], "word_ranges": [ [ 0, 27 ] ], "text": "They tell us about clinical symptoms of right failure, with edema and ascites. Therefore, we rule out left heart failure: EAo, dilated with DSVI and a MHO." }, "3": { "exist": true, "char_ranges": [ [ 373, 481 ] ], "word_ranges": [ [ 59, 73 ] ], "text": "in pulmonary hypertension, the tricuspid valve is responsible (a priori) for \"containing\" this overpressure." }, "4": { "exist": true, "char_ranges": [ [ 0, 155 ] ], "word_ranges": [ [ 0, 27 ] ], "text": "They tell us about clinical symptoms of right failure, with edema and ascites. Therefore, we rule out left heart failure: EAo, dilated with DSVI and a MHO." }, "5": { "exist": true, "char_ranges": [ [ 185, 355 ] ], "word_ranges": [ [ 34, 56 ] ], "text": "in constrictive pericarditis we have increased filling pressures in right chambers, which cause retrograde pressure increase with hepatic congestion, ascites, edema, etc." } }

{ "1": "Severe aortic stenosis.", "2": "Dilated cardiomyopathy with significant left ventricular dysfunction.", "3": "Primary pulmonary hypertension.", "4": "Obstructive hypertrophic cardiomyopathy.", "5": "Constrictive pericarditis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0367_422", "title": "[Contribution of echocardiography to the diagnosis of patients with chronic heart failure].", "score": 0.01960972796308757, "content": "The echocardiographic examination is generally performed in patients with heart failure and it often gives a significant contribution to the differential diagnosis. Firstly, the evaluation of left ventricular pump function by measuring the ejection fraction (EF) can distinguish patients with heart failure into two different groups, with depressed or preserved EF. The most frequent causes of heart failure and depressed EF are coronary artery disease, idiopathic dilated cardiomyopathy (DCM) and hypertensive heart disease. Although the echocardiographic features of coronary artery disease versus idiopathic DCM may be similar, the demonstration of inducible ischemia at dobutamine echocardiographic test suggests the presence of significant coronary artery disease and may be useful in the selection of cases for coronary arteriography. The association of left ventricular hypertrophy, hypokinesis and, sometimes, significant dilation is compatible with hypertensive heart disease or end-stage hypertrophic cardiomyopathy. No useful echocardiographic findings can identify the patients with genetic DCM or affected by myocarditis from other cases with idiopathic DCM. Some advanced cases of right ventricular dysplasia/cardiomyopathy may show a biventricular involvement and mimic DCM; these patients are usually characterized at echo by predominant right ventricular dilation and multiple a-dyskinetic bulges in the absence of pulmonary hypertension. Very difficult to manage are the patients with significant left ventricular dysfunction and severe valvular heart disease (such as aortic stenosis or mitral regurgitation). According to the literature, the left ventricular systolic function is relatively preserved (EF &gt; 40%) in 30-40% of patients with heart failure. In these cases a diastolic dysfunction may be hypothesized. Echo-Doppler evaluation can be helpful in the recognition of signs of increased left ventricular stiffness (\"restrictive filling pattern\") and of increased filling pressures. In the differential diagnosis one must first consider the most frequent heart disorders that may present with this clinical syndrome, coronary artery disease and hypertensive heart disease. Furthermore, other less common diseases characterized by heart failure due to predominant diastolic dysfunction are the following: hypertrophic and restrictive cardiomyopathies, infiltrative heart diseases, such as amyloidosis, and constrictive pericarditis. Restrictive cardiomyopathy is characterized by heart failure and preserved left ventricular EF in the absence of significant ventricular dilation and hypertrophy; typical, although not pathognomonic, echocardiographic features are atrial enlargement ad restrictive filling pattern. In distinguishing constrictive pericarditis from restrictive cardiomyopathy useful Doppler signs are the wide respiratory variability in flow velocities at mitral and tricuspid levels, due to increased ventricular interdependence caused by the presence of an abnormally rigid pericardium." }, { "id": "wiki20220301en074_50128", "title": "Restrictive cardiomyopathy", "score": 0.01759259259259259, "content": "It should not be confused with constrictive pericarditis, a disease which presents similarly but is very different in treatment and prognosis. Signs and symptoms Untreated hearts with RCM often develop the following characteristics: M or W configuration in an invasive hemodynamic pressure tracing of the RA Square root sign of part of the invasive hemodynamic pressure tracing Of The LV Biatrial enlargement Thickened LV walls (with normal chamber size) Thickened RV free wall (with normal chamber size) Elevated right atrial pressure (>12mmHg), Moderate pulmonary hypertension, Normal systolic function, Poor diastolic function, typically Grade III - IV Diastolic heart failure. Those afflicted with RCM will experience decreased exercise tolerance, fatigue, jugular venous distention, peripheral edema, and ascites. Arrhythmias and conduction blocks are common." }, { "id": "pubmed23n0396_4559", "title": "Primary diastolic heart failure.", "score": 0.016330513988288872, "content": "Diastolic heart failure is defined clinically when signs and symptoms of heart failure are present in the presence of preserved left ventricular systolic function (ejection fraction &gt;45%). The incidence and prevalence of primary diastolic heart failure increases with age and it may be as high as 50% in the elderly. Age, female gender, hypertension, coronary artery disease, diabetes, and increased body mass index are risk factors for diastolic heart failure. Hemodynamic consequences such as increased pulmonary venous pressure, post-capillary pulmonary hypertension, and secondary right heart failure as well as decreased cardiac output are similar to those of systolic left ventricular failure, although the nature of primary left ventricular dysfunction is different. Diagnosis of primary diastolic heart failure depends on the presence of preserved left ventricular ejection fraction. Assessment of diastolic dysfunction is preferable but not mandatory. It is to be noted that increased levels of B-type natriuretic peptide does not distinguish between diastolic and systolic heart failure. Echocardiographic studies are recommended to exclude hypertrophic cardiomyopathy, infiltrative heart disease, primary valvular heart disease, and constrictive pericarditis. Myocardial stress imaging is frequently required to exclude ischemic heart disease. The prognosis of diastolic heart failure is variable; it is related to age, severity of heart failure, and associated comorbid diseases such as coronary artery disease. The prognosis of severe diastolic heart failure is similar to that of systolic heart failure. However, cautious use of diuretics and/or nitrates may cause hypotension and low output state. Heart rate control is essential to improving ventricular filling. Pharmacologic agents such as angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers are used in selected patients to decrease left ventricular hypertrophy. To decrease myocardial fibrosis, aldosterone antagonists have a potential therapeutic role. However, prospective controlled studies will be required to establish their efficacy in primary diastolic heart failure." }, { "id": "pubmed23n1160_670", "title": "Right ventricular failure in left heart disease: from pathophysiology to clinical manifestations and prognosis.", "score": 0.01346448087431694, "content": "Right heart failure (RHF) is a clinical syndrome in which symptoms and signs are caused by dysfunction and/or overload of the right heart structures, predominantly the right ventricle (RV), resulting in systemic venous hypertension, peripheral oedema and finally, the impaired ability of the right heart to provide tissue perfusion. Pathogenesis of RHF includes the incompetence of the right heart to maintain systemic venous pressure sufficiently low to guarantee an optimal venous return and to preserve renal function. Virtually, all myocardial diseases involving the left heart may be responsible for RHF. This may result from coronary artery disease, hypertension, valvular heart disease, cardiomyopathies and myocarditis. The most prominent clinical signs of RHF comprise swelling of the neck veins with an elevation of jugular venous pressure and ankle oedema. As the situation worsens, fluid accumulation becomes generalised with extensive oedema of the legs, congestive hepatomegaly and eventually ascites. Diagnosis of RHF requires the presence of signs of elevated right atrial and venous pressures, including dilation of neck veins, with at least one of the following criteria: (1) compromised RV function; (2) pulmonary hypertension; (3) peripheral oedema and congestive hepatomegaly. Early recognition of RHF and identifying the underlying aetiology as well as triggering factors are crucial to treating patients and possibly reversing the clinical manifestations effectively and improving prognosis." }, { "id": "pubmed23n0505_14310", "title": "Constrictive pericarditis versus restrictive cardiomyopathy: challenges in diagnosis and management.", "score": 0.012942916694681637, "content": "This is the case of a patient who presented with severe right-sided heart failure due to diastolic dysfunction that caused a dilemma of differential diagnosis between restrictive cardiomyopathy and constrictive pericarditis. Restrictive cardiomyopathy was diagnosed based on noninvasive and invasive hemodynamic testing. However, the patient did not respond to therapy and succumbed to worsening heart failure and multiple comorbidities. Clinical features of right heart failure with edema, ascites, jugular venous distention, and tender hepatomegaly are commonly seen in clinical practice. When systolic function is determined to be normal, diastolic causes of heart failure must be ruled out. These include myocardial disorders with a broad range of pathologies leading to restrictive physiology, of which amyloidosis is a prototype. Pericardial disorders leading to diastolic heart failure are usually in the form of constrictive physiology, when pericardial tamponade is ruled out. Differentiation between restrictive and constrictive pathologies is often difficult and requires careful attention to hemodynamic and Doppler echocardiographic features. We report a case of severe right heart failure illustrating some of the complexities in decision-making and the importance of meticulous hemodynamic and ancillary testing in the diagnosis and treatment of this often fatal condition." }, { "id": "article-164817_15", "title": "Heart Failure With Preserved Ejection Fraction (HFpEF) -- Etiology -- Etiologies of Secondary Heart Failure With Preserved Ejection Fraction", "score": 0.012316715542521993, "content": "Secondary HFpEF occurs in the presence of a clinical condition that directly causes the heart to fail. These conditions are sometimes referred to as \"HFpEF mimics.\" [16] These mimics include but are not limited to restrictive and hypertrophic cardiomyopathies of any etiology, constrictive pericarditis, and valvular heart disease. [16] [7] In the United States, left-sided valvular disease is the most commonly encountered HFpEF mimic, and aortic stenosis should be suspected in all patients with signs, symptoms, or suspicion of HFpEF. [21] [16]" }, { "id": "wiki20220301en012_66433", "title": "Heart failure", "score": 0.011876408110717735, "content": "\"Cardiac asthma\" or wheezing may occur.Compromise of left ventricular forward function may result in symptoms of poor systemic circulation such as dizziness, confusion, and cool extremities at rest. Right-sided failure Right-sided heart failure is often caused by pulmonary heart disease (cor pulmonale), which is typically caused by difficulties of the pulmonary circulation, such as pulmonary hypertension or pulmonic stenosis. Physical examination may reveal pitting peripheral edema, ascites, liver enlargement, and spleen enlargement. Jugular venous pressure is frequently assessed as a marker of fluid status, which can be accentuated by eliciting hepatojugular reflux. If the right ventricular pressure is increased, a parasternal heave may be present, signifying the compensatory increase in contraction strength." }, { "id": "wiki20220301en046_22775", "title": "Exercise intolerance", "score": 0.011857537081752328, "content": "Hazards Certain conditions exist where exercise may be contraindicated or should be performed under the direction of an experienced and licensed medical professional acting within his or her scope of practice. These conditions include: Decompensated heart failure Recent myocardial infarction Hypertrophic cardiomyopathy or cardiomyopathy from recent myocarditis Active or suspected myocarditis or pericarditis Low left-ventricular ejection fraction (LVEF) Severe aortic stenosis Unstable ischemia Unstable arrythmia Irregular or resting pulse greater than 100 bpm Resting systolic blood pressure >200 mm Hg or resting diastolic blood pressure >110 mm Hg Severe pulmonary hypertension Chronic fatigue syndrome Suspected or known dissecting aortic aneurysm Recent systemic or pulmonary embolus Pneumothorax and haemoptysis Thrombophlebitis" }, { "id": "article-164817_65", "title": "Heart Failure With Preserved Ejection Fraction (HFpEF) -- Differential Diagnosis", "score": 0.011734506784011734, "content": "The differential diagnosis of exertional dyspnea with or without generalized fatigue is incredibly broad and includes cardiac and noncardiac etiologies. Additionally, because the clinical syndrome of heart failure is the common endpoint for many disease processes, the overarching differential diagnosis for heart failure is similarly broad. However, in patients with exertional dyspnea and an underlying risk factor for HFpEF or comorbidity strongly associated with the development of HFpEF, the following diagnoses should be considered: [7] [16] Coronary artery disease Hypertension Valvular disease, particularly left-sided valvular disease Infiltrative cardiac diseases such as amyloidosis, hemochromatosis, and sarcoidosis Hypertrophic cardiomyopathy Constrictive pericarditis." }, { "id": "wiki20220301en324_38027", "title": "List of causes of shortness of breath", "score": 0.011374191958446285, "content": "Obstruction of the airway Cancer of the larynx or pharynx Empty nose syndrome Pulmonary aspiration Epiglottitis Laryngeal edema Vocal cord dysfunction Immobilization of the diaphragm Lesion of the phrenic nerve Polycystic liver disease Tumor in the diaphragm Restriction of the chest volume Ankylosing spondylitis Broken ribs Kyphosis of the spine Obesity Costochondritis Pectus excavatum Scoliosis Disorders of the cardiovascular system Aortic dissection Cardiomyopathy Congenital heart disease CREST syndrome Heart failure Ischaemic heart disease Malignant hypertension Pericardium disorders, including: Cardiac tamponade Constrictive pericarditis Pericardial effusion Pulmonary edema Pulmonary embolism Pulmonary hypertension Valvular heart disease Disorders of the blood and metabolism Anemia Hypothyroidism Adrenal insufficiency Metabolic acidosis Sepsis Leukemia Holocarboxylase synthetase deficiency Disorders affecting breathing nerves and muscles" }, { "id": "wiki20220301en023_18115", "title": "Hypertrophic cardiomyopathy", "score": 0.011364749681591065, "content": "Clinically, cats with hypertrophic cardiomyopathy commonly have a systolic anterior motion (SAM) of the mitral valve (see graphic). Cats with severe HCM often develop left heart failure (pulmonary edema; pleural effusion) because of severe diastolic dysfunction of the left ventricle. They may also develop a left atrial thrombus that embolizes, most commonly, to the terminal aorta creating acute pain and rear limb paralysis (see below). Sudden death can also occur but appears to be uncommon. Ultrasound of the heart (echocardiography) is necessary to diagnose HCM in cats. Measurement of circulating cardiac biomarkers, like N‐terminal‐proBNP (NT‐proBNP) and troponin I (TnI) may be used in cats to strengthen the suspicion of cardiac disease. There is a Point-of-care test for feline NT-proBNP available which can be used at the veterinary clinic when echocardiography is not possible to perform." }, { "id": "InternalMed_Harrison_18796", "title": "InternalMed_Harrison", "score": 0.01084280303030303, "content": "The least common of the physiologic triad of cardiomyopathies is restrictive cardiomyopathy, which is dominated by abnormal diastolic function, often with mildly decreased contractility and ejection fraction (usually >30–50%). Both atria are enlarged, sometimes massively. Modest left ventricular dilation can be present, usually with an end-diastolic dimension <6 cm. End-diastolic pressures are elevated in both ventricles, with preservation of cardiac output until late in the disease. Subtle exercise intolerance is usually the first symptom but is often not recognized until after clinical presentation with congestive symptoms. The restrictive diseases often present with relatively more right-sided symptoms, such as edema, abdominal discomfort, and ascites, although filling pressures are elevated in both ventricles. The cardiac impulse is less displaced than in dilated cardiomyopathy and less dynamic than in hypertrophic cardiomyopathy. A fourth heart sound is more common than a third" }, { "id": "InternalMed_Harrison_20985", "title": "InternalMed_Harrison", "score": 0.010838715991387747, "content": "Diagnosis Due to the unstable condition of these patients, supportive therapy must be initiated simultaneously with diagnostic evaluation (Fig. 326-2). A focused history and physical examination should be performed, blood specimens sent to the laboratory, and an electrocardiogram (ECG) and chest x-ray obtained. Etiologies of Cardiogenic Shock or Pulmonary Edema Acute myocardial infarction/ischemia LV failure Ventricular septal rupture Papillary muscle/chordal rupture–severe MR Ventricular free wall rupture with subacute tamponade Other conditions complicating large MIs Post-cardiac arrest Post-cardiotomy Refractory sustained tachyarrhythmias Acute fulminant myocarditis End-stage cardiomyopathy LV apical ballooning Takotsubo’s cardiomyopathy Hypertrophic cardiomyopathy with severe outflow obstruction Aortic dissection with aortic insufficiency or tamponade Severe valvular heart disease Other Etiologies of Cardiogenic Shockb RV failure due to:" }, { "id": "article-19916_9", "title": "Constrictive Pericarditis -- History and Physical", "score": 0.010479975066230326, "content": "On physical examination, the jugular venous pressure (JVP) is usually elevated, however, may be normal in early constrictive pericarditis. JVP does not decrease with inspiration, and this is known as Kussmaul's sign. Kussmaul's sign is also present in tricuspid valve disease, and right-sided heart failure.Pulsus paradoxus (more than 10 mm Hg drop in systolic blood pressure during inspiration) can be seen however this is more common in patients with cardiac tamponade. An accentuated heart sound heard earlier than third heart sound called pericardial knock can be heard in almost half of the patients. Abdominal examination may reveal ascites or hepatomegaly. Other signs of chronic illness like muscle wasting may be present based upon the etiology. Peripheral edema may be present as well." }, { "id": "article-20863_30", "title": "Echocardiogram -- Clinical Significance", "score": 0.010465689570167181, "content": "Transthoracic Echocardiography (TTE): When a patient presents clinically with dyspnea or chest pain, and there is a high pre-test probability that the shortness of breath is of cardiac origin, TTE is recommended. It is useful in identifying the cause, location, and severity of myocardial ischemia, atrial sizes, ejections fraction (EF), left ventricular hypertrophy, and presence of valvular disease. [22] An EF is a common piece of information that is available from a TTE, especially in those with systolic congestive heart failure (CHF), because it dictates the course of treatment. An important assessment of cardiac structure by TTE is the size and thickness of the cardiac structures. Left and right atrial size will help aid in the diagnosis of diastolic dysfunction, and right and left ventricular hypertrophy will aid in the diagnosis of heart failure. This is especially important when the diagnosis of hypertrophic cardiomyopathy (HCM) is suspected. Asymmetric hypertrophy of left and right ventricles is the bases of the diagnosis for HCM. Patients who are found to have preserved ejection fraction (>50%) CHF are treated mainly with diuretics (furosemide, bumetanide) for symptom management. [23] On the contrary, those who are found to have reduced EF (<50%) CHF may be treated with diuretics, with the addition of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone antagonist which have shown to have a mortality benefit. This benefit is not seen in those with preserved EF heart failure. The evaluation of the mitral, tricuspid, aortic, and pulmonary valves is another important indication of TTE. Patients who have a new-onset heart murmur, clinical suspicion for infective endocarditis, dyspnea, and near-syncope may have structural valve pathology including tricuspid, mitral, aortic, and pulmonary stenosis and regurgitation. TEE is more sensitive for the diagnosis of valvular pathology, although TTE is generally performed first, as it is less invasive. [22] Another aspect of TTE is assessing heart chamber pressures, and the most useful of these is right pulmonary artery pressure, which aids in the diagnosis of pulmonary artery hypertension. In the acute setting, bedside TTE can assess pericardial effusions, and aid in the diagnosis of cardiac tamponade, this may require immediate interventions, including pericardiocentesis." }, { "id": "wiki20220301en063_19523", "title": "Valvular heart disease", "score": 0.009984520123839009, "content": "On auscultation of a patient with mitral stenosis, typically the most prominent sign is a loud S1. Another finding is an opening snap followed by a low-pitched diastolic rumble with presystolic accentuation. The opening snap follows closer to the S2 heart tone with worsening stenosis. The murmur is heard best with the bell of the stethoscope lying on the left side and its duration increases with worsening disease. Advanced disease may present with signs of right-sided heart failure such as parasternal heave, jugular venous distension, hepatomegaly, ascites and/or pulmonary hypertension (presenting with a loud P2). Signs increase with exercise and pregnancy. Mitral regurgitation Patients with mitral regurgitation may present with heart failure symptoms, such as dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea, palpitations, or pulmonary edema." }, { "id": "wiki20220301en194_20610", "title": "MYL4", "score": 0.009900990099009901, "content": "Clinical significance MYL4 expression in ventricular myocardium has shown to abnormally persist in neonates up through adulthood in patients with the congenital heart disease, tetralogy of Fallot. Altered ALC-1 expression is also altered in other congenital heart diseases, Double outlet right ventricle and infundibular pulmonary stenosis. Moreover, in patients with aortic stenosis or aortic insufficiency, ALC-1 expression in left ventricles was elevated, and following valve replacement decreased to lower levels; ALC-1 expression also correlated with left ventricular systolic pressure. Additionally, in patients with ischemic cardiomyopathy, dilated cardiomyopathy and hypertrophic cardiomyopathy, ALC-1 protein expression is shown to be reactivated, and ALC-1 expression correlates with calcium sensitivity of myofilament proteins in skinned fiber preparations, as well as ventricular dP/dtmax and ejection fraction. Interactions ALC-1 interacts with: ACTC1 MYH7 References" }, { "id": "pubmed23n0115_1601", "title": "[Evolution of dilated cardiomyopathy from hypertrophic obstructive cardiomyopathy: a case report].", "score": 0.009813434481541922, "content": "A 20-year-old woman whose echocardiograms showed a rare evolution from hypertrophic to dilated cardiomyopathy during a nine year observation period is described. This patient was initially diagnosed as having hypertrophic obstructive cardiomyopathy (HOCM) at the age of 12 years. Her echocardiogram showed marked thickening of the interventricular septum (IVS) and left ventricular posterior wall (LVPW), asymmetric septal hypertrophy (ASH) and systolic anterior motion of the mitral valve (SAM). Chest radiography revealed a prominent left ventricular border and a cardiothoracic ratio of 0.52. At 18 years of age she experienced onset of palpitation during the 16th week of pregnancy. Her echocardiogram recorded in June 1980 revealed a thickened IVS and LVPW with resolution of the SAM and of the narrow cavity. At 20 years of age she became pregnant again and was admitted to our hospital for the third time at 24 weeks gestation. On admission her blood pressure was 122/60 and her pulse was 56, and moist rales were audible over both lung fields. Peripheral edema was noted. Chest radiography revealed moderate cardiomegaly, a cardiothoracic ratio of 0.66, and congestion of the pulmonary vasculature. An echocardiogram showed thinning of the IVS and LVPW with hypokinesis and dilatation of the cavity compatible with dilated cardiomyopathy (DCM). She delivered a boy on July 15th 1982 at 32 weeks gestation following which she developed marked congestive heart failure. She expired one month later. A chest radiograph made one day before death revealed marked cardiomegaly, a cardiothoracic ratio of 0.76, prominent pulmonary vasculature and a pleural effusion. Autopsy was refused; therefore the terminal DCM-like features were not clarified pathologically. However, the slow progression from HOCM to HCM during eight years and then rapid progression from HCM to DCM during four months was most impressive." }, { "id": "wiki20220301en100_5617", "title": "List of MeSH codes (C14)", "score": 0.00980392156862745, "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": "pubmed23n0921_14772", "title": "Importance of Clinical and Laboratory Findings in the Diagnosis and Surgical Prognosis of Patients with Constrictive Pericarditis.", "score": 0.00980392156862745, "content": "International studies have reported the value of the clinical profile and laboratory findings in the diagnosis of constrictive pericarditis. However, Brazilian population data are scarce. To assess the clinical characteristics, sensitivity of imaging tests and factors related to the death of patients with constrictive pericarditis undergoing pericardiectomy. Patients with constrictive pericarditis surgically confirmed were retrospectively assessed regarding their clinical and laboratory variables. Two methods were used: transthoracic echocardiography and cardiac magnetic resonance imaging. Mortality predictors were determined by use of univariate analysis with Cox proportional hazards model and hazard ratio. All tests were two-tailed, and an alpha error ≤ 5% was considered statically significant. We studied 84 patients (mean age, 44 ± 17.9 years; 67% male). Signs and symptoms of predominantly right heart failure were present with jugular venous distention, edema and ascites in 89%, 89% and 62% of the cases, respectively. Idiopathic etiology was present in 69.1%, followed by tuberculosis (21%). Despite the advanced heart failure degree, low BNP levels (median, 157 pg/mL) were found. The diagnostic sensitivities for constriction of echocardiography and magnetic resonance imaging were 53.6% and 95.9%, respectively. There were 9 deaths (10.7%), and the risk factors were: anemia, BNP and C reactive protein levels, pulmonary hypertension &gt;55 mm Hg, and atrial fibrillation. Magnetic resonance imaging had better diagnostic sensitivity. Clinical, laboratory and imaging markers were associated with death." }, { "id": "article-20486_17", "title": "Heart Failure and Ejection Fraction -- History and Physical", "score": 0.009708737864077669, "content": "A thorough history and physical exam should be obtained and performed in all patients with suspected HF, as the entire basis of the diagnosis is on clinical symptoms and signs. It also should include assessment of risk factors and possible etiologies of the HF. Symptoms of HF are similar regardless of the EF. Symptoms are more severe with exertion and either secondary to fluid accumulation (dyspnea, orthopnea, edema, and abdominal discomfort from hepatic congestion and ascites in the setting of right heart failure) or due to decreased cardiac output (fatigue, anorexia, and weakness). Other less typical symptoms include nocturnal cough, loss of appetite, wheezing, palpitations, depression, syncope, bendopnea (shortness of breath while bending forward), and dizziness. In advanced HF, patients may have resting sinus tachycardia, diaphoresis, narrow pulse pressure (less than 25 mmHg due to decreased cardiac output), and peripheral vasoconstriction (cool and pale extremities due to decreased perfusion). Volume overload manifests as peripheral edema (extremities edema, ascites, scrotal edema, and hepatosplenomegaly), elevated jugular venous pressure (JVP), and pulmonary congestion (rales on the exam and pleural effusions). Displaced apical impulse (laterally past the midclavicular line, which is a sign of LV enlargement), parasternal lift (right ventricular enlargement), and an S3 gallop. At each clinic visit, symptoms and signs of HF require assessment to monitor response to therapy and stability over time. It is also important to check vital signs and assess volume status during each clinic visit." }, { "id": "pubmed23n0240_10034", "title": "Congestive heart failure in adults. Six considerations in systematic diagnosis.", "score": 0.009615384615384616, "content": "There are two key clinical questions to be answered in any patient with documented congestive heart failure. First, what is the underlying etiology? Second, what exacerbating factors are present? The ECG, the echocardiogram, and chest x-ray films may provide important diagnostic clues. The mode of presentation (acute vs chronic) is also of major importance. Attention should be paid to treatable or reversible factors, including infective endocarditis, occult aortic stenosis, recurrent pulmonary emboli, and chronic constrictive pericarditis. Finally, the possibility of unrecognized congenital heart disease (eg, atrial septal defect) should not be overlooked." }, { "id": "wiki20220301en023_18131", "title": "Dilated cardiomyopathy", "score": 0.009576986321172367, "content": "Signs and symptoms Dilated cardiomyopathy develops insidiously, and may not initially cause symptoms significant enough to impact on quality of life. Nevertheless, many people experience significant symptoms. These might include: Shortness of breath Syncope (fainting) Angina, but only in the presence of ischemic heart disease A person suffering from dilated cardiomyopathy may have an enlarged heart, with pulmonary edema and an elevated jugular venous pressure and a low pulse pressure. Signs of mitral and tricuspid regurgitation may be present." }, { "id": "article-17749_19", "title": "Aortic Valve Disease -- Differential Diagnosis", "score": 0.009528535980148883, "content": "The differential diagnosis for patients presenting with aortic valve disease symptoms includes but is not limited to: Hypertrophic obstructive cardiomyopathy Restrictive cardiomyopathy Constrictive cardiomyopathy Congestive heart failure with reduced ejection fraction (HFrEF) Coronary artery disease Atrial fibrillation Atrial flutter Ischemic heart disease Pericardial effusion Pulmonary hypertension Chronic obstructive pulmonary disease Restrictive lung diseases Symptomatic anemia" }, { "id": "wiki20220301en028_9481", "title": "Kussmaul's sign", "score": 0.009523809523809525, "content": "Causes The differential diagnoses of Kussmaul's sign includes constrictive pericarditis, restrictive cardiomyopathy, pericardial effusion, and severe right-sided heart failure. With cardiac tamponade, jugular veins are distended and typically show a prominent x descent and an absent y descent as opposed to patients with constrictive pericarditis (prominent x and y descent), see Beck's triad. Other possible causes of Kussmaul's sign include: Right ventricular infarction - low ventricular compliance Right heart failure Cardiac tumours Tricuspid stenosis Restrictive cardiomyopathy Pulmonary embolism Constrictive pericarditis History Kussmaul's sign is named after the German doctor who first described it, Adolph Kussmaul (1822-1902). He is also credited with describing Kussmaul breathing. See also Pulsus paradoxus References Symptoms and signs: Vascular" }, { "id": "pubmed23n0277_15763", "title": "[Clinical features of heart failure induced by pericarditis and myocarditis].", "score": 0.009523809523809525, "content": "The clinical condition of heart failure induced by pericarditis is expressed as cardiac tamponade or constrictive pericarditis. In both conditions, cardiac filling is impaired either by pericardial fluid or nonelastic pericardial sac under increased diastolic pressure and cardiac output is reduced. Patients show signs of right side heart failure. Immediate pericardiocentesis or pericardiotomy is required for cardiac tamponade, and pericardiectomy is essential for constrictive pericarditis. The clinical expression of myocarditis ranges from asymptomatic state to fulminant fatal congestive heart failure. Recently, identification of viral infection, using polymerase chain reaction (PCR), has contributed to the diagnosis of myocarditis, involving cases of idiopathic congestive cardiomyopathy." }, { "id": "wiki20220301en222_25082", "title": "Diabetic cardiomyopathy", "score": 0.009433962264150943, "content": "One particularity of diabetic cardiomyopathy is the long latent phase, during which the disease progresses but is completely asymptomatic. In most cases, diabetic cardiomyopathy is detected with concomitant hypertension or coronary artery disease. One of the earliest signs is mild left ventricular diastolic dysfunction with little effect on ventricular filling. Also, the diabetic patient may show subtle signs of diabetic cardiomyopathy related to decreased left ventricular compliance or left ventricular hypertrophy or a combination of both. A prominent “a” wave can also be noted in the jugular venous pulse, and the cardiac apical impulse may be overactive or sustained throughout systole. After the development of systolic dysfunction, left ventricular dilation and symptomatic heart failure, the jugular venous pressure may become elevated, the apical impulse would be displaced downward and to the left. Systolic mitral murmur is not uncommon in these cases. These changes are accompanied" }, { "id": "InternalMed_Harrison_17791", "title": "InternalMed_Harrison", "score": 0.009329335046884667, "content": "Suspected severe valve disease in symptomatic patients—dyspnea, angina, heart failure, syncope Infective endocarditis with need for cardiac surgery Asymptomatic patients with aortic regurgitation and cardiac enlargement or Prior to cardiac surgery in patients with suspected coronary artery disease New onset with angina or suspected undiagnosed coronary artery disease New-onset cardiomyopathy of uncertain cause or suspected to be due to coronary artery disease Prior to surgical correction, when symptoms or noninvasive testing suggests coronary disease Symptomatic patients with suspected cardiac tamponade or constrictive pericarditis Hypertrophic cardiomyopathy with angina Diseases of the aorta when knowledge of coronary artery involvement is necessary for management" }, { "id": "wiki20220301en031_48107", "title": "Peripartum cardiomyopathy", "score": 0.00926942501333166, "content": "Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy that is defined as a deterioration in cardiac function presenting typically between the last month of pregnancy and up to six months postpartum. As with other forms of dilated cardiomyopathy, PPCM involves systolic dysfunction of the heart with a decrease of the left ventricular ejection fraction (EF) with associated congestive heart failure and an increased risk of atrial and ventricular arrhythmias, thromboembolism (blockage of a blood vessel by a blood clot), and even sudden cardiac death. In essence, the heart muscle cannot contract forcefully enough to pump adequate amounts of blood for the needs of the body's vital organs. PPCM is a diagnosis of exclusion, wherein patients have no prior history of heart disease and there are no other known possible causes of heart failure. Echocardiogram is used to both diagnose and monitor the effectiveness of treatment for PPCM." }, { "id": "wiki20220301en025_7991", "title": "Pulmonary hypertension", "score": 0.009174311926605505, "content": "WHO Group II – Pulmonary hypertension secondary to left heart disease Left ventricular systolic dysfunction Left ventricular diastolic dysfunction Valvular heart disease Congenital/acquired left heart inflow/outflow tract obstruction and congenital cardiomyopathy Congenital/acquired pulmonary venous stenosis WHO Group III – Pulmonary hypertension due to lung disease, chronic hypoxia Chronic obstructive pulmonary disease (COPD) Interstitial lung disease Mixed restrictive and obstructive pattern pulmonary diseases Sleep-disordered breathing Alveolar hypoventilation disorders Chronic exposure to high altitude Developmental abnormalities WHO Group IV – chronic arterial obstruction Chronic thromboembolic pulmonary hypertension (CTEPH) Other pulmonary artery obstructions Angiosarcoma or other tumor within the blood vessels Arteritis Congenital pulmonary artery stenosis Parasitic infection (hydatidosis)" }, { "id": "article-22661_47", "title": "Congestive Heart Failure -- History and Physical -- Minor Criteria", "score": 0.009174311926605505, "content": "Ankle edema Dyspnea on exertion Hepatomegaly Nocturnal cough Pleural effusion Tachycardia (heart rate greater than 120 beats per minute)" }, { "id": "wiki20220301en074_50131", "title": "Restrictive cardiomyopathy", "score": 0.009144499420304054, "content": "The most common cause of restrictive cardiomyopathy is amyloidosis. Mechanism Rhythmicity and contractility of the heart may be normal, but the stiff walls of the heart chambers (atria and ventricles) keep them from adequately filling, reducing preload and end-diastolic volume. Thus, blood flow is reduced, and blood volume that would normally enter the heart is backed up in the circulatory system. In time, restrictive cardiomyopathy patients develop diastolic dysfunction and eventually heart failure. Diagnosis Diagnosis is typically made via echocardiography. Patients will demonstrate normal systolic function, diastolic dysfunction, and a restrictive filling pattern. 2-dimensional and Doppler studies are necessary to distinguish RCM from constrictive pericarditis. Cardiac MRI and transvenous endomyocardial biopsy may also be necessary in some cases. Reduced QRS voltage on EKG may be an indicator of amyloidosis-induced restrictive cardiomyopathy." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 443, 515 ] ], "word_ranges": [ [ 65, 76 ] ], "text": "Metastases are ruled out (there are no defects of hepatic infiltration)," }, "2": { "exist": true, "char_ranges": [ [ 516, 614 ] ], "word_ranges": [ [ 76, 90 ] ], "text": "intrahepatic tumor thrombosis (it would give another symptomatology and this would be more acute)," }, "3": { "exist": true, "char_ranges": [ [ 619, 741 ] ], "word_ranges": [ [ 91, 113 ] ], "text": "acute hepatitis and hemochromatosis (they are not in context nor is it what the author of the question wants us to think)." }, "4": { "exist": true, "char_ranges": [ [ 276, 442 ] ], "word_ranges": [ [ 42, 65 ] ], "text": "case). As in this case, cholestasis (elevation of alkaline phosphatase), mobilization of hepatic enzymes and lengthening of the prothrombin time indicate liver dysfunction." }, "5": { "exist": true, "char_ranges": [ [ 619, 741 ] ], "word_ranges": [ [ 91, 113 ] ], "text": "acute hepatitis and hemochromatosis (they are not in context nor is it what the author of the question wants us to think)." } }

{ "1": "Hepatic metastases.", "2": "Intrahepatic tumor thrombosis.", "3": "Acute hepatitis.", "4": "Presence of hepatotoxic substances produced by the tumor.", "5": "Hemochromatosis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0546_17696", "title": "Stauffer's syndrome variant with cholestatic jaundice: a case report.", "score": 0.01504603637996856, "content": "Cholestasis is a common feature of several malignant diseases, including pancreatic, hepatic, gallbladder, and ampullary carcinomas. It is usually secondary to main bile duct obstruction or widespread hepatic metastasis, but it can also be a paraneoplastic syndrome of other underlying malignancies. Stauffer's syndrome is a rare paraneoplastic manifestation of renal cell carcinoma (RCC) that is characterized by elevated alkaline phosphatase, erythrocyte sedimentation rate, alpha-2-globulin, and gamma-glutamyl transferase, thrombocytosis, prolongation of prothrombin time, and hepatosplenomegaly, in the absence of hepatic metastasis and jaundice. A rare variant of this syndrome with jaundice has recently been described in 3 cases in the literature. We report a patient who presented with abdominal pain and cholestatic jaundice in whom RCC was incidentally found during initial workup. Jaundice and liver dysfunction resolved completely after surgical resection of the tumor. This case illustrates the protean manifestations of RCC, and the importance of considering Stauffer's syndrome and its variant in the differential diagnosis of anicteric and icteric cholestasis, which may allow early recognition and treatment of an underlying malignancy." }, { "id": "pubmed23n0245_8042", "title": "Stauffer's syndrome in renal cell carcinoma evidence for intravascular coagulation.", "score": 0.01488095238095238, "content": "In 40 patients with non-metastasising (n = 31) and metastasising (n = 9) renal cell carcinoma, evidence of Stauffer's syndrome (increase in alkaline serum phosphatase and prolongation of prothrombin time) was found in 18 patients. Prolongation of prothrombin time was not due to depletion of vitamin K-dependent coagulation factors or manifest fibrinolysis, but due to the presence of circulating fibrinogen fibrinmonomer-FDP complexes. Ethanol gelation test was found to be positive in 28/40 subjects and soluble fibrin monomer complexes were increased in 38/40 patients. The resulting disturbance of fibrinogen-fibrin conversion was reflected by an increase in thrombin coagulase time and reptilase time. These findings suggests a state of latent compensated intravascular coagulation (presumably triggered within the vascular tumor). For diagnostic purposes the most sensitive indicator is thrombin coagulase time. Thrombin coagulase time normalised after tumor resection and was positive in patients with recurrent metastases. The increase in alkaline serum phosphatase was due to an increase in the hepatic isoenzyme. Such an increase was much more common than the elevation of total alkaline serum phosphatase. Regan's isoenzyme was only found in 1 subject. In parallel, gamma-GT was elevated in 24 patients. The study shows that Stauffer's syndrome occurs more frequently than commonly assumed when thrombin coagulase time, gamma-GT and the hepatic isoenzyme of alkaline serum phosphatase are determined in patients with renal cell carcinoma. DIC and low grade fibrinolysis may account for the coagulation abnormalities of the syndrome." }, { "id": "InternalMed_Harrison_23333", "title": "InternalMed_Harrison", "score": 0.013223249235222525, "content": "Type of Disorder Bilirubin Aminotransferases Alkaline Phosphatase Albumin Prothrombin Time Acute hepatocellular necrosis (viral and drug hepatitis, hepatotoxins, acute heart failure) Alcoholic hepatitis, cirrhosis Infiltrative diseases (tumor, granulomata); partial bile duct obstruction Normal to 86 μmol/L (5 mg/dL) 85% due to indirect fractions Elevated, often >500 IU, ALT > AST Elevated, but usually <300 IU AST:ALT >2 suggests alcoholic hepatitis or cirrhosis Normal to moderate elevation Normal to slight elevation Normal to <3× normal elevation Normal to <3× normal elevation Normal to <3× normal elevation Elevated, often >4× normal elevation Elevated, often >4× normal elevation Fractionate, or confirm liver origin with 5’nucleotidase or γ glutamyl transpeptidase Normal Usually normal. If >5× above control and not corrected by parenteral vitamin K, suggests poor prognosis Fails to correct with parenteral vitamin K Fails to correct with parenteral vitamin K" }, { "id": "pubmed23n0016_17", "title": "[Liver disease associated with hypernephroma. A case report (author's transl)].", "score": 0.013064442562064247, "content": "The observation of a non-metastatic reactive hepatopathy associated with a hypernephroma in a 39-year-old man who had had fever for 4 months led to a review of the literature and an analysis of basically three aspects of the disorder: a) The various manifestations of carcinoma of the kidney, which include a large number of paraneoplastic clinical symptoms (polycythemia, anemia, prolonged fever, hypercalcemia, hypertension, nefropathy, loss of salt, peripheral neuropathy, and amyloidosis); b) an alteracion of hepatic function known since 1961 which is characterized by an abnormal retention of sulfobromophthalein, increase of alkaline phosphatase, prothrombin decrease, dysproteinemia with hypoalbuminemia, and alpha2-globulin increase. It may or may not be accompanied by enlargement of the liver. c) Criteria of operability of the primary tumor." }, { "id": "wiki20220301en137_34287", "title": "Stauffer syndrome", "score": 0.012065492263512065, "content": "Stauffer syndrome is a constellation of signs and symptoms of liver dysfunction that arises due to presence of renal cell carcinoma, and, more rarely, in connection with other malignant neoplasms, though the specific pathogenesis is currently unknown. It is named for Dr. Maurice Stauffer, a gastroenterologist at the Mayo Clinic in Rochester, MN. The hepatic abnormalities are not due to tumor infiltration of the liver or intrinsic liver disease; they instead reflect the presence of a paraneoplastic syndrome. Stauffer syndrome causes abnormal liver function tests, especially those that reflect the presence of cholestasis, i.e. abnormal bile flow. Hepatosplenomegaly may also be observed. The symptoms and signs resolve if the renal cell carcinoma (or another associated tumor) is successfully ablated. It is due to release of IL-6 from cancerous cell." }, { "id": "pubmed23n0327_19406", "title": "Hepatocellular carcinoma after renal transplantation in the absence of cirrhosis or viral hepatitis: a case series.", "score": 0.011965811965811965, "content": "The occurrence of hepatocellular carcinoma (HCC) in renal transplant recipients has typically been associated with hepatitis B or C infection. We encountered two cases of HCC in renal transplant recipients with negative hepatitis B and C markers and no underlying liver pathology, in whom immunosuppression therapy consisted of prednisone and azathioprine (AZA). Patient no. 1 is a 66-year-old man with diabetes who underwent cadaveric renal transplantation 13 years before presentation. An ultrasound obtained for evaluation of a prolonged prothrombin time and decreased serum albumin level showed a suspicious nodular lesion in the left lobe of the liver. A computed tomographic (CT) scan confirmed a 4- x 5- x 5-cm mass that, on biopsy, was determined to be well-differentiated HCC. There was no evidence of metastasis, and the results of random biopsies of the surrounding parenchyma were normal. The patient underwent a left lateral segmentectomy, did well, and an initial alpha-fetoprotein (AFP) level of 85995 ng/mL decreased to 9 ng/mL. Approximately 20 months postoperatively, however, a surveillance CT scan showed three hypervascular lesions in the right lobe of the liver and the AFP level increased to 28,370 ng/mL. Subsequent percutaneous alcohol injections yielded good results, and the patient is alive and well 13 months later. Patient no. 2 is a 57-year-old man who underwent cadaveric renal transplantation 24 years earlier. A CT scan of the abdomen obtained for evaluation of lower abdominal pain showed a 4- x 4- x 6.5-cm mass in the right lobe of the liver that, on biopsy, was found to be poorly differentiated HCC. Multiple biopsies of adjacent liver parenchyma showed no evidence of cirrhosis, AFP level was normal, and imaging studies showed no evidence of tumor spread. The patient underwent a right hepatic lobectomy and is doing well without evidence of recurrence 27 months postoperatively. Our two patients had no evidence of viral hepatitis, cirrhosis, or metabolic liver disease, yet both developed HCC. The use of AZA may have had a role in the development of HCC. In renal transplant recipients on long-term immunosuppression therapy, particularly AZA, it is prudent to maintain a high index of suspicion for HCC when liver enzyme level or function abnormalities are encountered." }, { "id": "InternalMed_Harrison_3255", "title": "InternalMed_Harrison", "score": 0.01161261150162371, "content": "In addition to enzyme tests, all jaundiced patients should have additional blood tests—specifically, an albumin level and a prothrombin time—to assess liver function. A low albumin level suggests a chronic process such as cirrhosis or cancer. A normal albumin level is suggestive of a more acute process such as viral hepatitis or choledocholithiasis. An elevated prothrombin time indicates either vitamin K deficiency due to prolonged jaundice and malabsorption of vitamin K or significant hepatocellular dysfunction. The failure of the prothrombin time to correct with parenteral administration of vitamin K indicates severe hepatocellular injury. The results of the bilirubin, enzyme, albumin, and prothrombin time tests will usually indicate whether a jaundiced patient has a hepatocellular or a cholestatic disease and offer some indication of the duration and severity of the disease. The causes and evaluations of hepatocellular and cholestatic diseases are quite different." }, { "id": "pubmed23n0042_5469", "title": "[Stauffer syndrome, paraneoplastic hepatic dysfunction syndrome associated with renal cell carcinoma (author's transl)].", "score": 0.011605028845833195, "content": "In two patients with renal cell carcinoma, the following biochemical changes were found independently of hepatic metastases: increased alkaline phosphatase activity, rise in bromsulfothalein retention, hypoalbuminemia, increase in alpha2-globulin, and prolonged prothrombin time (Stauffer syndrome). In both cases the syndrome was found to be the first sign of the renal cell carcinoma. In one patient liver function returned to normal after removal of the neoplasm, in correlation with the good recovery. In the other case the abnormal laboratory findings persisted after total renal surgery. Clinically, diffuse pulmonary metastases occurred. Both case histories show the high significance in knowing Stauffer syndrome and its value for early diagnosis and operative success." }, { "id": "wiki20220301en220_29196", "title": "Metastatic liver disease", "score": 0.011521729766981091, "content": "A liver metastasis is a malignant tumor in the liver that has spread from another organ affected by cancer. The liver is a common site for metastatic disease because of its rich, dual blood supply (the liver receives blood via the hepatic artery and portal vein). Metastatic tumors in the liver are 20 times more common than primary tumors. In 50% of all cases the primary tumor is of the gastrointestinal tract, other common sites include the breast, ovaries, bronchus and kidney. Tumor emboli entering the sinusoids through the liver blood supply appear to be physically obstructed by the Kupffer cells, but if tumor emboli are larger, they tend to become lodged in the portal venous branches. Presentation Hepatomegaly - with a nodular free edge of liver Tenderness Cachexic Ascites Jaundice Pyrexia - up to 10% of patients Alkaline Phosphatase (ALP) and gamma glutamyl transpeptidase (GGT) elevated Ultrasound scan and CT scan - multiple filling defects." }, { "id": "wiki20220301en012_138026", "title": "Liver tumor", "score": 0.011419554985023535, "content": "Because hepatocellular adenomas are so rare, there are no clear guidelines for the best course of treatment. The complications, which include malignant transformation, spontaneous hemorrhage, and rupture, are considered when determining the treatment approach Estimates indicate approximately 20-40% of hepatocellular adenomas will undergo spontaneous hemorrhage. The evidence is not well elucidated, but the best available data suggests that the risk of hepatocellular adenoma becoming hepatocellular carcinoma, which is malignant liver tumor, is 4.2% of all cases. Transformation to hepatocellular carcinoma is more common in men. Currently, if the hepatic adenoma is >5 cm, increasing in size, symptomatic lesions, has molecular markers associated with HCC transformation, rising level of liver tumor markers such as alpha fetoprotein, the patient is a male, or has a glycogen storage disorder, the adenoma is recommended to be surgically removed. Like most liver tumors, the anatomy and location" }, { "id": "InternalMed_Harrison_23520", "title": "InternalMed_Harrison", "score": 0.010836961780358007, "content": "Neutropenia and lymphopenia are transient and are followed by a relative lymphocytosis. Atypical lymphocytes (varying between 2 and 20%) are common during the acute phase. Measurement of the prothrombin time (PT) is important in patients with acute viral hepatitis, because a prolonged value may reflect a severe hepatic synthetic defect, signify extensive hepatocellular necrosis, and indicate a worse prognosis. Occasionally, a prolonged PT may occur with only mild increases in the serum bilirubin and aminotransferase levels. Prolonged nausea and vomiting, inadequate carbohydrate intake, and poor hepatic glycogen reserves may contribute to hypoglycemia noted occasionally in patients with severe viral hepatitis. Serum alkaline phosphatase may be normal or only mildly elevated, whereas a fall in serum albumin is uncommon in uncomplicated acute viral hepatitis. In some patients, mild and transient steatorrhea has been noted, as well as slight microscopic hematuria and minimal proteinuria." }, { "id": "wiki20220301en012_138031", "title": "Liver tumor", "score": 0.010707508809975603, "content": "Available evidence suggests that bleeding occurs in approximately 63% of patients with liver cell adenomatosis. Liver cell adenomatosis is also associated with becoming hepatocellular carcinoma. Like hepatic adenomas, they are diagnosed with imaging and biopsies as needed. Treatment of liver cell adenomatosis is difficult due to the multiple, widespread lesions. Liver imaging should be reviewed to see if it is possible to surgically remove the tumors. Liver transplantation is a treatment option for some patients." }, { "id": "pubmed23n0296_12793", "title": "Acute liver failure due to diffuse intrasinusoidal metastases of urothelial carcinoma.", "score": 0.010503025617785834, "content": "We report one case of urothelial carcinoma with diffuse intrasinusoidal metastasis to the liver and clinical presentation mimicking fulminant hepatic failure. The patient was a 69-year-old man admitted to the hospital for upper gastrointestinal hemorrhage. Two years previously he had undergone a right nephrectomy for urothelial carcinoma (T2, GII). After five days of hospital admission, he developed progressive jaundice, ascites, deteriorating mental status with high serum enzyme activities (AST, ALT, LDH, alkaline phosphatase) and death 20 days after hospitalization. No grossly detectable hepatic metastatic nodules were demonstrated. A percutaneous postmortem liver biopsy revealed a diffuse infiltration of tumor cells into the hepatic sinusoids and venous invasion." }, { "id": "pubmed23n0807_9388", "title": "Nimesulide-induced fatal acute liver failure in an elderly woman with metastatic biliary adenocarcinoma. A case report.", "score": 0.010451612903225806, "content": "Nimesulide is a selective inhibitor of the enzyme cyclooxygenase 2. Although considered to be a safe drug, cases of acute hepatitis and fulminant liver failure have been reported in Europe, the United States and South America, especially among elderly female patients. Until now, there had not been any reports in the literature relating to Brazilian subjects. An 81-year old female who had been using nimesulide therapy for six days presented hematemesis and epistaxis two days before hospitalization. Clinical examination showed an extensive coagulation disorder, diffuse hematomas, hypotension and tachypnea. Laboratory tests revealed abnormalities in coagulation tests; leukocytosis; reduced platelet, hemoglobin and red blood cell counts; and elevated direct bilirubin, serum aspartate transaminase (AST), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase and renal function biomarkers. Hepatitis B and C tests were not reactive. Carcinoembryonic antigen (CEA), CA-19-9 and CA-125 levels were increased by, respectively, 1,000, 10,000 and 13 fold, whereas the alpha-fetoprotein level was normal, thus indicating a malignant tumor in the bile duct that did not originate from the liver. Thirty-six hours after hospitalization, the patient's condition worsened, leading to death. The necropsy findings included acute hepatitis with hepatocellular collapse, as well as metastasis of a carcinoma, probably from the bile duct. Despite the carcinoma presented by the patient, nimesulide use may have contributed towards the fatal acute liver failure. Until this issue has been clarified, caution is required in prescribing nimesulide for liver disease patients." }, { "id": "wiki20220301en224_11691", "title": "Fibrolamellar hepatocellular carcinoma", "score": 0.01039744062999877, "content": "Diagnosis Due to lack of symptoms, until the tumor is sizable, this form of cancer is often advanced when diagnosed. Symptoms include vague abdominal pain, nausea, abdominal fullness, malaise and weight loss. They may also include a palpable liver mass. Other presentations include jaundice, ascites, fulminant liver failure, encephalopathy, gynecomastia (males only), thrombophlebitis of the lower limbs, recurrent deep vein thrombosis, anemia and hypoglycemia. The usual markers for liver disease – aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase – are often normal or only slightly elevated. FHCC often does not produce alpha fetoprotein (AFP), a widely used marker for conventional hepatocellular carcinoma. It is associated with elevated neurotensin levels. Diagnosis is normally made by imaging (ultrasound, CT or MRI) and biopsy" }, { "id": "wiki20220301en225_16352", "title": "Metastasectomy", "score": 0.010024553382440099, "content": "Preoperative evaluation involves imaging of the liver and its metastases, for example with ultrasound, computed tomography or magnetic resonance imaging. Positron emission tomography can be useful to check the entire body for metastases, although the test can be falsely normal with small lesions or preoperative chemotherapy. Baseline blood tests typically include liver function tests and tumour markers. During surgery, intraoperative ultrasound can aid the surgeon to find additional metastases. A clinical risk score first proposed by Fong et al. is often used to assess the risk of recurrence after hepatic resection. The score assigns one point to each of the following: CEA level >200 ng/ml Disease-free interval from primary to metastasis <12 months Node-positive primary More than one liver metastasis Largest hepatic tumor >5 cm The median survival for each score is:" }, { "id": "InternalMed_Harrison_7109", "title": "InternalMed_Harrison", "score": 0.009872742200328407, "content": "has been reported to be safe and useful in the control of major branch portal or hepatic vein invasion (thrombosis) by tumors. The studies have all been small. Vitamin K has been assessed in clinical trials at high dosage for its HCC-inhibitory actions. This idea is based on the characteristic biochemical defect in HCC of elevated plasma levels of immature prothrombin (DCP or PIVKA-2), due to a defect in the activity of prothrombin carboxylase, a vitamin K–dependent enzyme. Two vitamin K randomized controlled trials from Japan show decreased tumor occurrence, but a major phase III trial aimed at limiting postresection recurrence was not successful." }, { "id": "wiki20220301en011_154474", "title": "Hepatocellular carcinoma", "score": 0.00980392156862745, "content": "Important features that guide treatment include: size spread (stage) involvement of liver vessels presence of a tumor capsule presence of extrahepatic metastases presence of daughter nodules vascularity of the tumor MRI is the best imaging method to detect the presence of a tumor capsule. The most common sites of metastasis are the lung, abdominal lymph nodes, and bone. Prevention Since hepatitis B and C are some of the main causes of hepatocellular carcinoma, prevention of infection is key to then prevent HCC. Thus, childhood vaccination against hepatitis B may reduce the risk of liver cancer in the future. In the case of patients with cirrhosis, alcohol consumption is to be avoided. Also, screening for hemochromatosis may be beneficial for some patients. Whether screening those with chronic liver disease for HCC improves outcomes is unclear." }, { "id": "pubmed23n1042_5573", "title": "Stauffer syndrome, clinical implications and knowledge gaps, does size matter? Case report.", "score": 0.00980392156862745, "content": "Stauffer Syndrome (SS) is a paraneoplastic disorder associated with renal cell carcinoma (RCC). First described by Herbert Maurice Stauffer in 1961, it is characterized by hepatic dysfunction in the absence of metastasis, and elevated alkaline phosphatase, aminotransferases and prolonged prothrombin time. Initial reports did not include jaundice as an inclusion criterion. We aim to report the rare SS jaundice variant in a patient with a small renal mass and review the literature to determine if the size of the renal mass could influence the development of the SS. The aim of this article is to present the case of a 53-year-old male with Stauffer syndrome jaundice variant secondary to a 2.5 cm renal mass, treated with laparoscopic radical nephrectomy with complete resolution of the syndrome. This syndrome is yet to be fully understood, and as far as the evidence shows, size does not matter. This entity should always be in mind when encountered with a patient with liver dysfunction and jaundice with a suspicion or confirmed diagnosis of a renal mass. To date, and to our knowledge, there have been eleven reported cases of paraneoplastic cholestatic jaundice syndrome including the current case. Six cases presented in patients with small renal mases (&lt; 4 cm), curiously there were not a laterality tendency." }, { "id": "wiki20220301en017_65304", "title": "Renal cell carcinoma", "score": 0.009708737864077669, "content": "In cases where the tumor has spread into the renal vein, inferior vena cava, and possibly the right atrium, this portion of the tumor can be surgically removed, as well. When the tumor involved the inferior vena cava, it is important to classify which parts of the vena cava are involved and to plan accordingly, as sometimes complete resection will involve an incision into the chest with increased morbidity. For this reason, Dr. Gaetano Ciancio, adapted liver mobilization techniques from liver transplant to address retrohepatic or even suprahepatic inferior vena caval thrombus associated with renal tumors. With this technique, the whole abdominal inferior vena cava is able to be mobilized. This facilitates milking of the tumor down below the major hepatic veins by the surgeon’s fingers, bypassing the need for a thoracoabdominal incision or cardiopulmonary bypass. In cases of known metastases, surgical resection of the kidney (\"cytoreductive nephrectomy\") may improve survival, as well" }, { "id": "InternalMed_Harrison_23330", "title": "InternalMed_Harrison", "score": 0.009670192085927976, "content": "The prothrombin time may be elevated in hepatitis and cirrhosis as well as in disorders that lead to vitamin K deficiency such as obstructive jaundice or fat malabsorption of any kind. Marked prolongation of the prothrombin time, >5 s above control and not corrected by parenteral vitamin K administration, is a poor prognostic sign in acute viral hepatitis and other acute and chronic liver diseases. The INR, along with the total serum bilirubin and creatinine, are components of the MELD score, which is used as a measure of hepatic decompensation and to allocate organs for liver transplantation. Although tests may direct the physician to a category of liver disease, additional radiologic testing and procedures are often necessary to make the proper diagnosis, as shown in Fig. 358-1. The most commonly used ancillary tests are reviewed here, as are the noninvasive tests available for assessing hepatic fibrosis." }, { "id": "wiki20220301en234_40286", "title": "Anabolic steroid", "score": 0.009615384615384616, "content": "Hepatic: elevated liver function tests (, , bilirubin, , ), hepatotoxicity, jaundice, hepatic steatosis, hepatocellular adenoma, hepatocellular carcinoma, cholestasis, peliosis hepatis; all mostly or exclusively with 17α-alkylated AAS. Renal: renal hypertrophy, nephropathy, acute renal failure (secondary to rhabdomyolysis), focal segmental glomerulosclerosis, renal cell carcinoma. Others: glucose intolerance, insulin resistance, immune dysfunction." }, { "id": "pubmed23n0522_20948", "title": "[Pitfalls in the workup of common hepatobiliary problems].", "score": 0.009615384615384616, "content": "Hepatobiliary problems are not uncommon in general practice. Many cases can be solved on the basis of a thorough history, clinical examination, blood tests and abdominal ultrasound. The focus of this tutorial paper lies on a number of possible pitfalls in the workup of such problems, based on brief case histories. Atypical presentations of lithogenic biliary obstruction, with or without cholangitis, are discussed as a relatively frequent cause of management difficulties. Furthermore, certain caveats in the interpretation of tumor marker CA19-9, prothrombin time/INR, and ferritin are highlighted." }, { "id": "wiki20220301en643_13332", "title": "CKLF-like MARVEL transmembrane domain-containing 5", "score": 0.009523809523809525, "content": "cancer, non-small-cell lung carcinoma, renal cell carcinoma, and breast cancer. The forced over expression of CMTM5-v1 in Huh7 human hepatic cells also inhibited the ability of these cells to grow in a mouse model of cancer. Finally, various cancer human cell lines including those of the liver, breast, prostate, colon, stomach, nasopharynx, laryngopharynx, esophagus, lung, and cervix express low levels of, or no, CMTM5-v1 and concurrently have highly methylated CpG sites near to the CMTM5 gene. These findings suggest that the CMTM5 gene may act as a tumor suppressor gene, i.e. a normal gene whose product(s) inhibit the development and/or progression of various cancers. The findings also support further studies to confirm and expand these relationships and determine if the expression of CMTM5 isoforms can be used as tumor markers for these cancers severities/prognoses and/or targets as for treating them." }, { "id": "pubmed23n1014_5323", "title": "Stauffer Syndrome: A Comprehensive Review of the Icteric Variant of the Syndrome.", "score": 0.009523809523809525, "content": "Stauffer syndrome is a rare paraneoplastic syndrome classically associated with renal cell carcinoma (RCC). This association gave it the historical name of nonmetastatic nephrogenic hepatic dysfunction syndrome without jaundice. It is a syndrome of unclear pathophysiology characterized by a reversible anicteric elevation of liver enzymes, alkaline phosphatase, erythrocyte sedimentation rate (ESR), thrombocytosis, prolongation of prothrombin time, and hepatosplenomegaly in the absence of direct hepatobiliary obstruction or jaundice. A rare atypical variant of this syndrome with jaundice has been recently described in the literature. Thus, it is important to consider both these variants of Stauffer syndrome in the differential diagnosis of unexplained cholestasis in the absence of hepatic metastasis. This may allow early recognition and treatment of an occult malignancy. Herein, we present a comprehensive review of the literature available on the icteric variant of the Stauffer syndrome, outlining its association with various malignancies and the diagnostic challenges it poses. The objective of this review is to help clinicians in its early diagnosis and management." }, { "id": "wiki20220301en544_13979", "title": "Bland embolization", "score": 0.009433962264150943, "content": "Patient with hepatic metastatic disease from neuroendocrine tumors, gastrointestinal stromal tumors other sarcomas, ocular melanoma, and a variety of “hypervascular” metastases (eg from breast cancer or renal cell cancer) may also be candidates for bland embolization, assuming the liver is the only site of disease, or when the procedure is being performed for palliation of symptoms. Since the purpose of hepatic embolization in these cases is to either treat symptoms or extend survival, patient who are asymptomatic from their secondary hepatic disease and who have disease elsewhere should probably not be considered candidates. Intra-arterial therapy based on ischemia induced by terminal vessel blockade should not be expected to be efficacious in patients with hypovascular tumors and has no proven role in the treatment of typical metastatic adenocarcinoma from most gastrointestinal malignancies." }, { "id": "wiki20220301en012_138024", "title": "Liver tumor", "score": 0.009419568822553896, "content": "Hepatocellular adenomas are most often asymptomatic and often found incidentally on imaging. However, if signs and symptoms are present they include non-specific abdominal pain, yellowing of skin, and higher than normal gamma glutamyl transferase and alkaline phosphatase laboratory values. They are, in most cases, located in the right hepatic lobe and are frequently seen as a single lesion. Their size ranges from 1 to 30 cm. They can be difficult to diagnosis with imaging studies alone, because it can be hard to tell the difference between hepatocellular adenoma, focal nodular hyperplasia, and hepatocellular carcinoma. Molecular categorization via biopsy and pathological analysis aids in both diagnosis and understanding prognosis, particularly because hepatocellular adenomas have the potential to become malignant. It is important to note, percutaneous biopsy should be avoided, because this method can lead to bleeding or rupture of the adenoma. The best way to biopsy suspected hepatic" }, { "id": "wiki20220301en305_21112", "title": "Elevated alpha-fetoprotein", "score": 0.009345794392523364, "content": "Other tumor Rare AFP-secreting tumor types include carcinoma in a mixed Müllerian tumor. The Sertoli-Leydig cell tumor, which itself is rare, rarely secretes AFP. In Wilms tumor AFP is rarely elevated, but when it is elevated it may serve as a marker of disease progression or recurrence. Other Increased serum levels in adults are also seen in acute hepatitis, colitis and ataxia telangiectasia. Increased serum levels of alpha-fetoprotein are sometimes found in citrullinemia and argininosuccinate synthetase deficiency. Amniotic fluid AFP in amniotic fluid has one or two sources. The fetus normally excretes AFP into its urine, hence into the amniotic fluid. A fetus with one of three broad categories of defects also releases AFP by other means. These categories are open neural tube defect, open abdominal wall defect, and skin disease or other failure of the interior or exterior body surface." }, { "id": "pubmed23n0852_18707", "title": "The prognosis in cases of hepatocellular carcinoma after hepatectomy: young patients versus older patients.", "score": 0.009345794392523364, "content": "Hepatocellular carcinoma (HCC) is uncommon in young adults and the prognosis of these patients is still unclear. In this retrospective study, we compared the clinicopathological characteristics and outcomes of young patients with HCC with those of older patients with HCC. We retrospectively reviewed the clinicopathological characteristics of a total of 1,124 patients with HCC who underwent hepatectomy at our institution between 2006 and 2010. Patients ≤40 years of age at the time of HCC diagnosis were classified in the younger group. One hundred and three patients (9.2%) were classified in the younger group. whereas, 1021 patients were classified in the older group. The incidences of hepatitis B virus infection, alpha-fetoprotein (AFP) levels, and indocyanine green retention test were all higher in younger patients than in older patients (p&lt;0.05). Disease-free survival and overall survival were longer in older patients than in younger patients, without statistical significance. In younger patients, increased levels of protein induced by vitamin K antagonist-II (PIVKA-II) and alkaline phosphatase, portal vein tumor thrombosis, and intrahepatic metastasis were all predisposing factors for tumor recurrence after hepatectomy. Although the AFP levels were higher in younger patients with HCC than in older patients with HCC, disease-free survival and overall survival after liver resection were not significantly different between the two groups." }, { "id": "wiki20220301en108_38710", "title": "5'-nucleotidase", "score": 0.009259259259259259, "content": "Medical relevance 5' Nucleotidase blood test The concentration of 5’nucleotidase protein in the blood is often used as a liver function test in individuals that show signs of liver problems. The combined assays of serum 5'nucleotisase and alkaline phosphatase (AP) activities are extremely helpful in differential diagnosis since serum 5'nucleotidase activity is increased in obstructive hepatobiliary disorders, but not in osseous disorders, whereas serum AP activity is generally increased in both categories of diseases. In other words, the test is used to determine if elevated protein levels are due to skeletal damage or liver damage. Normal levels of 5’nucleotidase are 2-17 units per liter. Elevated levels may indicate cholestasis, destruction of liver cells, hepatitis (liver inflammation), liver ischemia, a liver tumor, or use of liver-damaging drugs. Pregnancy and certain medications (acetaminophen, halothane, isoniazid, methyldopa, nitrofurantoin) may interfere with the test." }, { "id": "pubmed23n0222_9947", "title": "[A clinical study of renal tumors].", "score": 0.009259259259259259, "content": "Seventy one patients with renal tumors treated at our clinic during the 11 years from 1970 to 1980 were clinically examined. The results are summarized as follows. The frequency of patients with renal tumors was 0.22% of the outpatients and 1.72% of the inpatients. Of the 71 renal tumors, 41 were renal adenocarcinoma, and 26 were renal pelvic tumors of which 23 were transitional cell tumors, 2 were squamous cell tumors, and 1 was adenocarcinoma. The other tumors were 1 adenoma, 1 hemangioma, 1 hematoma, and 1 foreign body granuloma. The right and left kidneys were affected at equal frequencies. Male patients were more commonly affected, the sex ratio being 39 to 32. The youngest case was a 29-year-old female, and the eldest was a 84-year-old male. As the initial symptoms and chief complaints, gross hematuria was most frequent (52 cases, 73.2%), followed abdominal tumor mass (32 cases, 45.1%), and fever (26 cases, 36.6%). Only 2 cases showed the classic triad, while 1 case had none of them. The period between onset of symptoms and admission, was within 1 year for all patients except for 2 cases. Metastasis was found in 52 cases. The lung was the most frequent site of metastasis (12 cases, 23.1%), followed by lymphnodes, bones, and liver. The clinical examinations performed and diagnostic techniques used were, renal function (BUN, Serum Cr), Hb, WBC, liver function (T. Bil, GOT, GPT), serum protein fraction, serum LDH, serum Ca, ESR, tumor marker (AFP, CEA), urine cytological examination, blood pressure, IVP (or RP), angiography. As the therapeutic method, nephrectomy was performed in 25 cases (35.2%), combined nephrectomy and irradiation therapy in 12 cases (16.9%), combined nephrectomy and chemotherapy in 11 cases (15.5%), combined nephrectomy and other therapy in 15 cases (21.1%), and conservative therapy in 8 cases (11.3%). For the entire traced series of renal tumors, the 1-, 3-and 5-year survival rates were 72.3, 49.8, and 49.8% respectively. For renal parenchymal tumors (renal adenocarcinoma), the 1-, 3-and 5-year survival rates were 77.8, 53.0, and 53.0%. The most important factor of prognosis was the stage of tumor. Patients with elevated erythrocyte sedimentation rate, and dysproteinemia also had distinctly unfavorable prognosis. In this study of therapy, the highest survival rate was seen for the patients treated by combined nephrectomy and irradiation therapy of both renal parenchymal and pelvic tumors." }, { "id": "pubmed23n0417_17111", "title": "Outcome of right hepatectomies in patients older than 70 years.", "score": 0.009174311926605505, "content": "The increasing number of elderly patients undergoing liver resections mandates updating of clinical outcomes on this specific population. Case series. A tertiary care teaching hospital. Twenty-three patients older than 70 years who underwent right hepatectomies (including 7 extended right hepatectomies) between January 1, 1995, and October 31, 2001 (group 1) and 99 patients younger than 70 years who underwent 64 right hepatectomies and 35 extended right hepatectomies during the same period (group 2) were included for a total sample population of 122. Preoperative clinicopathological features, intraoperative factors, in-hospital mortality, postoperative complications, intensive care unit requirement, hospital stay, and course of main biochemical liver function test results of groups 1 and 2 were analyzed and compared. The 2 groups were similar for indications for surgery and the presence of underlying liver disease. Group 1 had a higher incidence of associated pulmonary diseases (21.7% vs 5%, P =.02) and patients with an American Society of Anesthesiologists score of III (ie, a patient with severe systemic disease limiting activity, but not incapacitating) (56.5% vs 26.3% of cases, P =.01). There were no differences in intraoperative requirement of packed red blood cells and in operation time. There were no in-hospital deaths in group 1; there were 2 deaths (2%) in group 2. Nine patients (39.1%) in group 1 and 32 patients (32.3%) in group 2 experienced postoperative complications (P =.53), of whom, respectively, 5 (21.7%) and 17 (17.2%) developed transient liver dysfunction (P =.56), and 4 (17.4%) and 5 (5.1%) required a supplementary intesive care unit stay (P =.06). The postoperative stay (mean [SD], 16 [14] days vs 13 [9] days, P =.88) and peak values of the aminotransferase level, total serum bilirubin level, and prothrombin time were similar in the 2 groups. The timing of the peak value of the total serum bilirubin level (mean [SD], 4.1 [4.8] days vs 2.5 [2.5] days, P =.28) and its period of normalization (mean [SD], 9.4 [10.8] days vs 6.7 [5.1] days, P =.67) were also similar for both groups. For patients with malignancies, the 3-year survival rate was 64.2% in group 1 and 53.9% in group 2 (P =.53). Being older than 70 years should not be a contraindication for major hepatectomies, provided that liver cirrhosis and severe associated medical conditions are ruled out during the preoperative evaluation." } ] } } }

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{ "1": "Deficiency of alpha 1 antitrypsin. Thoracic TAC to confirm emphysema.", "2": "Mucoviscidosis. Determination of chlorine in sweat.", "3": "Autoimmune hepatitis. Liver biopsy.", "4": "Glycogenosis type VI (phosphorylase deficiency). Muscle biopsy.", "5": "Wilson's disease. Determine ceruloplasmin and copper in blood and urine." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en003_5083", "title": "Wilson's disease", "score": 0.014932126696832578, "content": "There is no totally reliable test for Wilson's disease, but levels of ceruloplasmin and copper in the blood, as well of the amount of copper excreted in urine during a 24-hour period, are together used to form an impression of the amount of copper in the body. The gold standard—or most ideal test—is a liver biopsy. Ceruloplasmin Levels of ceruloplasmin are abnormally low (<0.2 g/L) in 80–95% of cases. It can, however, be present at normal levels in people with ongoing inflammation as it is an acute phase protein. Low ceruloplasmin is also found in Menkes disease and aceruloplasminemia, which are related to, but much rarer than Wilson's disease. The combination of neurological symptoms, Kayser–Fleischer rings and a low ceruloplasmin level is considered sufficient for the diagnosis of Wilson's disease. In many cases, however, further tests are needed." }, { "id": "pubmed23n1102_8955", "title": "You Only Find What You Are Looking for: Concurrent Alcoholic Liver Cirrhosis and Undiagnosed Wilson's Disease.", "score": 0.01435472739820566, "content": "Wilson's disease (WD), a rare genetic disorder characterized by copper accumulation, leads to a spectrum of hepatic dysfunction including liver cirrhosis, fulminant liver failure, and chronic hepatitis. Its manifestations could involve musculoskeletal, hematologic, neuropsychiatric, or renal systems. We present the case of a 27-year-old female with a past medical history of alcohol use disorder who presented with acute confusion, worsening abdominal distension, bilateral lower limb edema, and jaundice.The initial presentation was concerning for acute alcoholic hepatitis and decompensated alcoholic cirrhosis attributed to ongoing heavy alcohol consumption. However, due to the patient's young age, the severity of presentation, and the pattern of liver enzyme elevation, further workup was conducted to rule out concurrent pathologies. Viral, autoimmune, and metabolic workups were unrevealing. Subsequently, low ceruloplasmin levels and elevated urinary copper levels led to a diagnosis of WD with concomitant alcoholic liver disease. The coexistence of WD and alcohol-associated liver disease (ALD) has not been well described in the literature. Laboratory testing including alkaline phosphatase (ALP), bilirubin, and serum aminotransferases provides the most rapid and accurate method for diagnosing ALD due to WD, given that the conventional screening tests such as ceruloplasmin are less sensitive and specific in identifying patients with acute liver disease secondary to WD." }, { "id": "article-31370_19", "title": "Wilson Disease -- Evaluation", "score": 0.012051763311271363, "content": "There is no completely reliable test for Wilson disease, but levels of ceruloplasmin and copper in the blood, as well as copper excreted in urine during a 24-hour period, are used to form an impression of the amount of copper in the body. The gold standard is a liver biopsy. First and second-degree relatives need to be screened for Wilson disease." }, { "id": "wiki20220301en037_64388", "title": "Acute liver failure", "score": 0.011989459815546772, "content": "Initial laboratory analysis Prothrombin time/INR Complete blood count Chemistries Liver function test: AST, ALT, alkaline phosphatase, GGT, total bilirubin, albumin Creatinine, urea/blood urea nitrogen, sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphate Glucose Amylase and lipase Arterial blood gas, lactate Blood type and screen Paracetamol (acetaminophen) level, toxicology screen Viral hepatitis serologies: anti-HAV IgM, HBSAg, anti-HBc IgM, anti-HCV Autoimmune markers: ANA, ASMA, LKMA, immunoglobulin levels Ceruloplasmin level (when Wilson's disease suspected) Pregnancy test (females) Ammonia (arterial if possible) HIV status (has implication for transplantation) History taking should include a careful review of possible exposures to viral infection and drugs or other toxins. From history and clinical examination, the possibility of underlying chronic disease should be ruled out as it may require different management." }, { "id": "pubmed23n0768_15246", "title": "Spasmodic muscle cramps and weakness as presenting symptoms in Wilson disease.", "score": 0.01170545801007214, "content": "Wilson disease (WD) is an autosomal-recessive disorder of hepatic copper metabolism that has tremendous variability in its presentation. Phenotypic diversity of the disease can lead to delayed diagnosis. We describe a case of WD in a 10-year-old boy presenting with 3 months of increasingly intense, spasmodic lower extremity muscle cramps. Physical examination revealed tenderness on calf palpation and dark flat lesions over his ankles, knees, and elbows. Initial testing revealed creatine kinase of 302 IU/L (normal 24-248 IU/L), hemoglobin of 8.9 g/dL (11.5-15.5 g/dL), aspartate aminotransferase of 114 IU/L (16-52 IU/L), alanine aminotransferase of 54 IU/L (2-30 IU/L), and myoglobinuria. Extensive evaluation of his myopathy, including MRI and muscle biopsy, was negative. Additional laboratory tests revealed a prothrombin time of 21.3 seconds (11.8-15.5 seconds), total bilirubin of 1.4 mg/dL (&lt;1 mg/dL), direct bilirubin of 0.5 mg/dL (&lt;0.3 mg/dL), albumin of 2.1 g/dL (3.1-4.6 g/dL), a reticulocyte percentage of 4.5% (0.5%-2.5%), a negative Coombs direct antibody test, ceruloplasmin of 3 mg/dL (21-51 mg/dL), and 24-h urine copper of 393 μg/24 h (15-60 μg/24 h). Liver biopsy showed patchy advanced fibrosis, mild inflammation, positive staining for copper, and a tissue copper concentration of 768 µg/g (10-35 μg/g). Brain MRI revealed symmetric intrinsic T1 shortening within bilateral basal ganglia. Trientene therapy was initiated for WD. Symptoms and laboratory abnormalities resolved and remain normal at 21 months' follow-up. Musculoskeletal involvement in WD is uncommon and typically defined as bone demineralization, arthropathy, or hypokalemic muscle weakness. In patients with unexplained musculoskeletal symptoms and hepatic abnormalities, a diagnosis of WD should be considered and appropriate evaluation initiated. " }, { "id": "article-22249_17", "title": "Gilbert Syndrome -- Evaluation", "score": 0.01135448136958711, "content": "The provider should have a low threshold to consider other liver diseases that may cause hyperbilirubinemia before diagnosing Gilbert syndrome, as outlined above. If viral hepatitis is suspected, serologic tests for hepatitis A, B, and C should be considered. [44] [36] [45] If autoimmune hepatitis is a possibility, appropriate serology, quantitative immunoglobulins, and liver biopsy may be in order. [39] Laboratory evaluation, including serology with or without liver biopsy, is suggested for patients with suspected primary biliary cholangitis. [39] Testing for ceruloplasmin, serum, urine copper studies, liver biopsy, and slit-lamp examination for Kayser-Fleisher rings should be considered for suspected Wilson disease. [46] Finally, alpha-1-antitrypsin level and genotype would be appropriate if alpha-1-antitrypsin deficiency is a consideration. [47]" }, { "id": "article-20995_26", "title": "Liver Function Tests -- Results, Reporting, and Critical Findings", "score": 0.011335209505941215, "content": "The results of liver function tests should correlate with the initial findings in a complete patient history and physical examination. A thorough review should include important questions regarding the patient's age, past medical history (diabetes, obesity, hyperlipidemia, inflammatory bowel disease, celiac sprue, thyroid disorders, autoimmune hepatitis, acquired muscle disorders, alcohol use disorder, medication use, toxin exposure, and family history of genetic liver conditions (Wilson disease, alpha-1-antitrypsin deficiency, hereditary hemochromatosis). [30]" }, { "id": "pubmed23n0709_8692", "title": "Causes and evaluation of mildly elevated liver transaminase levels.", "score": 0.011080417434008595, "content": "Mild elevations in levels of the liver enzymes alanine transaminase and aspartate transaminase are commonly discovered in asymptomatic patients in primary care. Evidence to guide the diagnostic workup is limited. If the history and physical examination do not suggest a cause, a stepwise evaluation should be initiated based on the prevalence of diseases that cause mild elevations in transaminase levels. The most common cause is nonalcoholic fatty liver disease, which can affect up to 30 percent of the population. Other common causes include alcoholic liver disease, medication-associated liver injury, viral hepatitis (hepatitis B and C), and hemochromatosis. Less common causes include α(1)-antitrypsin deficiency, autoimmune hepatitis, and Wilson disease. Extrahepatic conditions (e.g., thyroid disorders, celiac disease, hemolysis, muscle disorders) can also cause elevated liver transaminase levels. Initial testing should include a fasting lipid profile; measurement of glucose, serum iron, and ferritin; total iron-binding capacity; and hepatitis B surface antigen and hepatitis C virus antibody testing. If test results are normal, a trial of lifestyle modification with observation or further testing for less common causes is appropriate. Additional testing may include ultrasonography; measurement of α(1)-antitrypsin and ceruloplasmin; serum protein electrophoresis; and antinuclear antibody, smooth muscle antibody, and liver/kidney microsomal antibody type 1 testing. Referral for further evaluation and possible liver biopsy is recommended if transaminase levels remain elevated for six months or more." }, { "id": "wiki20220301en253_16012", "title": "Cirrhosis", "score": 0.009900990099009901, "content": "Hereditary hemochromatosis usually presents with a family history of cirrhosis, skin hyperpigmentation, diabetes mellitus, pseudogout, or cardiomyopathy, all due to signs of iron overload. Wilson's disease is an autosomal recessive disorder characterized by low serum ceruloplasmin and increased hepatic copper content on liver biopsy, and elevated 24-hour urine copper. Patients may also have Kayser-Fleischer rings in the cornea and altered mental status. Indian childhood cirrhosis is a form of neonatal cholestasis characterized by deposition of copper in the liver. Alpha 1-antitrypsin deficiency is an autosomal recessive disorder of decreased levels of the enzyme alpha 1—antitrypsin. Cardiac cirrhosis is due to chronic right-sided heart failure, which leads to liver congestion. Galactosemia Glycogen storage disease type IV Cystic fibrosis Hepatotoxic drugs or toxins, such as acetaminophen, methotrexate, or amiodarone" }, { "id": "pubmed23n0334_16863", "title": "Is 'routine' laboratory testing a thing of the past? Current recommendations regarding screening.", "score": 0.009900990099009901, "content": "A 55-year-old man comes to you for a routine physical examination. He is a nonsmoker who takes no medications and has no signs of acute or chronic disease, and he has not seen a doctor in years. What blood work should you order for this patient? The authors of this article help you answer this question in light of recent advances in technology, restrictions in healthcare reimbursement, and increased sophistication in cost-benefit analysis for laboratory testing." }, { "id": "pubmed23n0756_20406", "title": "[Not Available].", "score": 0.00980392156862745, "content": "Elevated transaminases in asymptomatic patients can be detected in more than 5 % of the investigations. If there are no obvious reasons, the finding should be confirmed within the next 3 months. Frequent causes are non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), alcohol, hepatitis B or C, hemochromatosis and drugs or toxins. Rarer causes are autoimmune hepatitis, M. Wilson and α1-antitrypsine deficiency. There are also non-hepatic causes such as celiac disease or hemolysis and myopathies in the case of an exclusive increase of ASAT. I recommend a two-step investigational procedure; the more frequent causes are examined first before the rare causes are studied. The value of the proposed investigations is discussed." }, { "id": "wiki20220301en014_30895", "title": "Alpha-1 antitrypsin deficiency", "score": 0.009708737864077669, "content": "Diagnosis The gold standard of diagnosis for A1AD consists of blood tests to determine the phenotype of the AAT protein or genotype analysis of DNA. Liver biopsy is the gold standard for determining the extent of hepatic fibrosis and assessing for the presence of cirrhosis." }, { "id": "InternalMed_Harrison_32583", "title": "InternalMed_Harrison", "score": 0.009708737864077669, "content": "implications when multiple tests are ordered. If N independent tests are performed on a specimen, then the probability that at least one result will be outside the reference range is (1–0.95N). The greater the number of tests ordered (even for a healthy individual), the greater is the likelihood of an abnormal result (Fig. 480e-1). If 20 independent tests are performed on a healthy subject, the probability of at least one abnormal result is almost two-thirds." }, { "id": "wiki20220301en001_273599", "title": "Hepatitis", "score": 0.009615384615384616, "content": "Many people with autoimmune hepatitis have other autoimmune diseases. Autoimmune hepatitis is distinct from the other autoimmune diseases of the liver: primary biliary cirrhosis and primary sclerosing cholangitis. However, all of these diseases can lead to scarring, fibrosis, and cirrhosis of the liver. Genetic Genetic causes of hepatitis include alpha-1-antitrypsin deficiency, hemochromatosis, and Wilson's disease. In alpha-1-antitrypsin deficiency, a co-dominant mutation in the gene for alpha-1-antitrypsin results in the abnormal accumulation of the mutant AAT protein within liver cells, leading to liver disease. Hemochromatosis and Wilson's disease are both autosomal recessive diseases involving abnormal storage of minerals. In hemochromatosis, excess amounts of iron accumulate in multiple body sites, including the liver, which can lead to cirrhosis. In Wilson's disease, excess amounts of copper accumulate in the liver and brain, causing cirrhosis and dementia." }, { "id": "pubmed23n0574_12547", "title": "[Efficient diagnostics for elevated transaminases].", "score": 0.009615384615384616, "content": "The diagnosis of the cause of elevated transaminases is carried out stepwise. First, a medical history is taken and a physical examination and sonography of the abdomen are performed. The second step includes laboratory tests for chronic hepatitis B and C, hereditary haemochromatosis, Wilson's disease, autoimmune hepatitis and alpha-1-antitrypsin deficiency. The third step comprises the identification of possible extrahepatic causes. Serological tests to exclude celiac disease should be first carried out when TSH and CK values do not yield an indicative finding." }, { "id": "pubmed23n0872_8479", "title": "Mild Hypertransaminasemia in Primary Care.", "score": 0.009523809523809525, "content": "The liver enzymes, alanine transaminase (ALT) or aspartate transaminase (AST), are commonly used in clinical practice as screening as well as diagnostic tests for liver diseases. ALT is more specific for liver injury than AST and has been shown to be a good predictor of liver related and all-cause mortality. Asymptomatic mild hypertransaminasemia (i.e., less than five times normal) is a common finding in primary care and this could be attributed to serious underlying condition or has transient and benign cause. Unfortunately, there are no good literatures available on the cost-effectiveness of evaluating patients with asymptomatic mild hypertransaminasemia. However, if the history and physical examination do not suggest a clear cause, a stepwise approach should be initiated based on pretest probability of the underlying liver disease. Nonalcoholic fatty liver disease is becoming the most common cause of mild hypertransaminasemia worldwide. Other causes include alcohol abuse, medications, and hepatitis B and C. Less common causes include hemochromatosis, α1-antitrypsin deficiency, autoimmune hepatitis, and Wilson's disease. Nonhepatic causes such as celiac disease, thyroid, and muscle disorders should be considered in the differential diagnosis. Referral to a specialist and a possible liver biopsy should be considered if persistent hypertransaminasemia for six months or more of unclear etiology. " }, { "id": "wiki20220301en253_16020", "title": "Cirrhosis", "score": 0.009433962264150943, "content": "FibroTest is a biomarker for fibrosis that may be used instead of a biopsy. Other laboratory studies performed in newly diagnosed cirrhosis may include: Serology for hepatitis viruses, autoantibodies (ANA, antismooth muscle, antimitochondria, anti-LKM) Ferritin and transferrin saturation: markers of iron overload as in hemochromatosis, copper and ceruloplasmin: markers of copper overload as in Wilson's disease Immunoglobulin levels (IgG, IgM, IgA) – these immunoglobins are nonspecific, but may help in distinguishing various causes. Cholesterol and glucose Alpha 1-antitrypsin Markers of inflammation and immune cell activation are typically elevated in cirrhotic patients, especially in the decompensated disease stage: C-reactive protein (CRP) Procalcitonin (PCT) Presepsin soluble CD14 soluble CD163 soluble CD206 (mannose receptor) soluble TREM-1 Imaging" }, { "id": "pubmed23n0548_5253", "title": "Subcutaneous panniculitis-like T-cell lymphoma with hemophagocytic syndrome successfully treated with cyclosporin A.", "score": 0.009345794392523364, "content": "A 17-year-old girl previously in good health presented with a 2-month history of recurrent, high-grade fever; general fatigue; anorexia; a 10-kg weight loss; and multiple, painful, reddish skin lesions on the lower abdomen. Some lesions were ulcerated, with an oily yellowish brown discharge. A systemic review was unremarkable other than bleeding from the nose. Her medical and family histories were unremarkable. On examination, the patient was pale, jaundiced, and febrile (temperature of 39 degrees C). She had enlarged lymph nodes in the axillary and inguinal areas. There was moderate hepatosplenomegaly. Local skin examination revealed multiple erythematous, tender, and firm subcutaneous nodules of variable size (1-2 cm) on the lower abdomen. Some nodules were ulcerated, with oily yellowish brown discharge and overlying ecchymosis (Figures 1 and 2). Mucous membranes were free of lesions. Laboratory investigations showed pancytopenia, an elevated erythrocyte sedimentation rate (&gt;80 mm/h), normal renal function tests, abnormal hepatic function tests (alanine aminotransferase 172 U/L, aspartate aminotransferase 229 U/L, alkaline phosphatase 725 U/L, and total bilirubin 100 mmol/L [normal range 0-18 mmol/L]), conjugated bilirubin 45 mmol/L (normal range 0-5 mmol/L), and high triglycerides 855 mg/dL (normal range 20-200 mg/dL). Prolonged prothrombin time, 26 seconds (normal range 13-16 seconds); prolonged activated partial thromboplastin time, 61 seconds (normal range 26-38 seconds); positive disseminated intravascular coagulation studies evidenced by low fibrinogen, 74 mg/dL (normal range 160-350 mg/dL); and positive fibrinogen degradation products were also noted. Throat, midstream urine, and blood culture results were negative. Serologic tests for syphilis, HIV, and hepatitis B and C viruses were negative. Epstein-Barr virus and cytomegalovirus serologic values revealed evidence of past infection. Tuberculin and Coombs tests were negative. The alpha1-antitrypsin level was normal. Antinuclear and anti-smith antibodies, rheumatoid factor, and cryoglobulins were negative. CT showed enlarged lymph nodes in the axillary and inguinal areas, bilateral small pleural effusion, moderate hepatosplenomegaly, severe fatty infiltration of the liver, and thickening of lower abdominal subcutaneous tissue. A liver biopsy showed steatohepatitis. Bone marrow aspirate and trephine were normal. A deep punch biopsy of a nodule from the right lower abdomen revealed lobular panniculitis with atypical lymphocytes and large macrophages with cytophagocytosis (\"beanbag\" cells) (Figures 3 and 4). Immunohistochemistry showed that these atypical cells were positive for CD3, CD8, granzyme B, and perforin, and negative for CD56. T-cell gene rearrangement studies on skin lesions revealed a monoclonal T-cell receptor (gamma-chain) gene rearrangement, supporting the diagnosis of subcutaneous panniculitis-like T-cell lymphoma. On presentation, the initial treatment included 6 U of fresh frozen plasma, 2 U of packed red blood cells, and 2 g IV fibrinogen for 3 consecutive days. The patient was started on prednisolone 60 mg orally once daily and cyclosporine A 5 mg/kg/d orally in two divided doses. The fever and other systemic symptoms and skin lesions resolved within 2 weeks after the treatment. The prednisolone dose was tapered gradually, and a maintenance dose of cyclosporine A was continued. The patient's condition remained in remission at 12-month follow-up; there was no evidence of clinical relapse." }, { "id": "pubmed23n0021_4309", "title": "The diagnostic importance of the normal finding.", "score": 0.009345794392523364, "content": "When a diagnostic test is reported as normal, the clinician generally uses it only to rule out certain diseases. However, if properly interpreted, the normal value may help to differentiate among diagnoses that yield normal results with different frequencies. A simple method permits the extraction of such information. The physician estimates the probability of various diagnoses and then combines these estimates with the anticipated frequency of negative results for each disease under consideration." }, { "id": "pubmed23n0333_3829", "title": "The clinical significance of slightly to moderately increased liver transaminase values in asymptomatic patients.", "score": 0.009259259259259259, "content": "Our aim was to study liver disorders in asymptomatic patients with slightly to moderately increased liver transaminase values in a population living in an area with a low prevalence of viral and hereditary liver diseases. One hundred and fifty consecutive patients with slightly to moderately increased liver transaminases for at least 6 months without symptoms or signs of liver disease were included. Median (range) was 0.75 microkat/l (0.24-2.9) for aspartate aminotransferase (ASAT) and 1.18 microkat/l (0.28-4.5) for alanine aminotransferase (ALAT). A percutaneous liver biopsy was performed, and blood was sampled for a detailed biochemical and serologic profile. Chronic viral hepatitis C was found in 15.3% of the patients, autoimmune hepatitis in 1.3%, primary biliary cirrhosis in 1.3%, and heterozygotic alpha-1-antitrypsin deficiency in 0.7%. Presumed alcoholic liver disease was diagnosed in 8%, and non-alcoholic steatohepatitis in 2%. Chronic hepatitis with no obvious etiology was diagnosed in 24%, of whom 39% had interface hepatitis (piecemeal activity). Seventy-one per cent of these 39% had measurable levels of autoantibodies, but IgG levels within normal limits prevented the 'clinical' diagnosis of autoimmune hepatitis. Liver steatosis was the diagnosis in 40%. Most were overweight and had increased serum triglyceride levels. However, in 13.3% the fatty infiltration was considered 'essential', as both body mass index (BMI) and triglyceride levels were normal. Other diagnoses were liver fibrosis with no obvious inflammatory activity (3.3%), cirrhosis of unknown etiology (0.7%), and for the remaining (3.3%) patients histopathologic findings were considered 'normal'. Cirrhosis was found in five biopsy specimens: hepatitis C (n = 2), autoimmune hepatitis (n = 1), primary biliary cirrhosis (n = 1), and cryptogenic cirrhosis (n = 1). No concomitant disease was of importance for the diagnosis and/or histopathologic findings. No obvious drug-related increased liver test results were found with any single drug. However, patients with chronic hepatitis of unknown etiology, especially with interface hepatitis, significantly more often than the rest of the population were receiving drug treatment. Most transaminitis patients had steatosis, and some had defined diseases including chronic hepatitis C. Chronic hepatitis of unknown etiology was found in a substantial proportion (24%) of a population living in an area with a low burden of hepatic viruses and genetic disorders." }, { "id": "InternalMed_Harrison_32560", "title": "InternalMed_Harrison", "score": 0.009259259259259259, "content": "Differences between Screening Tests and Confirmatory Tests It is important to distinguish between clinical laboratory tests that can be used to screen for disease and those that offer a confirmatory result. Screening tests are generally less expensive and more widely available than are confirmatory tests, which often require more specialized equipment or personnel. As a general principle, screening tests are designed to identify all individuals who have the disease of interest, even if, in the process, some healthy individuals are misidentified as possibly having the disease. In other words, maximization of the diagnostic sensitivity of screening tests inevitably comes at the expense of reduced diagnostic specificity. Confirmatory testing is intended to correctly separate those individuals who have a disease from those who do not." }, { "id": "wiki20220301en115_8753", "title": "Non-alcoholic fatty liver disease", "score": 0.009174311926605505, "content": "Blood tests that are useful to confirm diagnosis or rule out others include erythrocyte sedimentation rate, glucose, albumin, and kidney function. Because the liver is important for making proteins used in blood clotting, coagulation-related studies are often carried out, especially the INR (international normalized ratio). In people with fatty liver with associated inflammatory injury (steatohepatitis) blood tests are usually used to rule out viral hepatitis (hepatitis A, B, C and herpesviruses such as Epstein-Barr virus or cytomegalovirus), rubella, and autoimmune diseases. Low thyroid activity is more prevalent in people with NASH, which would be detected by determining the thyroid-stimulating hormone. Some biomarker-based blood tests have been developed and may be useful for diagnosis." }, { "id": "pubmed23n0647_18564", "title": "[What shall I do with a patient with elevated liver tests?].", "score": 0.009174311926605505, "content": "In this article you will find a short reminder on the lab tests of the hepatic function and of the hepatic diseases. It shall help treat a patient with elevated liver tests. We will distinguish between an elevation of the liver enzymes of more/equal 5x and less than 5x the norm. An elevation of more/equal 5x the norm of the liver enzymes requires a rapid work-up. When the elevation is less than 5x the norm, one can proceed in two steps. A life style modification can be proposed after excluding a viral hepatitis and a hemochromatosis. If the liver enzymes still remind elevated, rarer causes must be searched." }, { "id": "InternalMed_Harrison_32558", "title": "InternalMed_Harrison", "score": 0.00909090909090909, "content": "One of the most frequent reasons for performing clinical laboratory tests is to support, confirm, or refute a diagnosis of disease that is suspected on the basis of other information sources, such as history, physical examination findings, and imaging studies. The following questions need to be considered: Which clinical laboratory tests may be of value in supporting, confirming, or excluding the clinical impression? What is the most efficient test-ordering strategy? Will a positive test result confirm the clinical impression or even definitively establish the diagnosis? Will a negative result disprove the clinical suspicion, and, if so, what further testing or alternative approach will be needed? What are the known sources of false-positive and false-negative results, and how are these misleading results recognized?" }, { "id": "wiki20220301en003_39891", "title": "Coeliac disease", "score": 0.009009009009009009, "content": "If all these antibodies are negative, then anti-DGP antibodies (antibodies against deamidated gliadin peptides) should be determined. IgG class anti-DGP antibodies may be useful in people with IgA deficiency. In children younger than two years, anti-DGP antibodies perform better than anti-endomysial and anti-transglutaminase antibodies tests. Because of the major implications of a diagnosis of coeliac disease, professional guidelines recommend that a positive blood test is still followed by an endoscopy/gastroscopy and biopsy. A negative serology test may still be followed by a recommendation for endoscopy and duodenal biopsy if clinical suspicion remains high." }, { "id": "pubmed23n0107_12223", "title": "Evaluation of laboratory tests used in screening ambulatory patients.", "score": 0.009009009009009009, "content": "Multiple other tests have been suggested for screening healthy patients. Hopefully, the above illustrations give a perspective with regards to the incidence of disease versus other causes that would lead to abnormal test results. The most frequent cause of an abnormal test result is physiologic variation, laboratory variation, or both. Even in laboratories with excellent quality assurance programs, the results falling outside the reference ranges most likely indicate physiologic variation, laboratory variation, or both. The physician will obtain more meaningful data from the laboratory when testing is ordered to confirm diagnostic suspicions that were raised during the history and physical examination of the patient. When a physician receives abnormal test results that were ordered as screening tests without any diagnostic suspicion, a search should be made for signs and symptoms that would correlate with that abnormal test. In the absence of any evidence that would indicate underlying disease, it would usually be unnecessary to pursue follow-up testing." }, { "id": "pubmed23n1077_8493", "title": "Glycogen Hepatopathy: A Reversible yet Relapsing Cause of Hepatitis in Type 1 Diabetics.", "score": 0.008928571428571428, "content": "Glycogen hepatopathy (GH), a rare glycogen storage disease caused by genetic or acquired overactivation of hepatic glycogen synthesis enzymes, can mimic non-alcoholic fatty liver disease (NAFLD). We describe a case of biopsy-proven GH in an adult with type 1 diabetes mellitus (DM). A 33-year-old Honduran woman with a 25-year history of type 1 DM complicated by gastroparesis, multiple episodes of diabetic ketoacidosis (DKA) and hypoglycemia, and recurrent pancreatitis was referred for abnormal liver enzymes. Family history was negative for liver disease. There was no history of alcohol or recreational drug use. Patients' medications included insulin and thyroxine. Physical exam showed hepatomegaly but no stigmata of chronic liver disease. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) had ranged from 100's to over 7000 U/L while alkaline phosphatase (ALP) was elevated to over 400 IU/L. Albumin, total bilirubin, platelets, international normalized ratio (INR), eosinophils, viral hepatitis panel, antinuclear antibody (ANA), smooth muscle antibody (Ab), anti-liver-kidney microsomal (LKM) Ab, celiac serologies, ceruloplasmin, alpha 1 antitrypsin, iron studies, and acetaminophen levels were all normal. An abdominal ultrasound showed \"fatty liver\" and an atrophic pancreas. CT abdomen showed hepatomegaly. The common bile duct (CBD) was found to be normal on endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP). A liver biopsy was pursued eventually, demonstrating glycogenotic hepatocytes. GH is frequently misdiagnosed as NAFLD, a more common liver disease that occurs in association with diabetes While GH is known to be reversible, NAFLD has been known to progress to advanced liver disease, ranging from cirrhosis to hepatocellular carcinoma. Definite diagnosis often requires liver biopsy because of overlapping clinical and radiographical pictures. Elevation of both glucose and insulin levels in the setting of fragile DM control is thought to play a role via overstimulation of glycogen synthesis. Recommended treatment is stable \"tight\" glycemic control; pancreatic transplantation has resulted in sustained GH remission in two case reports. The required degree of stability and tightness of glucose control is not yet known. An increased awareness of GH is needed in an attempt to prevent delay in diagnosis, in a condition with an otherwise unknown incidence." }, { "id": "InternalMed_Harrison_23338", "title": "InternalMed_Harrison", "score": 0.008928571428571428, "content": "As previously noted, the best way to increase the sensitivity and specificity of laboratory tests in the detection of liver disease is to employ a battery of tests that includes the aminotransferases, alkaline phosphatase, bilirubin, albumin, and prothrombin time along with the judicious use of the other tests described in this chapter. Table 358-1 shows how patterns of liver tests can lead the clinician to a category of disease that will direct further evaluation. However, it is important to remember that no single set of liver tests will necessarily provide a diagnosis. It is often necessary to repeat these tests on several occasions over days to weeks for a diagnostic pattern to emerge. Figure 358-1 is an algorithm for the evaluation of chronically abnormal liver tests." }, { "id": "wiki20220301en003_5066", "title": "Wilson's disease", "score": 0.008849557522123894, "content": "Wilson's disease is a genetic disorder in which excess copper builds up in the body. Symptoms are typically related to the brain and liver. Liver-related symptoms include vomiting, weakness, fluid build up in the abdomen, swelling of the legs, yellowish skin and itchiness. Brain-related symptoms include tremors, muscle stiffness, trouble in speaking, personality changes, anxiety, and psychosis. Wilson's disease is caused by a mutation in the Wilson disease protein (ATP7B) gene. This protein transports excess copper into bile, where is excreted in waste products. The condition is autosomal recessive; for a person to be affected, they must inherit a mutated copy of the gene from both parents. Diagnosis may be difficult and often involves a combination of blood tests, urine tests and a liver biopsy. Genetic testing may be used to screen family members of those affected." }, { "id": "pubmed23n0127_1341", "title": "Risk preference and laboratory test selection.", "score": 0.008849557522123894, "content": "The risk preferences in situations of potential gain, and of potential loss, expressed by 67 physicians were correlated with the numbers of laboratory tests they selected after review of identical copies of two outpatient charts. Physicians who chose a 50/50 gamble of losing ten or no years of life expectancy over an equivalent certain loss of five years selected twice as many tests as those who chose the loss (p less than 0.025). Risk preferences may provide some insight into why some physicians order more laboratory tests than do others." }, { "id": "pubmed23n0739_8513", "title": "Atomic Absorption Spectrometry in Wilson's Disease and Its Comparison with Other Laboratory Tests and Paraclinical Findings.", "score": 0.008771929824561403, "content": "Wilson's disease (WD) is an autosomal recessive disease with genetic abnormality on chromosome 13 causing defect in copper metabolism and increased copper concentration in liver, central nervous system and other organs, which causes different clinical manifestations. The aim of this study was to determine the sensitivity of different clinical and paraclinical tests for diagnosis of Wilson's disease. Paraffin blocks of liver biopsy from 41 children suspicious of WD were collected. Hepatic copper concentrations were examined with atomic absorption spectrophotometry (Australian GBC, model: PAL 3000). Fifteen specimens had hepatic copper concentration (dry weight) more than 250μg/g. Clinical and laboratory data and histologic slides of liver biopsies of these 15 children were reviewed retrospectively. Liver tissue was examined for staging and grading of hepatic involvement and also stained with rubeonic acid method for copper. Patients were 5-15 years old (mean age=9.3 years, standard deviation=2.6) with slight male predominance (9/15=60%). Five (33%) patients were 10 years old. Three (20%) of them were referred for icterus, 8 (54%) because of positive family history, 2 (13%) due to abdominal pain and 2 (13%) because of hepatosplenomegaly and ascites. Serum AST and ALT levels were elevated at the time of presentation in all patients. In liver biopsy, histological grade and stage was 0-8 and 0-6 respectively, 2 (13%) had cirrhosis, 1 (7%) had normal biopsy and 12 (80%) showed chronic hepatitis. Hepatic copper concentrations were between 250 and 1595 μg/g dry weight. The sensitivity of various tests were 85% for serum copper, 83% for serum ceruloplasmin, 53% for urinary copper excretion, 44% for presence of KF ring and 40% for rubeonic acid staining on liver biopsies. None of the tests stated in the article were highly sensitive for diagnosis of WD, so we suggest that diagnosis should be based on combination of family history, physical examination and different tests." }, { "id": "pubmed23n0060_4699", "title": "Realistic expectations of laboratory testing.", "score": 0.008771929824561403, "content": "The ordering, reviewing, and interpreting of laboratory tests require recognition and familiarity with the concepts of normal values, sensitivity, specificity, predictive values, and prevalence. The significance of these test properties in clinical decision-making is explained." } ] } } }

{ "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": [ [ 0, 157 ] ], "word_ranges": [ [ 0, 26 ] ], "text": "They describe pleural fluid parameters of transudate, so if the patient is not in heart failure it is a hydropic decompensation. No other studies are needed." } }

{ "1": "The study of the fluid with cell count, glucose, pH, ADA, cholesterol and culture should be extended. ADA, cholesterol and culture.", "2": "Blind pleural biopsy.", "3": "Diagnostic videothoracoscopy.", "4": "Empirical antibiotherapy for suspected parapneumonic effusion.", "5": "Continue treatment of his liver disease." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0314_499", "title": "Evaluation of pleural fluid in patients with cirrhosis.", "score": 0.015209326974032857, "content": "Although fluid analysis usually is the first step toward identifying the cause of pleural effusion in patients with cirrhosis and ascites, there are no available data on the reliability of this approach, therefore, we retrospectively evaluated hematologic and biochemical parameters from pleural fluid analysis in 21 patients with hepatic hydrothorax (with proven peritoneal-pleural communication) and 6 patients with primary pleural disease (2 with tuberculosis, 3 with parapneumonic effusion, and 1 with empyema). The criteria developed by Light were diagnostic of pleural \"exudate\" in only one of six patients with primary pleural disease, concentrations of leukocytes, total protein (TP), albumin, and lactic dehydrogenase (LDH) in both fluids were measured and pleural fluid-to-ascites ratios of these measurements were calculated. Only ratio values for leukocytes and TP were higher in the group of patients with primary pleural disease compared with those with hepatic hydrothorax. Ratio values for leukocytes and TP overlapped between both groups during baseline conditions and during episodes of spontaneous bacterial peritonitis and pleuritis. We conclude that pleural fluid analysis has limited diagnostic efficacy in the patient with cirrhosis. Data collected by other methods--clinical and radiologic--should assist in arriving at the correct diagnosis." }, { "id": "wiki20220301en167_881", "title": "Parapneumonic effusion", "score": 0.014731907973406035, "content": "A parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis. There are three types of parapneumonic effusions: uncomplicated effusions, complicated effusions, and empyema. Uncomplicated effusions generally respond well to appropriate antibiotic treatment. Diagnosis The criteria for a complicated parapneumonic effusion include Gram stain–positive or culture-positive pleural fluid, pleural fluid pH <7.20, and pleural fluid LDH that is greater than three times the upper limit of normal of serum LDH. Diagnostic techniques available include plain film chest x-ray, computed tomography (CT), and ultrasound. Ultrasound can be useful in differentiating between empyema and other transudative and exudative effusions due in part to relative echogenicity of different organs such as the liver (often isoechogenic with empyema)." }, { "id": "wiki20220301en628_16913", "title": "Hepatic hydrothorax", "score": 0.014066951566951567, "content": "The most noticeable symptoms are usually those of cirrhosis and portal hypertension. Most people have signs of end-stage liver disease. pleuroperitoneal communications. The main method of diagnosis is extracting the fluid via thoracentesis. After this, the fluid is analyzed for diagnosis and to help rule out other possible causes like infection or cancer. The fluid can be analyzed for serum, protein, albumin, lactate dehydrogenase, and cell count. The fluid is a transudate and similar to fluid found in ascites. There may be a higher protein and albumin content in hepatic hydrothorax due to the pleura absorbing the water. To rule out heart-related causes of pleural effusion, an echocardiogram can be performed. Pleuroperitoneal communications are best detected by peritoneal scintigraphy. In this procedure, radioactive tracer is injected via needle into ascitic fluid, a procedure known as paracentesis. After that, a gamma camera is used to take images, showing the tracer in the pleural" }, { "id": "wiki20220301en015_101883", "title": "Pleural effusion", "score": 0.013591800356506239, "content": "The ratio of pleural fluid protein to serum protein is greater than 0.5 The ratio of pleural fluid LDH and serum LDH is greater than 0.6 Pleural fluid LDH is greater than 0.6 or times the normal upper limit for serum. Different laboratories have different values for the upper limit of serum LDH, but examples include 200 and 300 IU/l." }, { "id": "wiki20220301en010_91068", "title": "Pleural cavity", "score": 0.013556067588325654, "content": "If malignant cells are present, a pathologist may perform additional studies including immunohistochemistry to determine the etiology of the malignancy. Chemical analysis Chemistry studies may be performed including pH, pleural fluid:serum protein ratio, LDH ratio, specific gravity, cholesterol and bilirubin levels. These studies may help clarify the etiology of a pleural effusion (exudative vs transudative). Amylase may be elevated in pleural effusions related to gastric/esophageal perforations, pancreatitis or malignancy. Pleural effusions are classified as exudative (high protein) or transudative (low protein)." }, { "id": "wiki20220301en063_55698", "title": "Thoracentesis", "score": 0.013461538461538462, "content": "The use of ultrasound for needle guidance can minimize the complication rate. Follow-up imaging While chest X-ray has traditionally been performed to assess for pneumothorax following the procedure, it may no longer be necessary to do so in asymptomatic, non-ventilated persons given the widespread use of ultrasound to guide this procedure. Interpretation of pleural fluid analysis Several diagnostic tools are available to determine the etiology of pleural fluid. Transudate versus exudate First the fluid is either transudate or exudate. A transudate is defined as pleural fluid to serum total protein ratio of less than 0.5, pleural fluid to serum LDH ratio > 0.6, and absolute pleural fluid LDH > 200 IU or > 2/3 of the normal." }, { "id": "pubmed23n0492_372", "title": "[Cuttoff values of biochemical tests on pleural fluid: their usefulness in differential diagnosis of 1,040 patients with pleural effusion].", "score": 0.013212977498691783, "content": "The aim of biochemical pleural fluid testing is to reach an etiological diagnosis of the pleural effusion. We assessed the utility of considering cuttoff points for the wide range of analytes used to investigate pleural fluid. Among 1,040 patients with pleural effusion, we sought the etiologies of those fluids which showed any of the following characteristics: red blood cell count = 10 x 109/L, leukocytes = 10 x 109/L, percentage of neutrophils or lymphocytes &gt;50%, protein = 50 g/L, glucose = 60 mg/dL, pH = 7.2, lactate dehydrogenase = 1,000 U/L, adenosine deaminase = 40 U/L, amylase = 100 U/L or cholesterol = 60 mg/dL. Some of the more prominent findings were: a) a sixth of transudates were blood-tinged or contained predominantly neutrophils; b) a groosly bloody fluid suggests malignant disease, trauma, or pulmonary embolization; c) nearly 90% of fluids containing = 10 x 10(9) leukocytes/L were parapneumonics; d) 73% of tuberculous pleural fluids had protein &gt; or = 50 g/L, e) tuberculosis and parapneumonics explained more than 90% of fluids with high adenosine deaminase content; f) one third of amylase-rich pleural effusions were malignant; g) a low pleural glucose or pH levels indicate that patient probably has a parapneumonic, tuberculous or malignant etiology; y h) the diagnostic yield of pleural fluid cytology in malignant effusions was 57%, a percentage which raised to 94% in those with low glucose fluid level. Cuttof values of biochemical pleural fluid tests may greatly support particular causes of pleural effusions." }, { "id": "wiki20220301en015_101869", "title": "Pleural effusion", "score": 0.01314798071127185, "content": "When a pleural effusion has been determined to be exudative, additional evaluation is needed to determine its cause, and amylase, glucose, pH and cell counts should be measured. Red blood cell counts are elevated in cases of bloody effusions (for example after heart surgery or hemothorax from incomplete evacuation of blood). Amylase levels are elevated in cases of esophageal rupture, pancreatic pleural effusion, or cancer. Glucose is decreased with cancer, bacterial infections, or rheumatoid pleuritis. pH is low in empyema (<7.2) and maybe low in cancer. If cancer is suspected, the pleural fluid is sent for cytology. If cytology is negative, and cancer is still suspected, either a thoracoscopy, or needle biopsy of the pleura may be performed. Gram staining and culture should also be done." }, { "id": "wiki20220301en063_55700", "title": "Thoracentesis", "score": 0.012955902695772462, "content": "Transudate Congestive heart failure Nephrotic syndrome Hypoalbuminemia Cirrhosis Atelectasis trapped lung Peritoneal dialysis Superior vena cava obstruction Amylase A high amylase level (twice the serum level or the absolute value is greater than 160 Somogy units) in the pleural fluid is indicative of either acute or chronic pancreatitis, pancreatic pseudocyst that has dissected or ruptured into the pleural space, cancer or esophageal rupture. Glucose This is considered low if pleural fluid value is less than 50% of normal serum value. The differential diagnosis for this is: rheumatoid effusion. The levels are characteristically low (<15 mg/dL). lupus effusion bacterial empyema malignancy tuberculosis esophageal rupture (Boerhaave syndrome) pH Normal pleural fluid pH is approximately 7.60. A pleural fluid pH below 7.30 with normal arterial blood pH has the same differential diagnosis as low pleural fluid glucose." }, { "id": "wiki20220301en063_55699", "title": "Thoracentesis", "score": 0.01269381249094334, "content": "A transudate is defined as pleural fluid to serum total protein ratio of less than 0.5, pleural fluid to serum LDH ratio > 0.6, and absolute pleural fluid LDH > 200 IU or > 2/3 of the normal. An exudate is defined as pleural fluid that filters from the circulatory system into lesions or areas of inflammation. Its composition varies but generally includes water and the dissolved solutes of the main circulatory fluid such as blood. In the case of blood it will contain some or all plasma proteins, white blood cells, platelets and (in the case of local vascular damage) red blood cells. Exudate hemorrhage Infection Inflammation Malignancy Iatrogenic Connective tissue disease Endocrine disorders Lymphatic disorders vs Constrictive pericarditis Transudate Congestive heart failure Nephrotic syndrome Hypoalbuminemia Cirrhosis Atelectasis trapped lung Peritoneal dialysis Superior vena cava obstruction" }, { "id": "pubmed23n0362_11326", "title": "Management of pleural effusions.", "score": 0.012633587786259542, "content": "This review summarizes current strategies in the treatment of patients with pleural effusion. To determine whether a patient has a transudative or exudative pleural effusion, Light's criteria should be applied to measure the concentrations of protein and lactate dehydrogenase (LDH) in the pleural fluid and serum. If the effusion is transudative, therapy should be directed toward the underlying congestive heart failure, cirrhosis, or nephrosis. Consideration should be given to pleurodesis with a sclerosant if patients with recurrent transudative effusion have severe dyspnea due to their effusion. If the effusion is exudative, attempts should be made to define the etiology. The diagnosis of pleural malignancy is most easily established via pleural fluid cytology. If this is negative and the patient is suspected of having pleural malignancy, thoracoscopy is indicated. The concentrations of adenosine deaminase and gamma-interferon in pleural fluid are useful in the diagnosis of pleural tuberculosis. Patients with pneumonia and pleural effusion should undergo therapeutic thoracentesis; the pleural fluid should be Gram-stained and cultured, and the differential cell count, glucose and LDH concentration, and pH should be determined. Indicators of a poor prognosis include the presence of frank pus, a positive Gram-stain, a pleural glucose concentration of less than 2.2 mmol/L, a pH less than 7.00, the presence of pleural loculations, and an LDH concentration greater than three times the upper limit of normal in serum. If the pleural fluid cannot be completely evacuated because of loculations, intrapleural thrombolytic therapy should be considered. If thrombolytics are ineffective, thoracoscopy or thoracotomy with decortication should be performed. Dyspneic patients with malignant pleural effusions whose dyspnea is relieved with therapeutic thoracentesis should be considered for pleurodesis using a tetracycline derivative. Talc is not recommended because it induces acute respiratory distress syndrome in about 5% of patients, with an overall mortality of 1%." }, { "id": "InternalMed_Harrison_3299", "title": "InternalMed_Harrison", "score": 0.011811443502372954, "content": "288 be measured. In contrast to “spontaneous” bacterial peritonitis, which may complicate cirrhotic ascites (see “Complications,” below), secondary peritonitis is suggested by an ascitic glucose level <50 mg/dL, an ascitic LDH level higher than the serum LDH level, and the detection of multiple pathogens on ascitic fluid culture. When pancreatic ascites is suspected, the ascitic amylase level should be measured and is typically >1000 mg/dL. Cytology can be useful in the diagnosis of peritoneal carcinomatosis. At least 50 mL of fluid should be obtained and sent for immediate processing. Tuberculous peritonitis is typically associated with ascitic fluid lymphocytosis but can be difficult to diagnose by paracentesis. A smear for acid-fast bacilli has a diagnostic sensitivity of only 0 to 3%; a culture increases the sensitivity to 35–50%. In patients without cirrhosis, an elevated ascitic adenosine deaminase level has a sensitivity of >90% when a cut-off value of 30–45 U/L is used. When" }, { "id": "wiki20220301en025_92727", "title": "Pleural empyema", "score": 0.011308203991130819, "content": "The most often used \"golden\" criteria for empyema are pleural effusion with macroscopic presence of pus, a positive Gram stain or culture of pleural fluid, or a pleural fluid pH under 7.2 with normal peripheral blood pH. Clinical guidelines for adult patients therefore advocate diagnostic pleural fluid aspiration in patients with pleural effusion in association with sepsis or pneumonic illness. Because pleural effusion in the pediatric population is almost always parapneumonic and the need for chest tube drainage can be made on clinical grounds, British guidelines for the management of pleural infection in children do not recommend diagnostic pleural fluid sampling." }, { "id": "wiki20220301en192_34039", "title": "Lactate dehydrogenase", "score": 0.01129745417713629, "content": "Testing in other body fluids Exudates and transudates Measuring LDH in fluid aspirated from a pleural effusion (or pericardial effusion) can help in the distinction between exudates (actively secreted fluid, e.g., due to inflammation) or transudates (passively secreted fluid, due to a high hydrostatic pressure or a low oncotic pressure). The usual criterion (included in Light's criteria) is that a ratio of fluid LDH versus upper limit of normal serum LDH of more than 0.6 or indicates an exudate, while a ratio of less indicates a transudate. Different laboratories have different values for the upper limit of serum LDH, but examples include 200 and 300 IU/L. In empyema, the LDH levels, in general, will exceed 1000 IU/L. Meningitis and encephalitis High levels of lactate dehydrogenase in cerebrospinal fluid are often associated with bacterial meningitis. In the case of viral meningitis, high LDH, in general, indicates the presence of encephalitis and poor prognosis." }, { "id": "wiki20220301en628_16907", "title": "Hepatic hydrothorax", "score": 0.011278195488721804, "content": "There are no specific symptoms, because it generally occurs with ascites and other manifestations of increased pressure in the portal vein caused by liver disease. Pleural fluid can far more easily cause symptoms than ascitic fluid, due to the lower volume of the pleural cavity as compared to the abdominal cavity. The main symptoms are usually related to the symptoms of liver cirrhosis and ascites. Less often, it may be the only manifestation of chronic liver disease. The symptoms depend on many factors, such as the effusion's volume, rate of accumulation, and the co-existence of cardiopulmonary disease. The disease may cause no symptoms and be incidentally detected by medical scans, or it may cause large pleural effusions that result in respiratory symptoms like cough, shortness of breath, low blood oxygen, and respiratory failure. Most people have progressive difficulty breathing and reduced tolerance for exercise. Rarely, there may be acute cases that accumulate fluid rapidly and" }, { "id": "wiki20220301en628_16904", "title": "Hepatic hydrothorax", "score": 0.011035965188214324, "content": "Hepatic hydrothorax is a rare form of pleural effusion that occurs in people with liver cirrhosis. It is defined as an effusion of over 500 mL in people with liver cirrhosis that is not caused by heart, lung, or pleural disease. It is found in 5-10% of people with liver cirrhosis and 2-3% of people with pleural effusions. It is much more common on the right side, with 85% of cases occurring on the right, 13% on the left, and 2% in both. Although it is most common in people with severe ascites, cases have been reported where people only had mild or no ascites. Symptoms are not specific, and mostly involve the respiratory system." }, { "id": "wiki20220301en063_55701", "title": "Thoracentesis", "score": 0.01074549670055288, "content": "pH Normal pleural fluid pH is approximately 7.60. A pleural fluid pH below 7.30 with normal arterial blood pH has the same differential diagnosis as low pleural fluid glucose. Triglyceride and cholesterol Chylothorax (fluid from lymph vessels leaking into the pleural cavity) may be identified by determining triglyceride and cholesterol levels, which are relatively high in lymph. A triglyceride level over 110 mg/dl and the presence of chylomicrons indicate a chylous effusion. The appearance is generally milky but can be serous. The main cause for chylothorax is rupture of the thoracic duct, most frequently as a result of trauma or malignancy (such as lymphoma). Cell count and differential The number of white blood cells can give an indication of infection. The specific subtypes can also give clues as to the type on infection. The amount of red blood cells are an obvious sign of bleeding." }, { "id": "wiki20220301en427_20595", "title": "Urinothorax", "score": 0.010596343800678166, "content": "Diagnosis Due to the main symptoms typically being urological rather than respiratory, the condition requires exclusion of other conditions and the identification of specific symptoms before diagnosis. Pleural fluid analysis is one way to diagnose the condition. The pleural fluid is most often straw-colored, and it has a distinct smell like ammonia. The fluid usually has a nucleated cell count between 50 and 1500 per cm3. The pH of the fluid is usually between 5 and 7. Primary factors for diagnosing urinothorax by pleural fluid include low protein and high lactate dehydrogenase content. Low glucose levels and acidity are also described, but are not reliable ways to diagnose or rule out urinothorax. The most important chemical diagnostic factor of the fluid is that the ratio of creatinine to serum is more than 1 and usually more than 10." }, { "id": "InternalMed_Harrison_20549", "title": "InternalMed_Harrison", "score": 0.010591867149244198, "content": "Perform diagnostic thoracentesis Measure pleural fluid protein and LDH Exudate Further diagnostic procedures Transudate Treat CHF, cirrhosis, nephrosis Measure PF glucose Obtain PF cytology Obtain differential cell count Culture, stain PF PF marker for TB Consider:Malignancy Bacterial infections Rheumatoid pleuritis Glucose < 60 mg/dL No diagnosis Consider pulmonary embolus (spiral CT or lung scan) Treat for PE Treat for TB PF marker for TB Observe Consider thoracoscopy or image-guided pleural biopsy Any of following met? PF/serum protein > 0.5 PF/serum LDH > 0.6 PF LDH > 2/3 upper normal serum limit Pleural effusion Yes No Yes Yes Yes No No No SYMPTOMS IMPROVING FIGURE 316-1 Approach to the diagnosis of pleural effusions. CHF, congestive heart failure; CT, computed tomography; LDH, lactate dehydrogenase; PE, pulmonary embolism; PF, pleural fluid; TB, tuberculosis." }, { "id": "article-17881_14", "title": "Ascites -- Evaluation", "score": 0.010554980895484579, "content": "Additional tests may be performed only if a specific diagnosis is suspected clinically. LDH and glucose level should be determined in suspected cases of secondary peritonitis. Other tests to consider include amylase (greater than 1000 U/L suggests pancreatic ascites). Mycobacterial culture should be performed only if tuberculosis is strongly suspected. Other ascitic fluid indices such as lactate and pH offer little to no additional information. Chest x-ray may reveal elevated diaphragm." }, { "id": "wiki20220301en015_101882", "title": "Pleural effusion", "score": 0.01014827292199555, "content": "Transudative pleural effusions are defined as effusions that are caused by systemic factors that alter the pleural equilibrium, or Starling forces. The components of the Starling forces – hydrostatic pressure, permeability, and oncotic pressure (effective pressure due to the composition of the pleural fluid and blood) – are altered in many diseases, e.g., left ventricular failure, kidney failure, liver failure, and cirrhosis. Exudative pleural effusions, by contrast, are caused by alterations in local factors that influence the formation and absorption of pleural fluid (e.g., bacterial pneumonia, cancer, pulmonary embolism, and viral infection). An accurate diagnosis of the cause of the effusion, transudate versus exudate, relies on a comparison of the chemistries in the pleural fluid to those in the blood, using Light's criteria. According to Light's criteria (Light, et al. 1972), a pleural effusion is likely exudative if at least one of the following exists:" }, { "id": "pubmed23n0368_1316", "title": "The value of ascitic fluid polymorphonuclear cell count determination during therapy of spontaneous bacterial peritonitis in patients with liver cirrhosis.", "score": 0.009900990099009901, "content": "Spontaneous bacterial peritonitis is one of the most common complications attending the onset of ascites in patients with liver cirrhosis. The aim of this study was to demonstrate whether it is possible, on the basis of ascitic fluid polymorphonuclear cell count in patients with liver cirrhosis and spontaneous bacterial peritonitis, to determine the optimal duration of cefotaxime therapy, as the most frequently applied empirical therapy, and possibly anticipate the disease recurrence. In 16 patients with alcoholic liver cirrhosis and confirmed diagnosis of spontaneous bacterial peritonitis, cefotaxime therapy was administered 2g t.i.d. during 5 days. Before the therapy, at 48 hours, 5 days and 15-20 days after the cefotaxime therapy was started, in all patients with spontaneous bacterial peritonitis diagnostic abdominal paracentesis was performed, each time determining the ascitic fluid polymorphonuclear cell count together with microbiological analysis. In the course of the \"primary\" spontaneous bacterial peritonitis attack, 3 patients died (18.8%). In 4 patients the recurrence of spontaneous bacterial peritonitis was observed within 15-20 days after therapy was discontinued. Two patients died during the therapy of spontaneous bacterial peritonitis recurrence. After 48 hours of therapy, 11 patients with the \"primary\" spontaneous bacterial peritonitis attack were without any symptoms (68.8%). Out of these 11, 10 patients (62.5%) had the ascitic fluid polymorphonuclear cell count lower than 250/mm3. After 5 days of therapy, 12 patients (75%) were free of symptoms, and the number of ascitic fluid polymorphonuclear cell count &lt; 250/mm3 was still found in 10 (62.5%) patients. No association between the presence of symptoms 48 hours after the therapy and the recurrence of spontaneous bacterial peritonitis was established. A significant association was found between the ascitic fluid polymorphonuclear cell count determined 48 hours after the therapy and the recurrence of spontaneous bacterial peritonitis. A recurrence occurred in only 1 patient with the number of ascitic fluid polymorphonuclear cell count &lt; 250/mm3, 48 hours after the therapy was started. A recurrence of spontaneous bacterial peritonitis occurred in all the patients who had an ascitic fluid PMN cell count &gt; or = 250/mm3, 48 hours after the therapy was started. By monitoring the ascitic fluid PMN cell count it seems to be possible to determine the efficacy and optimal duration of cefotaxime therapy in patients with spontaneous bacterial peritonitis when it is of most importance that the number of ascitic fluid PMN cell count should decrease below 250/mm3 during the therapy." }, { "id": "pubmed23n0026_1638", "title": "The clinical value of ascitic fluid culture and leukocyte count studies in alcoholic cirrhosis.", "score": 0.009708737864077669, "content": "Because of the paucity of studies establishing the accepted leukocyte count is sterile ascites, less than 300 WBC per mm3 with 25% polymorphonuclear (PMN) leukocytes, peritoneal fluid WBC counts and bacterial cultures were studied in 63 consecutive hospitalized patients with alcoholic cirrhosis and ascities. In 58 culture-negative patients the ascitic fluid WBC count range was 28 to 1800 and 50% of counts were greater than 300 WBC per mm3. The percentage of PMN leukocytes ranged from 2 to 98%. Five patients with spontaneous bacterial peritonitis (SBP), proven by positive cultures, had an ascitic WBC count range of 300 to 6320 WBC per mm3 and a PMN leukocyte range of 20 to 76%. Physical findings did not allow clear separation of the two groups. Anaerobic organisms were not found. It is concluded: (1) differentiation of SBP from sterile ascities relies on prompt ascitic fluid bacteriology; (2) the improved survival of 40% of SBP patients in this study may be related to an increased awareness of the entity and early treatment." }, { "id": "pubmed23n0326_18388", "title": "Diagnosing ascitic etiology on a biochemical basis.", "score": 0.009615384615384616, "content": "The analysis of ascitic fluid has been complicated by several new tests. To simplify its assessment, we evaluated ascitic fluid pH with six other parameters prospectively and simultaneously in blood and ascitic fluid in sixty patients with ascites. Sixty patients were selected on whom abdominal paracentesis was performed in order to determine which tests were the most reliable for the etiological diagnosis of ascites. Their ascitic fluid pH, cholesterol, albumin, and total proteins were analyzed to distinguish between malignant and cirrhotic ascites. The diagnosis of cirrhosis was based on histological findings, and/or clinical, biochemical, and endoscopic/ultrasonographic findings in whom percutaneous liver biopsy was contraindicated. The serum-ascites albumin gradient was higher (p&lt;0.001) in cirrhotic as compared to tubercular, malignant or cardiac ascites. We discovered that ascitic fluid lactate dehydrogenase and cholesterol were best for diagnosing malignant ascites, ascitic fluid glucose and ascitic fluid/blood glucose ratio were perfect for diagnosing tubercular ascites, and ascitic fluid pH and lactate dehydrogenase were suitable for diagnosing spontaneous bacterial peritonitis. Correspondingly, ascitic fluid albumin, ascitic fluid/serum albumin, total proteins, and serum ascites albumin gradient were best for diagnosing sterile cirrhotic ascites. Diagnostic paracentesis is a useful procedure. The practice of ordering a battery of tests on every ascitic fluid specimen should be abandoned. Rather, an algorithm approach should be adopted in which the results of initial analysis guide us to further relent tests that help in arriving at the etiology of ascites." }, { "id": "pubmed23n0226_13908", "title": "The pH of ascitic fluid in the diagnosis of spontaneous bacterial peritonitis in alcoholic cirrhosis.", "score": 0.009523809523809525, "content": "Fifty-six patients with alcoholic cirrhosis and ascites were studied. The ascitic fluid was analyzed for pH, PO2, PCO2 glucose, protein, specific gravity, amylase, lactic dehydrogenase, white blood cell count, polymorphonuclear count, and cytology. It was also cultured aerobically and anaerobically. Simultaneously, arterial blood was analyzed for pH, PO2, and PCO2. Venous blood was analyzed for complete blood count, protein, aspartate transaminase, and it was also cultured under aerobic and anaerobic conditions. Six patients had spontaneous bacterial peritonitis (SBP), i.e., culture was positive for Escherichia coli in five and Streptococcus faecalis in one. The mean (+/- S.E.) ascitic fluid pH in the SBP group wa 7.25 +/- 0.06 with a range of 7.12 to 7.31, while the ascitic fluid pH in the group with sterile ascites was 7.47 +/- 0.07 with a range of 7.39 to 7.58. The pH of the blood in both groups was 7.47 +/- 0.03. The pH of the ascites in the SBP group was significantly different from the pH in the group with sterile ascites, p less than 0.001. It was also significantly different from the blood pH, p less than 0.001. Highly significant inverse correlations existed between the ascitic pH in the SBP group and the ascitic white blood cell count (r = 0.84, p less than 0.01) and between the ascite pH in the SBP group and the ascitic polymorphonuclear count (r = -0.87 ,p less than 0.01). The ascitic fluid pH is recommended as an easy, quick, sensitive, and specific means of diagnosing SBP and it overcomes the problem of the present SBP diagnostic methods of utilizing an absolute white blood cell count greater than 500 per mm3 or a polymorphonuclear count greater than 250 per mm3 in which false positive interpretations occur." }, { "id": "pubmed23n1154_26189", "title": "Characteristics of pleural effusion with a high adenosine deaminase level: a case-control study.", "score": 0.009433962264150943, "content": "Increased pleural fluid adenosine deaminase (ADA) is useful for diagnosing tuberculous pleurisy (TB), but high ADA levels are associated with other diseases. In this study, we compare various disease characteristics in patients with high-ADA pleural effusion. We retrospectively collected data for 456 patients with pleural fluid ADA levels of ≥ 40 U/L from January 2012 to October 2021. Cases were classified as TB (n = 203), pleural infection (n = 112), malignant pleural effusion (n = 63), nontuberculous mycobacteria (n = 22), malignant lymphoma (ML) (n = 18), autoimmune diseases (n = 11), and other diseases (n = 27), and data were compared among those diseases. Predictive factors were identified by comparing data for a target disease to those for all other diseases. A diagnostic flowchart for TB was developed based on those factors. The most frequent disease was TB, though 60.0% of patients were diagnosed with other diseases. Median ADA levels in patients with TB were 83.1 U/L (interquartile range [IQR] 67.2-104.1), higher than those of patients with pleural infection (median 60.9 [IQR 45.3-108.0], p = 0.004), malignant pleural effusion (median 54.1 [IQR 44.8-66.7], p &lt; 0.001), or autoimmune diseases (median 48.5 [IQR 45.9-58.2], p = 0.008), with no significant difference from NTM (p = 1.000) or ML (p = 1.000). Pleural fluid lactate dehydrogenase (LDH) levels of &lt; 825 IU/L were beneficial for the diagnosis of TB. Neutrophil predominance or cell degeneration, white blood cell count of ≥ 9200/µL or C-reactive protein levels of ≥ 12 mg/dL helped in diagnosing pleural infection. Pleural fluid amylase levels of ≥ 75 U/L and a pleural fluid ADA/total protein (TP) ratio of &lt; 14 helped in diagnosing malignant pleural effusion. High serum LDH and high serum/pleural fluid eosinophils helped in diagnosing ML and autoimmune diseases, respectively. The flowchart was comprised of the following three factors: pleural fluid LDH &lt; 825 IU/L, pleural fluid ADA/TP of &lt; 14, and neutrophil predominance or cell degeneration, which were decided by a decision tree. The diagnostic accuracy rate, sensitivity, and specificity for the diagnosis of TB were 80.9%, 78.8%, and 82.6%, respectively. Cases involving high pleural fluid ADA levels should be investigated using several factors to distinguish TB from other diseases." }, { "id": "pubmed23n0752_6269", "title": "Frequency of microbial spectrum of spontaneous bacterial peritonitis in established cirrhosis liver.", "score": 0.009433962264150943, "content": "Spontaneous bacterial peritonitis is one of the most frequent and serious complication in patients with liver cirrhosis and ascites associated with high mortality. Empiric antibiotic therapy should be initiated before the results of ascitic fluid cultures are available, guided by knowledge of the microbial spectrum of spontaneous bacterial peritonitis in a particular population. This is a descriptive study which was carried out in the Department of Gastroenterology and Hepatology, Postgraduate Medical Institute Hayatabad Medical Complex, Peshawar from January 2007 to December 2007. Fifty consecutive patients of established cirrhosis liver with ascites presenting with suspicion and or risk factors for spontaneous bacterial peritonitis were included in the study after informed consent. All selected patients were subjected to ascitic fluid tap. Twenty ml of ascitic fluid was aspirated in a heparinised disposable syringe; out of it 10 ml was immediately inoculated into blood culture bottle at bedside and sent for bacterial culture along with the remaining 10 ml for routine biochemical and cytological examination. Out of 50 patients, 28 (56%) were diagnosed to have spontaneous bacterial peritonitis or its variants. Classic spontaneous bacterial peritonitis was present in 11 patients (39.28%), 16 (57.14%) patients were found to have culture negative neutrocytic ascites and one patient (3.57%) had bacterascites. Out of 28 cases of spontaneous bacterial peritonitis 12 samples of ascitic fluid showed positive culture reports. E. coli was the most frequently cultured organism isolated in 8 (66.66%) cases, Streptococcus pneumonae in 2 patients (16.66%), S taphylococcus aurus and Klebsiella each in 1 case (8.33%). Spontaneous bacterial peritonitis and its variants is a common complication of liver cirrhosis with ascites. E. coli is the most frequent offending organism in these cases. Knowledge of the microbial spectrum of spontaneous bacterial peritonitis in a particular population is important for the selection of the most appropriate empiric antibiotic regimen." }, { "id": "pubmed23n0132_1935", "title": "Immediate diagnostic criteria for bacterial infection of ascitic fluid. Evaluation of ascitic fluid polymorphonuclear leukocyte count, pH, and lactate concentration, alone and in combination.", "score": 0.009345794392523364, "content": "We prospectively evaluated the ascitic fluid (AF) polymorphonuclear cell (PMN) count, pH, and lactate concentration in single ascitic fluids from 60 patients to determine their relative predictive values for the immediate diagnosis of ascitic fluid infection. Nine of the 60 ascitic fluids were malignant. Of the remaining 51 samples, nine from cirrhotic patients were infected. The mean AF pH, lactate concentration, and PMN count in the infected group were 7.20 +/- 0.19, 80 +/- 51 mg/dl, and 18,199 +/- 19,650 cells/mm3, respectively, and all were significantly different from the corresponding values in noninfected ascites. Mean arterial blood-ascitic fluid (B-AF) pH and lactate gradients in the infected group were 0.23 +/- 0.17 and -46 +/- 31 mg/dl, respectively, and were significantly different from the corresponding values in noninfected ascites (p less than 0.05). Significant differences were not found between infected and malignant ascites, except for the AF PMN count (p less than 0.001). In cirrhosis with ascites, an AF pH less than or equal to 7.34 was the most specific single test (100%) and had the highest diagnostic accuracy (98%). In the larger group of patients with ascites of diverse etiology, a B-AF pH gradient greater than or equal to 0.10 or an AF PMN count greater than or equal to 500 cells/mm3 were the single tests with the highest diagnostic accuracy (92%). Combining an AF PMN count greater than 500 cells/mm3 with any of the other diagnostic criteria increased the specificity and diagnostic accuracy (up to 98%) compared to the best single criterion. Although our data support the use of a number of different combinations of AF measurements for the immediate diagnosis of infection, the simplest and most readily obtainable measurements are the pH and PMN count. Therefore, in the clinical setting we recommend the use of either an AF pH less than or equal to 7.34 or a B-AF pH gradient greater than or equal to 0.10 in combination with an AF PMN count greater than 500 cells/mm3 to obtain the highest degree of accuracy in the immediate diagnosis of ascitic fluid infection." }, { "id": "pubmed23n0014_14252", "title": "Analysis of ascitic fluid in cirrhosis.", "score": 0.009259259259259259, "content": "In order to determine the composition of \"normal\" ascitic fluid, the results of analysis of the first paracentesis on 347 consecutive cirrhotic patients with ascites at the West Haven Veterans Administration Hospital between 1955 and 1976 were examined. The ascites was considered \"normal\" in 259 patients. Bacterial peritonitis was present in 51, malignant ascites in 18, pancreatitic ascites in 15, and ascites of other types in 4 patients. Normal ascites is sterile, usually clear, and contains 281 +/- 25 leukocytes/mm3 (mean +/- SEM), 27 +/- 2% of which are polymorphonuclear. In spontaneous bacterial peritonitis the fluid is usually cloudy, contains 6084 +/- 858 white blood cells/mm3, 77 +/- 4% of which were PMN and culture is positive for a single bacterial species, usually enteric in origin. Malignant and pancreatitis ascites are sterile, often cloudy, and contain an average of 696 +/- 273 and 1821 +/- 833 leukocytes/mm3, respectively, about half of which are polymorphonuclear. Amylase activity is increased in pancreatitic ascites, but not in other types of ascites. Stained smears of sediment for bacteria are often positive in bacterial peritonitis, but not in the other categories. Neither the specific gravity, protein concentration, nor glucose level is useful in the differential diagnosis of ascites. Based on the critical number of leukocytes alone, (500/mm3), one can accurately differentiate infected from uninfected fluid in over 90% of ascitic patients." }, { "id": "pubmed23n0132_9159", "title": "The diagnosis of bacterial peritonitis: comparison of pH, lactate concentration and leukocyte count.", "score": 0.009174311926605505, "content": "It has been suggested that the hydrogen ion and lactate concentrations may be superior to the polymorphonuclear cell count (PMN) in ascitic fluid, in the diagnosis of bacterial peritonitis (BP). In order to compare the diagnostic accuracy of ascitic fluid measurements of pH, lactate, glucose and the PMN in BP, we analyzed the ascitic fluids of 70 consecutive patients in whom pH, lactate, glucose and the PMN count were measured in ascitic fluid and arterial blood. Fifty-one were cirrhotic patients with uninfected ascites, 14 had BP, one tuberculous peritonitis, two ascites secondary to peritoneal metastases and two with neoplastic liver involvement but without peritoneal metastases. Statistically, highly significant differences between patients with uninfected ascitic fluid and BP were observed for ascitic fluid PMN (122 vs. 2,686 per cu mm), ascitic fluid pH (7.45 vs. 7.24), arterial-ascitic fluid pH gradient (0.02 vs. 0.22), arterial lactate (12 vs. 25 mg per dl), ascitic fluid lactate (15 vs. 45 mg per dl) and arterial-ascitic fluid lactate gradient (-3 vs. -20 mg per dl). The most reliable diagnostic cutoff levels were determined for each of the parameters: PMN greater than 500 per cu mm; ascitic fluid pH less than 7.35; arterial-ascitic fluid pH gradient greater than 0.10; ascitic fluid lactate greater than 25 mg per dl; arterial-ascitic fluid lactate gradient less than -20 mg per dl; ascitic fluid glucose less than 60 mg per dl; arterial-ascitic fluid glucose gradient greater than 60 mg per dl.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en015_101884", "title": "Pleural effusion", "score": 0.009102831134768187, "content": "The sensitivity and specificity of Light's criteria for detection of exudates have been measured in many studies and are usually reported to be around 98% and 80%, respectively. This means that although Light's criteria are relatively accurate, twenty percent of patients that are identified by Light's criteria as having exudative pleural effusions actually have transudative pleural effusions. Therefore, if a patient identified by Light's criteria as having an exudative pleural effusion appears clinically to have a condition that usually produces transudative effusions, additional testing is needed. In such cases, albumin levels in blood and pleural fluid are measured. If the difference between the albumin level in the blood and the pleural fluid is greater than 1.2 g/dL (12 g/L), this suggests that the patient has a transudative pleural effusion. However, pleural fluid testing is not perfect, and the final decision about whether a fluid is a transudate or an exudate is based not on" }, { "id": "pubmed23n0205_8444", "title": "[Diagnostic value of laboratory examination of ascites fluid (author's transl)].", "score": 0.00909090909090909, "content": "Measurement of lactate dehydrogenase (LDH), glucose and protein was performed in ascites fluid of 44 patients in addition to bacteriological and cytological examinations. In patients with cirrhosis of the liver protein content of ascites was low, LDH normal, and the ascites/serum ratio of glucose concentration was higher than 1. These values were statistically significant different from the values in patients with tumorous or inflammatory disease of the peritoneum - protein and LDH in the ascites fluid being high and the ascites/serum ratio of glucose concentration being below 1. Cirrhosis however and tumors of the liver could not be differentiated by this method. Ascites from patients with cardiac failure had high protein content. In patients with liver cirrhosis high concentrations of protein in ascitic fluid may mean possibly a better survival time." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 61 ] ], "word_ranges": [ [ 0, 12 ] ], "text": "The rest are not indications. The target BP is < 130/85 mmHg." }, "2": { "exist": true, "char_ranges": [ [ 0, 29 ] ], "word_ranges": [ [ 0, 5 ] ], "text": "The rest are not indications." }, "3": { "exist": true, "char_ranges": [ [ 0, 29 ] ], "word_ranges": [ [ 0, 5 ] ], "text": "The rest are not indications." }, "4": { "exist": true, "char_ranges": [ [ 0, 29 ] ], "word_ranges": [ [ 0, 5 ] ], "text": "The rest are not indications." }, "5": { "exist": true, "char_ranges": [ [ 0, 29 ] ], "word_ranges": [ [ 0, 5 ] ], "text": "The rest are not indications." } }

{ "1": "Maintain blood pressure below 110/70 mmHg.", "2": "Smoking cessation.", "3": "Maintain a body mass index (BMI) less than 21.", "4": "Perform daily basal capillary glycemia.", "5": "Avoidance of animal fats in the diet." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en416_22144", "title": "Diabetes", "score": 0.014189886480908152, "content": "Glycated hemoglobin is better than fasting glucose for determining risks of cardiovascular disease and death from any cause. Prevention There is no known preventive measure for type 1 diabetes. Type 2 diabetes—which accounts for 85–90% of all cases worldwide—can often be prevented or delayed by maintaining a normal body weight, engaging in physical activity, and eating a healthy diet. Higher levels of physical activity (more than 90 minutes per day) reduce the risk of diabetes by 28%. Dietary changes known to be effective in helping to prevent diabetes include maintaining a diet rich in whole grains and fiber, and choosing good fats, such as the polyunsaturated fats found in nuts, vegetable oils, and fish. Limiting sugary beverages and eating less red meat and other sources of saturated fat can also help prevent diabetes. Tobacco smoking is also associated with an increased risk of diabetes and its complications, so smoking cessation can be an important preventive measure as well." }, { "id": "pubmed23n0537_1924", "title": "[Diet therapy in non-insulin dependent diabetes mellitus (NIDDM)].", "score": 0.0140625, "content": "The main approach in NIDDM therapy is diet. Most patients present insulin resistance characterized by overweight, VLDL increase, minimal increase of LDL, decrease of HDL cholesterol, and hypertension. The overall goals of nutrition therapy are the maintenance of near normal glucose levels, and the achievement of optimal serum lipid levels with adequate calories for maintaining or attaining a reasonable body weight. In presence of obesity and hypertension even a slightly weight loss could achieve an improvement in metabolic control and in hypertension with a better life expectance. General-ly carbohydrate intake would represent the 50-60% of total caloric amount (with preference to those with low glycemic index), and lipids no more than 35% (less than 10% of these 10-15% from monounsaturated fats with less than 300 mg/day of cholesterol). If elevated very low density lipoproteins level is the primary problem, a beneficial approach is 10% of total caloric intake from saturated fats, 10% from polyunsaturated, and 15-20% from monounsaturated fats with less than 200 mg/day of cholesterol and 40% of carbohydrates. A large amount of fructose (20% of calories) may increase LDL levels but sweeteners as saccarine or aspartame are approved and determine a better diet compliance. Daily consumpion of 20-35 g of dietary fibres from food sources is recommended for metabolic control. Protein intake would be of about 10% of total caloric amount especially in presence of diabetic nepropathy. Alcohol would not exceed 30 g/day for men and 20 g/day for women keeping in mild that alcohol may worsen metabolic control, diet compliance, and may be dangerous itself. For people with hypertension a decrease of dietary sodium intake is recommended. Nutritional recommendations are developed to meet treatment goals and desired outcomes. Monitoring metabolic parameters, blood pressure, and body weight is very important to ensure successful outcomes." }, { "id": "wiki20220301en180_32367", "title": "Prediabetes", "score": 0.01236736943640623, "content": "Management There is evidence that prediabetes is a curable disease state. Although some drugs can delay the onset of diabetes, lifestyle modifications play a greater role in the prevention of diabetes. Intensive weight loss and lifestyle intervention, if sustained, may improve glucose tolerance substantially and prevent progression from IGT to type 2 diabetes. The Diabetes Prevention Program (DPP) study found a 16% reduction in diabetes risk for every kilogram of weight loss. Reducing weight by 7% through a low-fat diet and performing 150 minutes of exercise a week is the goal. The ADA guidelines recommend modest weight loss (5–10% body weight), moderate-intensity exercise (30 minutes daily), and smoking cessation. There are many dietary approaches that can reduce the risk of progression to diabetes. Most involve the reduction of added sugars and fats but there remains a lack of conclusive evidence proving the best approach." }, { "id": "InternalMed_Harrison_28057", "title": "InternalMed_Harrison", "score": 0.010769369126309635, "content": "Based on the guidelines provided by the ADA, priorities in the treatment of dyslipidemia are as follows: (1) lower the LDL cholesterol, (2) raise the HDL cholesterol, and (3) decrease the triglycerides. A treatment strategy depends on the pattern of lipoprotein abnormalities. Initial therapy for all forms of dyslipidemia should include dietary changes, as well as the same lifestyle modifications recommended in the nondiabetic population (smoking cessation, blood pressure control, weight loss, increased physical activity). The dietary recommendations for individuals with DM include increased monounsaturated fat and carbohydrates and reduced saturated fats and cholesterol (Chap. 421). According to guidelines of the ADA, the target lipid values in diabetic individuals (age >40 years) without CVD should be as follows: LDL <2.6 mmol/L (100 mg/dL); HDL >1 mmol/L (40 mg/ dL) in men and >13 mmol/L (50 mg/dL) in women; and triglycerides <1.7 mmol/L (150 mg/dL). In patients >40 years, the ADA" }, { "id": "pubmed23n0301_12473", "title": "[Guidelines on treatment of hypertension in the elderly, 1995--a tentative plan for comprehensive research projects on aging and health-- Members of the Research Group for \"Guidelines on Treatment of Hypertension in the Elderly\", Comprehensive Research Projects on Aging and Health, the Ministry of Health and Welfare of Japan].", "score": 0.009900990099009901, "content": "We propose the following guidelines for treatment of hypertension in the elderly. 1. Indications for Treatment. 1) Age: Lifestyle modification is recommended for patients aged 85 years and older. Antihypertensive therapy should be limited to patients in whom the merit of the treatment is obvious. 2) Blood pressure: Systolic BP &gt; 160 mmHg, diastolic BP &gt; 90 approximately 10 mmHg. Systolic BP &lt; age + 100 mmHg for those aged 70 years and older. Patients with mild hypertension (140-160/ 90-95 mmHg) associated with cardiovascular disease should be considered for antihypertensive drug therapy. 2. Goal of Therapy for BP: The goal BP in elderly patients is higher than that in younger patients (BP reduction of 10-20 mmHg for systolic BP and 5-10 mmHg for diastolic BP). In general, 140-160/&lt; 90 mmHg is recommended as the goal. However, lowering the BP below 150/85 should be done with caution. 3. Rate of Lowering BP: Start with half the usual dose, observe at the same dose for at least four weeks, and reach the target BP over two months. Increasing the dose of antihypertensive drugs should be done very slowly. 4. Lifestyle Modification: 1) Dietary modification: (1) Reduction of sodium intake is highly effective in elderly patients due to their high salt-sensitivity. NaCl intake of less than 10 g/day is recommended. Serum Na+ should be occasionally measured. (2) Potassium supplementation is recommended, but with caution in patients with renal insufficiency. (3) Sufficient intake of calcium and magnesium is recommended. (4) Reduce saturated fatty acids. Intake of fish is recommended. (2) Regular physical activity: Recommended exercise for patients aged 60 years and older: peak heart rate 110/minute, for 30-40 minutes a day, 3-5 days a week. (3) Weight reduction. (4) Moderation of alcohol intake, smoking cessation. 5. Pharmacologic Treatment: 1) Initial drug therapy. First choice: Long-acting (once or twice a day) Ca antagonists or ACE inhibitors. Second choice: Thiazide diuretics (combined with potassium-sparing diuretic). 2) Combination therapy. (1) For patients without complications, either of the following is recommended. i) Ca antagoinst + ACE inhibitor, ii) ACE inhibitor + Ca antagonist (or low-dose diuretics), iii) diuretic + Ca antagonist (or ACE inhibitor), iv) beta-blockers, alpha 1-blockers, alpha + beta blockers can be used according to the patho-physiological state of the patient. (2) For patients with complications. Drug(s) should be selected according to each complication. 3) Relatively contraindicated drugs. beta-Blockers and alpha 1-blockers are relatively contraindicated in elderly patients with hypertension in Japan. Centrally acting agents such as reserpine, methyldopa and clonidine are also relatively contraindicated beta-Blockers are contraindicated in patients with congestive heart failure, arteriosclerosis obliterans, chronic obstructive pulmonary disease, diabetes mellitus (or glucose intolerance), or bradycardia. These conditions are often present in elderly subjects. Elderly subjects are susceptible to alpha 1-blocker-induced orthostatic hypotension, since their baroreceptor reflex is diminished. Orthostatic hypotension may cause falls and bone fractures in the elderly." }, { "id": "pubmed23n0536_22451", "title": "[Comparison of dietary intake of type I diabetic patients and nutritional recommendations].", "score": 0.009900990099009901, "content": "The management of type I diabetes mellitus requires a careful balance between nutrient intake, energy expenditure and dose and timing of insulin. According to the recommendations of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) the calories should be prescribed according to energy needs to achieve and maintain a desirable body weight. Many studies have shown that diets in which carbohydrates provide 50-60% of total energy are associated with improved blood glucose control and lower levels of LDL cholesterol. Whenever acceptable to the patients, natural foods containing unrefined carbohydrate should be substituted for the highly refined carbohydrates that are low in fiber. The high risk of macrovascular disease in patients with diabetes dictates a need to restrict total fat (25-30% of total energy) and cholesterol intake (300 mg/day). ADA and EASD suggest that reduction of protein intake (0.8 g/kg/day) may reduce proteinuria and progression to renal failure during the earliest stages of diabetic nephropathy. The goal of this study was to describe macronutrient intakes in type I diabetic patients of our Centre by a validated 3 day record. Mean energy intake was 2022+/-427 Kcal/die (vs 2596+/-501 recommended intake). Average protein intake was well above the level of 0.8 g/kg/day required to ensure an adequate protein intake in type I diabetes mellitus. Total fats contributed 29.8+/-7.4 of total energy (vs 27% recommended intake) and saturated fat provided significantly more than 10% of energy. Carbohydrates intake was above 50% of total energy but fiber intakes was substantially lower than the recommendation (12.7+/-5.5 vs 20.1+/-6.6 g/day). These data indicate current problems in the nutritional intake of type I diabetes mellitus; in fact the majority of our group of patients are not meeting the recommended dietary intakes for protein, total fat, saturated fat and fiber." }, { "id": "pubmed23n0420_21438", "title": "[Type 2 diabetes in the middle aged. Strict goals from the very beginning!].", "score": 0.00980392156862745, "content": "Type 2 diabetes mellitus in the middle-aged, that is the onset of diabetes before the age of 65, accounts for fifty percent of all diabetic patients. Because of their relatively long life expectancy, this age group carries a particular risk of experiencing microvascular and macrovascular sequelae. In view of this, the following therapeutic objectives must be strictly applied: near-normalization of blood glucose, HbA1c (&lt; 7.0%), blood pressure (&lt; 140/90 mmHg), LDL cholesterol (&lt; 130/100 mg/dl). Permanent weight reduction in the initial phase may delay disease progression for years. Guidelines issued by the German Diabetes Association require that middle-aged type 2 diabetics should receive 20-24 hours of structured instruction in closed groups, since the brief information provided by the doctor's assistant is inadequate in this age group." }, { "id": "pubmed23n0507_6066", "title": "NIDDM: new once-daily intervention for type 2 diabetes mellitus: Diaprel MR.", "score": 0.009791370317686107, "content": "Pharmacological treatment of hyperglycemia should address to both abnormalities in T2DM treatment, that is reduction of insulin resistance and restoration of normal insulin secretion. Gliclazide is a sulfonylurea compound oral hypoglycemic drug that has a unique feature of restoring the first-phase insulin secretion, which is lost in T2DM being one of the early features of disease. Laboratoires Servier conducted in Romania a an open non randomized surveillance on the efficacy and safety of Diaprel MR in type 2 diabetic patients. 199 patients in 14 treatment centers were enrolled. Eligibility criteria were as it follows: men and women with diabetes, previously on diet alone and not treated with other OAD, over 35 years old with FPG (mg/dl) at enrollment between 126 and 180. The clinical trial lasted for 16 weeks. During this period the doctors examined the patients 6 times. First visits were at a 2 weeks interval and the last two visits at a 4 weeks interval. At each visit the doctor renewed the prescription for the subsequent period according to the following protocol: the starting dose was 30 mg Diaprel MR/day, if the FPG (mg/dl) was over 140 (at the next visit) the dosage was increased with 30 mg Diaprel MR/day, if the FPG (mg/dl) was under 140 the dosage remained the same as the previous dosage. The maximum dosage was 120 mg Diaprel MR/day. The following parameters were measured on first and last (seventh) visit: blood pressure (systolic and diastolic), heart rate (bpm), body mass index-BMI (kg/m2), fasting plasma glucose FPG (mg/dl and mmol/l), glycated hemoglobin HbA1c (%) and Hb-Hct (mg/dl-%), creatinine (mg/dl), SGPT (UI/I), cholesterol (mg/dl) and triglycerides (mg/dl). Blood pressure (systolic and diastolic), heart rate, BMI and FPG were measured from the second to sixth visit also. On each visit there was registered other data such as: associated illnesses, concomitant medication and adverse events. Primary end points. The average values of end points HbA1c (%) and PFG (mg/dl) registered a significant decrease during the 16 weeks of medication, from the enrollment moment (S0) to the last week (S16). The decrease was significant on the total sample of the main analysis group but also on subsamples of age, gender and BMI. HbA1c (%) average values decreased in the main analysis group (S16 compared to S0): with 22% on the total sample (from 7.7 to 6.0); p &lt; 0.05. FPG (mg/dl) average values decreased in the main analysis group (S16 compared to S0): with 21% on the total sample (from 159 to 126); p &lt; 0.05. Secondary end points. There were no significant changes registered in the average level of cholesterol and triglycerides, BMI, diastolic blood pressure, heart rate, creatinine, SGPT. A significant decline of the average systolic blood pressure was registered. Diaprel MR can be used safely in diabetic patients newly diagnosed, uncontrolled on diet or other oral antidiabetic drugs, overweight, safely in those with cardio-vascular disease, or in patients with creatinine clearance 50-80 ml/min." }, { "id": "pubmed23n0355_11939", "title": "Prevention of coronary heart disease. Part I. Primary prevention.", "score": 0.009708737864077669, "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": "pubmed23n0095_2375", "title": "The dietary treatment of diabetes mellitus.", "score": 0.009708737864077669, "content": "The most important dietary goal for individuals with type I diabetes mellitus is the establishment of a regular meal pattern with consistent day-to-day caloric and carbohydrate intake. Ideally, the diet should contain 55 to 60 per cent of total calories as carbohydrate, less than 30 per cent of calories as fat, less than 10 per cent of calories as saturated fat, and less than 300 mg of cholesterol per day. The best tool for helping type I individuals achieve these objectives is the Exchange Lists for Meal Planning. A second important dietary goal in type I diabetes is to avoid weight gain during intensive treatment programs. The most important dietary and therapeutic goal in obese persons with type II diabetes is weight loss. Unfortunately, no dietary method, whether initiated by self-help groups like TOPS, physicians, or other health care professionals, has been demonstrated to be effective in achieving and maintaining weight loss. Nevertheless, some individual patients will be successful, and it therefore is appropriate to attempt weight reduction with a balanced diet moderately restricted in calories. A reduction of 500 calories per day below the weight maintenance level is reasonable and can be expected to produce weight loss of about 1 lb per week. For those type II diabetic patients who are not able to lose weight and are at least twice their ideal body weight, gastric reduction surgery could be considered. The Glycemic Index of Foods is a new concept that has not been evaluated adequately. Recent evidence suggests that differences among foods are reduced when the foods are combined in a meal and thus raises questions about the utility of glycemic indexing. The longstanding restriction on the use of sucrose in the diabetic diet is without scientific basis. Recognizing this, the American Diabetes Association recently sanctioned consumption of modest amounts of sucrose in the diabetic diet. Although conclusive evidence is not yet available that high fiber diets improve glycemic control or reduce serum lipids in diabetic persons, it appears reasonable to encourage the consumption of natural foods high in soluble fiber. Vegetables (particularly legumes), oats, and many fruits are good sources. The American Diabetes Association recommends a goal of 40 g of soluble fiber intake per day. The dietary treatment of diabetes is likely to be more successful if physicians learn more about its essential features and pay it greater attention. The goals of dietary therapy are difficult to achieve and often require significant sacrifices.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n1075_8297", "title": "Clinical and Anthropometric Improvements with a Tailored Dietary Approach in Pediatric Crohn's Disease.", "score": 0.009615384615384616, "content": "Pediatric Crohn's disease (CD) is more common today than in prior decades. Therapeutic goals in children with CD are to reduce symptomatology, promote normal growth, and avoid nutritional deficiencies. Diet plays a crucial role in the treatment of CD. However, there is a lack of comprehensive guidelines and individualized dietary approaches. A 12-and-a-half-year-old boy presented with chronic diarrhea, intermittent fever, abdominal pain, and a history of eczema. At the first visit, his body mass index (BMI) was 14.4, and his BMI-for-age was in the 1st percentile, classifying him as underweight. He received the diagnosis of Crohn's ileocolitis and gastritis and was unresponsive to treatment for 10.5 months. The patient was placed on a tailored dietary approach based on the in vitro leukocyte activation assay-MRT (LAA-MRT®), known as the Lifestyle Eating and Performance (LEAP) program. The LEAP program is an elimination diet built on the selection of less-immune-reactive foods and chemicals identified by the LAA-MRT® results. After 39 days of following the LEAP program, his fecal calprotectin levels decreased from &gt;2000 μg/g to 185.9 μg/g. A repeat esophagogastroduodenoscopy (EGD) and colonoscopy with 10 biopsies showed complete histologic remission 1 year after beginning diet therapy. At that point, the patient discontinued his pharmacologic therapy and maintained clinical remission of CD after more than 3 years of follow-up. In addition, his anthropometric measurements and laboratory biomarkers were normalized. This case presents evidence supporting the use of the LEAP program in clinical practice as an adjunctive, tailored dietary option to manage pediatric CD." }, { "id": "pubmed23n0257_15574", "title": "[Six-year follow up on recently diagnosed NIDDM patients].", "score": 0.009615384615384616, "content": "The six-year prospective data on 100 newly detected NIDDM patients aged 40-69 years were analysed. After careful and controlled dietetic training, the carbohydrate metabolism parameters (glycohaemoglobin, mean blood sugar level and glycosuria), the physical status, fundus picture and laboratory data (lipids and renal function) were examined yearly and the alterations of the treatment were registered. 24 patients dropped out during six years. 10 patients died. The carbohydrate status was also favourable and a moderate weight reduction was reached. After two years 59% of the patients proved well controlled. At the end of six years 41% of the patients were still well controlled merely by dietary means. The data were compared with those on 100 similarly detected new NIDDM patients whose education and control were provided by family physicians. There were non essential differences between the two groups in specific complications, BMI and lipids. The level of carbohydrate metabolism control was significantly better in the diabetic clinic-controlled patients; the proportion of sulfanylurea-treated patients was only 40.5% after six years compared with 73% among family physicians-controlled patients. The importance of a correct and controlled diet, good education and continuous control is emphasized." }, { "id": "wiki20220301en477_24824", "title": "Management of hypertension", "score": 0.009523809523809525, "content": "Hypertension is managed using lifestyle modification and antihypertensive medications. Hypertension is usually treated to achieve a blood pressure of below 140/90 mmHg to 160/100 mmHg. According to one 2003 review, reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34% and of ischaemic heart disease by 21% and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease. Blood pressure target For most people, recommendations are to reduce blood pressure to less than or equal to somewhere between 140/90 mmHg and 160/100 mmHg. In general, for people with elevated blood pressure, attempting to achieve lower levels of blood pressure than the recommended 140/90 mmHg will create more harm than benefits, in particular for older people. In those with diabetes or kidney disease, some recommend levels below 120/80 mmHg; however, evidence does not support these lower levels." }, { "id": "pubmed23n0305_8304", "title": "Reduction in body weight helps to delay the onset of diabetes even in non-obese with strong family history of the disease.", "score": 0.009523809523809525, "content": "Of the 1200 non-diabetic offspring of non-insulin-dependent diabetic patients registered under the prevention programme, 262 (M:F 189:73) were available for analysis with greater than or equal to 4 years of follow-up. All of them had been prescribed a calorie restricted diet to suit their body weight, occupation and age, and were advised to restrict the use of refined carbohydrates and fats. Regular exercise was also advised. Compliance with these prescriptions was assessed at each follow up. At the time of analysis, it was noted that only 14.5% had developed diabetes in a period of 8 +/- 4.2 years even though many of them had impaired glucose tolerance at entry in the programme. Multiple regression analysis showed that initial 2 h plasma glucose, initial glucose tolerance and gain in body weight were strong predictors of diabetes. Weight loss occurred in persons who adhered to diet and exercise programmes and conversion to diabetes was lower in them compared to those who gained weight (P &lt; 0.002). Although the rate and degree of obesity is less among Indians, it has been observed in several earlier studies that even a minor increase in body mass index increased the risk of diabetes. This study highlights the fact that measures to control weight helps to delay the onset of diabetes even in the non-obese despite a strong family history of the disorder." }, { "id": "wiki20220301en170_30310", "title": "Anterior cerebral artery syndrome", "score": 0.009433962264150943, "content": "Management Pulse oximetry can guide the use of supplemental oxygen to maintain oxygen saturation greater than 94%. Hyperoxia should be avoided as may be detrimental in stroke. Hypertension is common in an acute ischemic stroke. A low BP is uncommon and may indicate symptoms exacerbation of a previous stroke due to poor perfusion. Blood pressure of 220/120 mmHg should receive treatment. There is a consensus approach of allowing permissive hypertension up to 220/120 mmHg for patients that are not candidates for thrombolysis.[21] However, for a patient that is a potential candidate for alteplase, attempt to control BP should be made immediately as goal BP for initiation of IV alteplase is 185/110 mmHg. Usually, titratable short-acting intravenous hypotensive agents are recommended to avoid dropping the BP too much once the patient is at goal. Hypotensive agents that can be options include labetalol, nicardipine, clevidipine, hydralazine, enalaprilat.[21]" }, { "id": "pubmed23n0224_14305", "title": "[Long-term results (5-year minimum) of the diet treatment of adult obesity. Elements of weight prognosis. Apropos of 138 patients].", "score": 0.009433962264150943, "content": "One hundred and thirty-eight out of 250 obese patients admitted to hospitals between 1972 and 1976 for dietetic treatment comprising 1,000 calories and 100 g carbohydrates were recontacted with a minimum follow-up of 5 years. Seventy-five patients refused to answer the questionnaire or attend an outpatient appointment. Four patients were later excluded from the study. Finally, fifty-nine patients were reassessed. The percentage of good results at 5 years (defined as greater than or equal to 5 p. 100 loss of initial body weight) was 45.5 p. 100 of those reassessed, a minimum of 20 p. 100 of the total number recontacted. The course of obesity was not linear. During the follow-up period there were 45.5 p. 100 of secondary failures (regain of initial body weight after having lost at least 5 p. 100), but also 17 p. 100 of secondary successes. The prognosis was not related to the age of onset of obesity, its duration, sex, occupation, alleged trigger factors, apparent motivation, duration of hospital admission, or treatment before or after hospitalisation. The prognosis was better in patients under 30 or over 50 years of age at the time of treatment (P less than 0.01) and when the body weight had not varied +/- 5 kg in the years preceding treatment (P less than 0.01). The following factors may also play a favourable role (but not statistically significant): the degree of obesity (better results in major obesity greater than or equal to 50 p. 100 overweight), a positive family history, the detection of a physical factor (glucose intolerance) during investigation, and the repetition of medical check-ups after initial counselling." }, { "id": "pubmed23n0661_7252", "title": "The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy.", "score": 0.009345794392523364, "content": "To update the evidence-based recommendations for the prevention and treatment of hypertension in adults for 2010. For lifestyle and pharmacological interventions, randomized trials and systematic reviews of trials were preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the general lack of long-term morbidity and mortality data in this field. Progressive renal impairment was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease. A Cochrane Collaboration librarian conducted an independent MEDLINE search from 2008 to August 2009 to update the 2009 recommendations. To identify additional studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence. For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to 1500 mg (65 mmol) per day in adults 50 years of age or younger, to 1300 mg (57 mmol) per day in adults 51 to 70 years of age, and to 1200 mg (52 mmol) per day in adults older than 70 years of age; perform 30 min to 60 min of moderate aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week for men or nine standard drinks per week for women; follow a diet that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, and that is low in saturated fat and cholesterol; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in patients with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, considerations for initial therapy should include thiazide diuretics, angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of ACE inhibitors and ARBs should not be used, unless compelling indications are present to suggest consideration of dual therapy. Agents appropriate for first-line therapy for isolated systolic hypertension include thiazide diuretics, long-acting dihydropyridine CCBs or ARBs. In patients with coronary artery disease, ACE inhibitors, ARBs or betablockers are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. In selected high-risk patients in whom combination therapy is being considered, an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide diuretic. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian lipid treatment guidelines. Selected patients with hypertension who do not achieve thresholds for statin therapy, but who are otherwise at high risk for cardiovascular events, should nonetheless receive statin therapy. Once blood pressure is controlled, low-dose acetylsalicylic acid therapy should be considered. All recommendations were graded according to the strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 80% consensus. These guidelines will continue to be updated annually. The Canadian Hypertension Education Program process is sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the College of Family Physicians of Canada, the Canadian Pharmacists Association, the Canadian Council of Cardiovascular Nurses, and the Heart and Stroke Foundation of Canada." }, { "id": "pubmed23n0129_15393", "title": "[Liberalized diabetic diet for type I diabetics under intensive insulin injection therapy. Follow-up observations for over 2 years].", "score": 0.009345794392523364, "content": "The dietary habits and metabolic status of 14 selected ambulant type-1 diabetics, who were previously treated with conventional insulin therapy, were investigated over a period of 2 years under intensified insulin injection therapy. In this, multiple doses of regular insulin in combination with intermediate-acting insulin were injected daily and the regular metabolic controls as well as adjustment of the insulin dosage were undertaken by the patients themselves. Whereas conventional insulin therapy made exclusive use of intermediate-acting insulin, 41% of the daily dose in the intensified insulin injection therapy was regular insulin. The total daily insulin dose of 51 +/- 12 U/d was therefore not significantly different from that in the conventional insulin therapy (49 +/- 10 U/d). During the intensified insulin injection therapy the usual diabetic diet was relaxed in several aspects: neither the daily intake of fat, protein and calories, nor substitution in the diet using exchange lists was specified. Despite this liberalization HbA1c values decreased significantly from 9.3 +/- 1.2% to 7.8 +/- 0.7% (P less than 0.05) and blood lipids remained in the normal range. The results of this retrospective investigation lead to the conclusion that despite some measure of diet liberalization, selected, trained, type-1 diabetics of normal body weight and without primary dyslipoproteinaemia can attain good metabolic control under intensified insulin injection therapy." }, { "id": "wiki20220301en380_24390", "title": "Health status of Asian Americans", "score": 0.009259259259259259, "content": "With the adaptation of American culture, immigrant populations can be seen to have increased risks of diseases as Western diets are being introduced into their daily food consumptions. However, there is a heightened risk of type 2 diabetes amongst Asian Americans as its presence makes up 21% of the Asian American population, twice as high as non-Hispanic whites. Due to various genetic and environmental factors, Asian Americans are more likely to develop type 2 diabetes than other racial and ethnic groups, even though their body mass index (BMI) tends to be lower. Asian Americans have a higher percentage of body fat for their BMIs which in turn elevates the risk of type 2 diabetes when BMI levels are lowered; they in fact may have a higher percentage of body fat which contributes to a greater risk of developing diabetes and other health concerns that are commonly overseen. Because of their BMIs, which are usually lower than other racial and ethnic groups, there is a common" }, { "id": "pubmed23n0102_10865", "title": "Dietary therapy in NIDDM.", "score": 0.009259259259259259, "content": "Clearly the dietary treatment of the NIDDM patient remains an act of faith bearing in mind the poor compliance of the patient to dietary advice, and the lack of long-term studies confirming the efficacy of diets (old or new) in the prevention of diabetic vascular complications. Few of the newer recommended diets seem to have been tested in the hurly-burly of the busy, understaffed diabetic clinic. Perhaps another major hurdle has been the attitude of patients and doctors in failing to regard diet therapy as a form of treatment, akin to tablets. The phrase 'I eat my diet, doctor, then I have my usual meal' sums up the problem. There needs to be a change in attitude to diet by both doctors and patients so that the dietary changes suggested should be eating habits which would become second nature to patients--the so called 'healthy eating'--more fibre, less refined carbohydrate, less total and saturated fat and more polyunsaturated fats. It seems difficult for a majority of NIDDM patients to add onto 'healthy eating' calorie restriction to achieve weight loss. This difficulty also applies to non-diabetic obese subjects with similar poor results. One cannot help but feel that NIDDM patients should benefit from the general change in attitude of the general population towards nutrition, but reinforced education concerning diet goals for NIDDM patients is an urgent requirement and needs closer examination by the diabetic health care team as to how it may be delivered to the individual NIDDM patients. Perhaps dietitians in particular should become more critical in their approach to diet strategies and should investigate and report on the results of this treatment." }, { "id": "pubmed23n0810_23470", "title": "Outcomes in weight loss, fasting blood glucose and glycosylated hemoglobin in a sample of 415 obese patients, included in the database of the European accreditation council for excellence centers for bariatric surgery with laparoscopic one anastomosis gastric bypass.", "score": 0.009174311926605505, "content": "Obesity is a risk factor for the development of diseases such as type 2 Diabetes Mellitus. Bariatric surgery with laparoscopic single anastomosis gastric bypass is an effective treatment for morbid obesity and diabetes type 2 complete remission, and it has been proven to generate an improvement in glycemic levels and glycosylated hemoglobin (HbA1c) keeping the weight loss for a long time. In a period of time between June 2002 until May 2012, 2070 patients underwent surgery with LOAGB technique. Between January 2010 an May 2012, 415 patients were included in the European Accreditation Council for Excellence Centers for Bariatric Surgery (EAC-BS) database, from which 79 patients with a glycemic level disturbance in the preoperative blood sample where chosen. Of this group, 47 patients were pre-diabetic (fast plasma glucose ≥ 110 mg/dl ≤ 125 mg/dl) and glycosylated hemoglobin (HbA1c) levels between 5.7-6.4% and 32 were diabetic (fast plasma glucose ≥ 126 mg/dl) and glycosylated hemoglobin (HbA1c) levels ≥ 6.5%. We described the weight evolution, the excess body mass index lost percentage (%EBMIL) the glycemia and the glycosylated hemoglobin levels; and we reported regular laboratory controls during the first year after surgical intervention. Both patient groups achieved their lowest mean weight loss 12 months after surgery, being average weight in the pre-diabetic group 62,41 ± 10,93 and 68,36 ± 11,16 in the diabetic group. Since 3 months after surgery, pre-diabetic patients achieve a mean BMI &lt; 30, according to the Spanish Society for Obesity Study (SEEDO 2007) this amount is outside of the definition of obesity. Not being the case of the diabetic patients who don´t achieve this result until 6 months after surgery. The weight loss was excellent in both study groups, achieving an excess body mass index loss percentage (% EBMIL) greater than 65%, since the first three-month postoperative control. Glycemia levels descend in both groups, achieving the pre-diabetic group a mean glycemia level of &lt; 110 mg/ dl in the second day after LOAGB surgery. Pre-diabetic patients maintain more stable glycemia with better controls, and very favorable outcomes 12 months after surgery. The diabetic patients achieve the mean glycemia level of &lt; 110 mg/dl at the first month after surgery and maintained it 12 months after surgery which is the time of this study. The glycosylated hemoglobin levels descended in both groups, achieving levels of 4% three months after surgery in the prediabetic group and 4.8% at six months in the diabetic group. LOAGB proved to be an efficient bariatric technique for complete remission of pre-diabetes and diabetes mellitus type 2 and also with the excess weight loss resolution. We showed that the excess weight loss, the glycemia and glycosylated hemoglobin levels continue being normal after one year of follow up after surgery. The best results are obtained in pre-diabetic patients who underwent LOAGB, this group is integrated with people who are at high risk of suffering a deterioration of their obesity and a rapid advance of the diabetes and the associated comorbidities, that's why surgery has to be performed as soon as possible when the medical exam continues being favorable." }, { "id": "pubmed23n0537_23021", "title": "[Identification of factors predicting early evolution of secondary oral hypoglycaemic agent failure and evaluation of clinical standards applied by primary care physicians during qualification to insulin therapy of patients with type 2 diabetes].", "score": 0.009174311926605505, "content": "Effective control of metabolic disturbances, in particular hyperglycaemia, hypertension and lipid abnormalities, is a prerequisite condition for clinically important reduction in the risk of death related to diabetes and its complications. It appears that type 2 diabetes is a progressive disease and hyperglycaemia aggravates with time. Secondary failure of oral hypoglycaemic agents is a common evolution of long-standing type 2 diabetes and placement on insulin is necessary when maximal sulfonylurea therapy is inadequate. This study was designed to identify factors predicting early hyperglycaemia progression and evolution of secondary oral hypoglycaemic agent (OHA) failure, estimate the prevalence of metabolic disturbances associated with type 2 diabetes and evaluate clinical practices of family physicians during qualification to insulin therapy. Medical records of 56 diabetic patients, 24 males and 32 females with a mean age of 65 years (42-91 yrs), were analyzed. Information about fasting plasma glucose and lipid levels, blood pressure, body mass, kidney status, coronary artery disease and other complications, and treatment were retrospectively extracted from patient charts. All patients were treated by their family physicians. The duration of the disease ranged from 1 to 18 years. All patients were started on insulin during the last three years. Metabolic abnormalities, especially hypertension, lipid abnormalities and obesity, were common findings in type 2 diabetes patients. Hypertension occurred in 77% of patients. Treatment of hypertension was generally not effective and only 16% of patients fulfilled recommendations of ADA. Lipid abnormalities were common. EDPG and ADA criteria were met by 30% and 18% of the patients, respectively. BMI lower than 25 kg/m2 was found in 23% of patients. A multiple regression model and analysis of proportional hazard regression according to Cox were used to identify factors independently associated with early progression of hyperglycaemia and early evolution of secondary OHA failure. It was found that high fasting glycaemia in the early phase of OHA treatment and history of hypertension prior to diabetes, in particular high diastolic pressure, were independent predictors of early progression of hyperglycaemia and necessity of adding insulin to the hypoglycaemic regimen. Hypertension prior to diabetes increased by more than twice the relative risk of exceeding 150 and 180 mg% for glycaemia and the risk of switching to insulin. Assessment of compliance with clinical recommendations by family physicians revealed a significant delay in qualification to insulin therapy. Treatment with OHA was continued in spite of clear signs of metabolic decompensation. On the average, OHA were continued for 4.5 years after fasting glycaemia exceeded 150 mg%. Insulin was added to the hypoglycaemic regimen when fasting glycaemia reached an average of 234 mg% and the maximal postprandial glycaemia reached 390 mg%. The present findings suggest that compliance with clinical recommendations in primary care as a measure to retard complications in patients with type 2 diabetes should be improved, especially with regard to control of hyperglycaemia, hypertension and dyslipidemia." }, { "id": "pubmed23n0478_16744", "title": "Sweeteners and beta-glucans improve metabolic and anthropometrics variables in well controlled type 2 diabetic patients.", "score": 0.00909090909090909, "content": "The introduction of fat and carbohydrates replacers has been a revolutionary advance in treating obesity and diabetes mellitus. Since these materials have shown to have beneficial effects on the metabolic profiles of diabetic patients, they should be useful in designing specific foods for patients with diabetes. To compare metabolic and anthropometric improvements elicited by a diet based on the American Diabetic Association's nutrition recommendations with a modified, low-energy diet incorporating fat replacers and non-sucrose sweeteners. A total of 16 male, well controlled type 2 diabetes patients were divided into two groups of eight; one group received the diet based on the American Diabetic Association's nutrition recommendations, and the other was fed a modified, low-calorie diet containing a fat replacer (beta-glucans derived from oats) and the sweeteners, sucralose and fructose. Both groups were maintained on their respective diets for 4 weeks. All patients performed daily aerobic exercise consisting of walking for 60 minutes. Body weight, body mass index, basal glycemia, hemoglobin HbA1C, and lipid profile were determined in each patient before starting the diets and after 4 weeks of dietary intervention. Both diets produced significant improvements in weight, body mass index, lipid profile, basal glucose, and HbA1C. However, the experimental diet was superior to the American Diabetic Association's diet in improving metabolic and anthropometric profile: greater increase in HDL cholesterol and larger decreases in HbA1C, weight, and body mass index. A diet incorporating a fat replacer and non-sucrose sweeteners produced a greater improvement in metabolic and anthropometric variables in well controlled type 2 diabetic patients when compared with a diet based on American Diabetic Association's nutrition recommendations." }, { "id": "pubmed23n0230_2302", "title": "Diet liberalization and metabolic control in type I diabetic outpatients treated by continuous subcutaneous insulin infusion.", "score": 0.00909090909090909, "content": "In 10 type I diabetic outpatients treated by continuous subcutaneous insulin infusion (CSII), dietary habits and metabolic control were investigated. Under conditions of a conventional diabetes diet (including 5-6 meals per day and a strictly planned meal intake) as well as under a \"less restricted diabetes diet\" (e.g., free choice of number, timing, and amount of carbohydrate intake) near normoglycemia could be achieved. Mean daily blood glucose levels did not change significantly when the patients' nutrition was alternated between both diets. During the \"less restricted diabetes diet,\" the patients opted for a rather high fat intake (51 +/- 5% fat, 34 +/- 5% carbohydrate, and 15 +/- 2% protein). Despite this unintended dietary behavior, serum lipids and body weight remained normal after an observation period of 4-6 mo. It is concluded that during permanent near normoglycemia achieved by CSII a partial liberalization of the diabetes diet does not introduce any short-term or long-term metabolic risk factors for cardiovascular diseases." }, { "id": "wiki20220301en204_12500", "title": "Liraglutide", "score": 0.009009009009009009, "content": "Liraglutide was approved for medical use in the European Union in 2009, and in the United States in 2010. In 2019, it was the 142nd most commonly prescribed medication in the United States, with more than 4million prescriptions. Medical uses Liraglutide is a medication used for the treatment of type 2 diabetes or obesity. Type 2 diabetes Liraglutide improves control of blood glucose. As of 2017 it is unclear if incretin mimetics like liraglutide affect a person's risk of death. In diabetes it is a less preferred agent. It may be used in those in who metformin and another antidiabetic medication such as a sulfonylurea are not sufficient. Obesity Liraglutide may also be used together with diet and exercise for chronic weight management in adult patients. The body mass index (BMI) needs to be greater than 30 kg/m2, or greater than 27 kg/m2 together with high blood pressure, type 2 diabetes mellitus, or dyslipidemia." }, { "id": "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": "pubmed23n0615_21440", "title": "[Arterial hypertension and dyslipidemia in patients with chronic kidney disease (CKD). Anti-platelet aggregation. Goal oriented treatment].", "score": 0.008928571428571428, "content": "TREATMENT OF ARTERIAL HYPERTENSION - Blood pressure (BP) should be regularly measured in all patients with CKD (Strength of Recommendation C). - BP control and proteinuria reduction delay progression of CKD (Strength of Recommendation A) and reduce cardiovascular risk (Strength of Recommendation C). Thus, control of both factors should be the treatment objective. - The BP target in patients with CKD should be &lt; 130/80 mmHg, and 125/75 mmHg if proteinuria is &gt; 1 g/24 hours (Strength of Recommendation A). - Lifestyle changes should be made: low-sodium diet (less than 100 mEq/day of sodium or 2.4 g/day of salt); weight reduction if patient is overweight (body mass index 20-25 kg/m2); regular aerobic physical exercise and moderate alcohol intake for BP control and prevention of cardiovascular risk (Strength of Recommendation A). - The choice of the antihypertensive drug in patients with CKD depends on the etiology of CKD, cardiovascular risk, or presence of clinical or subclinical cardiovascular disease (Strength of Recommendation A). - Two or more antihypertensive drugs are usually required to control blood pressure in patients with CKD (Strength of Recommendation B), and will frequently include a diuretic, which in stages 4-5 should be a loop diuretic (Strength of Recommendation B). - Renin-angiotensin-aldosterone system (RAAS) inhibitors are first choice drugs in patients with diabetic nephropathy, patients with non-diabetic nephropathy with a protein/creatinine ratio higher than 200 mg/g, and patients with heart failure (Strength of Recommendation A). The combination of ACEIs and ARBs is indicated for reducing proteinuria that remains high despite treatment with a RAAS inhibitor, provided potassium levels do not exceed 5.5 mEq/L (Strength of Recommendation B). - When RAAS blockers are started or their dose is changed in patients with advanced CKD, kidney function and serum potassium levels should be monitored at least after 1-2 weeks. DIAGNOSIS AND TREATMENT OF DYSLIPIDEMIA - A complete evaluation of the lipid profile including total cholesterol, LDL-C, HDL-C, and triglycerides should be performed in any patient with CKD at baseline and at least annually (Strength of Recommendation B). - In patients with stage 4-5 CKD and LDL-C &gt;or= 100 mg/dL, treatment to decrease levels to &lt; 100 mg/dL should be considered because of their high CV risk. This reduction is recommended in secondary prevention and in primary prevention in diabetic patients. Lipid-lowering treatment is recommended in all other patients, although no evidence showing its benefits is available yet (Strength of Recommendation C). - In patients with stage 4-5 CKD and triglyceride levels &gt;or= 500 mg/dL which are not corrected by treating the underlying cases, treatment with triglyceride-lowering drugs may be considered to reduce the risk of pancreatitis. However, treatment with fibrates should be used with caution, and these drugs should not be associated to statins due to the risk of rhabdomyolysis (Strength of Recommendation C). There is little experience on the efficacy and safety of omega-3 fatty acids for the treatment of hypertriglyceridemia in patients with grade 4-5 CRF, but they may be considered a possibly safer alternative to fibrates (Strength of Recommendation C). SMOKING - Smoking is a cardiovascular risk factor and a risk factor for progression of kidney disease in patients with CRF (Strength of Recommendation B). - Use of active measures to achieve smoking cessation is recommended in patients with CRF (Strength of Recommendation C). HOMOCYSTEINE - Hyperhomocysteinemia has been postulated as a cardiovascular risk factor in the general population and in kidney patients, but the available evidence is not consistent. - There is no evidence that vitamin therapy decreases cardiovascular risk in patients with CRF, and recommendation of routine vitamin measurement and start of vitamin therapy to reduce cardiovascular risk in these patients is therefore questionable (Strength of Recommendation B). LEFT VENTRICULAR HYPERTROPHY - Left ventricular hypertrophy (LVH) is a cardiovascular risk factor in patients with CRF (Strength of Recommendation B). - It is advisable to perform an echocardiogram at baseline and every 12-24 months and to consider treatments allowing for LVH regression (Strength of Recommendation C). The approach to LVH should be early and multifactorial because its reversibility is limited once established (Strength of Recommendation C). - RAAS blockade with ACEIs or ARBs partially reverts LVH in patients with CRF (Strength of Recommendation B). ANTI-PLATELET AGGREGATION - Because of the high cardiovascular risk in patients with CKD, anti-platelet aggregant therapy, especially low-dose aspirin, would be indicated in patients with type 2 diabetes as primary prevention, and in all patients with CKD as secondary prevention. There is however no evidence of the benefits of anti-platelet aggregant therapy in primary prevention in patients with CKD, particularly in stages 4-5; indication for treatment in this situation should therefore be individualised because of its greater risk of bleeding. - Adequate good blood pressure control should previously be achieved to minimise the risk of haemorrhagic stroke (Strength of Recommendation C)." }, { "id": "pubmed23n0556_8260", "title": "[Weight changes and the effect of anti-diabetes treatment in the first 5 years after diabetes diagnosis - secondary publication].", "score": 0.008928571428571428, "content": "We monitored changes in patients' weight during the first 5 years after diabetes diagnosis. Data were from 711 newly diagnosed diabetic patients aged 40 or over managed in general practice. Patients whose only treatment was advice on diet generally maintained an initial weight loss of 5-7 kg over the 5 years. Patients receiving metformin or sulfonylureas maintained an average weight loss of 2-4 kg depending on age and sex, while an acceptable average glycaemic control was achieved. The results indicate that weight reduction is a practicable treatment in diabetic patients." }, { "id": "pubmed23n0956_4804", "title": "Autism Spectrum Disorder and Mental Health Comorbidity Leading to Prolonged Inpatient Admission.", "score": 0.008849557522123894, "content": "Sam is a 6-year-old boy with a diagnosis of autism spectrum disorder (ASD) who recently relocated and has an appointment with you, his new pediatric clinician, to establish care. He was previously followed by a psychiatrist for 2 years for additional diagnoses of insomnia, bipolar disorder, anxiety, attention deficit hyperactivity disorder, and intellectual disability. He has tried and (apparently) failed multiple psychotropic trials including stimulants, nonstimulants, mood stabilizers, atypical antipsychotics, and nonbenzodiazepine hypnotics. He has a delayed sleep onset and frequent night awakenings each night for the past 3 months, during which he \"screams, cries, and thrashes and can stay up for over an hour.\" His behaviors are described as irritable, self-injurious, and aggressive with no clear pattern of triggers according to his mother. He is nonverbal and communicates by leading and rarely pointing. The patient's current medication regimen includes clonidine 0.2 mg at night, lorazepam 1.5 mg as needed at night, olanzapine 5 mg twice daily, and diphenhydramine as needed for sleep/agitation. His mother is concerned that he is developing \"tolerance\" to the regimen and wants to wean him off some of the medications. His mother is struggling to take care of the patient given his worsening behavior and body habitus (body mass index &gt;99%; z = 3.41).There is a family history of depression, anxiety, bipolar disorder, and autism. He has a 3-year-old sister, who is also diagnosed with ASD, though she is not as severely impacted. His mother's partner recently moved in along with 2 children of his own, aged 3 and 4 years. Sam attends a specialized school, where he receives behavior therapy and occupational therapy. He has undergone inpatient pediatric hospitalization twice, 1 time for 3 weeks and the other for 6 days, for aggressive behavior, and in both instances, he was discharged before inpatient psychiatric placement because of a lack of available beds.After urgent consultation with your local developmental and behavioral pediatrician, a slight reduction was made in the lorazepam because of concerns about tolerance and side effects. However, within a week of this, he was brought to the emergency department for continued self-injurious behavior and increased trouble with sleeping. His mother voiced concerns about his safety in the home, which were particularly related to aggression toward his younger sister. He was admitted to the pediatric inpatient floor for observation, and medication adjustment (increasing olanzapine), which was initially helpful in improving behavior, but mostly behavioral/environmental strategies were used to soothe him, including frequent wagon rides through the hospital corridors.Despite the patient being stable from the medical standpoint, Sam's mother did not feel comfortable taking him home. Social work contacted local community mental health services to pursue outpatient resources and respite care options and sought inpatient pediatric psychiatry. After several failed attempts to find placement, he remained in pediatric inpatient care for 1 and a half months with no acute medical interventions other than his oral medications.He was finally accepted to the in-state pediatric psychiatric facility when a bed was available. During his week-long stay, he had further medication adjustments with a decrease in olanzapine and optimization of his clonidine dose. During his psychiatric hospital stay, care coordination succeeded in arranging center-based applied behavior analysis interventions and respite care and parent training for his family. Sam began to show improvement in his overall agitation and aggression, requiring less clonazepam, and his mother then maintained outpatient follow-up.The day before discharge, you visit him in the hospital, and a medical student asks you why he was in the hospital for so long. How would you answer the question?" }, { "id": "pubmed23n0031_2557", "title": "[Behavior of the body weight in 2261 maturity-onset diabetics under conditions of ambulatory care].", "score": 0.008849557522123894, "content": "Of 2,261 maturity-onset-diabetics (970 males, 1,691 females) body weight, size and Broca-index were established at the beginning of the treatment, one year after the beginning of the treatment and at the date of analysis (x=5.7 years after the manifestation of diabetes). 72% of the females and 49% of the males had a Broca-index of more than 10 at the beginning of the treatment. The average loss of weight of the diabetics of adult type with overweight with a Broca-index of more than 5 was in the first year 7.6 kg in males and 5.2 kg in females. In the first year after beginning of the disease in the diet group and in the buformin group was achieved an average reduction of weight in males of about 7 kg and in females of about 6 kg. After the first year of treatment in the groups mentioned the body weight remained or rose to one kg. The patients treated with sulfonylureas--compared with the diet-biguanide group--showed in the first year of treatment, indeed, a loss of weight which was about 50% smaller, however, also in the following years (x=4.7) a further continuous reduction of weight could be recognized. The initial results and the late results in the treatment of elderly diabetics with overweight show that, compared with former years, partial success is to be achieved with reduction cures performed in outpatient departments. The importance of the reduction of weight in elderly diabetics for the improvement of the carbohydrate tolerance and the fat metabolism is emphasized." }, { "id": "pubmed23n0624_3065", "title": "Effects of aggressive approach to the multiple risk factors for diabetic nephro-pathy on proteinuria reduction in diabetes type 2 patients.", "score": 0.008771929824561403, "content": "Dietary interventions with protein and salt restriction, good glucose control, smoking cessation, aggressive blood pressure control, good control of cholesterol and triglycerides, use of ACE inhibitors and ARBs can delay the progression of diabetic nephropathy. The aim of this study was to present the effects of aggressive treatment of the multiple risk factors for diabetic nephropathy on proteinuria in patients with type 2 diabetes. In this study we included 15 patients with diabetes type 2 and insufficient regulation of glycaemia. The patients were followed for three months period. Glycated haemoglobin (HbA1c), fasting plasma glucose (FPG), postprandial plasma glucose (PPG), blood pressure, cholesterol and triglycerides and proteinuria were followed prior and after the study. Prior the study patients were treated with premix insulin divided in two daily doses + metformin after the lunch and they had insufficient regulation of glycaemia. During the study patients were treated with one daily dose of basal insulin, three doses of metformin (2550 mg), one daily dose of atorvastatin (20 mg) and one daily dose of ramipril (5 to 10 mg). Doses of insulin were titrated separately for each patients (0,7-1,0 IU/kg). Patients were advised to start with lifestyle modification, increased physical activity and dietary interventions with protein and salt restriction, energy restricted diet and smoking cessation. A total of 20 patients (male 12 and female 8) with diabetes type 2 were studied. The mean age of the subjects was 53+/-5,25 years. The mean diabetes duration was 4,05+/-1,96 years. The mean body mass index decreased from 28,1+/-1,67 kg/m2 to 25,9 +/-1,22 kg/m2 after the study. Mean HbA1c decreased from 8,82 +/- 0,53 % to 7,15 +/- 0,23 % (p&lt;0,05). Mean fasting glycemia decreased from 8,79+/-0,58 mmol/dm3 to 7,03+/-0,18 mmol/dm3 (p &lt; 0,05). Mean postmeal glycemia decreased from 9,93 +/- 0,77 mmol/dm3 to 7,62 +/- 0,42 mmol/dm3 (p&lt;0,05). The mean cholesterol level decreased from 7,99 +/-0,64 mmol/dm3 to 5,93 +/- 0,65 mmol/dm3 (p&lt;0,05). The mean triglicerides level decreased from 4,05 +/- 0,97 mmol/dm3 to 1,96 +/- 0,24 mmol/dm3 (p&lt;0,05). The significant decrease of proteinuria was recorded, prior the study the mean albuminuria was 1,05 +/- 0,31 g/dm3 and after the study was 0,07 +/- 0,145 g/dm3 (p&lt;0,05). Mean blood pressure prior the study was 153+/-8,69/91,5 +/- 3,78 mm Hg (p&lt;0,05), after the study was 125 +/- 6,32/ 79,25+/-3,26 mmHg. Effective control of glycaemia, blood pressure, cholesterol and triglycerides, use of ACE inhibitors, dietary interventions with protein and salt restriction, smoking cessation, can delay the progression of nephropathy in type 2 diabetes." }, { "id": "pubmed23n0125_2915", "title": "Natural history of diabetes presenting age 40-69 years: a prospective study of the influence of intensive dietary therapy.", "score": 0.008771929824561403, "content": "Two hundred and twenty-three newly-diagnosed symptomatic diabetic patients with onset age 40-69 years enrolled in a prospective study of intensive dietary management of diabetes were observed for a period of six years and the data obtained is analysed. The variables studied were weight and fasting levels of plasma glucose and insulin, and of serum total cholesterol and triglyceride. These tests were monitored throughout the study and in addition the oral glucose tolerance test was analysed at entry to the study, after six months intensive dietary management and again after 72 months. Blood pressure, electrocardiogram and the presence of posterior tibial artery pulsation were recorded at entry to the study and at 36 months and 72 months. Approximately 80 per cent of the patients were managed solely by dietary restriction for the entire six years, but 25 patients received oral hypoglycaemic drugs and 26 required insulin treatment. Weight, and fasting glucose and triglyceride values fell in the first few months of intensive dietary management. Analysis of possible risk factors in survivors and patients dead at six years showed no significant differences, apart from a higher mean age at diagnosis in those who died. During the six years of intensive dietary management the mortality from all causes in these diabetic patients was no greater than that for the general population of Northern Ireland." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 134, 293 ] ], "word_ranges": [ [ 25, 49 ] ], "text": "they specify that the patient presents gait instability, which is not justified by a Horner due to carotid dissection affecting the superior cervical ganglion," }, "4": { "exist": true, "char_ranges": [ [ 386, 472 ] ], "word_ranges": [ [ 69, 84 ] ], "text": "If the patient really has ataxia, the only possible location would be the spinal cord." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "III cranial pair.", "2": "Optic chiasm.", "3": "Superior cervical ganglion.", "4": "Spinal bulb.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0078_12406", "title": "[Bilateral internuclear ophthalmoplegia in association with basilar artery occlusive disease].", "score": 0.01951637471439452, "content": "A 56 year-old man presented with vertigo and the right sided weakness. Neurological examination revealed a lethargic man with good orientation to three spheres. His neck was supple. He had anisocoria, the right pupil being larger than the left by 1.5 mm with sluggish light reaction bilaterally. He had exotropia of the right eye in primary gaze. The abduction of both eyes were full with terminal horizontal nystagmus. The adduction of both eyes were quite limited in each eye. He had a limited upward gaze with poor convergence. These were interpreted as the syndrome of the medial longitudinal fasciculus (MLF) bilaterally. He had a depressed gag reflex on the right side with tongue deviation to the right. He had a mild weakness of the right side limb and also had the right sided hemihyperesthesia including his face to pain and temperature. Twenty four hours after the onset, the left brachial angiography revealed a complete occlusion of the rostral portion of the basilar artery without visualization of the posterior cerebral and superior cerebellar arteries bilaterally. CT scans three days after the onset revealed a low density area in the mid pons with extension rostrally up to the mesencephalon. Four days later he became quadriplegic with bilateral horizontal gaze palsy. No more internuclear ophthalmoplegia is noted on both sides. The midline location of the MLF in the pons, and the separate blood supplies by different paramedian branches of the basilar artery, form the anatomical explanation for the frequent unilaterality of vascular and bilaterality of demyelinating lesions. Bilateral MLF syndrome has been considered almost pathognomonic of multiple sclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0314_1466", "title": "[A 62-year-old man with an acute onset of consciousness disturbances].", "score": 0.016207349081364827, "content": "We report a 62-year-old man who developed coma and died in a fulminant course. The patient was well until May 1, 1996 when he noted chillness, tenderness in his shoulders, and he went to bed without having his lunch and dinner. In the early morning of May 2, his families found him unresponsive and snoring; he was brought into the ER of our hospital. He had histories of hypertension, gout, and hyperlipidemia since 42 years of the age. On admission, his blood pressure was 120/70, heart rate 102 and regular, and body temperature 36.3 degrees C. His respiration was regular and he was not cyanotic. Low pitch rhonchi was heard in his right lower lung field. Otherwise general physical examination was unremarkable. Neurologic examination revealed that he was somnolent and he was only able to respond to simple questions such as opening eyes and grasping the examiner's hand, but he was unable to respond verbally. The optic discs were flat; the right pupil was slightly larger than the left, but both reacted to light. He showed ptosis on the left side, conjugate deviation of eyes to the left, and right facial paresis. The oculocephalic response and the corneal reflex were present. His right extremities were paralyzed and did not respond to pain Deep tendon reflexes were exaggerated on the right side and the plantar response was extensor on the right. No meningeal signs were present. Laboratory examination revealed the following abnormalities; WBC 18,400/ml, GOT 131 IU/l GPT 50 IU/l, CK616 IU/l, BUN 30 mg/dl, Cr 2.1 mg/ dl, glucose 339 mg/dl, and CRP 27.4 mg/dl. ECG showed sinus tachycardia and ST elevation in II, III and a VF leads and abnormal q waves in I, V5, and V6 leads. Chest X-ray revealed cardiac enlargement but the lung fields were clear. Cranial CT scan revealed low density areas in the left middle cerebral and left posterior cerebral artery territories. The patient was treated with intravenous glycerol infusion and other supportive measures. At 2: 10 AM on May 3, he developed sudden hypotension and cardiopulmonary arrest. He was pronounced dead at 3:45 AM. The patient was discussed in a neurological CPC, and the chief discussant arrived at the conclusion that the patient had acute myocardial infarction involving the inferior and the true posterior walls and left internal carotid embolism from a mural thrombus. Post mortem examination revealed occlusion of the circumflex branch of the left coronary artery due to atherom plaque rupture and myocardial infarction involving the posterior and the lateral wall with a rupture in the postero-lateral wall. Marked atheromatous changes were seen in the left internal carotid, the middle cerebral and the basilar arteries; the left internal carotid and the middle cerebral arteries were almost occluded by thrombi and blood coagulate. The territories of the left middle cerebral and the occipital arteries were infarcted; but the left thalamic area was spared. The neuropathologist concluded that the infarction was thrombotic origin not an embolic one as the atherosclerotic changes were severe. Cardiac rupture appeared to be the cause of terminal sudden hypotension and cardiopulmonary arrest. It appears likely that a vegetation which had been attached to the aortic valve induced thromboembolic occlusion of the left internal carotid artery which had already been markedly sclerotic by atherosclerosis. It is also possible that the vegetations in the aortic valve came from mural thrombi at the site of acute myocardial infarction, as no bacteria were found in those vegetations." }, { "id": "pubmed23n0298_11176", "title": "[A 56-year-old man with fever, backache and tetraparesis].", "score": 0.015178671446174526, "content": "We report a 56-year-old man who developed progressive paraparesis. He was apparently well, except for left Bell's palsy which developed on May 9 of 1994, for which he received stellate ganglion block on the left side more than ten times until July 2nd of 1994, when he noted pain in his left shoulder and in his lumbar region. On July 5th, he noted some difficulty in urination. On July 6th, he noted tingling sensation in his four extremities and difficulty in gait. He was admitted to another hospital where he was treated with intravenous infusion of glycerol. After this treatment, his gait and sensory disturbance showed some improvement, however, on July 7th, his shoulder and lumbar pain worsened, and he became unable to stand. His temperature went up to 39 degrees C on the next day. Lumbar CSF on that day contained 119 cells/microliters, 112 mg/dl of protein, and 53 mg/dl of sugar. He was transferred to our hospital on July 14th. His past medical history revealed that he had suffered from frequent bouts of osteomyelitis since the age of 13 years. He was operated on several times on osteomyelitis. He had been treated on his tooth ache until shortly before the onset of the present illness. He also received steroid hormone for his Bell's palsy. On admission, his consciousness varied from alert to stupor. His BP was 150/100 mmHg, HR 98/min and regular, BT 39.4 degrees C. The bulbar conjunctiva appeared somewhat icteric. Otherwise, general physical examination was unremarkable. On neurologic examination, there was no apparent dementia. Higher cerebral functions appeared intact. The optic discs were flat. Pupils were round and isocoric reacting to light and accommodation promptly. Ocular movements were full without nystagmus. Some exophthalmos was noted bilaterally. The sensation of the face and facial muscles were intact. The remaining cranial nerves also appeared intact. Nuchal rigidity was present. He was unable to stand or walk. Muscle strength was markedly diminished in all four limbs; manual muscle testing revealed 1 to 2/5 weakness in both upper and lower extremities bilaterally. Muscle stretch reflexes were decreased or lost in both upper and lower limbs, but the plantar response was extensor on the right. Sensation appeared to be diminished in legs, but detail was not clear because of disturbance of consciousness. Pertinent laboratory findings were as follows: WBC 12,800/microliter, GPT 58 IU/l, total bilirubin 2.65 mg/dl, and CRP 16.8 mg/dl. Cerebrospinal fluid contained 34 cells/microliter (approximately two thirds were neutrophils), RBC 1,110/microliter, 2,949 mg/dl of protein, and 119 mg/dl of glucose; stapylococcus aureus was cultured from the CSF. Myelogram showed a filling defect in the anterior epidural space between the low thoracic and the upper lumbar region. The patient was treated with cephotaxim, aminobenzyl penicillin, and chloramphenicol. On the second hospital day, his BT was still 39 degrees C and he was agitated His weakness was worse than the previous day. Spinal MRI was attempted; as he was agitated 5 mg of diazepam was given intravenously at 4 PM. His respiration was rapid and somewhat shallow. At 6 PM, gadolinium DTPA was injected intravenously; at that time, he was breathing and pupils were 3 mm on both sides. At 6:35 PM, an examiner noted that he stopped breathing; the left pupil was dilated to 5 mm. Cardiopulmonary resuscitation was initiated immediately, and intubation was performed. He was placed on a respirator. His blood pressure did not reach 100 mmHg; he was in deep coma. Cardiac arrest occurred at 8:53 AM on the next morning. The patient was discussed in a neurological CPC. Most of the participants thought that the patient had either spinal epidural empyema or spinal subdural abscess. The question was what might be the original focus of infection. Three possibilities were considered, i.e., stellate ganglion block, teeth infection, and osteomyelitis..." }, { "id": "pubmed23n0308_15735", "title": "[A 76-year-old man with loss of vision and dementia].", "score": 0.013378052457039493, "content": "We report a 76-year-old man who developed blurred vision and dementia. He was apparently well until April 4, 1990 (70-year-old at that time) when he had a sudden onset of bilateral loss of vision. Corrected vision was 0.1 (right) and 0.09 (left). He was admitted to the ophthalmology service of our hospital on April 9, 1990, and neurological consultation was asked on April 11. Neurologic examination revealed alert and oriented man without dementia. Higher cerebral functions were intact. He had bilateral large visual field defects with loss of vision; he was only able to count the digit number with his right eye and to recognize hand movement with his left eye. Otherwise neurologic examination was unremarkable. General physical examination was also unremarkable; he had no hypertension. Cranial CT scan was normal on April 11; lumber spinal fluid contained 1 cell/microliter, 63 mg/dl of sugar, and 97 mg/dl of protein; myelin basic protein was detected, however, oligoclonal bands were absent. He was treated with methylprednisolone pulse therapy and oral steroid, however, no improvement was noted in his vision. He started to show gaze paresis to left, ideomotor apraxia, agnosia of the body, and dementia. Cranial CT scan on June 11 revealed a low density area in the deep left parietal white matter facing the trigonal area of the lateral ventricle. He was discharged on July 2, 1990. Hasegawa dementia scale was 2/32.5 upon discharge. In the subsequent course, he showed improvement in his mental capacity and Hasegawa dementia scale was 22.5/32.5 in 1991, however, no improvement was noted in his vision. In 1994, he started to show mental decline in that he became disoriented, and showed delusional ideation of self persecution and depersonalization with occasional confusional state. He also showed unsteady gait. Cranial MRI on February 13, 1996 revealed a T2-high signal intensity lesion on each side of the parietal deep white matter more on the left and another T2-high signal intensity lesion in the left pons as well as in the right thalamus. He complained of right hypochondrial pain and was admitted to another hospital on April 22, 1996. He was markedly confused and demented. He continued to show bilateral loss of vision, but no motor palsy was noted. Cranial CT scan on April 23, 1996 revealed diffuse cortical atrophy and ventricular dilatation in addition to the low density areas in both parietal deep white matter. He developed jaundice in the middle of May. Abdominal CT scan revealed multiple low-to iso-density areas in the liver and marked iso-to high-density swelling of the right kidney. The patient expired on June 9th, 1996. The patient was discussed in a neurological CPC and the chief discussant arrived at the conclusion that the patient had had a carcinomatous limbic encephalitis with optic neuropathy and a choleduct carcinoma. Other opinions entertained included acute disseminated encephalomyelitis with optic neuritis, and granulomatous angiitis of the central nervous system. Some participants thought the primary site of the carcinoma was the right kidney with metastasis to the liver. Post mortem examination revealed a mixed type carcinoma in the right kidney with liver metastases. Neuropathologic examination revealed an incomplete softening in the optic chiasm and the left optic nerve, and in the left parieto-occipital areas. (The right hemisphere was frozen for future biochemical assay.) One of the adjacent cortical arteries had an organized thrombus. Other arteries and arterioles also showed sclerotic changes. Some of the leptomeningeal arteries were positive for Congored staining as well as for beta-amyloid immunostaining. Many senile plaques were seen diffusely in the cerebral cortex and neurofibrillary tangles were seen in the CA1 area and the parahippocampal gylus. No cellular infiltrations or demyelinated foci were seen. The neuropathologic features were consistent with circulatory disturbance based on the amyloid angiopa" }, { "id": "pubmed23n0089_18943", "title": "[An adult case of congenital Horner's syndrome with heterochromia iridis--with special reference to alteration of Horner's sign associated with development].", "score": 0.012295081967213115, "content": "It is well known that when the Horner's syndrome is congenital, a defect in pigmentation of the iris is usual; all or part of the iris remains light brown. We reported an adult case of congenital Horner's syndrome with remission and relapse of unilateral ptosis. A 25-year-old man was admitted to our hospital for ophthalmologic surgical treatment of right ptosis. According to the patient's mother, the patient was delivered with the aid of forceps at birth, and the right ptosis was observed during the first few days of his life. At 2 to 3 years of age, his parents noted lighter color of the right eye. The right ptosis was gradually improved as he grew older. However, he developed right ptosis again with left meralgia paresthesia since eighteen age. At age 25 years, he was noted to have right ptosis, right miosis (the left pupil measured 4.5 mm in diameter and the right 3.0 mm), right heterochromia iridis with pigmented iris nevi, and left meralgia paresthesia . Laboratory data of urine, blood and CSF as well as radiological studies of chest X-ray, skull X-ray, spine X-ray, brain MRI and spinal cord MRI showed unremarkable. Sweating test was intact, pharmacologic test to Horner's syndrome with 5% cocaine and 1.25% 1-epinephrine indicated that the damage was pointed to the post ganglionic sympathetic neuron. Ten patients with congenital Horner's syndrome reported in Japan since 1953 were reviewed including our case. Ten of eleven were male and Horner's sign was recorded on the left eye in 8 cases.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "Neurology_Adams_1840", "title": "Neurology_Adams", "score": 0.010653723768477867, "content": "Figure 12-2 illustrates the visual field defects caused by lesions of the retina, optic nerve and tract, lateral geniculate body, geniculocalcarine pathway, and striate cortex of the occipital lobe. In the alert, cooperative patient, the visual fields can be plotted fairly accurately at the bedside. With one of the patient’s eyes covered and the other fixed on the corresponding eye of the examiner (patient’s right with examiner’s left), a target—such as a moving finger, a cotton pledget, or a white disc mounted on a stick—is brought from the periphery toward the center of the visual field (confrontation testing). With the target at an equal distance between the eye of the examiner and that of the patient, the fields of the patient and examiner are then compared. Similarly, the patient’s blind spot can be aligned with the examiner’s, and its size determined by moving a small target outward from the blind spot until it is seen. For reasons not known, red-green test objects are more" }, { "id": "pubmed23n1052_9242", "title": "An Interesting Case of Pupillary Changes During the Testing of Ocular Movements and its Influence on the Diagnosis?", "score": 0.009900990099009901, "content": "To describe an unusual case presentation of a decompensating exotropia with an incidental pupil anomaly highlighting the importance of observing pupils during the assessment of ocular movements. A case whose signs included an exotropia and an enlarged tonic pupil which were initially mistaken for an atypical case of Oculomotor nerve palsy, triggering immediate imaging investigations. We discuss how understandable it would be for experienced clinicians to arrive at this case's misdiagnosis and how it could have been avoided thereby helping to preserve where possible costly resources of neuro imaging and inpatient stays. A 71 year old man who was seen as a tertiary referral case by the Queen Elizabeth Hospital Birmingham's (QEHB's) neuro-ophthalmology service, where a second opinion for the patient was sought from a neurology team from another hospital. He was seen by the orthoptist and neuro-ophthalmologist consultant. On presentation at QEHB visual acuity measured 6/9 Snellens in each eye with varifocals, improving to 6/6 with pinhole testing, the fundi and optic discs were normal. Anisocoria was noted with the left pupil being larger than the right pupil. Orthoptic assessment revealed a small angle left exotropia on cover test, increasing in size on alternate cover test with a blink type recovery to its original angle. An orthoptic diagnosis of a decompensating left microexotropia with identity was given. In the left eye there was a slight mechanical restriction in adduction, underacting superior rectus and a larger underacting inferior rectus with an \"A\" type alphabet pattern with symptoms of horizontal diplopia on all right gaze positions. There was no evidence of ptosis, convergence was intact and saccades were fast and appeared of a normal velocity. The anisocoria appeared more obvious when the patient looked to right gaze where his left pupil seemed to enlarge further. Assessment of the pupillary function led to the patient being diagnosed as having bilateral asymmetrical Adies (tonic) pupils. This case highlights the importance of not only carrying out a detailed pupil reaction assessment but also the necessity of observing the pupils during the assessment of ocular movements. This case highlights how anisocoria can mislead a clinician's attention to believing that only one particular pupil is abnormal where as it could be both. Also it highlights that the classic combination of symptoms and observations of diplopia, exotropia, longstanding incomitance and anisocoria in terms of a dilated pupil may not necessarily be an Oculomotor cranial nerve palsy and requiring the patient to undergo imaging investigations on an urgent basis may be avoided." }, { "id": "pubmed23n1081_21469", "title": "A cataract, 'a million cut' radial keratotomy, and Marfan syndrome February consultation #1.", "score": 0.00980392156862745, "content": "A 56-year-old man with an ocular history of 20+ cut radial keratotomy (RK) in both eyes and Marfan syndrome presented with blurred vision in both eyes 2 years previously. He was intolerant of contact lenses and was correctable with spectacles for the past 10 years. His presenting photographs and corneal topographies are shown in Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202102000-00022/figure1/v/2021-04-12T204757Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202102000-00022/figure2/v/2021-04-12T204757Z/r/image-tiff, respectively. His left eye had greater than 270 degrees of zonulopathy and a visually significant cataract. He underwent a planned pars plana lensectomy/vitrectomy and implantation of a scleral-fixated CZ70BD (Alcon Laboratories, Inc.) intraocular lens (IOL). He has enjoyed adequate vision in the left eye and now has a worsening cataract in his right eye. He is a practicing dentist and requested the fastest visual rehabilitation possible. His corrected distance visual acuity was 20/50 with a manifest refraction of +5.00-4.00 × 90 in the right eye and 20/25 with a manifest refraction of +1.75-2.50 × 180 in the left eye. Intraocular pressure (IOP) was measured at 16 mm Hg in both eyes, and extraocular motility, confrontational visual fields, and pupils were normal in both eyes. On slitlamp examination, he had mild ptosis in both eyes, the corneas had 20+ RK with multiple arcuate incisions at the 3- and 9-o'clock positions in both eyes, the anterior chamber (AC) was deep and quiet in both eyes, both irides had mild iridodonesis, the right lens had a 2 to 3+ nuclear sclerotic cataract with 6 clock hours of superotemporal zonulopathy that was only evident with dilation (Figure 3JOURNAL/jcrs/04.03/02158034-202102000-00022/figure3/v/2021-04-12T204757Z/r/image-tiff) and no phacodonesis. The left lens had a well-positioned CZ70BD IOL fixated at 6 and 12 o'clock without extrusion or exposure of the Gore-Tex suture. The posterior segment examination was unremarkable. What counseling would you provide for this patient in preparation for surgery? How would you plan the IOL calculations? What intraoperative techniques would you use to achieve the safest outcomes given his comorbidities?" }, { "id": "pubmed23n0087_15017", "title": "[Superior oblique myokymia--a case report and pathogenetic consideration].", "score": 0.00980392156862745, "content": "A 30-year-old male visited us with complaints of dizziness and diplopia of abrupt onset in September, 1988. Neurological studies demonstrated paroxysmal rotatory to-and-fro oscillations of the left eye. There has been the same clinical episode at 25 years of age, lasting approximately 6 months. The characteristics of his ocular involuntary movement with the mild IVth cranial nerve paresis were as follows: quick, nonrhythmic, initially counterclockwise-rolling, more prominent in moving the left eye to the lower medial side, persisting for 1-10 seconds and rapidly repeated oscillations. When oscillations were prominent, he complained of faintness in addition to double vision. Except for the ocular signs, other neurological and laboratory examinations including cerebrospinal fluid, brain MRI and brain stem auditory evoked response, failed to disclose the precise location and nature of the lesion. Abnormal ocular movement was fluctuating for 4 months and gradually disappeared without any medication. In conclusion, the faintness could be considered to result from a lesion of reticular activating system adjacent to the IVth cranial nerve nucleus and its rostral (excitatory or inhibitory) supranuclei, and it suggests that a responsible lesion of the abnormal ocular movement is located at a region of the dorsomedial midbrain." }, { "id": "pubmed23n1028_14773", "title": "Unilateral progressive epitheliopathy after LASIK.", "score": 0.009708737864077669, "content": "A 36-year-old man was referred back to our clinic after an uneventful laser in situ keratomileusis (LASIK) surgery 6 months previously, with a chief complaint of declining vision in the left eye for the last several months. His pertinent ocular history prior to the LASIK surgery was significant for episodic left eye irritation and inflammation of the superior part of the left cornea secondary to contact lens-induced keratopathy, according to his optometrist.This was a femtosecond-assisted LASIK surgery using the WaveLight FS200 femtosecond laser (Alcon) with the Allegretto EX500 excimer laser (Alcon) for attempted correction of -4.50 diopter (D) of myopia in both eyes under an 8.8 mm flap with a thickness of 100 μm. The uncorrected distance visual acuity (UDVA) was 20/15 in both eyes for the first 2 weeks; at the 1-month follow-up visit, a well-demarcated, wavelike plaque of coarse, thickened corneal epithelium along the superior aspect of the cornea was noted. The UDVA had declined to 20/30 in the left eye. The right eye remained clear with a UDVA of 20/15. The patient was treated for presumed interface inflammation with 1% topical prednisolone acetate for 3 weeks on a tapering regimen and it was noted that there was some improvement in the vision subjectively although the epithelial ridge involving the superior one third of the LASIK flap was present without any change.Over the course of the next 2 months, a progressive decline in vision was noted in the left eye. At no point did his right eye experience symptoms or visual decline. Four months postoperatively the UDVA had declined to 20/60 in the left eye. A linear epithelial ridge extending from limbus at 11 to 2 o'clock position was noted superiorly; staining showed the ridge involved the superior aspect of the flap. The patient was again given corticosteroid treatment, which would improve the symptom of irritation without any change in the visual acuity. Over the course of the next few months, a new wave of abnormal epithelium involving the inferior aspect of the limbus and the flap, encompassing the 2 o'clock position of the flap from the 4 to 6 o'clock positions, was also noted ().(Figure is included in full-text article.)Conjunctival staining using lissamine green and fluorescein dye showed staining of the well-demarcated epithelial ridge superiorly and inferiorly involving the flap encroaching the visual axis. On examination, the patient's corrected distance visual acuity was now 20/80 in the left eye. , , and show the tomographic, topographic, and optical coherence tomography (OCT) results at the 6-month follow-up post-LASIK surgery.(Figure is included in full-text article.)(Figure is included in full-text article.)(Figure is included in full-text article.)Preoperatively the patient denied any ocular history but on further questioning at the 6-month follow-up visit, he provided information about the use of systemic isotretinoin (Accutane) for juvenile acne for 1 year at age 17 and potential exposure to chemicals during military service although he denied any specific ocular exposure. He is a barbeque enthusiast and brews his own alcohol but denies any thermal or direct injury to either eye. His mother had recently told him that he might have had battery acid exposure when he was very young, before age 10, but never required medical attention.What is the most likely diagnosis? What medical or surgical interventions would you recommend for this patient? What is the prognosis for this patient?" }, { "id": "pubmed23n0224_8413", "title": "[An acute syndrome of opsoclonus and body tremulousness. A case report of benign encephalitis].", "score": 0.009708737864077669, "content": "A 30-year-old woman was admitted to our hospital in May 1977, suffering from oscillation, body tremulousness and astasia-abasia. Two months prior to admission she had caught a common cold and felt paresthesia on the right arm. Three days before admission, she had photophobia, tremulousness of the trunk and head, and astasia-abasia. A neurological examination revealed difficulty in standing, and jerky movement of the body and right arm, her limbs were well coordinated. An ocular examination resulted in normal findings except for intermittent oscillation of the eyeballs. As the pupils and fundi were normal, so were the routine laboratory tests. The cerebrospinal fluid was clear and colorless under normal pressure, and showed no more than 6 mononuclear cells in any of the three examinations. CSF protein was registered 20 mg/dl, glucose 75 mg/dl, and no virus titers were elevated. Electroencephalogram was slightly abnormal due to a slowing of the Alpha wave in the background activity. Both computerized tomography and vertebral-angiography were normal. A slow and steady abatement of all symptoms started while she was taking steroid treatment in hospital. Electrooculogram showed irregular disconjugation of the eyes rotating or moving in horizontal and vertical direction. There movements conjugated or disconjugated in both eyes with 5-7 Hz of frequency and 10-20 degrees of amplitude. They decreased when the eyelids were closed or staying in a dark room. These ocular movements were regarded as opsoclonus. Then opsoclonus changed to flutter-like oscillation.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0494_1430", "title": "Rapid, painless unilateral vision loss in a 37-year-old healthy woman.", "score": 0.009615384615384616, "content": "A 37-year-old woman experienced painless, progressive vision loss to no light perception in the left eye over the course of 3 days. The right eye was unaffected. On examination, the only other abnormal finding was a +4 left afferent pupillary defect. She was initially diagnosed with retrobulbar optic neuritis and admitted for treatment with intravenous methylprednisolone. Neuro-imaging revealed a large right anterior cerebral artery aneurysm that crossed the midline to compress the left optic nerve. The aneurysm was treated with coil embolization, which was technically successful but which did not lead to significant improvement in vision." }, { "id": "Anatomy_Gray_2869", "title": "Anatomy_Gray", "score": 0.009600566454246324, "content": "Most of these changes are transient and are usually due to traction injuries during the surgical procedure. A 33-year-old fit and well woman came to the emergency department complaining of double vision and pain behind her right eye. She had no other symptoms. On examination of the right eye the pupil was dilated. There was a mild ptosis. Testing of eye movement revealed that the eye turned down and out and the pupillary reflex was not present. These findings revealed that the patient had an ipsilateral third nerve palsy (palsy of the oculomotor nerve [III]). The oculomotor nerve [III] is the main motor nerve to the ocular and extra-ocular muscles. It arises from the midbrain and pierces the dura mater to run in the lateral wall of the cavernous sinus. The oculomotor nerve [III] leaves the cranial cavity and enters the orbit through the superior orbital fissure. Within this fissure it divides into its superior and inferior divisions." }, { "id": "pubmed23n0667_22897", "title": "Anti-aquaporin-4 antibody-positive optic neuritis treated with double-filtration plasmapheresis.", "score": 0.009523809523809525, "content": "The anti-aquaporin-4 (AQP4) antibody was recently reported to be associated with neuromyelitis optica (NMO). Optic nerve involvements in many NMO cases are bilateral and the prognosis is poor. However, it has been suggested that plasma exchange is effective for those patients when steroid pulse therapy is ineffective. Herein, we report successful treatment of a patient with NMO using double-filtration plasmapheresis (DFPP). A 22-year-old woman consulted a neurologist for neck pain in March 2008. High-intensity lesions were shown in the cervical spinal cord by T2-weighted magnetic resonance imaging. On July 15, the patient was referred to our department for a headache and pain and blurred vision in the left eye. The best-corrected visual acuity was 20/50 and 20/500 in the right and left eyes, respectively, with visual field defects observed in both. After 3 courses of steroid pulse therapy, anti-AQP4 antibodies were positive. In November, the patient again noticed visual acuity loss in the left eye and was treated by additional steroid pulse therapy, which was not effective. Next, she underwent plasma exchange therapy, though it was stopped due to hypotension and dyspnea. The next day, the patient underwent DFPP treatment and visual function gradually recovered. It is important to consider NMO when steroid pulse therapy is not effective. We successfully and safely treated NMO in a young adult patient using DFPP." }, { "id": "article-20650_1", "title": "Doll's Eyes -- Definition/Introduction", "score": 0.009523809523809525, "content": "The oculocephalic reflex is performed by holding a patient’s eyelids open and moving their head from side to side. The examination should only be performed on patients with a stable cervical spine without c-spine precautions. With the patient's eyelids open, the examiner briskly rotates the patient's head from side to side while the examiner observes the patient’s eyes. The examiner observes a positive oculocephalic reflex when the patient moves their eyes opposite of the rotation of their head, such that their eyes stay looking forward (like a doll’s eyes). The examiner observes a negative oculocephalic reflex when the patient’s eyes stay midline and do not move while the examiner rotates the head. A similar examination is performable for vertical eye movements. [6] Note that the designation of \"positive\" (eyes moving in the opposite direction of head movement indicating an intact brainstem function) or \"negative\" (eyes moving towards the same direction of head movement indicating severe brainstem dysfunction) doll's eyes reflex is an oversimplification and that some eye movement with nystagmus can occur in pathologic states. [7] The reflex is suppressed in a conscious adult with normal neurologic function but is active in a comatose patient with gross brainstem function, absent if there is damage to the reflex arc. [6]" }, { "id": "Neurology_Adams_2040", "title": "Neurology_Adams", "score": 0.009495090079641229, "content": "Normally, movement of the head at a rate of one to two cycles per second does not cause blurring of vision because of the rapidity with which the VOR accomplishes compensatory eye movements. Dynamic visual acuity is a term applied to testing by having the patient read an eye chart while the head is rotated back-and-forth. A substantial drop in acuity occurring with head movements at this speed is indicative of failure of the VOR. Zee has described yet another means of testing the VOR in which the examiner observes the optic nerve head while the patient rotates the head back and forth. With a normal VOR, the optic disc does not appear to move since the eye’s position in space has remained unchanged. However, if the VOR is impaired, the optic nerve head appears to oscillate. Visual Fixation Reflex (Suppression of the Vestibuloocular Reflex)" }, { "id": "pubmed23n0322_20086", "title": "Consultation section. Cataract surgical problem.", "score": 0.009433962264150943, "content": "A 68-year-old diabetic Pakistani presented with a 3 year history of progressive bilateral painless loss of vision. Although he was previously untreated for glaucoma, his examination revealed the following: visual acuity, finger counting in the right eye and 20/60 in the left; intraocular pressure (IOP), 41 and 31 mm Hg, respectively. Physical findings included bilateral shallow anterior chambers, minimal nuclear and cortical cataract formation, and extensive glaucomatous optic nerve cupping and atrophy worse in the right eye than in the left. Gonioscopy revealed angles narrowed to grade 1 for 360 degrees in both eyes. Visual field analysis was commensurate with the marked degree of optic nerve damage and reduced visual acuity. Bilateral laser iridotomies and a combination of topical antiglaucoma agents reduced IOP to the mid-20s in both eyes. Subsequently, the right eye had an uneventful trabeculectomy with application of intraoperative mitomycin. Postoperatively, the patient developed posterior aqueous entrapment and was managed with topical cycloplegics, aqueous suppressants, and corticosteroids. After a few weeks, a shallow anterior chamber was present centrally, a filtration bleb was noted, and IOP was 9 mm Hg. Unexpectedly, the patient returned to his native country, discontinued medications, and was lost to follow-up for 1 year. Upon his return, he presented with these findings: visual acuity, hand motion in the right eye and 20/60 in the left eye; IOP, 10 and 30 mm Hg, respectively. Physical findings in the right eye (Figure 1) included a superiorly oriented, thin-walled filtration bleb, a formed anterior chamber with multiple broad peripheral and midperipheral synechias, and a bound pupil covering a dense nuclear sclerotic cataract. The left eye had progressive glaucomatous optic nerve changes. Given the patient's history, now would you manage the glaucoma in the left eye, and what surgical methods would you plan for the right eye, assuming cataract surgery is indicated?" }, { "id": "pubmed23n0085_11973", "title": "[Subacute sensory neuropathy manifestated by tonic pupils associated with small cell carcinoma of the lung].", "score": 0.009433962264150943, "content": "Only a few cases of carcinomatous neuropathy with tonic pupils have been reported. In the present paper we described a 53-year-old woman with subacute sensory neuropathy who had presented with bilateral tonic pupils. She noticed numbness over the medial aspect of the left thigh in March, 1988, and then developed dysesthesia over the left forearm and hand, mild weakness of left upper and lower extremities and urinary disturbance. Neurological symptoms were subacutely progressive and she was bed-ridden in May. She was admitted to our hospital in June, 1988. On examination, she had body-weight loss of 6 kg during the last six months and general status was otherwise unremarkable. She had anisocoria; the left pupil was larger in daylight than the right, while smaller in dim light. The left pupil scarcely reacted to light, but promptly constricted to near vision. The right pupil constricted normally to light and near vision. An instillation of 0.0625% pilocarpine solution showed supersensitive response of both pupils. An instillation of 1.25% epinephrine solution demonstrated mild dilation of both pupils. Thus, it was conceivable that she had postganglionic ciliary nerve damage characteristic of tonic pupil as well as the lesion of sympathetic nerve innervating pupillary dilator. She had severe sensory ataxia and pseudoathetosis of the hands. Weakness was mild to moderate in extremities. Almost all deep tendon reflexes were absent. All modalities of sensation, particularly on deep sense, were severely involved with sea-level-type distribution below Th7, and over C2 to C3 regions on the left side.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0063_728", "title": "Human ocular torsional position before and after unilateral vestibular neurectomy.", "score": 0.009345794392523364, "content": "The static ocular torsional position of both eyes of 23 patients was measured by means of fundus photographs one day before and one week after unilateral vestibular neurectomy for the treatment of acoustic neuroma, Ménière's disease or paroxysmal vertigo. The results showed that in all patients the vestibular neurectomy caused both eyes to tort (i.e. to roll around the visual axis) toward the side of the neurectomy when measured one week after operation. The extent of this torsion was an average of 9.5 degrees one week after operation and there was no statistically significant difference in the average magnitude of the torsion in the two eyes. In 8 of these patients, additional measurements were made at intervals up to one year after operation and it was found that in these patients there is a significant reduction in torsion over time from an average of 10.2 degrees one week after operation to an average of 2.8 degrees by 16 weeks after operation. The change in torsional eye position following the neurectomy was accompanied by a change in the perceived visual orientation of a small (9.5 degrees visual angle) illuminated horizontal line at a straight ahead eye level position in an otherwise completely darkened room. One week after operation when asked to adjust the line to the perceived gravitational horizontal by rotating it in roll (i.e. around an X axis), patients who had had a right vestibular neurectomy consistently set the line so that the right side of the line (from the patient's point of view) was below the true gravitational horizontal. Similarly patients after a left neurectomy consistently set the line so that the left side of the line was below the true gravitational horizontal. There is a high correlation (r = 0.95) between the direction and magnitude of the change in torsional eye position and the direction and magnitude of the change in the perceived visual horizontal one week after operation.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n1111_4751", "title": "Anisocoria after scopolamine transdermal patch contamination: A case report.", "score": 0.009259259259259259, "content": "We report a case of anisocoria that occurred after contamination with a scopolamine transdermal patch, and introduce a diagnostic approach for anisocoria patients. A 35-year-old woman with no past ophthalmologic history presented to the ophthalmology department complaining of a dilated pupil in the right eye. Corrected visual acuities was 20/20 in both eyes, and the intraocular pressures were 20 and 18 mm Hg in the right and left eye, respectively. The anterior chambers in both eyes were unremarkable on slit-lamp examination. The pupil size was 5.0 mm in the right eye and 2.0 mm in the left eye, and the extraocular muscles of both eyes were intact. The patient neither did present with facial anhidrosis nor did she present with ptosis. Furthermore, as we did not observe dilatation lag in the smaller pupil, we applied 1% apraclonidine in the left eye in order to rule out Horner syndrome and did not observe dilatation of the pupil. We then applied 0.125% and 1% pilocarpine to exclude oculomotor nerve palsy; however, it could not be ruled out as constriction of pupil to 3.1 mm in the right eye was observed after applying 1% pilocarpine. Moreover, upon further investigation, we discovered that the patient had a scopolamine transdermal patch applied for 2 days prior to the clinic visit. Artificial tears were administered and the patient was observed and monitored. The pupil size in the right eye gradually decreased to 4.5 mm on the second day of observation and to 3.6 mm on the fourth day of observation. A detailed history of the use of medications such as scopolamine patches in patients with unilateral dilated pupils without vision loss is of utmost importance. We report the exclusion of important diseases using pilocarpine and apraclonidine hydrochloride. It was confirmed that improvement naturally occurs over time." }, { "id": "pubmed23n1046_1962", "title": "[Saturday night retinopathy: A French case of post-compressive CRAO].", "score": 0.009259259259259259, "content": "We report herein the first French case of Saturday Night Retinopathy. A 39-year-old man presented to the emergency room with unilateral vision loss in the left eye with redness but no pain. Visual acuity OS was \"light perception\" and OD 20/20. The left eye was hyperemic with a fixed, dilated pupil; fundus examination revealed a macular cherry-red spot within a pale, ischemic retina. The patient was admitted to a stroke centre. The neurological work-up and head CT were normal. He also underwent evaluation for possible carotid or cardiac etiologies, all of which were negative. Current smoking was the only cardiovascular risk factor found. The patient reportedly fell asleep face down at his kitchen table after consuming a large amount of alcohol, with his left eye pressed into his arm throughout the night. Six similar cases have been reported in the literature since 1973. The prognosis for vision is dismal. Only public awareness and prevention might avoid this serious functional disability." }, { "id": "pubmed23n0968_15434", "title": "Isolated Horner syndrome as a rare initial presentation of nasopharyngeal carcinoma: a case report.", "score": 0.009174311926605505, "content": "Horner syndrome refers to a set of clinical presentations resulting from disruption of sympathetic innervation to the eye and adnexa. Classically, the clinical triad consists of ipsilateral blepharoptosis, pupillary miosis, and facial anhidrosis. Ocular sympathetic denervation may signify life-threatening causes. Timely investigation and accurate diagnosis are essential in patients with oculosympathetic denervation. A 33-year-old Asian man with a heavy smoking habit presented with a 3-week history of left ptosis and no other complaints. His visual acuity was 20/20 bilaterally. An ophthalmic examination was significant for mild ptosis of his left eyelid and anisocoria (smaller left pupil), which was greater in the dark. Both pupils reacted to light briskly without an afferent pupillary defect. Anhidrosis was found on the medial side of the left forehead. A 10% cocaine test was positive. At his first visit, neurologic examination was unremarkable. Comprehensive radiological investigations were scheduled for a left-sided isolated Horner syndrome. Two weeks after his first visit, he experienced a left-sided headache along with ipsilateral Horner syndrome. Neurologic examination revealed hypoesthesia in the left cranial nerve V<sub1-3</sub territories. Emergent computed tomography angiography was suspected for petrous part of the left internal carotid artery (ICA) dissection. Magnetic resonance imaging demonstrated an enhancing infiltrative lesion with its epicenter at the left sphenoid bone. The lesion encased the left ICA and invaded the left Meckel cave. Rhinoscopy with incisional biopsy revealed squamous cell nasopharyngeal carcinoma. This case involved an unusual initial presentation of nasopharyngeal carcinoma: isolated Horner syndrome with clinical progression to adjacent structures. Infiltration involving the Meckel cave and ICA at the foramen lacerum can present as postganglionic Horner syndrome associated with trigeminal pain and hypoesthesia. These clinical findings may mimic carotid artery dissection on computed tomography angiography. Detailed magnetic resonance imaging with careful attention to the skull base should be performed." }, { "id": "pubmed23n0499_15004", "title": "[Neurosyphilis presenting the left total ophthalmoplegia: a case report].", "score": 0.009174311926605505, "content": "We report a 73-year-old woman with meningitis-type neurosyphilis presenting the main symptom of the left total ophthalmoplegia. Three months after the appearance of the deviation of the eyeball to the inside and ptosis of the left eyelid, the left eyelid was completely closed. On admission, about four months after the appearance of neurosyphilis, she showed paralysis of the left oculomotor nerve, trochlearis nerve and abducens nerve, and the right mydriasis and absent light reflex. She was diagnosed as meningovascular neurosyphilis because syphilitic antibodies reactions in both serum and cerebrospinal fluid were highly positive. We treated her with intravenous infusion drop of penicillin G (eighteen-million units/day) for ten days, and those symptoms mentioned above other than light reflex were completely recovered. Bilateral internal carotid arteries situated close each other at the supraclinoid portion. The internal carotid arteries were not enhanced on Gd-MRI and the stenosis of the arteries were not detected on MRA. However, we suppose that the inflammation of meninges at that portion spreads to the bilateral internal carotid arteries, and that the III, IV and VI nerves close to the left internal carotid artery were damaged. There have been no reports of meningovascular neurosyphilis with the manifestation of unilateral ophthalmoplegia. In the patients of meningovascular neurosyphilis, however, various cranial nerve palsies can be appeared. Therefore we suggest that neurosyphilis should always be taken into consideration as differential diagnosis of cranial nerve palsies." }, { "id": "pubmed23n0387_1798", "title": "A case of Brown-Sequard syndrome with associated Horner's syndrome after blunt injury to the cervical spine.", "score": 0.00909090909090909, "content": "A 26 year old motorcyclist was received by the trauma team in our accident and emergency department after a head on collision with a motor vehicle. He had been correctly immobilised and his primary survey was essentially normal. He was alert and orientated with a Glasgow Coma score of 15 and had no symptoms or signs of spinal injury. His cervical spine radiography was also normal. Neurological examination however, revealed anisocoria, his left pupil being smaller than his right, and a Brown-Sequard syndrome, with a sensory level at C6. Immobilisation was maintained and he was transferred to the regional neurosurgical centre where magnetic resonance imaging revealed a contusion of the left half of the spinal cord adjacent to the 6th cervical vertebrae. Computed tomography revealed no bony injury but spinal column instability was demonstrated after flexion-extension spinal views and he underwent surgery to fuse his spine at the C5-C6 level. This report highlights the necessity to observe strict ATLS guidelines. This must include a thorough examination of the central and peripheral nervous system where spinal injury is suspected, even in the absence of radiographic abnormality and neck pain. This article also presents the unusual phenomena of Brown-Sequard syndrome and unilateral Horner's syndrome after blunt traumatic injury to the cervical spine." }, { "id": "article-18523_16", "title": "Brain Death Criteria -- Clinical Significance -- I. Physical Examination", "score": 0.00909090909090909, "content": "CN III, IV, VI: Loss of pupillary light reflex as mentioned above (CN III). For cranial nerves IV, VI, and VIII, the oculocephalic reflex can be tested by holding a patient's eyelids open and turning their head from side to side. A positive oculocephalic reflex is present when the eyes reflexively look in the position opposite to that of the direction the head is turning. When the oculocephalic reflex is absent, the eyes will turn in the same direction in which the head is turning (Doll's eyes). It is imperative to only perform this examination maneuver in patients with a stable cervical spine who are not in cervical spine precautions." }, { "id": "pubmed23n1081_21454", "title": "Management of hypotony-related maculopathy after combined phacoemulsification and trabeculectomy: January consultation #1.", "score": 0.009009009009009009, "content": "A 59-year-old man with mild to moderate pigmentary glaucoma was referred for management of hypotony-related maculopathy 3 years after combined phacoemulsification and trabeculectomy in his right eye. His ocular history is significant for retinal detachment in the right eye that was surgically treated with a pars plana vitrectomy and scleral buckle 5 years prior to the current presentation and 1 year prior to his combined phacoemulsification-trabeculectomy procedure. After trabeculectomy, he reportedly had a wound leak with hypotony and choroidal effusion. The patient was referred to a second surgeon who performed a bleb revision with a pericardial patch graft, but the patient had a severe intraocular pressure (IOP) spike in the immediate postoperative period requiring suture removal. This resulted in recurrent hypotony with maculopathy. A second bleb revision with pericardial patch graft was performed but was not successful in raising the IOP out of the single digits or in resolving the maculopathy. Accordingly, the patient was referred for further assessment. At presentation, the patient's corrected distance visual acuity was 20/100 in the right eye and 20/20 in the left eye. Applanation tonometry IOP was 4 mm Hg and 16 mm Hg for the right and left eyes, respectively. Central corneal thickness was 609 μm in the right eye and 574 μm in the left eye. The right pupil was noted to be slightly irregular with a relative afferent pupillary defect. Slitlamp examination of the right eye was notable for a moderately elevated, Seidel test-negative bleb, and deep anterior chamber. The left eye had a Krukenberg spindle and mild nuclear sclerotic cataract but was otherwise unremarkable. Fundus examination of the right eye was notable for significant macular folds with edematous nerve fiber layer (NFL) and optic nerve. The left optic nerve and fundus examination were unremarkable. Gonioscopy revealed open angles with dense trabecular meshwork pigment in both eyes. There was a nicely patent superior sclerostomy in the right eye. There was no cyclodialysis cleft. Optical coherence tomography (OCT) of the macula showed chorioretinal folds and NFL edema in the right eye and was normal in the left eye (Figure 1JOURNAL/jcrs/04.03/02158034-202101000-00022/figure1/v/2021-01-04T143903Z/r/image-tiff). The OCT of the optic nerve in the right eye was distorted secondary to the chorioretinal folds, whereas the left eye was notable for mild superior thinning of the NFL (Figure 2JOURNAL/jcrs/04.03/02158034-202101000-00022/figure2/v/2021-01-04T143903Z/r/image-tiff). Humphrey visual field revealed a superior nasal step in the right eye (Figure 3JOURNAL/jcrs/04.03/02158034-202101000-00022/figure3/v/2021-01-04T143903Z/r/image-tiff). Axial lengths were 25.33 mm and 26.53 mm in the right and left eye, respectively; it is notable that the right eye had a shorter axial length despite the scleral buckle, which demonstrates the degree of axial shortening from hypotony (Figure 4JOURNAL/jcrs/04.03/02158034-202101000-00022/figure4/v/2021-01-04T143903Z/r/image-tiff). What would be your approach for managing this patient's hypotony? Does the fact that the referring surgeon had performed 2 failed bleb revision procedures prior to referral influence your approach? Given that a previous attempt at revision resulted in an extreme IOP spike would you also recommend a glaucoma procedure? If so, what procedure would you perform? Would you do it coincident with the revision or in a staged procedure later on an as-needed basis?" }, { "id": "InternalMed_Harrison_1791", "title": "InternalMed_Harrison", "score": 0.009009009009009009, "content": "The range of eye movements and whether they are equal in each eye should be observed. Peripheral eye movement disorders (e.g., cranial neuropathies, eye muscle weakness) are usually disconjugate (different in the two eyes). One should check pursuit (the ability to follow a smoothly moving target) and saccades (the ability to look back and forth accurately between two targets). Poor pursuit or inaccurate (dysmetric) saccades usually indicates central pathology, often involving the cerebellum. Finally, one should look for spon taneous nystagmus, an involuntary back-and-forth movement of the eyes. Nystagmus is most often of the jerk type, in which a slow drift (slow phase) in one direction alternates with a rapid saccadic movement (quick phase or fast phase) in the opposite direction that resets the position of the eyes in the orbits. Except in the case of acute vestibulopathy (e.g., vestibular neuritis), if primary position nystagmus is easily seen in the light, it is probably due to a" }, { "id": "InternalMed_Harrison_2258", "title": "InternalMed_Harrison", "score": 0.009004098277915732, "content": "FIguRE 39-2 Demonstration of a relative afferent pupil defect (Marcus Gunn pupil) in the left eye, done with the patient fixating on a distant target. A. With dim background lighting, the pupils are equal and relatively large. B. Shining a flashlight into the right eye evokes equal, strong constriction of both pupils. C. Swinging the flashlight over to the damaged left eye causes dilation of both pupils, although they remain smaller than in A. Swinging the flashlight back over to the healthy right eye would result in symmetric constriction back to the appearance shown in B. Note that the pupils always remain equal; the damage to the left retina/optic nerve is revealed by weaker bilateral pupil constriction to a flashlight in the left eye compared with the right eye. (From P Levatin: Arch Ophthalmol 62:768, 1959. Copyright © 1959 American Medical Association. All rights reserved.) damage to the ciliary ganglion in the orbit. Common mechanisms are infection (herpes zoster, influenza)," }, { "id": "pubmed23n1115_14514", "title": "Acute iris toxicity following bilateral gel stent implantation with mitomycin-C and intracameral moxifloxacin January consultation #1.", "score": 0.008928571428571428, "content": "A 72-year-old woman with moderate primary open-angle glaucoma was referred for management of her glaucoma and photophobia. Her ocular history is significant for routine cataract surgery in both eyes 6 years prior to presentation. She was diagnosed with glaucoma 7 months prior to presentation at which time the patient underwent sequential, ab externo, open conjunctival, Xen Gel Stent (Allergan, Inc.) placement with mitomycin-C (MMC) in each eye, approximately 2 weeks apart. The history obtained directly from the surgeon revealed that MMC dosing was 0.2 mL in a concentration of 0.2 mg/mL delivered through subconjunctival injection after placement of the gel stent. Intracameral moxifloxacin was injected at the time of surgery, and moxifloxacin and Maxitrol eyedrops were used in the postoperative period. The patient noted that, approximately 1 month after each surgery, she developed significant photophobia. An outside examination noted bilateral tonic pupils and concern for early bleb failure in the left eye. 2 months after the initial gel stent placement in the left eye, she underwent a bleb revision with a McCannel suture iris cerclage in the left eye. The intraocular pressure (IOP) in both eyes remained well controlled off pressure-lowering medications; however, the tonic pupils and photophobia persisted. The patient was subsequently referred for further assessment. At presentation, the patient's corrected distance visual acuity was 20/20 in each eye. Applanation tonometry IOP was 17 mm Hg and 14 mm Hg for the right and left eyes, respectively. Pupils were tonic and irregular. The lack of pupillary response prevented testing for relative afferent pupillary defects directly or by reverse testing. Slitlamp examination of the right eye was notable for a minimally elevated superior bleb and severe iris stromal atrophy with diffuse transillumination defects. The intraocular lens (IOL) appeared well positioned in the capsular bag without signs of pseudophacodonesis (Figure 1JOURNAL/jcrs/04.03/02158034-202201000-00021/figure1/v/2021-12-20T152346Z/r/image-tiff). The left eye was notable for a diffuse superior bleb and similar iris and IOL findings to the right eye, except for 2 McCannel iris sutures in the iris stroma (Figure 2JOURNAL/jcrs/04.03/02158034-202201000-00021/figure2/v/2021-12-20T152346Z/r/image-tiff). In both eyes, the anterior chambers were deep and quiet, and there were no corneal endothelial abnormalities. Fundus examinations of both the right and left eyes were notable for glaucomatous-appearing optic nerves and otherwise healthy macula, vessels, and periphery. Gonioscopy revealed open angles in each eye with fairly marked, densely layered pigment throughout the inferior angle and trabecular meshwork. The gel stents were positioned just anteriorly to the trabecular meshwork superiorly, well away from iris tissue. Optical coherence tomography (OCT) of the nerve fiber layer (NFL) showed moderate to severe thinning inferiorly and superiorly in the right eye, with mild to moderate thinning inferiorly in the left eye (Supplemental Figure 1, http://links.lww.com/JRS/A510). Ganglion cell analysis correlated with the NFL findings (Supplemental Figure 2, http://links.lww.com/JRS/A510). Humphrey visual field testing revealed a dense superior arcuate in the right eye and moderate inferior arcuate in the left eye (Supplemental Figures 3 and 4, http://links.lww.com/JRS/A510). OCT of the macula in both eyes was unremarkable. Finally, specular microscopy showed normal endothelial density and configuration of each eye (Supplemental Figure 5, http://links.lww.com/JRS/A510). What part of the patient's ocular history would you consider relevant to the development of tonic, atrophic pupils? What additional information would you want to know to help refine your differential diagnosis? What is your preferred surgical technique when implanting the Xen Gel Stent? Please include whether ab interno or ab externo and open or closed conjunctival approach to be used and mention antifibrosis dosing and method of administration. Finally, what would be your approach for managing this patient's severe photophobia, in the setting of her moderate open-angle glaucoma?" }, { "id": "pubmed23n0291_13124", "title": "Recovery from bilateral vestibular failure: implications for visual and cervico-ocular function.", "score": 0.008928571428571428, "content": "We report a patient who sustained severe bilateral labyrinthine lesions during Streptococcus suis meningitis but considerably recovered vestibular function over a 7 month period. This unique case allowed us to examine the cervico-ocular reflex (COR) and visual function at various levels of activity of his vestibular system. The slow phase COR, elicited by trunk oscillation (0.2 Hz) with the head earth-stationary, was negligible immediately after the acute vestibular loss but rose to a gain of 0.51 one month after. Seven months later, when vestibular function was improved, COR gain dropped to a gain of 0.15. Measurements of spatial visual function during whole body oscillation in the acute stage and after 6 months showed marked improvement which correlated entirely with VOR measurements in the dark and during optic fixation. This patient also showed the unique feature that, in the acute stage, eye movement gain and visual function were poorer during whole body motion than during identical visual target motion. These findings suggest that: i) the COR may be inhibited by the presence of vestibular signals, ii) spatial vision measurements provide accurate assessment of the patient's visual blur during head motion, and iii) the severe oscillopsia experienced by patients in the acute stage of vestibular loss may not only be due to the absence of the VOR; additional degradation in eye movements during head motion, perhaps arising from acutely distorted labyrinthine signals, may also play a part." }, { "id": "pubmed23n0529_6005", "title": "[Avulsion of the optic nerve: two case studies].", "score": 0.008849557522123894, "content": "Avulsion of the optic nerve is a rare and serious injury. The authors report two cases of optic nerve avulsion. The first one concerns a 5-year-old boy who presented ocular trauma after falling on the handlebars of a bicycle. His visual acuity was light perception in the right eye, and his right pupil was unresponsive to light. The anterior segment was normal. The ophthalmoscopic examination showed a total separation of the optic nerve head from the sclera with peripapillary hemorrhage. The second case concerns a 30-year-old man who was hit in the right eye with a stick. On admission, he had no light perception in the right eye, a right afferent pupil defect, a small laceration of the right lower eye lid and no abnormalities on the anterior segment. The fundus examination showed a mild vitreous hemorrhage. Ocular ultrasonography showed vitreous hemorrhage coming directly from the optic nerve head in a mushroom pattern. A CT scan of the orbit revealed a thickened optic nerve. Color Doppler ultrasonography documented slowing of blood flow in the central retinal artery. The two patients received 1 mg/kg/day of prednisone for 2 weeks. No improvement was noted. Optic nerve avulsion is often caused by sudden and forceful rotation of the eye with tearing of the optic nerve as it exits the globe. The nerve can be partially or totally avulsed. The prognosis is usually poor." }, { "id": "pubmed23n0615_18630", "title": "Symptomatic trigeminal autonomic cephalalgia associated with allodynia in a patient with multiple sclerosis.", "score": 0.008771929824561403, "content": "A patient with symptomatic trigeminal autonomic cephalalgia (TAC) provides a chance to understand the pathophysiology and anatomic correlates of TAC. A 28-year-old woman experienced intermittent sharp and excruciating pain over her right temporal, ear and neck regions for 3 days. The headaches lasted 10-20 minutes each, occurred 1-2 times a day, and were accompanied by prominent ipsilateral lacrimation and conjunctival injection. The patient had hiccups, 4-limb numbness and impaired visual acuity in both eyes. She had also had 3 episodes of left-side optic neuritis in the past half year. Neurologic examination showed brushing allodynia over the right face and scalp during the headache attacks. The visual acuity of her right eye was 6/60 and that of the left eye was 1/60. Brain magnetic resonance imaging showed non-enhancing lesions on the right lateral tegmentum of the lower pons where the spinal trigeminal nucleus is located and the floor of the 4th ventricle. The patient was diagnosed as having multiple sclerosis with symptomatic TAC. Her headaches, autonomic signs and allodynia subsided 3 days after pulse therapy and gabapentin treatment were given. We suggest that the spinal trigeminal nucleus lesion was responsible for the symptomatology of TAC and cutaneous allodynia in our patient." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 37, 232 ] ], "word_ranges": [ [ 6, 37 ] ], "text": "Both for the type of treatment and to study the prognostic factor and adjuvant treatment, it is necessary to know the different hormonal receptors (estrogen and progesterone) as well as HER2-neu." }, "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": "Complete phenotypic study by flow cytometry.", "2": "Study of hormone receptors and HER2.", "3": "Study of hormone receptors, e-cadherin and study of first-degree relatives.", "4": "Study of BRCA 1-2 and study of first-degree relatives.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0267_6734", "title": "The significance of family history for patients with carcinoma of the breast.", "score": 0.01526510212950891, "content": "Since the risk of carcinoma of the breast is increased in women with a family history of the disease, new primary carcinomas of the breast may be increased after treatment. Women with several relatives with carcinoma of the breast are thought to be at higher risk of having a second primary carcinoma of the breast develop and mastectomy is more frequently recommended. The computerized registry of the Mount Sinai Medical Center Breast Service was used to identify 1,337 patients with complete information concerning family history. Three hundred fifty-nine patients with a family history of carcinoma of the breast were compared with women with no family history. Compared with patients with no family history of carcinoma of the breast, patients with a family history of carcinoma of the breast were significantly younger (54.0 versus 55.8 years of age, p &lt; 0.01), were significantly more likely to have used oral contraceptives (26 versus 13 percent, p &lt; 0.001), had significantly more ductal carcinoma in situ (10 versus 4 percent, p &lt; 0.01), and were significantly more often treated with breast conservation (42 versus 31 percent, p &lt; 0.001). Simultaneous contralateral carcinoma of the breast was diagnosed more frequently in patients with a family history (3 versus 1 percent, p &lt; 0.025), but metachronous contralateral carcinomas were not increased. In comparing the two groups, there were no significant differences in proportion premenopausal, parity, use of postmenopausal hormones, tumor size, tumor differentiation, nodal involvement, TNM stage, estrogen receptor status, or use of adjuvant radiation, chemotherapy, or tamoxifen. Complete five-year follow-up evaluation for 748 patients, 179 with a family history, found no differences in local, distant, or disease-free survival rates for mastectomy or breast conservation in relation to family history. Outcome for patients with first-degree affected relatives and those with more than one affected relative was the same as those with no family history. These results indicate that women with a family history of carcinoma of the breast should be treated no differently than women with no family history." }, { "id": "wiki20220301en304_20305", "title": "BRCA mutation", "score": 0.013982004234297813, "content": "Relative indications for testing for a mutation in BRCA1 or BRCA2 for newly diagnosed or family members include a family history among 1st (FDR), 2nd (SDR), or 3rd(TDR) degree relatives usually on the same side of the family but not limited: A known mutation (BRCA1 or BRCA2) in a cancer susceptibility gene within the family Women affected with any breast cancer diagnosed under the age of 30 Women affected with triple negative breast cancer (TNBC) (estrogen receptor negative, progesterone receptor negative, and HER2/neu negative) under the age of 50 Two relatives (FDR/SDR) diagnosed under the age of 45 Three relatives (FDR/SDR) diagnosed with average age of 50 or less Four relatives at any ages Ovarian cancer with either an additional diagnosed relative or a relative with male breast cancer A single family member with both breast and ovarian cancer Male breast cancer Pancreatic cancer with breast or ovarian cancer in the same individual or on the same side of the family" }, { "id": "pubmed23n0556_5828", "title": "Influence of young age at diagnosis and family history of breast or ovarian cancer on breast cancer outcomes in a population-based cohort study.", "score": 0.013529894810933404, "content": "The objective of this study was to examine the association of: (i) diagnosis at age &lt;/=35, (ii) first-degree family history of breast or ovarian cancer (BOC) and (iii) a research based definition of genetic risk, with tumor characteristics, treatment and survival in breast cancer (BC). Consenting female participants in the population-based Ontario Familial Breast Cancer Registry diagnosed with primary invasive BC between 1996 and 1998 were followed prospectively until 2005. Among 967 women, 105 were &lt;/=35 years old at diagnosis and 686 were classified as genetic risk cases, including 349 with a first-degree family history. Individuals diagnosed at age &lt;/=35 were more likely to self-detect tumors, to present with inflammatory BC, to have invasive ductal carcinoma of no special type, high T stage, and tumors with lymphovascular invasion (LVI), high grade and negative estrogen receptors. Younger women were more likely to receive chemotherapy and less likely to receive hormonal therapy. Diagnosis &lt;/=35 years old was associated with significantly reduced distant recurrence free survival, an effect that did not persist after adjustment for tumor and treatment related variables. Poor outcomes were restricted to younger women with hormone responsive BC. Family history was associated with increased rates of mammographic detection of BC, lower tumor stage and less frequent inflammatory BC, but had no association with BC outcomes. Women diagnosed with BC at age &lt;/=35 have more aggressive tumors; these adverse tumor characteristics, rather than age, lead to poor outcomes. Family history was not associated with survival." }, { "id": "pubmed23n1012_9657", "title": "Clinical features and first degree relative breast cancer, their correlation with histological tumor grade: a 5-year retrospective case study of breast cancer in Mizoram, India.", "score": 0.013218741820085507, "content": "The aim was to assess the association of histological tumor grade with other clinical features and epidemiological factors of women with invasive breast carcinoma. A retrospective study of 103 Mizo breast cancer patients visiting hospitals was made in Aizawl, Mizoram, Northeast India. With a prior consent, information on epidemiological factors and family history in relation to cancer was obtained. Clinical reports were obtained from their medical records. The frequency of distribution was calculated for age at diagnosis and tumor characteristics. Statistical analysis for different variables was done using a chi-square test. p &lt; 0.05 was considered significant. The histological tumor grades in our studies were found to be associated with lymph node invasion (p &lt; 0.021), different subtype of hormone receptor such as ER status (p &lt; 0.004), ER/PR status (p &lt; 0.007), HER2/neu status (p &lt; 0.014), and ER/PR/HER2 status (p &lt; 0.025). A patient with a family history of breast cancer in their 1st degree relative is also seen to have association in determining the tumor grade (p &lt; 0.003). Reproductive history, lifestyle and dietary habits, tobacco, and alcohol consumption were found to have no influence on breast cancer tumor grade. Our results showing significant correlation between status of lymph node, ER, PR, and HER2/neu oncoprotein and family history with 1st degree relative breast cancer are the first time report to target and focus on the possible role of biomarkers for diagnosis among the Mizo tribal breast cancer patients." }, { "id": "pubmed23n0657_19800", "title": "Four new cases of double heterozygosity for BRCA1 and BRCA2 gene mutations: clinical, pathological, and family characteristics.", "score": 0.013045434098065677, "content": "Double heterozygosity (DH) for BRCA1 and BRCA2 mutations is a very rare finding, particularly in non-Ashkenazi individuals, and only a few cases have been reported to date. In addition, little is known on the pathological features of the tumors that occur in DH cases and on their family history of cancer. Four carriers of pathogenic mutations in both BRCA1 and BRCA2 were identified among women who underwent genetic counseling for hereditary susceptibility to breast and ovarian carcinoma at three different Italian institutions. Clinical, pathological, and family history data were collected from medical records and during genetic counseling sessions. All identified DH cases developed breast carcinoma and three of them were also diagnosed with ovarian carcinoma. Mean ages of breast and ovarian cancer diagnosis were 42.7 and 48.6 years, respectively. The majority of breast cancers showed a BRCA1-related phenotype, being negative for hormone receptors and HER2. Two cases reported different gastrointestinal tumors among relatives. Although the individuals described in this study show more severe clinical features in comparison to previously reported BRCA1 and BRCA2 DH cases, our observations support the hypothesis of a non specific phenotype of DH cases in terms of age of disease onset. In addition, our observations indicate that in DH patients breast carcinogenesis appears to be driven mainly by the mutations in BRCA1. The possible association of DH for BRCA gene mutations with gastrointestinal tumors is in keeping with previous reports, but needs to be confirmed by further analyses." }, { "id": "wiki20220301en377_32343", "title": "Cancer biomarker", "score": 0.012981959674566678, "content": "Similarly, additional laboratory research has shown that tumor cells undergoing apoptosis can release cellular components such as cytochrome c, nucleosomes, cleaved cytokeratin-18, and E-cadherin. Studies have found that these macromolecules and others can be found in circulation during cancer therapy, providing a potential source of clinical metrics for monitoring treatment. Recurrence Cancer biomarkers can also offer value in predicting or monitoring cancer recurrence. The Oncotype DX® breast cancer assay is one such test used to predict the likelihood of breast cancer recurrence. This test is intended for women with early-stage (Stage I or II), node-negative, estrogen receptor-positive (ER+) invasive breast cancer who will be treated with hormone therapy. Oncotype DX looks at a panel of 21 genes in cells taken during tumor biopsy. The results of the test are given in the form of a recurrence score that indicates likelihood of recurrence at 10 years." }, { "id": "pubmed23n0671_14807", "title": "Family history of breast cancer in first-degree relatives and triple-negative breast cancer risk.", "score": 0.012732365673542145, "content": "Triple-negative breast cancer accounts for less than 20% of breast cancers overall, but is the predominant subtype among carriers of mutations in BRCA1. However, few studies have assessed the association between breast cancer family history and risk of triple-negative breast cancer. We examined the relationship between having a family history of breast cancer in first-degree relatives and risk of triple-negative breast cancer, and risk of two other breast cancer subtypes defined by tumor marker expression. We evaluated data collected by the Breast Cancer Surveillance Consortium from 2,599,946 mammograms on 1,054,466 women, among whom 15% reported a first-degree family history of breast cancer. Using Cox regression in this cohort, we evaluated subtype-specific associations between family history and risk of triple-negative (N = 705), estrogen receptor-positive (ER+, N = 10,026), and hormone receptor-negative/HER2-expressing (ER-/PR-/HER2+, N = 308) breast cancer among women aged 40-84 years. First-degree family history was similarly and significantly associated with an increased risk of all the subtypes [hazard ratio (HR) = 1.73, 95% confidence interval (CI): 1.43-2.09, HR = 1.62, 95% CI: 1.54-1.70, and HR = 1.56, 95% CI: 1.15-2.13, for triple-negative, ER+, and ER-/PR-/HER2+, respectively]. Risk of all the subtypes was most pronounced among women with at least two affected first-degree relatives (versus women with no affected first-degree relatives, HR(triple-negative) = 2.66, 95% CI: 1.66-4.27, HR(ER+) = 2.05, 95% CI: 1.79-2.36, HR(ER)-(/PR)-(/HER2+) = 2.25, 95% CI: 0.99-5.08). Having a first-degree family history of breast cancer was associated with an increased risk of triple-negative breast cancer with a magnitude of association similar to that for the predominant ER+ subtype and ER-/PR-/HER2+ breast cancer." }, { "id": "pubmed23n0715_5826", "title": "Negative/low HER2 expression alone or combined with E-cadherin positivity is predictive of better prognosis in patients with breast carcinoma.", "score": 0.01247457627118644, "content": "The loss of E-cadherin expression leads to absence of tissue integrity, an essential step in tumor progression. Methylation of CpG islands in the promoter region of the CDH1 gene coding E-cadherin might be an alternative for gene silencing. In the present study, we investigate the expression of E-cadherin and hormone receptors in invasive ductal breast carcinoma (IDCs). Protein expression was analysed immunohistochemically in 87 cases, including 26 familial tumors. The most interesting results revealed a significantly reduced E-cadherin expression in cases with familial history compared to sporadic tumors (p=0.009), as well as with tumors ≤5 cm (p=0.022). Moreover, HER2 over-expression was associated with distant metastasis (p=0.011) and overall survival (p log rank=0.028). Tumors displaying negative/low HER2 expression combined with E-cadherin positivity confer better patient survival (p=0.052). Triple Negative tumors (TN) were more frequently found in patients with advanced grade (GIII) (p=0.001) and TNM (III+IV) (p=0.018) which supports the aggressive behavior of TN tumors. On the other hand, hypermethylation of CDH1 gene promoter was observed in 46% of hereditary cases and strongly associated with loss of E-cadherin expression (p=0.002). Furthermore, patients with unmethylated CDH1 pattern have a better 5-year disease free survival (p=0.021). In conclusion, in patients with hereditary breast cancer, the CpG methylation event contributes to the loss of E-cadherin expression. On the other hand, HER2 over-expression is predictive of worse prognosis, either alone or combined with loss of E-cadherin expression in Tunisian patients with breast cancer." }, { "id": "pubmed23n0887_4130", "title": "Seven-year survey of classical and pleomorphic invasive lobular breast carcinomas in women from southeastern Serbia: Differences in clinicopathological and immunohistochemical features.", "score": 0.012441280093951849, "content": "The occurrence of different variants of invasive lobular carcinoma (ILC) of the breast is variable. For example, the pleomorphic variant of ILC has an incidence of around 5%; however, the number of analyzed cases of ILC is shadowed by the number of ductal type carcinoma (IDC). Thus, we aimed to analyze the classical and pleomorphic ILCs in women from southeastern Serbia. Analyzed were 296 cases (11.91%) diagnosed with ILC, out of 2486 cases of all breast cancers (BCs), during a 7-year period (2005-2011) from southeastern Serbia. The differences in clinicopathological and immunohistochemical features (estrogen receptor/ER, progesterone receptor/ PR, HER-2, Ki-67, BRCA-1, p53 and E-cadherin) of these cases of ILCs were assessed and compared. Pleomorphic ILC occurred relatively rarely compared to other variants, however almost one fifth of the ILC cases were pleomorphic. No statistically significant correlation was found between patient age, tumor stage and the presence/absence of multifocality (MFC), multicentricity (MCC) and bilaterality (BL) on one side, and ILC variant on the other. Only the expression of two prognostic and predictive immunohistochemical markers, important for endocrine therapy, ER and PR, showed significant correlation with the ILC variant. Although higher tumor stage, incidence of multicentricity, overexpression of HER2 and higher p53 positivity were deemed to be characteristic of pleomorphic ILC, in our study that included a much larger number of cases than previous studies did, such correlations were not observed. Thus, it appears that the only two features of pleomorphic ILCs is absence of ER and PR positivity." }, { "id": "pubmed23n0289_14463", "title": "Breast cancer and family history: a multivariate analysis of levels of tumor HER2 protein and family history of cancer in women who have breast cancer.", "score": 0.011782661782661782, "content": "The HER2 gene, located on the long arm of chromosome 17, codes for a protein with the characteristics of a growth factor receptor. In a preliminary study, we reported that high levels of tumor HER2 (erbB-2/neu) protein are associated with a family history of breast cancer (that is, one or more female blood relatives with breast cancer). We have now collected a larger number of subjects (94) and performed a multivariate analysis of the independent variables family history of breast cancer, tumor estrogen receptor, age, and tumor DNA index. Family history of breast cancer was assessed by questioning the patient, in many cases by telephone. HER2 levels were significantly higher in women with a family history of breast cancer (p = 0.015, two-tailed t-test). The 27 women with family history were predominantly postmenopausal, mean age 61 +/- 2.3 (mean +/- SEM), versus a mean age of 56 +/- 1.7 for the 67 women with no family history. Of the 27 women with a family history of breast cancer, 13 had a first-degree relative (mother or sister) with the disease. The remaining 14 women had other relatives (grandmothers, aunts, cousins, or a niece) with breast cancer. The results of multiple linear regression analysis, with HER2 as the dependent variable, showed that family history of breast cancer was significantly associated with elevated HER2 levels in the tumors (p = 0.0038), after controlling for the effects of age, tumor estrogen receptor, and DNA index. The association of family history of breast cancer and elevated tumor HER2 protein suggests that postmenopausal familial breast cancer may be associated with altered HER2 expression." }, { "id": "pubmed23n0976_164", "title": "BRCA1/BRCA2 mutations in Japanese women with ductal carcinoma in situ.", "score": 0.011595079653155878, "content": "Ductal carcinoma in situ (DCIS) is considered a component of the clinical spectrum of breast cancer even in those with BRCA1/2 mutation. The aim of this study was to report the feature of DCIS raised in Japanese women with BRCA1/2 mutations. A total of 325 Japanese women with breast cancer (BC) (with or without invasive cancer) were referred for genetic counseling and underwent genetic testing for mutations in the BRCA1 and BRCA2 genes in Showa University Hospital between December 2011 and August 2016. And 49 of them who were pathologically diagnosed as DCIS were included in this study. Logistic regression models were fit to determine the associations between potential predictive factors and BRCA status. A Cox proportional hazards model is used to predictive value of parameters for Ipsilateral breast tumor recurrence (IBTR) and contralateral breast tumor recurrence (CBTR). (a) Of 325 patients (with or without invasive cancer), 19.1% (62/325) tested positive for BRCA1/BRCA2 mutations. And 18.4% (9/49) was positive for BRCA1/BRCA2 mutations in DCIS, compared with 19.2% (53/276) in IDC (p = 1.000). Among BRCA mutations, 14.5% (9/62) had DCIS compared with nonmutations (15.2%, 40/263). Incidence of DCIS was 3.0% (1/33) of BRCA1 mutations and 27.5% (8/29) of BRCA2 mutation (p = 0.009). (b) Median age of diagnosis in BRCA mutation carriers was 39 years, compared with 46 years in noncarriers. Age, Family history (FH) of BC, FH of first or second BC and total number of relatives with BC diagnosis (DX) has significant difference between BRCA mutation carriers and noncarriers in univariate analysis. In a multivariate logistic model, total relatives with BC DX ≥ 2 (odds ratio [OR], 5.128; 95% confidence interval [CI], 1.266-20.763; p = 0.022), age at diagnosis ≤35 years (OR 0.149, 95% CI 0.023-0.954, p = 0.045) and ER+/HER2+ status (OR 5.034, 95% CI 1.092-23.210, p = 0.038) remained as independent significant predictors for BRCA mutation. Ki67 index (cut off by 14% or 30%) did not differ between BRCA mutation carriers and noncarriers (p = 0.459 and p = 0.651). (c) There was a significant difference in ER-positive tumors among BRCA2 carriers and noncarriers (p = 0.042). Subgroup analysis showed BRCA2 carriers tend to be of higher grade (Grade 2 and 3), more frequently ER+/PR+ (p = 0.041) and lower proliferation (Ki67 index) than noncarriers, whereas differences in nuclear grade and ki67 index were not found significantly in our study. (d) BRCA mutation was not associated with an increased risk of IBTR and CBTR. DCIS is equally as prevalent in patients who were BRCA mutation carriers as in high familial-risk women who were noncarriers, but occurs at earlier age. BRCA2 carriers have higher incidence in DCIS than that of BRCA1 carriers, and tend to be higher grade and more frequently ER positive and lower proliferation. Total relatives with BC DX ≥2, age at diagnosis ≤35 years and ER+/HER2+ might be independent predictors for BRCA mutation in Japanese women with DCIS and patients of these risk factors should be recommended to receive genetic counseling and BRCA testing." }, { "id": "article-18576_4", "title": "Male Breast Cancer -- Etiology", "score": 0.009947393591582976, "content": "Similarly to women, males have a higher risk of breast cancer if they have a first- or second-degree relative with breast cancer. Studies have shown that an affected sibling or parent of either gender may increase the risk of breast cancer in either the males or females in the family. Bevier et al. (2012) noted in their study that the relative risk (RR) of breast cancer was similar in either offspring when the father or mother was affected (RR = 1.73 and 1.74, respectively), but the risk was slightly higher in the females when the brother is affected as opposed to when the sister is affected (RR = 2.48 and 1.39, respectively). [3] Also, in addition to a family history of breast cancer, males with a BRCA mutation appear to have increased risk for breast cancer as well. Although rare for a male to have a BRCA mutation, those with BRCA2 carrier mutation have a 6% increased risk and BRCA1 with a 4% risk of developing the disease. [4] Other genetic disorders have been implicated in increasing the risk of MBC, including Klinefelter syndrome (47, XXY), Cowden syndrome ( PTEN tumor suppressor gene), Li-Fraumeni syndrome ( TP53 ), Lynch syndrome ( PALB2 and mismatch repair genes). [2] [4]" }, { "id": "wiki20220301en191_9178", "title": "Metaplastic carcinoma", "score": 0.009900990099009901, "content": "Metaplastic carcinoma, otherwise known as metaplastic carcinoma of the breast (MCB), is a heterogeneous group of cancers that exhibit varied patterns of metaplasia and differentiation along multiple cell lines. This rare and aggressive form of breast cancer is characterized as being composed of a mixed group of neoplasms containing both glandular and non-glandular patterns with epithelial and/or mesenchymal components. It accounts for fewer than 1% of all breast cancer diagnoses. It is most closely associated with invasive ductal carcinoma of no special type. (IDC), and shares similar treatment approaches. Relative to IDC, MCB generally has higher histological grade and larger tumor size at time of diagnosis, with a lower incidence of axillary lymph node involvement. MCB tumors are typically estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor-2 (HER-2) negative, meaning hormone therapy is generally not an effective treatment option, which correlates to" }, { "id": "pubmed23n0598_18737", "title": "Breast cancer expression of E-cadherin does not differ between patients with positive and negative oncological history.", "score": 0.009900990099009901, "content": "The question of whether or not non-sporadic breast malignancies have different immunohistochemical features than sporadic malignancies has not been investigated previously. Consequently, the purpose of this study was to compare the expression of E-cadherin (EC) in breast cancer patients with positive and negative oncologic histories. The study included 98 breast cancer patients divided into two groups: 1) without the personal or familial history of previous malignancies, and 2) with the personal history of previous malignancies and/or with the data on cancer episodes in first- and/or second-degree relatives. There were no significant differences in the expression of EC between breast malignancies of the two groups. Moreover, statistical relationships were not observed between the positive or negative oncologic history, the age, and the menopausal status of patients, or histological tumor grade. Although the results of our series revealed no significant differences in the expression of EC between assumed sporadic and assumed non-sporadic malignancies, there is a need for further comparative studies on the immunohistochemistry of both the breast carcinoma types in order to find the other biological markers that could suggest or exclude cancer susceptibility in a given patient. Nevertheless, the results of our study suggest that EC immunohistochemistry cannot be used as a surrogate marker for screening for hereditary breast cancer." }, { "id": "wiki20220301en188_32824", "title": "Somatostatin receptor 2", "score": 0.00980392156862745, "content": "other components of the endocrine system and nervous system, so it can be drawn that the receptor family has great influence among these systems. The family was first discovered in a segment of a rat's pituitary gland known as the tumor cell line. A cell line is grown as a culture under controlled conditions, so the first discovery was found by culturing these cells in controlled conditions and in an environment outside of its norm. There, researchers found that the tumor cell line expresses a cell dividing inhibitor known as the transforming growth factor beta (TGF-beta) and also acts as an inhibitor to the milk producing hormone in female mammals, prolactin, and growth hormones. Researchers studied the activity of the receptors by conducting an assay with Ligand binding studies, which basically means they were conducting studies to see how prevalent the binding of the receptors occurred. Differences in how prevalently they receptors bonded revealed the existence of multiple" }, { "id": "pubmed23n0396_8364", "title": "Does family history influence survival in breast cancer cases?", "score": 0.00980392156862745, "content": "A few studies have suggested a relatively better prognosis for breast cancer (BC) cases reporting a positive family history (FH). We aimed at comparing the survival of patients according to FH in a large hospital-based series of 1,278 BC cases. Information on FH for BC was obtained at diagnosis by interview. All cases reporting a first- or second-degree FH for breast carcinoma were compared with cases without FH. Overall survival was estimated using a product-limit method. Hazard ratios (HRs) and the corresponding 95% confidence intervals (95% CIs), adjusted for confounding factors, were computed using proportional hazard models. Overall, 240 (18.8%) cases reporting, at diagnosis, a positive FH (156 with at least 1 first-degree relative and 84 with at least 1 second-degree relative) were compared with 1,038 patients without FH for BC. No significant differences were found in terms of distribution of age at diagnosis, tumor stage, nodal involvement, receptor status and histology. Cumulative survival rates at 5 years for cases without FH and with first-degree and second-degree FH for BC were 79.8 (95% CI 77.0-83.0), 78.6 (95% CI 70.0-88.0) and 80.2 (95% CI 68.0-92.0), respectively (log-rank test, chi(2) (2) = 0.02, p = 1.0). After adjustment for age, pathologic size and nodal involvement, the HR among cases of invasive cancer with a first-degree FH of BC was 0.91 (95% CI 0.55-1.48); however, the HR for cases with second-degree FH was 1.18 (95% CI 0.62-2.25) compared to cases without FH. Our study, based on a large series of consecutive invasive BC cases, did not find any significant survival differences associated with a positive FH for breast carcinoma, suggesting the existence of a large heterogeneity among BC cases with FH." }, { "id": "wiki20220301en301_10160", "title": "Combined small-cell lung carcinoma", "score": 0.009708737864077669, "content": "Pemetrexed has been shown to improve survival in non-squamous cell NSCLC, and is the first drug to reveal differential survival benefit in large cell lung carcinoma. C-SCLC appear to express female hormone (i.e. estrogen and/or progesterone) receptors in a high (50–67%) proportion of cases, similar to breast carcinomas. However, it is at present unknown whether blockade of these receptors affects the growth of c-SCLC. Prognosis Current consensus is that the long-term prognosis of c-SCLC patients is determined by the SCLC component of their tumor, given that \"pure\" SCLC seems to have the worst long-term prognosis of all forms of lung cancer. Although data on c-SCLC is very sparse, some studies suggest that survival rates in c-SCLC may be even worse than that of pure SCLC, likely due to the lower rate of complete response to chemoradiation in c-SCLC, although not all studies have shown a significant difference in survival." }, { "id": "pubmed23n0324_15364", "title": "Clinical characteristics of breast cancer patients with family history.", "score": 0.009708737864077669, "content": "This study was conducted to acquire information as to the clinicopathological characteristics of breast cancer patients with family history. Of 583 patients with breast cancer, 60 (10.3%) had family history in at least one relative within the second-degree. The affected family member was most frequently a sister (43%), followed by the mother (23%) and an aunt (20%). Comparison of the data for the patients between with and without family history revealed no significant differences for any of mean age, menopausal status, histological type, histological staging, and estrogen receptor status. Although the sample size was small, neither the survival rate nor the bilaterality of disease was influenced by the family history of breast cancer." }, { "id": "wiki20220301en034_42642", "title": "Selective estrogen receptor modulator", "score": 0.009615384615384616, "content": "Tamoxifen is a first-line hormonal treatment of ER-positive metastatic breast cancer. It is used for breast cancer risk reduction in women at high risk, and as adjuvant treatment of axillary node-negative and node-positive, ductal carcinoma in situ. Tamoxifen treatment is also useful in the treatment of bone density and blood lipids in postmenopausal women. Adverse effects include hot flushes and more serious is two to three times higher relative risk of developing endometrial cancer compared to women of an age-matched population. Toremifene, a chlorinated tamoxifen derivative, causes fewer DNA adducts in liver than seen with tamoxifen in preclinical studies and was developed to avoid hepatic carcinomas. It is used as endocrine therapy in women with ER/PR-positive stage 4 or recurrent metastatic breast cancer and has demonstrated similar efficacy compared to tamoxifen as adjuvant treatment of breast cancer and in the treatment of metastatic breast cancer." }, { "id": "wiki20220301en188_32364", "title": "Parathyroid hormone 1 receptor", "score": 0.009523809523809525, "content": "Interactions Parathyroid hormone 1 receptor has been shown to interact with Sodium-hydrogen exchange regulatory cofactor 2 and Sodium-hydrogen antiporter 3 regulator 1. Model organisms Model organisms have been used in the study of PTH1R function. A conditional knockout mouse line called Pth1rtm1a(EUCOMM)Hmgu was generated at the Wellcome Trust Sanger Institute. Male and female animals underwent a standardized phenotypic screen to determine the effects of deletion. Additional screens performed: - In-depth immunological phenotyping See also Parathyroid hormone receptor References Further reading External links G protein-coupled receptors" }, { "id": "pubmed23n0494_12555", "title": "Prognosis of breast cancer patients with familial history classified according to their menopausal status.", "score": 0.009523809523809525, "content": "Breast cancer patients were classified in the family history positive (FHP) group when they had at least one second-degree relative who was a breast cancer patient. The results of a comparative study with patients classified in the family history negative (FHN) group showed the prognosis of the FHP group was significantly better than that of the FHN group. However, when those patients were classified according to their menopausal status at onset, there were no significant differences in survival rates between the FHP and FHN groups with onset before menopause, whereas the survival rate of the FHP group was significantly higher than that of the FHN group with onset after menopause. The same results were found when the FHP group was subgrouped into the FHP group with first-degree relatives and the FHP group with second-degree relatives. Further investigations on background factors revealed that the patients with onset before menopause showed no significant differences between the FHP and FHN groups in age at surgery, diameter of the tumor, histologic grade, the number of metastatic lymph nodes, body weight, estrogen receptor (ER) status, and the values of CEA and CA15-3 before surgery. On the other hand, the FHP patients with onset after menopause showed significantly lower numbers of metastatic lymph nodes and trends showing higher ER values and lower CA15-3-values. Therefore the favorable prognosis in the FHP group seems to be attributable to the higher survival rate of the FHP patients with onset after menopause." }, { "id": "wiki20220301en615_20221", "title": "Karen E. Knudsen", "score": 0.009433962264150943, "content": "Research Knudsen is an oncology researcher whose studies are focused on precision medicine in advanced prostate cancer, with an emphasis on understanding therapeutic relapse and designing new means of clinical intervention. Her translational studies have resulted in new clinical trials targeting DNA repair, cell cycle, and hormonal regulation pathways in patients with advanced disease. Knudsen and her colleagues discovered the mechanisms by which androgen signaling impacts cancer cell proliferation and DNA repair processes, and identified novel strategies for therapeutic intervention. Notable discoveries include identification of RB tumor suppressor loss as a major mechanism of therapeutic bypass, discovery of the androgen-DNA repair axis, and elucidation of androgen receptor function in the mitotic cell cycle. Her discoveries were amongst the first to propose utilization of PARP 1/2 inhibitors for advanced disease, now an FDA-approved agent for selected prostate cancers." }, { "id": "pubmed23n0263_11157", "title": "A clinicopathological analysis of breast cancer in patients with a family history.", "score": 0.009433962264150943, "content": "A study was conducted to investigate the clinical and pathological characteristics of breast cancer in patients with a family history (FH). Among 4,481 primary breast cancer patients, 394 (8.8%) had families which included two or more breast cancer patients within three generations (FH(+)group). This group was compared with the remaining 3,969 patients (FH(-) group) with the following results: (1) The tumor diameter in the FH(+) group was slightly less than that in the FH(-) group [not significant (NS)], with fewer lymph node metastases (P &lt; 0.05); (2) the positive rates for the estrogen receptor were 52% (138/266) and 49% (1,216/2,481), respectively (NS); (3) expression of the c-erbB-2 protein was observed in 14 out of 40 (35%) and 32 out of 100 cases (32%), respectively (NS); (4) the relative risk of bilateral occurrence in the FH(+) group was 1.4, with a 95% confidence interval of 0.9-2.4; (5) the 15-year survival rate was 72% and 60%, respectively, suggesting a better prognosis for the FH(+) group (P &lt; 0.01); and (6) multivariate analysis showed that the contribution of FH to postoperative survival was marginal (P = 0.07). Factors related to the hormonal environment such as age at menarche (P = 0.08) and age at menopause (P = 0.08) made a greater but non-significant contribution to the prognosis of the FH(+) group than to that of the FH(-) group. However, further genetic and molecular biological analyses of familial breast cancer are needed in order to clarify the mechanisms of cancer accumulation within families." }, { "id": "pubmed23n0845_17093", "title": "Does the age of breast cancer diagnosis in first-degree relatives impact on the risk of breast cancer in BRCA1 and BRCA2 mutation carriers?", "score": 0.009423968218936218, "content": "The purpose of this study is to estimate the age-specific annual risks of breast cancer in a woman with a germline BRCA mutation and an affected first-degree relative according to the age of breast cancer diagnosis in the relative. Women with BRCA mutations with no previous diagnosis of breast cancer and with one first-degree relative with breast cancer were followed for breast cancers for a mean of 5.9 years (minimum 2 years). Age-specific annual breast cancer risks were calculated, according to the age of breast cancer diagnosis in the proband and the first-degree relative. 1114 cancer-free women with a BRCA mutation with a single first-degree relative with breast cancer were eligible for the study. 122 women (11.0 %) were diagnosed with incident breast cancer. The annual risk of breast cancer was 2.0 % for women with BRCA1 mutations and was 1.6 % for women with BRCA2 mutations. The age of breast cancer diagnosis in the first-degree relative did not affect the annual breast cancer risks for BRCA1 mutation carriers. For BRCA2 mutation carriers, the annual breast cancer risk was 4.5 % for women with a first-degree relative diagnosed with breast cancer under the age of 30 years and was 0.7 % for women with a relative diagnosed over the age of 60. Among women with BRCA2 mutations, a family history of early-onset breast cancer is a risk factor for developing breast cancer. Risk assessment for healthy BRCA2 mutation carriers should consider the ages of breast cancers diagnosed in first-degree relatives." }, { "id": "wiki20220301en490_9660", "title": "Abemaciclib", "score": 0.009345794392523364, "content": "As of early 2016, abemaciclib was involved in 3 Phase III clinical trials: The JUNIPER Study is comparing abemaciclib against erlotinib in patients with stage IV non-small-cell lung carcinoma Due to collect data until September 2017. The MONARCH 2 study is investigating the effectiveness of abemaciclib in combination with fulvestrant for women with breast cancer. It is due to end in Feb 2017. In March 2017, Eli Lilly announced that it had met its primary endpoint of superior progression-free survival (PFS) over placebo plus fulvestrant in patients with estrogen receptor positive and HER2 negative advanced or metastatic breast cancer. This result led to the September 2017 FDA approval. The MONARCH 3 study is investigating the effectiveness of abemaciclib, plus either anastrozole or letrozole, as a first-line treatment for women with breast cancer. The trial is expected to end in June 2017." }, { "id": "wiki20220301en406_12297", "title": "Dynamic angiothermography", "score": 0.009259259259259259, "content": "DATG is able to detect changes in blood flow that are indicative of breast cancer, may be used for younger patients, is completely non-invasive (no need for radiation or contrast agent, no need for compression of the breast) and is lower cost than alternatives requiring minimal facilities. This technology, performed quickly (5–6 minutes for visit) and very precise, is useful for screening and is also able to detect precancerous lesions. Studies have been conducted that have shown how it is possible, by means of this methodology, to diagnose invasive ductal carcinoma and infiltrating lobular carcinoma with the same accuracy. DATG can be strategic for young patients, or patients with dense breasts where the contrastive performance of mammography is challenged. Another application of DATG is the monitoring of at-risk patients with increased changes of breast cancer who take hormone replacement therapy (sometimes taken to reduce menopause symptoms) and participate in in-vitro" }, { "id": "pubmed23n0933_10246", "title": "Family History and Risk of Second Primary Breast Cancer after <i>In Situ</i> Breast Carcinoma.", "score": 0.009259259259259259, "content": "<bBackground:</b Incidence rates of <iin situ</i breast carcinomas have increased due to widespread adoption of mammography. Very little is known about why some women with <iin situ</i breast cancer later develop second primary breast cancers.<bMethods:</b In this population-based nested case-control study among <iin situ</i breast cancer survivors, including 539 cases with a second primary breast cancer and 994 matched controls, we evaluated the association between first-degree family history of breast cancer and risk of developing a second primary breast cancer.<bResults:</b First-degree family history of breast cancer was associated with an increased risk of developing a second primary breast cancer among women with a previous <iin situ</i breast cancer [odds ratio (OR) = 1.33, 95% confidence interval (CI), 1.05-1.69] and those with two or more affected first-degree relatives had an even higher risk (OR = 1.94; 95% CI, 1.15-3.28). Those whose relative was diagnosed at less than 50 years old were more likely to develop a second primary breast cancer (OR = 1.78; 95% CI, 1.24-2.57). No difference in risks associated with number or age of affected relatives was observed by menopausal status.<bConclusions:</b Results from this study suggest that first-degree family history of breast cancer may be an important risk factor for development of a second primary breast cancer among women with a previous <iin situ</i breast cancer.<bImpact:</b Given the growing population of <iin situ</i breast cancer survivors, a better understanding of risk factors associated with development of a second primary breast cancer is needed to further understand risk. <iCancer Epidemiol Biomarkers Prev; 27(3); 315-20. ©2018 AACR</i." }, { "id": "pubmed23n0416_23268", "title": "Linking Histopathology and Family History in Breast Cancer.", "score": 0.009174311926605505, "content": "In order to assess the prognostic value of family history (FH) of malignancies in patients afflicted with breast cancer (BC), we examined FH and histopathologic characteristics of 542 Iranian primary BC patients. Cases with distant metastasis at the time of diagnosis were excluded. Mean age of the studied population was 49 and the most common presenting stage was stage IIA followed by stage IIB. Data on a total of 6089 relatives (1st to 4th generations with the assumption of probands as the 3rd generation) were gathered. FH of BC and other malignancies (OM) was positive in 29 and 54% of cases, respectively. The most common OM's were gastric (67), lung (52) and uterus (47) cancers. We found that a FH of BC does not have any significant correlation with proven prognostic factors but a history of BC among relatives at or before the age of 36 is associated with more aggressive tumours. On the other hand, although FH of OM was associated with an older age of the probands (which is generally associated with a favourable prognosis), tumours of the cases with FH of OM had higher grades, lymphatic invasion being detected more frequently. Also we noted that the younger the age of the relatives diagnosed with cancer, the higher the stage of the probands themselves. All together our study indicates the possibility of a relation between FH of BC and OM, and histopathologic characteristics of the probands' tumours which would put forward FH as a prognostic factor rather than a simple risk factor in BC." }, { "id": "pubmed23n0895_25005", "title": "Family history of cancer other than breast or ovarian cancer in first-degree relatives is associated with poor breast cancer prognosis.", "score": 0.00909090909090909, "content": "Whether a first-degree family history of others cancers (FHOC) than breast or ovarian cancer (BOC) is associated with breast cancer prognosis remains unknown. Thus, the aim of the present study was to clarify this issue. Women who were diagnosed with invasive breast cancer at the Renmin Hospital of Wuhan University from 2010 to 2013 were included in the study. The demographic and clinicopathological characteristics of these patients were extracted. FHOC was considered positive for any patient who had a relative who had been diagnosed with cancer other than BOC. Disease-free survival (DFS) was calculated based on the date of diagnosis. DFS was analyzed using the Cox proportional hazards model. A total of 434 breast cancer patients were included in this study. Among these patients, 61 (14.06%) had a positive FHOC in first-degree relatives. Patients with a positive FHOC tended to have HER2-positive breast cancer (p = 0.03). In the survival analysis, FHOC was associated with poor DFS in both univariate (HR = 2.21 (1.28-3.83), 95% CI: 1.28-3.83, p &lt; 0.01) and multivariate (HR = 2.50, 95% CI: 1.24-5.04, p = 0.01) analyses, especially in patients with luminal A subtypes. The results demonstrated an increased risk of recurrence in breast cancer patients with FHOC, especially in patients with luminal A subtype." }, { "id": "wiki20220301en200_7950", "title": "CDH1 (gene)", "score": 0.009009009009009009, "content": "Clinical significance Loss of E-cadherin function or expression has been implicated in cancer progression and metastasis. E-cadherin downregulation decreases the strength of cellular adhesion within a tissue, resulting in an increase in cellular motility. This in turn may allow cancer cells to cross the basement membrane and invade surrounding tissues. E-cadherin is also used by pathologists to diagnose different kinds of breast cancer. When compared with invasive ductal carcinoma, E-cadherin expression is markedly reduced or absent in the great majority of invasive lobular carcinomas when studied by immunohistochemistry. E-cadherin and N-cadherin temporal-spatial expression are tightly regulated during cranial suture fusion in craniofacial development. Interactions CDH1 (gene) has been shown to interact with CBLL1, CDC27, CDON, CDH3, C-Met, CTNND1, CTNNB1, CTNNA1 FOXM1, HDAC1, HDAC2, IQGAP1, FYN, NEDD9, Plakoglobin, Vinculin, PTPmu(PTPRM) PTPrho(PTPRT)" }, { "id": "pubmed23n0759_12700", "title": "Retrospective analysis of clinicopathological characteristics and family history data of early-onset breast cancer: a single-institutional study of Hungarian patients.", "score": 0.009009009009009009, "content": "Patients at young age (≤ 35 years) diagnosed with breast cancer (BC) are considered to have poor prognosis. The aim of the present study was to retrospectively analyse clinicopathological characteristics and prognosis in a group of young BC patients. We included women diagnosed with invasive breast carcinoma younger than/or at the age of 35 years. Between 1999 and 2009, 107 women with early-onset BC were selected from the database of the 2nd Department of Pathology at Semmelweis University. For clinicopathological comparison, 55 women (36-45 years), 214 women (46-65 years), 110 women (66-75 years) and 58 women (76 ≤ years) were also included in the analysis. Family history, clinicopathological and follow-up data were analysed. The tissue specimens were reviewed for histological type, nuclear grade, and estrogen receptor (ER), progesterone receptor (PgR), Ki67 and HER2 status (IHC4). The mean age in the study group was 31.6 years at the time of diagnosis. Histology showed a high incidence of grade III tumours in this group of patients (67.9 %), while only four cases (3.8 %) were considered grade I. According to the immunohistochemical results, 35.3 % of the study cases were considered as Luminal B (LumB: either being higly proliferative or co-expressing HER2) and 33.3 % as triple negative breast carcinomas (TNBC). The detailed questionnaire related to family history was completed and received in 49/107 cases (45.8 %). Analysis of these data revealed an affected family history of breast or ovarian carcinoma in first and second degree relatives in 51.0 %. A high proportion (52.0 %) of TNBC was observed among young women with a family history of the disease. Survival analysis of the 107 patients showed that 25 (23.3 %) women died until 31 December 2012. No significant difference in survival was detectable considering the regimen of systemic treatment (p = 0.188). Regarding clinicopathological parameters, the immunophenotypes, grade, pT and pN values differred substantially between the age groups (p = 0.001, for all), and the shortest relapse-free survival was seen among the youngest BC patients. This analysis illustrates that breast cancer arising in young women is characterized by the presence of less favorable subtypes such as LumB and TNBC. The increased proportion of TNBC was especially remarquable in the group of patients presenting with family history of the disease. The fact that a high rate of death occurred and no significant difference in OS were notable regarding the scheme of systemic therapies (neoadjuvant vs. adjuvant) highlight the necessity of the development of new treatment strategies." }, { "id": "wiki20220301en470_13910", "title": "Eftilagimod alpha", "score": 0.008928571428571428, "content": "Clinical Trials Ongoing Clinical Studies As of February 2020, three clinical studies are ongoing: Metastatic breast carcinoma (HER2− HR+) In the AIPAC study efti is administered in combination with paclitaxel to women with HER2− metastatic breast cancer whose disease progressed after endocrine therapy. This Phase IIb trial is a randomized, double-blind, placebo-controlled study aiming to enroll 241 patients. It had an open run-in phase with 15 patients being treated and the results were published at the 2018 ASCO annual meeting. The study is ongoing and is expected to show results in the first half of 2020. Solid Tumors The INSIGHT Phase I study is investigating the feasibility and safety of different routes of drug delivery (e.g. intra-tumoral, intra-peritoneal, and subcutaneous)." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 92, 294 ] ], "word_ranges": [ [ 18, 46 ] ], "text": "Post-surgical endophthalmitis is more associated with patients in the immediate postoperative period, besides being very painful with rapidly progressive decrease in visual acuity, so it is not correct." }, "2": { "exist": true, "char_ranges": [ [ 295, 443 ] ], "word_ranges": [ [ 46, 70 ] ], "text": "Retinal detachment is consistent with the clinical case because it is also a myopic patient who tend to have a special predisposition to detachment." }, "3": { "exist": true, "char_ranges": [ [ 444, 524 ] ], "word_ranges": [ [ 70, 83 ] ], "text": "ARMD usually occurs in older patients and the decrease in vision is progressive." }, "4": { "exist": true, "char_ranges": [ [ 525, 684 ] ], "word_ranges": [ [ 83, 113 ] ], "text": "In PVD there may or may not be a slight decrease in visual acuity and the patient usually reports some discomfort or pain at the onset of the clinical picture." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Post-surgical endophthalmitis.", "2": "Retinal detachment.", "3": "Age-related macular degeneration, wet form.", "4": "Posterior vitreous detachment.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0725_4623", "title": "[Posterior vitreous detachment and cystoid macular oedema post-cataract surgery: a case report].", "score": 0.015582808280828083, "content": "The posterior vitreous detachment consists in the separation between the posterior vitreal cortex and internal limiting membrane of the retina. This is the peak of the vitreal para-physiological age-related modifications. This problem occurs in 6% of normal people of age between 45 and 65 years and in 65% of individuals between 65 and 85 years. Several elements can be responsible for vitreous modifications, such as senility, myopia, aphakia, pseudophakia, diabetes, degeneration vitreous retinal hereditary, traumatisms, inflammation. A 75 year old male patient has come to our attention for a left eye cataract. He has undergone to a series of OCT: the first before surgery showed a perifoveal vitreous detachmen; the following ones until six months after surgery put in evidence the DPV progression accompanied by EMC, relating it with visual symptomatology. Therefore, OCT is a useful tool for a clinical analysis but also for the contribution to research concerning the pathogenesis of diseases due to vitreo-retinal modification." }, { "id": "wiki20220301en028_4306", "title": "Retinal detachment", "score": 0.01475924291458272, "content": "Retinal detachment is more common in those with severe myopia (above 5–6 diopters), as their eyes are longer, their retina is thinner, and they more frequently have lattice degeneration. The lifetime risk increases to 1 in 20. Myopia is associated with 67% of retinal detachment cases. Patients suffering from a detachment related to myopia tend to be younger than non-myopic detachment patients. Retinal detachment can occur more frequently after surgery for cataracts. The estimated of risk of retinal detachment after cataract surgery is 5 to 16 per 1000 cataract operations. The risk may be much higher in those who are highly myopic, with a frequency of 7% reported in one study. Young age at cataract removal further increased risk in this study. Long term risk of retinal detachment after extracapsular and phacoemulsification cataract surgery at 2, 5, and 10 years was estimated in one study to be 0.36%, 0.77%, and 1.29%, respectively." }, { "id": "pubmed23n1107_19022", "title": "Bilateral Retinal Detachments in a Healthy 22-year-old Woman After Moderna SARS-COV-2 Vaccination.", "score": 0.014381914381914381, "content": "Although uncommon, retinal detachments are medically urgent and can result in permanent vision loss if untreated. Bilateral retinal detachments in healthy individuals are even more rare. In addition, there are no cases to date of retinal detachment associated with either coronavirus disease 2019 (COVID-19) or after receiving the Moderna (mRNA-1273) severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccine. A 22-year-old woman with myopia but no ocular trauma or other major medical history presented to the emergency department with 5 days of progressive, painless vision loss in her right eye. On examination, her visual acuity with corrective lenses was 20/70 in the right eye, 20/20 in the left eye, and 20/25 with both eyes open. Point-of-care ultrasound of the eye showed a retinal detachment in the right eye. She was subsequently seen by ophthalmology and diagnosed with bilateral retinal detachments (macula off in the right, macula on in the left), despite being asymptomatic in her left eye. She underwent bilateral vitrectomies for simultaneous rhegmatogenous retinal detachments. Although the patient denied any preceding trauma, she did note having received her second dose of the COVID-19 vaccine 10 days before the onset of symptoms.Why Should an Emergency Physician Be Aware of This? We present a rare and unusual case of simultaneous bilateral retinal detachments in a healthy, young woman with no major medical history or medications. She received the COVID-19 vaccine a few days prior. Our case outlines a possible association with the vaccine and emphasizes the importance of ultrasonography in diagnosing time-sensitive medical conditions." }, { "id": "pubmed23n0688_8193", "title": "[Pseudophakic retinal detachment].", "score": 0.014043245756800743, "content": "Modern phacoemulsification has established itself as a safe and very rewarding surgical procedure. Patients and surgeons may not associate late complications with the initial surgery. However, recent studies have demonstrated that such a causal relationship may persist for many years after the cataract procedure and that there is a significant increase in the risk for developing a retinal detachment during the postoperative years. The mean time period between cataract surgery and pseudophakic retinal detachment is between 3 and 4 years. Even uncomplicated cataract surgery alters the physiological processes within the eye and can lead to progressive destruction of the vitreous for many years after the surgery. Therefore, the risk for a retinal detachment is increased for at least 10 years after the initial procedure. In recent epidemiological studies, the most important risk factors for pseudophakic retinal detachment were myopia, younger age and male gender. If all factors are combined, the cumulative risk for developing a retinal detachment after cataract surgery may rise to 20 %. Additional factors that may increase this risk are additional intraoperative complications, for example, rupture of the posterior capsule, vitreous loss or dropped nucleus. Compared to phakic retinal detachments, pseudophakic patients on average present with a shorter history of visual symptoms, are older, more commonly male and display fewer, smaller and more anteriorly located retinal breaks that frequently are only detected during surgery. The anatomic success rates have improved significantly over the past years, in particular through the advances and increasing popularity of primary vitrectomy. However, functional results are still disappointing. Only about half of the patients will achieve reading ability without low vision aids. The increased and long-term risk for pseudophakic retinal detachment should be part of the preoperative consent process of any cataract surgery, in particular, in young myopic males." }, { "id": "wiki20220301en059_60326", "title": "Posterior vitreous detachment", "score": 0.013674798721527694, "content": "Age and refractive error play a role in determining the onset of PVD in a healthy person. PVD is rare in emmetropic people under the age of 40 years, and increases with age to 86% in the 90s. Several studies have found a broad range of incidence of PVD, from 20% of autopsy cases to 57% in a more elderly population of patients (average age was 83.4 years). People with myopia (nearsightedness) greater than 6 diopters are at higher risk of PVD at all ages. Posterior vitreous detachment does not directly threaten vision. Even so, it is of increasing interest because the interaction between the vitreous body and the retina might play a decisive role in the development of major pathologic vitreoretinal conditions, such as epiretinal membrane. PVD may also occur in cases of cataract surgery, within weeks or months of the surgery." }, { "id": "pubmed23n0060_696", "title": "[Stability of posterior chamber lenses 3-5.5 years after implantation in capsular rupture].", "score": 0.013654943179266047, "content": "In cases of PC-IOL implantation and ruptured capsule there will be a higher risk of the lens loosening into the vitreous, although many successful cases have been reported. Three years ago we investigated 42 eyes with PC-IOL that had experienced previous posterior capsular or zonular rents and partial vitreous loss. Three to 5.5 years after PC-IOL implantation we have now performed a second investigation on 38 of these patients to examine fixation of the lenses, visual acuity, intraocular pressure and the fundus of the eye. The 38 lenses all remained stable. The rate of patients achieving 20/40 or better visual acuity decreased from 68% at the first investigation to 55% (21/38). Excluding all patients with vision-limiting preoperative conditions such as age-related macular degeneration, we found a relation-ship of 83% to 75% (21/28). In addition to the three retinal detachments and two cases of endophthalmitis found during the first investigation, we also found another retinal detachment at the follow-up examination. Only two of these six eyes with severe complications had useful vision. We conclude from our investigation that PC-IOL implanted following a posterior capsule-zonular break during ECCE can remain stable, but still lead to serious complications." }, { "id": "pubmed23n0566_13361", "title": "Two-year results of surgical removal of choroidal neovascular membranes related to non-age-related macular degeneration.", "score": 0.01266025641025641, "content": "To present the 2-year outcomes of surgical removal of non-age-related macular degeneration (AMD)-related choroidal neovascular membranes and to evaluate any association between visual outcome and baseline clinical factors. Retrospective consecutive case series. All patients who had surgery for non-AMD-related choroidal neovascularisation (CNV) between November 1997 and March 2003 under the care of a single surgeon (WA) were included in the study. Baseline data including patient age, duration of subfoveal CNV, preoperative visual acuity (VA), lesion size, lesion components and aetiology were collected. The primary outcome was VA change with secondary outcomes retinal detachment, operative peripheral retinal break formation, CNV recurrence and cataract. A total of 52 eyes were included in the study. The aetiology of CNV was: punctate inner choridopathy 21 (40%); idiopathic 8 (15%); pathologic myopia 6 (12%); ocular histoplasmosis syndrome 1 (2%); and other 16 (31%). The mean age of patients was 41(range 14-72) years. 24-month follow-up was available for 41 (80%) eyes. The mean logMAR equivalent baseline acuity was 1.1 and mean lesion size 1.2 disc areas. An improvement in VA &gt;1 Snellen line was noted in 26 (63%) eyes, whereas 10 (24%) eyes remained the same (within 1 line) and 5 (12%) lost &gt;1 line of acuity. Improvement in VA was associated with worse baseline VA (84% for eyes with VA &lt;or=6/36 vs 31% for those with VA&gt;6/36, p=0.001). No evidence of association between 2-year visual outcome and any other baseline factor under study was observed. Peripheral retinal breaks were noted in 5 (10%) eyes at the time of surgery, and 3 (5.8%) eyes developed postoperative retinal detachments. Persistent/recurrent CNV was noted in 17 (33%) eyes. The median time to presentation of CNV in these eyes was 27 (range 2-172) weeks. Five eyes underwent cataract surgery during the follow-up period. The mean age of these patients was significantly higher than the mean age of those who did not require cataract surgery (57 vs 37 years, p=0.014). Surgical excision of non-AMD-related CNV resulted in improvement of VA in the majority of eyes. Worse presenting acuity was associated with better visual improvements." }, { "id": "pubmed23n0502_2778", "title": "[Macular translocation--first experience].", "score": 0.012546269238262225, "content": "The age related macular degeneration (ARMD) is the most common cause of the central visual acuity loss in persons of age more than 60 years in the well developed countries. Rotation of the macula is nowadays a progressive method of choice of treatment of the exsudative form of ARMD. The aim of this surgical technique is to relocate the neuroretinal epithelium of the central region of the retina to a position situated outside the border of the subfoveolar lesion. Three eyes of three patients (2 woman and one man) were operated on during the period between March and May 2001 at the Department of Ophthalmology of the School of Medicine, Charles University in Pilsen. The method used was the scleral imbrication, which belongs to methods designated as \"limited translocation\". The mean age of the patients was 62 years and the follow up period was 2 years. After the surgery the relocation of the fovea was observed in all three eyes. In two eyes, the postoperative period was complicated by tractional retinal detachment that occurred three weeks after the surgery as a consequence of progressive proliferative vitreoretinopathy (PVR). Both eyes with the retinal detachment were re-operated. In both of them, the repeated pars plana vitrectomy, epiretinal membranes removal with relaxing retinectomy was performed and after maximal mobilization of the retina, the silicone oil implantation followed. In the second patient, the postoperative period was complicated by elevation of the intraocular pressure and a radial retinal fold running from the encircling buckle indentation up to the macula. Slightly improved function was noticed only in the first patient after following cataract surgery with intraocular lens implantation. In the two other eyes, as noticed at the last follow up check, the postoperative complications caused severe decrease of the central visual acuity although the retina remained attached. Macular translocation procedure is in stage of development and its surgical techniques are being further modified. The risk of postoperative complications with profound loss of central visual acuity corresponds to the level of the technical difficulty and extent of surgical intervention." }, { "id": "wiki20220301en536_30480", "title": "Atul Kumar (ophthalmologist)", "score": 0.012146743900298403, "content": "Achievements and positions Kumar is a specialist in diseases of the retina, vitreous and uvea and their management. His academic disciplines include Vitreoretinal surgery, Ophthalmic Lasers, Uveal diseases, Macular Hole surgery, anti-VEGF injections, Age Related Macular Degeneration, Retinal Detachment surgery, Myopic Traction Maculopathy, Pathological Myopia and Macular Hole Retinal Detachment." }, { "id": "pubmed23n0597_21915", "title": "Fellow eye findings of highly myopic subjects operated for retinal detachment associated with a macular hole.", "score": 0.011972693856117626, "content": "To identity anatomic risk factors involved in the onset of retinal complications causing decrease of visual acuity (VA) in the fellow eyes of highly myopic patients operated for retinal detachment with macular hole (RDMH). Cohort study. Ninety-eight patients (mean age, 51.5+/-8.0 years) with bilateral high myopia (mean myopia of the fellow eye, 20.4+/-5.5 diopters) affected by RDMH in the other eye at baseline. Evaluation of the anatomic features at baseline and during 84+/-2.7 months of follow-up by biomicroscopic examination, indirect binocular ophthalmoscopy, B-scan ultrasonography, and optical coherence tomography. Detection of anatomic features associated with onset of retinal complications causing decrease of VA during the follow-up period. The fellow eyes were divided into 2 groups according to the clinical features of the RDMH eyes: Group 1, presence of posterior vitreous detachment (PVD); and Group 2, presence of posterior vitreous schisis (PVS). At baseline, the incidence of PVD in group 1 was 31 of 47 eyes (65.9%) and the incidence of PVS in Group 2 was 42 of 51 eyes (82.3%). At the end of follow-up, group 1 eyes had a lower incidence of retinal complications causing visual decrease than group 2 eyes (group 1, 2/47 eyes; group 2, 9/51 eyes). Fellow eyes of RDMH cases with higher degree of myopia and peculiar vitreoretinal features including PVS, posterior epiretinal membrane, severe posterior staphyloma, and chorioretinal atrophy are more likely to develop retinal complications causing decrease of VA." }, { "id": "wiki20220301en564_9633", "title": "Acute visual loss", "score": 0.011518046709129513, "content": "Acute visual loss is a rapid loss of the ability to see. It is caused by many ocular conditions like retinal detachment, glaucoma, macular degeneration, and giant cell arteritis, etc. Main causes Retinal detachment Retinal detachment should be considered if there were preceding flashes or floaters, or if there is a new visual field defect in one eye. If treated early enough, retinal tear and detachment can have a good outcome. Glaucoma Angle-closure glaucoma should be considered if there is painful loss of vision with a red eye, nausea or vomiting. The eye pressure will be very high typically greater than 40 mmHg. Emergent laser treatment to the iris may prevent blindness. Macular degeneration Wet macular degeneration should be considered in older people with new distortion of their vision with bleeding in the macula. Vision can often be regained with prompt eye injections with anti-VEGF agents. Giant cell arteritis" }, { "id": "pubmed23n0988_22962", "title": "Retinal Detachment in 31 Eyes with Retinitis Pigmentosa.", "score": 0.011185474375658425, "content": "To describe clinical features and treatment outcomes of retinal detachment (RD) in eyes with retinitis pigmentosa (RP). Single-center, retrospective, interventional case series. All RP patients with RD examined between April 2003 and December 2013 and minimum 2 months of follow-up. Medical records of RP patients were screened and 31 eyes with RD were included. Family history of RP, duration of symptoms, age at presentation, associated ocular and systemic findings, and detailed ophthalmic evaluation including presenting visual acuity, type and amount of refractive error, fundus findings, electroretinogram details, surgical details, and postoperative complications and outcomes were evaluated. Univariate analysis was done to determine risk factors associated with RD in eyes with RP and risk factors associated with poor visual outcomes after treatment. Subset analysis was also done for comparing the functional and anatomical outcomes between patients undergoing scleral buckling or vitrectomy. Final surgical reattachment rate, best-corrected visual acuity. Mean age at presentation was 22 years (median, 17; range, 4-63). Mean duration of symptoms was 12 months (median, 3 months: range, 3 days-60 months). Associated ocular findings included nyctalopia (n = 23), myopia (n = 21), and hyperopia (n = 10). Systemic associations included hearing loss (n = 5), deaf-mutism (n = 1), and Bardet-Biedel syndrome (n = 1). No association between degree of myopia and RD was noted (P = 0.63). Observed retinal breaks included horse-shoe-shaped tear (n = 15), lattice with hole (n = 7), atrophic retinal hole (n = 3), retinal dialysis (n = 3), and macular hole (n = 3). The most common location of breaks was superotemporal quadrant (n = 15). Younger age, male gender, and presence of posterior vitreous detachment were strongly associated with RD with odds ratio of 1.3 (P = 0.001), 8.3 (P = 0.010), and 6 (P = 0.003), respectively. Retinal reattachment was achieved in 13 of 13 eyes (100%) with scleral buckle and 9 of 10 eyes (90%) with vitrectomy. Vision improved from 1.63±0.52 to 0.87±0.25 logarithm of the minimum angle of resolution (P &lt; 0.001) at a mean follow-up of 33 months (median, 24, range; 1-145). Rhegmatogenous RD in eyes with RP is rare. Precocious vitreous degeneration and sparse pigmentation in younger male patients has a role in etiopathogenesis. Visual prognosis remains poor despite satisfactory surgical outcomes." }, { "id": "pubmed23n1072_5904", "title": "Incidence of Retinal Detachment after Macular Surgery.", "score": 0.009900990099009901, "content": "Macular surgery has become an increasingly atraumatic procedure for the eye with the surgical methods that have been further developed in recent years. The most common complications include cystoid macular oedema and retinal detachment, more rarely endophthalmitis. The aim of this retrospective study is to record the number of retinal detachments following elective macular surgery. In this study we included all patients who underwent pars plana vitrectomy (ppV, 20 or 25 gauge) in the years 2009 - 2016. We then identified the patients who were hospitalised again because of retinal detachment. For the affected patients, the rate of retinal detachment, functional outcomes and possible risk factors were recorded. A total of 904 eyes were identified, of which 667 had surgery for epiretinal membrane, 188 for macular hole, and 49 for vitreomacular traction with a 20 or 25 gauge ppV. Of these 904, retinal detachment occurred in 17 (1.88%) cases. The mean time between first ppV and second ppV with retinal detachment was 248 days (3 - 1837 days). Two of the 17 patients had at least one retinal break before or during surgery. The retinal break was located inferior in six cases, superior in four; in four cases PVR retinal detachment and in three cases the foramina were distributed. Mean visual acuity was 0.27 (decimal) before macular surgery and 0.28 at the time of last presentation. Modern vitrectomy techniques reduce the complications in elective macular surgery, but do not replace the surgeon's experience." }, { "id": "pubmed23n1073_5019", "title": "Posterior pole retinal breaks causing posterior pole retinal detachment in a middle-aged man with retinal vasculitis and moderate myopia.", "score": 0.00980392156862745, "content": "A 38-year-old man presented with sudden decreased vision in the right eye 3 years ago due to vitreous haemorrhage. During follow-up, right eye fundus showed evidence of vasculitis, non-perfusion areas and neovascularisation elsewhere. Systemic evaluation findings of positive Mantoux test, QuantiFERON Gold test and right apical pleuroparenchymal fibrosis observed on high-resolution CT of the chest were suggestive of postinfection probable tubercular aetiology. He was treated with oral steroids, antitubercular therapy, intravitreal bevacizumab and anterior retinal cryopexy, leading to resolution of vasculitis and vitreous haemorrhage. Later he developed peripheral retinal flap and posterior retinal breaks at 8-month and 11-month follow-up, respectively, which were managed by barrage laser. He maintained a stable visual acuity of 20/20, N6 for the next 2 years. He then presented with sudden decreased vision in the right eye (20/50, N10). Right eye fundus showed posterior pole retinal detachment with lifting of previously barraged posterior retinal breaks. He underwent vitreoretinal surgery with gas tamponade. Recent 1-month postoperative visit showed successful retinal reattachment and visual recovery of 20/20, N6." }, { "id": "pubmed23n0786_4332", "title": "Rhegmatogenous retinal detachment--an ophthalmologic emergency.", "score": 0.00980392156862745, "content": "Rhegmatogenous retinal detachment is the most common retinological emergency threatening vision, with an incidence of 1 in 10 000 persons per year, corresponding to about 8000 new cases in Germany annually. Without treatment, blindness in the affected eye may result. Selective review of the literature. Rhegmatogenous retinal detachment typically presents with the perception of light flashes, floaters, or a \"dark curtain.\" In most cases, the retinal tear is a consequence of degeneration of the vitreous body. Epidemiologic studies have identified myopia and prior cataract surgery as the main risk factors. Persons in the sixth and seventh decades of life are most commonly affected. Rhegmatogenous retinal detachment is an emergency, and all patients should be seen by an ophthalmologist on the same day that symptoms arise. The treatment consists of scleral buckle, removal of the vitreous body (vitrectomy), or a combination of the two. Anatomical success rates are in the range of 85% to 90%. Vitrectomy is followed by lens opacification in more than 70% of cases. The earlier the patient is seen by an ophthalmologist, the greater the chance that the macula is still attached, so that visual acuity can be preserved. Rhegmatogenous retinal detachment is among the main emergency indications in ophthalmology. In all such cases, an ophthalmologist must be consulted at once." }, { "id": "pubmed23n0360_23255", "title": "[Analysis of 100 cases of retinal detachment treated with conventional surgery in the years 1997-1998].", "score": 0.009708737864077669, "content": "The observed increasing number of severe cases of retinal detachment was the ground of the attempt to state the causes of this phenomenon. Retrospective evaluation of 100 consecutive cases of retinal detachment operated on with conventional methods between September 1997 and October 1998 was performed. The following data were analysed: sex and age of patients, period between the first symptoms and time of diagnosis and surgery. The clinical characteristics of retinal surgery comprise: extent of detachment, macular involving, type and number of breaks, degenerations and PVR. In the majority of cases very severe retinal detachments were observed, including 3-4 quadrants, with large tears or multiple breaks, with PVR B or C. Duration of the detachment ranged from several days in very few cases to several months, on average lasting several weeks. Attachment of the retina was achieved in 80 cases, improvement of the visual acuity in 47. Our data indicate the necessity to improve the early diagnosis of retinal detachment and changes predisposing to its development." }, { "id": "pubmed23n0852_3539", "title": "MYCOBACTERIUM MANITOBENSE MASQUERADING AS CORYNEBACTERIUM PSEUDODIPHTHERITICUM IN A CASE OF POSTCATARACT SURGERY ENDOPHTHALMITIS.", "score": 0.009615384615384616, "content": "To describe a case of postoperative Mycobacterium manitobense endophthalmitis with good visual outcome that is the first report of endophthalmitis by this organism. Clinical and microbiological description of a patient with postoperative endophthalmitis. A 50-year-old chronic alcoholic man was referred to us with decreased vision in his right eye for 4 days. He had undergone cataract surgery with intraocular lens implantation in his right eye a month ago. The presenting vision in his right eye was counting fingers close to face. He was diagnosed as a case of postoperative endophthalmitis. Subsequently, the patient underwent pars plana vitrectomy and vitreous biopsy. The microbiologic investigation of the vitreous biopsy showed poorly stained gram-positive beaded bacilli that were acid fast, and growth in culture was identified as Corynebacterium pseudodiphtheriticum by Vitek 2 bacterial identification system. However, DNA analysis confirmed the organism to be M. manitobense. The patient responded well to repeat interventions with intravitreal antibiotics with a final reported visual acuity of 20/30 at 4 months after first intervention. Although known to be an organism causing soft-tissue infections, M. manitobense can also cause postsurgical endophthalmitis. The diagnosis can be confused with Corynebacterium sp. on smear and culture. Subsequent DNA sequencing of the culture provides definite identification of the organism." }, { "id": "pubmed23n0678_14026", "title": "[Clinical observations of macular hole with and without retinal detachment in high myopic eyes].", "score": 0.009615384615384616, "content": "To study the clinical features and the pathogenesis of macular hole with and without retina detachment (RD) in high myopic eyes. It was a retrospective series case study. The charts of high myopic patients with macular hole at our hospital from June 2006 to February 2007 were retrospectively reviewed and analyzed. Patients were divided into two groups (the RD group and non-RD group) depending on the presence of RD or not. Their clinical data and optic coherence tomography (OCT) results were further analyzed. SPSS 13.0 was used for the statistic analysis. When comparing the quantitative aspects like age, axial length and refraction, t-test was used. Categorical data, such as sex ratio, occurrence of vitreous traction, posterior staphyloma and retinoschisis were compared by using χ(2) test. Fisher's test was used in comparing eye laterality, incidence of white hole, visual acuity and posterior vitreous detachment (PVD). During this period, there were 43 patients fitting the including criteria. Among them, 36 patents (37 eyes) were in the RD group and 7 patients (7 eyes) in the no-RD group. In the RD group, the average age was 56.1, 24.3% of them (9/37) were male; percentage of left and right eyes was (11/37) and 70.3% (26/37), respectively; average refraction was (-8.9 ± 2.2) D; average axial length was (28.7 ± 2.0) mm. Visual acuity was ≤ 0.05 (72.2%) in 26 eyes and 0.05 - 0.2 (27.8%) in 10 patients. The incidence of complete and non-complete PVD was 89.2% (33/37) and 10.8% (4/37), respectively. White hole presented in 35.1% (3/37) patients. Vitreous traction and retinoschisis presented in 27.0% (10/37) and 35.1% (13/37) patients, respectively. In the non-RD group, the average age was 47.6; 16.7% of them (1/7) were male; left and right eyes were involved in 42.9% (3/7) and 57.1% (4/7), respectively. Average refraction was (-9.0 ± 1.9) D; average axial length was (28.9 ± 1.5) mm. Vision acuity was ≤ 0.05 in 3 patients (42.9%); between 0.05 - 0.2 in 3 eyes (42.9%) and ≥ 0.2 in 1 eye (14.3%). Incidence of complete and non-complete PVD was 85.7% (6/7) and 14.3% (1/7), respectively. White hole was observed in 14.3% (1/7) patients; 42.9% (3/7) patients were accompanied with vitreous traction and 71.4% (5/7) with retinoschisis. B-scan ultrasonography showed posterior staphyloma in all 44 eyes. The results of statistical analysis showed that the gender (χ(2) = 0.008) and eye laterality (χ(2) = 0.449) as well as refraction (t = 0.193), axial length (t = -0.25) and visual acuity (χ(2) = 4.509) of these two groups were similar (P &gt; 0.05). The incidences of vitreous traction (χ(2) = 0.709), white hole (χ(2) = 1.179), PVD (χ(2) = 0.071) and retinoschisis (χ(2) = 3.207) were also similar (P &gt; 0.05). But the age of the non-RD group is significantly younger than the RD group (t = 1.66, P &lt; 0.05). Various pathogenesis may involved in the occurrence of retinal detachment in highly myopic eyes with macular hole. Further study is required to improve our understanding of this entity." }, { "id": "pubmed23n0318_15287", "title": "[Early posterior capsule fibrosis after combined cataract and vitreoretinal surgery with intraocular air/SF6 gas tamponade].", "score": 0.009523809523809525, "content": "The surgical approach in treating coexisting vitreoretinal disease and cataract is controversial. We report on patients who developed early posterior capsular fibrosis after combined cataract and vitreoretinal surgery with air/SF6-gas tamponade. The medical records of 15 consecutive eyes (13 patients) who underwent combined phacoemulsification with intraocular lens implantation and vitreoretinal surgery with intraocular air/SF6-gas tamponade were retrospectively analyzed. The indications for vitreous surgery included: subfoveal neovascular membrane in age-related macular degeneration (5 eyes), macular hole (4 eyes), macular pucker (2 eyes), rhegmatogenous retinal detachment (2 eyes), persistent vitreous haemorrhage after branch retinal vein occlusion (1 eye), persistent vitreous haemorrhage and/or tractional retinal detachment in proliferative diabetic retinopathy (1 eye). The mean follow-up period was 7 months (1-13 months). A control group consisted of 15 eyes (15 patients) who underwent the equal combined operation without intraocular tamponade. The indications for vitreous surgery were persistent vitreous haemorrhage in proliferative diabetic retinopathy (5 eyes), persistent vitreous haemorrhage after branch retinal vein occlusion (5 eyes), asteroid hyalosis (2 eyes), macular pucker (1 eye), posttraumatic vitreous haemorrhage (1 eye), acute retinal necrosis (1 eye). The mean follow-up was 8 months (2-13 months). The posterior capsule was examined at the slit lamp microscopy with maximal dilated pupils. We defined posterior capsular opacification (PCO) as severe if posterior capsule was fibrotic, diffusely thickened and opaque. Modest PCO was characterized by focal fibrotic opacifications at otherwise clear posterior capsule. Severe posterior capsular fibrosis developed in 9 eyes (60%) after 2-14 weeks postoperatively (mean 8 weeks) including 3 of 6 eyes with air tamponade (50%) and 6 of 9 eyes with 20% SF6-gas tamponade (66.7%). In 6 eyes (40%) Nd:YAG-laser capsulotomy was performed 4-14 weeks postoperatively (mean 8.5 weeks). In the control group modest PCO developed in 8 eyes (53.3%) 1-13 months postoperatively (mean 6.5 months) none requiring Nd:YAG-laser capsulotomy during follow-up period. Combined cataract and vitreoretinal surgery with intraocular air/SF6-gas tamponade induces severe posterior capsular fibrosis in the early postoperative period. The capsular fibrosis is presumably caused by accumulation of fibrin and proliferation stimulating factors in the narrow space between intraocular lens and air/SF6-gas bubble." }, { "id": "pubmed23n0819_20135", "title": "[Bilateral retinal detachment and high myopia: report of nine cases].", "score": 0.009523809523809525, "content": "Bilateral retinal detachments are rare, but their occurrence increases in cases of high myopia. The objective of our research is to study their incidence, management and postoperative results. This is a study of the medical records of nine patients with high myopia and simultaneous or consecutive bilateral rhegmatogenous retinal detachment. This is a retrospective study of the medical records of nine patients (18 eyes), aged 11-38 years old, with high myopia and simultaneous or consecutive bilateral retinal detachment. All had surgery on our medical service between September 1, 2010 and September 1, 2011. Bilateral retinal detachments represented 4.11% of the total cases operated during this period (219 patients) and 9.17% of the retinal detachments with high myopia (98 patients). The sex ratio is 1 male to 8 females, with an average age of 31 years old. The detachments were simultaneously bilateral for 3 patients. The initial corrected visual acuity varied between 1/40 and 4/10, macular retinoschisis was found in one case, and the breaks found were atrophic holes and horseshoe breaks. Scleral buckling with cryotherapy was performed in all patients, with a primary reattachment rate of 88.8%; and no vitreoretinal surgery was performed. The final visual acuity varied between 1/20 and 6/10. The incidence of bilateral retinal detachment increases in cases of associated high myopia; it is observed essentially among young patients. Management is difficult because of the risk of associated vitreoretinal proliferation, and the final visual recovery depends on the type of detachment and the degree of myopia. Classical surgery performed correctly and early allows for satisfactory results in most cases." }, { "id": "wiki20220301en056_16268", "title": "Visual impairment", "score": 0.009433962264150943, "content": "The most common causes of blindness worldwide in 2010 were: Cataracts (51%) Glaucoma (8%) Age-related macular degeneration (5%) Corneal opacification (4%) Childhood blindness (4%) Refractive errors (3%) Trachoma (3%) Diabetic retinopathy (1%) Undetermined (21%) About 90% of people who are visually impaired live in the developing world. Age-related macular degeneration, glaucoma, and diabetic retinopathy are the leading causes of blindness in the developed world. Among working-age adults who are newly blind in England and Wales the most common causes in 2010 were: Hereditary retinal disorders (20.2%) Diabetic retinopathy (14.4%) Optic atrophy (14.1%) Glaucoma (5.9%) Congenital abnormalities (5.1%) Disorders of the visual cortex (4.1%) Cerebrovascular disease (3.2%) Degeneration of the macula and posterior pole (3.0%) Myopia (2.8%) Corneal disorders (2.6%) Malignant neoplasms of the brain and nervous system (1.5%) Retinal detachment (1.4%) Cataracts" }, { "id": "pubmed23n0965_21245", "title": "[Outpatient vitreoretinal surgery without next-day examination: Feasibility and acceptability].", "score": 0.009433962264150943, "content": "To assess the feasibility and acceptability of outpatient care without next-day examination for patients undergoing retinal surgery. Patients undergoing ambulatory vitreoretinal surgery between November 2013 and February 2016 at the Vienna medical center were included in this retrospective study. The age, comorbidities, indication, surgical technique and type of anesthesia used, symptoms, intraocular pressure and biomicroscopic examination data at the D0, D7 and M1 visits were recorded. Patient satisfaction with the outpatient treatment was collected by phone call in April 2016. Fifty-three surgeries on 49 patients (24 women, 25 men) with a mean age of 70 years (range, 39-91 years) were analyzed. The surgery was pars plana vitrectomy in all cases, with 26 cases of epiretinal membrane surgery, 7 vitreomacular traction syndrome, 4 vitreous hemorrhage, 6 macular hole, 4 dislocation of lens material, 5 retinal detachment and 1 macular retinoschisis in high myopia. The type of anesthesia was general in 64.1 % of cases (34) and local in 36.9 % of cases (19). Of the D0 examination data, 100 % were compatible with the patient being discharged to home. One patient consulted before the D7 exam for the occurrence of a subconjunctival hemorrhage. There were seven cases (13.2 %) of intraocular pressure elevation and two cases of vitreous hemorrhage (3.8 %) on the D7 examination data. Twenty-seven patients (55.1 %) were reached by phone and all of them were satisfied with their outpatient management. Outpatient treatment of patients without next-day examination for vitreoretinal surgery is possible and well accepted." }, { "id": "wiki20220301en059_60325", "title": "Posterior vitreous detachment", "score": 0.009347631423766573, "content": "Complications The risk of retinal detachment is the greatest in the first 6 weeks following a vitreous detachment, but can occur over 3 months after the event. The risk of retinal tears and detachment associated with vitreous detachment is higher in patients with myopic retinal degeneration, lattice degeneration, and a familial or personal history of previous retinal tears/detachment. Causes The vitreous (Latin for \"glassy\") humor is a gel which fills the eye behind the lens. Between it and the retina is the vitreous membrane. With age the vitreous humor changes, shrinking and developing pockets of liquefaction, similar to the way a gelatin dessert shrinks and detaches from the edge of a pan. At some stage the vitreous membrane may peel away from the retina. This is usually a sudden event, but it may also occur slowly over months." }, { "id": "pubmed23n0203_8283", "title": "Treatment of Candida endophthalmitis.", "score": 0.009345794392523364, "content": "A 51-year-old man who was being treated with corticosteroids for chronic extrinsic asthma developed biliary tract sepsis, candidemia, and Candida endophthalmitis with vitreous fluff-ball lesions in both eyes. Extensive vitreous fibrosis and retinal detachment with loss of useful vision occurred in his left eye, which had a vitreous biopsy. Useful vision was maintained in his right eye with two full courses of systemic amphotericin B, 5-flucytosine, and a cataract extraction. Encapsulated Candida organisms remained in the vitreous of his right eye at the time of death. Useful vision can be preserved without aggressive vitreous surgery and intravitreal anti-fungal agents in eyes with intravitreal Candida albicans." }, { "id": "pubmed23n0988_22919", "title": "Long-Term Safety and Efficacy of Limited Vitrectomy for Vision Degrading Vitreopathy Resulting from Vitreous Floaters.", "score": 0.009259259259259259, "content": "Vitreous floaters can lower visual acuity (VA) and degrade contrast sensitivity function (CSF). Limited vitrectomy improves VA and normalizes CSF, but long-term results in a large series with objective quantitative outcome measures are lacking. Case series. One hundred ninety-five eyes of 145 patients (87 men, age = 57.6 ± 4.3 years; 58 women, age = 61.5 ± 12.0 years) reporting bothersome vitreous floaters were compared to 70 age-matched controls. Posterior vitreous detachment (PVD) alone was the cause in 96/195 (49.2%), myopic vitreopathy alone was the cause in 30/195 (15.4%), PVD with myopic vitreopathy was the cause in 56/195 (28.7%), and asteroid hyalosis was the cause in 13/195 eyes (6.7%). Limited vitrectomy with 25-gauge instruments was performed without surgical PVD induction, preserving 3 to 4 mm of retrolental vitreous in phakic eyes. Follow-up averaged 32.6 ± 23.5 months (range, 3-115 months), with 2 years or more in 144 eyes, 3 years or more in 69 eyes, 4 years or more in 51 eyes, and 5 years or more in 24 eyes. Visual acuity, 39-item National Eye Institute Visual Function Questionnaire (VFQ) results, CSF (Weber index), and quantitative ultrasonography results. After surgery, vitreous echodensity decreased by 94.1% (P &lt; 0.0001) and VFQ results improved by 19.3% (P &lt; 0.0001). Preoperative VA was 0.68 ± 0.21, improving to 0.77 ± 0.19 after surgery (P &lt; 0.0001). Preoperative CSF was degraded by 91.3% compared with controls (P &lt; 0.0001), normalizing at 1, 3, 6, 12, 24, 36, and 48 months after surgery (P &lt; 0.00005 for each). There were no cases of endophthalmitis. There were 3 retinal tears and 3 retinal detachments that underwent successful repair. Clinically significant vitreous hemorrhage developed in 2 patients, clearing spontaneously. Two macular puckers and 4 recurrent floaters from new PVD were cured by re-operation. Cataract surgery occurred in 21 of 124 patients (16.9%; mean age, 64 ± 7 years; none younger than 53 years), an average of 13.1 ± 6.8 months after vitrectomy. Limited vitrectomy for Vision Degrading Vitreopathy decreases vitreous echodensity, improves patient well-being, improves VA, and normalizes CSF. The long-term efficacy and safety profiles suggest this may be a safe and effective treatment for clinically significant vitreous floaters, warranting a prospective randomized trial." }, { "id": "pubmed23n0547_24031", "title": "[The incidence of retinal tears in patients with posterior vitreous detachment].", "score": 0.009259259259259259, "content": "Posterior vitreous detachment (PVD) is a common finding in older patients, characterized by detachment of the posterior hyaloid membrane (PHM) from the retinal surface. The detachment of PHM normally occurs without complications, however, one has to be aware that retinal tear is its most common complication. The aim of the study was to determine the incidence of retinal tears in eyes with PVD. A series of 40 patients (70 eyes) with PVD were included in this retrospective study. Eyes with a history of ocular trauma, surgery or intraocular inflammation were excluded. Patient charts were reviewed to collect the following information: age, sex, profession, type and duration of symptoms, best corrected visual acuity, refractive status, prior ocular disease, coincidental retinal pathology-lattice degeneration, number, type and location of retinal tears and treatment. Statistical analysis was done with the SPSS 11.0.3 software (SPSS Inc., USA). Besides descriptive statistics, Student's t-test and chi2-test were used. Among all study eyes with PVD, 34 (48.6%) were myopic, 24 (34.3%) hypermetropic and 12 (17.1%) emetropic; statistical analysis showed a significant difference (chi2 = 10.40, df=2, p &lt; 0.01). In 6 (8.6%) eyes with PVD lattice malignant degeneration of peripheral retinal was diagnosed. Thorough examination of the fundus periphery revealed 16 (22.8%) eyes with PVD were found to have retinal tears, 11 (15.7%) had only one retinal tear and 5 (7.1%) two retinal tears. All retinal tears were treated with argon laser photocoagulation. Superotemporal eye quadrant was the most common localization of retinal tears (56.25%). These results indicate that thorough fundus periphery examination should be done in all patients with PVD because it can cause rather rarely though retinal tears that represent a potentially sight threatening condition." }, { "id": "pubmed23n1049_24556", "title": "Long-term effects of phacoemulsification and intraocular lens implantation in a patient with pathologic myopia and extremely long axial length: A case report.", "score": 0.009174311926605505, "content": "To report a rare case of phacoemulsification cataract surgery and intraocular lens implantation that improved visual acuity and capsular stability in a patient with pathologic myopia and axial length &gt;38 mm. A 51-year-old Chinese man with high myopia since childhood who had lost sight in his left eye at the age of 25 due to retinal detachment. He was referred for ophthalmological assessment due to decreased vision in the right eye, in which the best-corrected visual acuity at distance was hand motion. The patient was diagnosed with cataract, high myopia, subluxated lens, and loose zonules in the right eye. The left eyeball showed atrophy. The patient underwent uneventful phacoemulsification. An intraocular lens (Sensar AR40M) and capsular tension ring were implanted within the capsular bag. After surgery, the patient was given eye drops containing tobramycin and dexamethasone eye drops for 1 month and eye drops containing 0.1% sodium diclofenac for 2 months. There were no postoperative complications. During 1-year follow-up, uncorrected visual acuity was 20/80 and the manifest refraction was -2.50DS/-1.00DC*80, with corrected distance visual acuity of 20/60. Cataract surgery maintained adequate vision for daily living. Implantation of specific lens and capsular tension ring as well as prolonged use of non-steroidal anti-inflammatory drugs may help prevent capsular contraction and posterior capsule opacification in patients with pathologic myopia and extremely long axial length." }, { "id": "pubmed23n0135_16897", "title": "Bilateral rhegmatogenous retinal detachment.", "score": 0.009174311926605505, "content": "During a 4-year period, 1978-1981, 34 patients with bilateral rhegmatogenous retinal detachment were operated on at the University Eye Hospital in Helsinki. The incidence of bilaterality in the entire detachment population was 10%, in the aphakic group it was 16%. In 24 cases (71%) the interval from the first to the second eye detachment was less than 5 years, 6 patients (18%) had bilateral detachment simultaneously. The mean age of the patients when the first eye was affected (46 years, range 6-73) was significantly younger than the mean age of those with unilateral detachment (58 years, range 6-83) (P less than 0.001). Previous eye diseases were significantly (P less than 0.01) more common in patients with bilateral than in those with unilateral detachment, but the incidences of myopia, aphakia and lattice degeneration of the retina did not differ significantly between these groups. At least one of these predisposing factors was found in 85% and two or more of them in 53% of bilateral detachments. The retina was re-attached in 80% of the 44 eyes operated on during the study period. Of the 24 eyes operated on earlier, 71% were blind (visual acuity CF 1 m or worse). The latest visual acuities in both eyes or in the better eye for all patients were: greater than or equal to 0.5 in 38%, 0.4-0.2 in 35%, 0.1-CF2 m in 12%, and less than or equal to CF1 m in 15%." }, { "id": "wiki20220301en028_4308", "title": "Retinal detachment", "score": 0.00909767595732363, "content": "Although retinal detachment usually occurs in one eye, there is a 15% chance of developing it in the other eye, and this risk increases to 25–30% in patients who have had cataracts extracted from both eyes. Symptoms of Rhegmatogenous Retinal Detachment A retinal detachment is commonly but not always preceded by a posterior vitreous detachment which gives rise to these symptoms: flashes of light (photopsia) – very brief in the extreme peripheral (outside of center) part of vision a sudden dramatic increase in the number of floaters Sometimes a detachment may be due to atrophic retinal holes in which case it may not be preceded by photopsia or floaters. Although most posterior vitreous detachments do not progress to retinal detachments, those that do produce the following symptoms:" }, { "id": "pubmed23n0912_6575", "title": "A Case of Rhegmatogenous Retinal Detachment at Late Stage following Endogenous Bacterial Endophthalmitis.", "score": 0.00909090909090909, "content": "To report a case of rhegmatogenous retinal detachment in the late stage, despite the fact that it had previously been halted after intravitreal injection of an antimicrobial agent against endogenous bacterial endophthalmitis (EBE). This study involved a 62-year-old male who had previously been diagnosed with septicemia due to liver abscess and the detection of <iKlebsiella pneumoniae</i in a culture of his liver abscess, and who underwent ophthalmic examination after his conjunctival hyperemia had failed to improve. Visual acuity could not be measured due to his general condition being poor and his declining level of consciousness. Slit lamp examination revealed bilateral iritis and cataracts, and the fundus was invisible due to vitreous opacity. Ultrasonic B-mode examination showed subretinal abscess and exudative retinal detachment, leading to the diagnosis of EBE. Vitreous injections of antibiotics were administered to both of his eyes. His right eye became affected by phthisis bulbi, but the condition in his left eye subsided, leaving a scarred lesion near the macula. However, complete retinal detachment occurred in his left eye approximately 10 months after the vitreous injection. During vitreous surgery, proliferative membrane formation was observed in the posterior pole area, and an irregular retinal break was detected in the scar margin caused by the traction of the proliferative membrane. After vitreous surgery, the retina was reattached under silicone oil. In cases of EBE, even if the inflammation has previously subsided, strict follow-up examinations are necessary, since complications such as rhegmatogenous retinal detachment may occur at a late stage." }, { "id": "First_Aid_Step1_605", "title": "First_Aid_Step1", "score": 0.009062149198897846, "content": "Breaks more common in patients with high myopia and/or history of head trauma. Often preceded by posterior vitreous detachment (“flashes” and “floaters”) and eventual monocular loss of vision like a “curtain drawn down.” Surgical emergency. Central retinal artery Acute, painless monocular vision loss. Retina cloudy with attenuated vessels and “cherry-red” spot occlusion at fovea (center of macula) A . Evaluate for embolic source (eg, carotid artery atherosclerosis, cardiac vegetations, patent foramen ovale). Retinitis pigmentosa Inherited progressive retinal degeneration. Nyctalopia (night blindness) Ž peripheral vision loss. Bone spicule-shaped deposits A . Papilledema Optic disc swelling (usually bilateral) due to  ICP (eg, 2° to mass effect). Enlarged blind spot and elevated optic disc with blurred margins A . Leukocoria Loss (whitening) of the red reflex. Important causes in children include retinoblastoma A , congenital cataract, toxocariasis." }, { "id": "pubmed23n0672_22709", "title": "Combined vitreous and cataract surgeries in highly hyperopic eye.", "score": 0.009009009009009009, "content": "We report a case of a patient with a highly hyperopic eye who underwent cataract surgery combined with vitreous surgery to create a posterior vitreous detachment (PVD) to prevent choroidal neovascularization (CNV). A 78-year-old man noticed a decrease in his vision due to a cataract in his right eye. The patient had a severe visual loss in his left eye because of a CNV 2 years after a cataract surgery. His visual acuities were 20/30 OD and 20/600 OS, and funduscopic examination showed an orange-colored lesion OD and degenerative subretinal fibrosis OS. The posterior vitreous was attached to the retina in both eyes. The axial length was 18.9 mm OD and 19.0 mm OS. Cataract surgery combined with vitreous surgery to create PVD was performed on the right eye, and the vision improved to 20/20 with no signs of developing CNV after 5 years. We conclude that cataract surgery combined with vitreous surgery to create a PVD may prevent the development of CNV in highly hyperopic eyes." } ] } } }

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{ "1": "Contact the duty court.", "2": "Immediate gynecological examination with cervical cytology.", "3": "Administer 500 mg of intramuscular ceftriaxone, 1 g of azithromycin orally and 2 g of tinidazole orally in single doses.", "4": "Administer 1500 mg of levonorgestrel orally in a single dose.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0414_22036", "title": "Disseminated gonococcemia.", "score": 0.012453258547008548, "content": "A 26-year-old woman presented with a high-grade fever and chills of 2 days' duration. She complained of associated joint pain, especially in the wrists and knees. One day before admission, tender skin lesions began to develop on the fingers, and subsequently spread to the more proximal extremities. The patient recalled having a sore throat and a nonproductive cough before the onset of the fever and eruption. The past medical history was significant for Gardnerella vaginitis and several urinary tract infections. The patient was taking oral contraceptive pills; her most recent menstruation was 3 weeks before admission. She reported having sexual intercourse with her boyfriend 2 weeks before admission. The patient's temperature was 40 degrees C. Dermatologic examination revealed a 6-mm, hemorrhagic pustule on an ill-defined pink base, overlying the volar aspect of the left second proximal interphalangeal joint (Fig. 1a). Scattered on the upper and lower extremities were occasional round, ill-defined pink macules with central pinpoint vesiculation (Fig. 1b). A skin biopsy of the digit revealed a dense neutrophilic infiltrate with leukocytoclasis and marked fibrin deposition in the superficial and deep dermal vessels (Fig. 2a). Gram stains demonstrated the presence of Gram-negative diplococci (Fig. 2b). Laboratory findings included leukocytosis (leukocyte count of 20 x 109/L, with 81% neutrophils). Analysis of an endocervical specimen by polymerase chain reaction was positive for Neisseria gonorrhoeae and negative for Chlamydia trachomatis. Throat and blood cultures grew N. gonorrhoeae. Specimen cultures obtained by skin biopsy yielded no growth. Results of serologic analysis for human immunodeficiency virus, hepatitis, syphilis, and pregnancy were negative. Beginning on admission, intravenous ceftriaxone, 2 g, was administered every 24 h for 6 days, followed by oral cefixime, 400 mg twice daily for 4 days. Oral azithromycin, 1 g, was administered to treat possible coinfection with C. trachomatis. By treatment day 4, the patient was afebrile, with the resolution of leukocytosis and symptomatic improvement of arthralgias." }, { "id": "Gynecology_Novak_1484", "title": "Gynecology_Novak", "score": 0.011724048834054647, "content": "A single dose of 1 g of azithromycin orally or 100 mg of doxycycline orally twice a day for 7 days for treatment of chlamydia (if the patient is pregnant at the time of the assault, erythromycin 500 mg orally four times a day for 7 days may be substituted for doxycycline), PLUS: c. A single dose of 2 g of metronidazole orally for the treatment of trichomoniasis and/or bacterial vaginosis 2. Hepatitis B vaccination should be offered if the sexual assault survivor has experienced vaginal, oral, or anal penetration. Hepatitis B is 20 times more infectious than HIV during intercourse (114). Vaccination is recommended at the time of the initial evaluation. Subsequent doses are provided 1 month and 6 months after the first dose is administered. It is not necessary to treat the patient with hepatitis B immune globulin (167). Vaccination is not necessary if the patient has documented hepatitis B immunity. 3." }, { "id": "Gynecology_Novak_2909", "title": "Gynecology_Novak", "score": 0.011367942402425162, "content": "Table 18.4 Clinical Criteria for the Diagnosis of Pelvic Inflammatory Disease Additional criteria to increase the specificity of the diagnosis Endometrial biopsy showing endometritis Elevated C-reactive protein or erythrocyte sedimentation rate Temperature higher than 38◦C (100.4◦F) Leukocytosis Positive test for gonorrhea or chlamydia Table 18.5 Guidelines for Treatment of Pelvic Inflammatory Disease Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally concurrently, or Ceftriaxone, 250 mg intramuscularly, or Plus: Doxycycline, 100 mg orally 2 times daily for 14 days, or Azithromycin, 500 mg initially and then 250 mg daily for a total of 7 days Cefoxitin, 2 g intravenously every 6 hours, or Cefotetan, 2 g intravenously every 12 hours Plus: Doxycycline, 100 mg orally or intravenously every 12 hours Clindamycin, 900 mg intravenously every 8 hours Plus:" }, { "id": "Obstentrics_Williams_2425", "title": "Obstentrics_Williams", "score": 0.0110786541166288, "content": "Symptoms following misoprostol are common within 3 hours and include vomiting, diarrhea, fever, and chills. Bleeding and cramping with medical termination typically is signiicantly worse than with menses. Thus, adequate analgesia, usually including a narcotic, is provided. If bleeding soaks two or more pads per hour for at least 2 hours, the woman is instructed to contact her provider to determine whether she needs to be seen . At the follow-up appointment, routine postabortal sonographic examination is typically unnecessary (Clark, 2010). Instead, assessment of the clinical course along with bimanual pelvic examination is recommended. If sonography is indicated TABLE 18-7. Various Regimens for Medical Termination of Pregnancy aMifepristone, 200-600 mg orally; followed in 24-48 hr by: bMisoprostol, 200-600 �g orally or 400-800 �g vaginally, buccally, or sublingually" }, { "id": "Pharmacology_Katzung_5050", "title": "Pharmacology_Katzung", "score": 0.0104767336248231, "content": "Camille E. Beauduy, PharmD, & Lisa G. Winston, MD motion tenderness is present. A first-catch urine specimen is obtained for chlamydia and gonorrhea nucleic acid amplifi-cation testing. A urine pregnancy test is also ordered as the patient reports she “missed her last period.” Pending these results, the decision is made to treat her presumptively for chlamydial cervicitis. What are two potential treatment options for her possible chlamydial infection? How does her potential pregnancy affect the treatment decision? A 22-year-old woman presents to her college medical clinic complaining of a 2-week history of vaginal discharge. She denies any fever or abdominal pain but does report vaginal bleeding after sexual intercourse. When questioned about her sexual activity, she reports having vaginal intercourse, at times unprotected, with two men in the last 6 months. A pelvic examination is performed and is positive for muco-purulent discharge from the endocervical canal. No cervical" }, { "id": "Gynecology_Novak_2919", "title": "Gynecology_Novak", "score": 0.01039272030651341, "content": "3. One to three extremely painful ulcers, accompanied by tender inguinal lymphadenopathy, are unlikely to be anything except chancroid. This is especially true if the adenopathy is fluctuant. 4. An inguinal bubo accompanied by one or several ulcers is most likely chancroid. If no ulcer is present, the most likely diagnosis is LGV. Recommended regimens for the treatment of chancroid include azithromycin, 1 g orally in a single dose; ceftriaxone, 250 mg intramuscularly in a single dose; ciprofloxacin, 500 mg orally twice a day for 3 days; or erythromycin base, 500 mg orally four times daily for 7 days. Patients should be reexamined 3 to 7 days after initiation of therapy to ensure the gradual resolution of the genital ulcer, which can be expected to heal within 2 weeks unless it is unusually large." }, { "id": "wiki20220301en001_192626", "title": "Urethritis", "score": 0.009900990099009901, "content": "A variety of drugs may be prescribed based on the cause of urethritis: Gonococcal urethritis (caused by N. gonorrhoeae): The CDC recommends administering an injection dose of ceftriaxone 250 mg intramuscularly and oral dose of azithromycin 1g simultaneously. Cefixime 400 mg oral single dose can be used as an alternative if ceftriaxone is not available. Non-gonococcal urethritis (caused by Chlamydia trachomatis): The CDC recommends administering an oral single dose of azithromycin 1g or a 7-day course of doxycycline 100 mg orally twice daily.' Alternative treatments can also be used when the above options are not available: Erythromycin base 500 mg orally four times daily for 7 days Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days Levofloxacin 500 mg orally once daily for 7 days Ofloxacin 300 mg orally twice daily for 7 days" }, { "id": "pubmed23n0795_18698", "title": "Not your average birth: considering the possibility of denied or concealed pregnancy.", "score": 0.009900990099009901, "content": "A 23-year-old woman presented to the emergency department (ED) with a 3-day history of lower back pain. She had seen her general practitioner 2 days previously who prescribed trimethoprim for a confirmed urinary tract infection. Routine admission observations showed she was tachycardic, tachypnoeic and slightly hypotensive but non-feverish with normal oxygen saturations. Her urine sample revealed that she was pregnant but was otherwise negative. The patient maintained that she was unaware she was pregnant. She was reviewed by an ED staff grade who was suspicious of a ruptured ectopic pregnancy. She was subsequently referred to the obstetrics and gynaecology registrar who on examination found she had a gravid uterus and vaginal examination revealed that her cervix was 8 cm dilated. The patient was very promptly admitted onto the labour ward for further assessment. She gave birth to a live male infant in the early hours of the next morning. " }, { "id": "article-19261_15", "title": "Cervicitis -- Treatment / Management", "score": 0.009870464022713157, "content": "1g single oral dose azithromycin PLUS either 800 mg cefixime in a single oral dose or 250 mg intramuscular ceftriaxone in a single dose 100 mg oral doxycycline twice daily for 7 days PLUS either 800 mg cefixime in a single oral dose or 250 mg intramuscular ceftriaxone in a single dose For severe allergy to penicillins/cephalosporins: 2g oral azithromycin in a single dose [2] [3] [15] For infectious agents identified by laboratory investigations, the treatment is as follows: Chlamydia: A single oral dose of 1g azithromycin OR 100mg doxycycline twice daily for 7 days Gonorrhea: 250mg intramuscular ceftriaxone PLUS a single oral dose of 1g azithromycin Mycoplasma: 400mg moxifloxacin after treatment failure with 1g oral azithromycin Trichomonas: A single oral 2g dose of metronidazole OR tinidazole Bacterial vaginosis: Twice daily 500mg metronidazole for 7 days OR intravaginal 0.75% metronidazole gel once daily for 5 days HSV: Oral 400mg acyclovir three times daily for 7 to 10 days" }, { "id": "wiki20220301en017_53006", "title": "Haemophilus ducreyi", "score": 0.00980392156862745, "content": "Pathogenesis H. ducreyi is an opportunistic microorganism that infects its host by way of breaks in the skin or epidermis. Inflammation then takes place as the area of infection is inundated with lymphocytes, macrophages, and granulocytes. This pyogenic inflammation causes regional lymphadenitis in the sexually transmitted disease chancroid. Diagnosis Although antigen detection, serology, and genetic amplification methods are sometimes used to diagnose infections with H. ducreyi and the genetic tests have greater sensitivity, they are not widely available, so cultures are currently considered the \"gold standard\" test. Treatment The first line treatments are one of four options : azithromycin 1 g orally in a single dose, ceftriaxone 250 mg intramuscularly in a single dose, ciprofloxacin 500 mg orally 2 times a day for 3 days, or erythromycin base 500 mg orally 3 times a day for 7 days. See also Sexually transmitted disease References" }, { "id": "wiki20220301en168_30047", "title": "One Woman's Insanity", "score": 0.00980392156862745, "content": "\"Show Me\" also entered the non-genre-specific Billboard Bubbling Under Hot 100 chart, an extension of the Hot 100, peaking at number 22 on the chart dated December 25, 1993. On the Dance Singles Sales chart, the double-A-side release of \"Show Me\"/\"Joy\" peaked at number 21 on the September 4, 1993, chart. The single also proved a minor hit outside of the United States, entering the UK Singles Chart and peaking at number 62 on the chart dated January 29, 1994. Critical" }, { "id": "pubmed23n0540_20027", "title": "[Three Japanese cases of hypnic headache].", "score": 0.009793836526509794, "content": "We described three cases of hypnic headache with successful treatment by lithium carbonate or caffeine. This is the first detail report of Japanese cases. An endocrinological test and rhythm analyses of ambulatory blood pressure (ABP) and heart rate variability in a case suggested possible association between hypnic headache and hypothalamic-pituitary dysfunction. Case 1: A 48-year-old female migraineur complained of new-onset nocturnal headaches. Her headache awakened her from sleep between 1 AM and 2 AM. The headache occurred 3-4 times per week and lasted from 1 hour to 2 hours. The headache were moderate intensity and bilateral dull throbbing pain that located in the forehead to temples. There was no accompanying symptoms such as nausea, phonophobia, photophobia, nor the other autonomic features including conjunctival injection or tearing during the headache attacks. Physical and neurological examinations showed normal results except slight weakness and mild dysesthesia of the left arm due to a vertebral disk herniation at C5/6 level. In the pituitary endocrinological test, the prolactin level remarkably increased in response to the TRH loading. The single cosinor analysis demonstrated significant circadian rhythm of ABP parameters. However, the analysis did not demonstrate any significant circadian rhythm of Holter ECG parameters of time domain analysis and frequency analysis. Receiving 200 mg lithium bicarbonate before sleep, her nocturnal headache completely disappeared. Case 2: A 68-year-old woman had been followed up by her chronic tension-type headache since her forties. At her 66-years, she suffered from a new nocturnal headache. She awoke from sleep by the headache about 3 AM and the headache lasted 30 min. Moderate, dull headache located on her left temple to parietal head, 3-4 times/week. She was able to go back asleep without any medication after spontaneous headache cessation. She first complained the nocturnal headache at the 10 months later of the new headache appearance. She received 200 mg caffeine just before sleep and her headache has been disappeared. Case 3: 70-year-old women had been regularly visited our clinics for her migraine and chronic tension-type headache. She received amitriptyline and her headaches was well controlled. At her 69 years, she complained nocturnal headache. It occured every other day. The headache was moderate pulsative dull pain on the occipital region and lasted 90 minutes without any autonomic symptoms. Headache began between midnight and 1 AM. She told us her new nocturnal headache one year later of the onset. Oral caffeine (200 mg) just before sleep did not improve her headache and caused insomnia. Receiving 100 mg lithium before sleep, her hypnic headache disappeared completely. These three cases are compatible with the diagnostic criteria proposed in ICHD-II. There were some patients with hypnic headache in Japan and neurologists should pay attentions to this form of benign headache, because some beneficial treatments are currently available." }, { "id": "wiki20220301en014_132704", "title": "Creatine", "score": 0.009708737864077669, "content": "Maintenance phase After the 5–7 day loading phase, muscle creatine stores are fully saturated and supplementation only needs to cover the amount of creatine broken down per day. This maintenance dose was originally reported to be around 2–3 g/day (or 0.03 g/kg/day), however, recent studies have suggested 3–5 g/day maintenance dose to maintain saturated muscle creatine. Absorption Endogenous serum or plasma creatine concentrations in healthy adults are normally in a range of 2–12 mg/L. A single 5 gram (5000 mg) oral dose in healthy adults results in a peak plasma creatine level of approximately 120 mg/L at 1–2 hours post-ingestion. Creatine has a fairly short elimination half life, averaging just less than 3 hours, so to maintain an elevated plasma level it would be necessary to take small oral doses every 3–6 hours throughout the day. Clearance It has been shown that once supplementation of creatine stops, muscle creatine stores return to baseline in 4–6 weeks." }, { "id": "InternalMed_Harrison_14089", "title": "InternalMed_Harrison", "score": 0.009708737864077669, "content": "C. trachomatis infections in adults. Azithromycin causes fewer adverse gastrointestinal reactions than do older macrolides such as erythromycin. The single-dose regimen of azithromycin has great appeal for the treatment of patients with uncomplicated chlamydial infection (especially those without symptoms and those with a likelihood of poor compliance) and of the sexual partners of infected patients. These advantages must be weighed against the considerably greater cost of azithromycin. Whenever possible, the single 1-g dose should be given as directly observed therapy. Although not approved by the FDA for use in pregnancy, this regimen appears to be safe and effective for this purpose. However, amoxicillin (500 mg three times daily for 7 days) also can be given to pregnant women. The fluoroquinolones are contraindicated in pregnancy. A 2-week course of treatment is recommended for complicated chlamydial infections (e.g., PID, epididymitis) and at least a 3-week course of doxycycline" }, { "id": "wiki20220301en000_98859", "title": "Ciprofloxacin", "score": 0.009615384615384616, "content": "Ciprofloxacin is weakly bound to serum proteins (20–40%). It is an inhibitor of the drug-metabolizing enzyme cytochrome P450 1A2, which leads to the potential for clinically important drug interactions with drugs metabolized by that enzyme. Ciprofloxacin is about 70% orally available when administered orally, so a slightly higher dose is needed to achieve the same exposure when switching from IV to oral administration The extended release oral tablets allow once-daily administration by releasing the drug more slowly in the gastrointestinal tract. These tablets contain 35% of the administered dose in an immediate-release form and 65% in a slow-release matrix. Maximum serum concentrations are achieved between 1 and 4 hours after administration. Compared to the 250- and 500-mg immediate-release tablets, the 500-mg and 1000-mg XR tablets provide higher Cmax, but the 24‑hour AUCs are equivalent." }, { "id": "wiki20220301en067_31981", "title": "I Am Woman", "score": 0.009615384615384616, "content": "Despite the chord it was striking with television viewers, the song's trek to the top of the charts was still a long, hard climb. It first entered the Billboard Hot 100 at number 99 in the issue of the magazine dated June 24, 1972, peaked at number 97 two weeks later, fell off the Hot 100, re-entered at number 87 two months later in the September 16 issue, and reached number one three months later, in the December 9 issue." }, { "id": "wiki20220301en046_25187", "title": "Synephrine", "score": 0.009523809523809525, "content": "200 mg caused side-effects such as heart palpitations, headache, sweating, and feelings of apprehension. When given intravenously, doses of 25–50 mg sufficed to produce a mean maximum increase in the blood pressure of 29 mmHg in 2 minutes, and a return to baseline within 30 minutes. Respiration was generally not affected during these experiments. Subcutaneous administration of synephrine in doses ≤ 200 mg had no effects on blood pressure or pulse rate. Oral doses of 500–1500 mg of the drug did not affect blood pressure or respiration, but pulse rate was increased by ~12%, and the highest doses caused nausea and vomiting." }, { "id": "wiki20220301en241_16766", "title": "She's Every Woman", "score": 0.009523809523809525, "content": "Chart history \"She's Every Woman\" debuted at number 38 on the Billboard Hot Country Singles & Tracks charts on the chart week of September 9, 1995, climbing to number 10 the next week. It reached its peak of number 1 on the chart week of October 21, its seventh week on the charts." }, { "id": "wiki20220301en446_29233", "title": "Gabapentinoid", "score": 0.009433962264150943, "content": "(as active gabapentin) is about 2.1 to 2.6 hours across all doses (350–2,800 mg) with single administration and 1.6 to 1.9 hours across all doses (350–2,100 mg) with repeated administration. Conversely, the Tmax of the extended-release (XR) formulation of gabapentin enacarbil is about 5.1 hours at a single dose of 1,200 mg in a fasted state and 8.4 hours at a single dose of 1,200 mg in a fed state. The Tmax of phenibut has not been reported, but the onset of action and peak effects have been described as occurring at 2 to 4 hours and 5 to 6 hours, respectively, after oral ingestion in recreational users taking high doses (1–3 g)." }, { "id": "pubmed23n0064_4202", "title": "[Three cases of psittacosis].", "score": 0.009433962264150943, "content": "Case 1 was a 55 year old female whose primary complaint was pyrexia. Anamnesis consisted of a fever at a 39 degrees C level beginning on September 15, 1987 with headache and muscle pain. The patient was examined by a nearby physician. Despite taking medication, there was no break in the fever. The patient was examined and admitted to this institution on September 18. Case 2 was a 32 year old female whose primary complaint was pyrexia and an abnormal sensation in the pharynx. Anamnesis consisted of a fever at a 39 degrees C level beginning on February 13, 1989 and the manifestation of a cough beginning on February 17. Although the fever broke on February 20, as the abnormal sensation in the pharynx persisted, the patient was examined and admitted to this institution on February 21. Case 3 was a 42 year old male whose primary complaint was pyrexia. Anamnesis consisted of a fever of 38 degrees C, cough and a sensation of pressure in the right precordia beginning on November 18, 1989. The patient was examined and admitted to this institution on November 21. Chest X-rays revealed the presence of atypical pneumonia in all three cases. As a significant rise in antibodies to the Chlamydia of parrot fever was observed in the cases at the time of admittance as well as after admittance, treatment was begun by administration of Minocycline.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en450_23448", "title": "TIK-301", "score": 0.009345794392523364, "content": "Pharmacokinetics TIK-301 is administered orally. Compared to melatonin, it has nine times greater bioavailability and six times greater area under the curve (AUC), which means the body retains more of an administered dose. TIK-301 was detected in blood plasma within 10 to 15 minutes of administration of a single oral dose and remains in a patient's system until 12 hours after the single dose. Plasma concentrations increased rapidly and peaked at 1 hour after the dose, independent of dose size. TIK-301's half-life is about 1 hour. This extended half-life may be partially due to the chlorine in its structure. Elimination constants depended on dose, 20 mg dose had a different elimination constant from all other doses above 35 mg." }, { "id": "pubmed23n0695_10894", "title": "Just a sore throat?", "score": 0.009345794392523364, "content": "A man, 43 years of age, presents to his general practitioner with a 6 day history of sore throat. There are no other symptoms of an upper respiratory tract infection. In passing, the patient mentions that 6 days ago he experienced an episode of exertional chest pain. On further questioning it is found the chest pain was central with no radiation, it lasted 30 minutes, resolved spontaneously and was associated with nausea. He did not seek medical assessment at the time and has no cardiac history. He takes no regular medication and has no allergies. He is an exsmoker with a 15 pack-year history (he quit 7 years ago) but has no other known cardiac risk factors. He does not drink alcohol or take illicit drugs. On examination, he appears well built with a body mass index of 27. He is not in distress apart from a moderate sore throat. He is afebrile. His heart rate is 66 bpm, regular and his blood pressure is 122/80 mmHg. His tonsils and uvula are neither inflamed nor swollen. He has no cervical lymphadenopathy. His lungs are clear on auscultation and his heart sounds are dual with no murmur. His electrocardiogram is shown in Figure 1." }, { "id": "wiki20220301en061_51733", "title": "Drospirenone", "score": 0.009259259259259259, "content": "Pharmacokinetics Absorption The oral bioavailability of drospirenone is between 66 and 85%. Peak levels occur 1 to 6 hours after an oral dose. Levels are about 27 ng/mL after a single 4 mg dose. There is 1.5- to 2-fold accumulation in drospirenone levels with continuous administration, with steady-state levels of drospirenone achieved after 7 to 10 days of administration. Peak levels of drospirenone at steady state with 4 mg/day drospirenone are about 41 ng/mL. With the combination of 30 μg/day ethinylestradiol and 3 mg/day drospirenone, peak levels of drospirenone after a single dose are 35 ng/mL, and levels at steady state are 60 to 87 ng/mL at peak and 20 to 25 ng/mL at trough. The pharmacokinetics of oral drospirenone are linear with a single dose across a dose range of 1 to 10 mg. Intake of drospirenone with food does not influence the absorption of drospirenone." }, { "id": "Gynecology_Novak_53", "title": "Gynecology_Novak", "score": 0.009259259259259259, "content": "Physical Examination A thorough gynecologic physical examination is typically performed at the time of the initial visit, on a yearly basis, and as needed throughout the course of treatment (Table 1.6). The extent of the physical examination during the gynecologic visit is often dictated by the patient’s primary concerns and symptoms. For example, for healthy teens without symptoms who are requesting oral contraceptives before the initiation of intercourse, a gynecologic examination is not necessarily required. Some aspects of the examination—such as assessment of vital signs and measurement of height, weight, blood pressure, and calculation of a body mass index— should be performed routinely during most office visits. Typically, examination of the breasts and abdomen and a complete examination of the pelvis are considered to be essential parts of the gynecologic examination. It is often helpful to ask the patient if the gynecologic examination was difficult for her in the past; this" }, { "id": "wiki20220301en017_7716", "title": "Chancroid", "score": 0.009174311926605505, "content": "Antibiotics Macrolides are often used to treat chancroid. The CDC recommendation is either a single oral dose (1 gram) of azithromycin, a single IM dose (250 mg) of ceftriaxone, oral (500 mg) of erythromycin three times a day for seven days, or oral (500 mg) of ciprofloxacin twice a day for three days. Due to a paucity of reliable empirical evidence it is not clear whether macrolides are actually more effective and/or better tolerated than other antibiotics when treating chancroid. Data is limited, but there have been reports of ciprofloxacin and erythromycin resistance. Aminoglycosides such as gentamicin, streptomycin, and kanamycin has been used to successfully treat chancroid; however aminoglycoside-resistant strain of H. ducreyi have been observed in both laboratory and clinical settings.[7] Treatment with aminoglycosides should be considered as only a supplement to a primary treatment." }, { "id": "Obstentrics_Williams_8990", "title": "Obstentrics_Williams", "score": 0.009174311926605505, "content": "Distinct from allergy, a Jarisch-Herxheimer reaction develops following penicillin treatment in most women with primary syphilis and approximately half with secondary infection. Uterine contractions, mild maternal temperature elevation, decreased fetal movement, and fetal heart rate decelerations are findings. Reaction treatment is supportive with antipyretics as needed, hydration, and oxygen supplementation (Klein, 1990). In a study of 50 gravidas who received benzathine penicillin for syphilis, Myles and associates (1998) reported a 40-percent incidence of Jarisch-Herxheimer reactions. Of the 31 women monitored electronically, 42 percent developed regular uterine contractions, and 39 percent developed variable decelerations. All contractions resolved within 24 hours of therapy. Accordingly, for fetuses of viable age, some recommend administering the irst dose of antibiotic in labor and delivery and with continuous fetal monitoring for at least 24 hours (Rae, 2017). Others recommend" }, { "id": "wiki20220301en480_30583", "title": "Darolutamide", "score": 0.00909090909090909, "content": "The absolute bioavailability of darolutamide with oral administration of a single 300-mg dose without food is approximately 30%. The bioavailability of darolutamide is increased by about 2- to 2.5-fold when administered with food, with a similar increase in exposure occurring for ketodarolutamide. Exposure to darolutamide and ketodarolutamide increases in a nearly linear or dose-proportional manner across a dose range of 100 to 700 mg (or about 0.17- to 1.17-fold the recommended 600-mg dosage). No further increase in exposure to darolutamide was observed at a dosage of darolutamide of 900 mg twice per day (or 1.5 times the recommended 600-mg dosage), indicating a saturation of absorption at doses above 700 mg. Following a single 600-mg dose of darolutamide, peak levels of darolutamide occur after approximately 4 hours. Steady-state levels of darolutamide occur after 2 to 5 days of continuous administration with food, during which time an approximate 2-fold accumulation in darolutamide" }, { "id": "pubmed23n0217_6420", "title": "\"One-minute treatment\" with thiamphenicol in 50,000 cases of gonorrhea: a 22-year study.", "score": 0.00909090909090909, "content": "The results obtained with single-dose (2.5 g of thiamphenicol) therapy of gonorrhea in 50,000 patients are reported. Male patients included recent cases of acute or subacute urethritis and uncomplicated cases; all female patients had uncomplicated gonorrhea. Asymptomatic gonorrhea in both men and women was included in the therapy trial in all cases when \"epidemiological\" treatment was necessary. Tolerance of thiamphenicol was excellent; we observed only 62 cases of gastralgia or nausea and 12 cases of generalized pruritus reaction. No hematologic side effect was reported. The prescribed dose does not conceal incubating syphilis since 211 cases of recent syphilis were observed. Failures are reported year by year from 1961 to 1982 and, on the average, failure rates for men and women were 3.42% and 3.24%, respectively." }, { "id": "wiki20220301en027_67269", "title": "Glucosamine", "score": 0.009009009009009009, "content": "A number of studies have measured the bioavailability of glucosamine after oral administration to horses. When given as a single oral dose (9 g) with or without chondroitin sulfate (3 g) to ten horses, glucosamine (hydrochloride) was detected in the blood with a maximum level of at two hours after dosing. Another study examined both the serum and the joint synovial fluid after nasogastric (oral) or intravenous administration of 20 mg/kg glucosamine hydrochloride to eight adult horses. Although joint fluid concentrations of glucosamine reached 9–15 μmol/L following intravenous dosing, it was only 0.3–0.7 μmol/L with nasogastric dosing. The authors calculated that these glucosamine synovial fluid levels achieved by the oral route were 500 times lower than that required to have a positive effect on the metabolism of cartilage cells. A follow up study by the same research group compared glucosamine sulfate with glucosamine hydrochloride at the same dose (20 mg/kg) in eight horses and" }, { "id": "pubmed23n0498_10724", "title": "Infectious disease capsules: a pox on your house.", "score": 0.009009009009009009, "content": "A 31-year-old, previously healthy white man presented to the emergency department with complaints of malaise, fevers, shortness of breath, a non-productive cough, and a \"rash.\" His physical exam revealed a temperature of 100.2F, a pulse of 129 bpm, respiratory rate of 14 BPM, and blood pressure of 140/74 mm Hg. He was alert, oriented, and in no distress. His oropharynx was dry, his neck was supple, and cervical lymphadenopathy was absent. He had tachycardia, bilateral wheezes, and rhonchi with prolonged expirations. There was a diffuse vesicular eruption enveloping his entire body with involvement sparing his palms and soles (Figures 1 and 2). Laboratory values showed a hemoglobin of 16.0 g/dL and a white blood cell count of 7100 cells/pL, with 39%neutrophils, 23% bands, and 35% lymphocytes. His platelet count was mildly decreased to 86,000 x 103/pL. Chest radiograph revealed bilateral diffuse interstitial infiltrates. A diagnosis of acute varicella-zoster virus pneumonia (varicella pneumonia) was made, and the patient was started on IV acyclovir (10 mg/kg every 8 hours). Upon further questioning, the patient stated that his daughter had been diagnosed with \"chickenpox\" 7 days ago. The patient had numerous exposures to chickenpox in the past but had never developed clinical expressions of varicella. He was not at risk for HIV infection, not having multiple sexual partners, IV drug abuse, or blood transfusions. During the 1 day of in-hospitalization, his fever abated and the pulmonary signs diminished. Following discharge, IV acyclovir was replaced by valacyclovir to complete a 7-day course of therapy." }, { "id": "pubmed23n0405_5764", "title": "The behavioral and cognitive effects of two benzodiazepines associated with drug-facilitated sexual assault.", "score": 0.008928571428571428, "content": "Recently, sexual assaults have included the use of benzodiazepines to impair the victim. Our aim was to examine the physiological, cognitive, and behavioral effects of flunitrazepam (FN) and clonazepam (CLO). In the first study, ten healthy volunteers received a single oral dose of 2 mg of FN. Mini Mental State Examination (MMSE), behavioral reports and staff observations were then collected. In the second study, ten healthy volunteers received a single oral dose of 3 mg of CLO. Vital signs, performance on the MMSE and Digit Symbol Substitution Test, and behavioral changes were examined. FN significantly decreased systolic and diastolic blood pressure 4 h post drug ingestion with diastolic remaining low at 6 h. CLO was associated with changes in temperature and decreased systolic pressure. FN affected memory and attention 4 h following ingestion. CLO affected memory and attention throughout the study (6 h), and psychomotor performance was decreased 2 h post ingestion. In both studies, subjects were disinhibited and did not perceive their own impairment." }, { "id": "wiki20220301en144_37796", "title": "Robert Spencer (doctor)", "score": 0.008928571428571428, "content": "According to Rothstein, Spencer inserted something to dilate X's cervix and instructed the women to return in the morning. The next morning, Rothstein was left in a room while X went with Spencer to another room for her abortion. \"Eventually,\" Rothstein wrote, \"Dr. Spencer returned with X over his shoulder in a fireman's carry, out cold. He gently unloaded her onto the cot; her eyes were rolled back so only the whites showed. After she came to and had rested, he checked her, gave her post-op instructions and antibiotics, and wished her well. The entire charge, including anesthesia, was $50.\" Spencer's records Spencer's records were burned by his second wife, preventing researchers from accurately documenting his practice. Thus, neither his technique nor the number and type of patients treated can be verified. The Mary Davies case" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 170, 290 ] ], "word_ranges": [ [ 27, 47 ] ], "text": "The tendon that runs alongside the ulnar nerve, inserting into the pisiform, is the flexor carpi ulnaris, thus answer 1." }, "2": { "exist": true, "char_ranges": [ [ 0, 100 ] ], "word_ranges": [ [ 0, 16 ] ], "text": "Both the flexor carpi radialis and the abductor pollicis longus are anatomically far from the ulnar." }, "3": { "exist": true, "char_ranges": [ [ 101, 169 ] ], "word_ranges": [ [ 16, 27 ] ], "text": "The palmaris longus is medial, as is the flexor digitorum profundus." }, "4": { "exist": true, "char_ranges": [ [ 0, 100 ] ], "word_ranges": [ [ 0, 16 ] ], "text": "Both the flexor carpi radialis and the abductor pollicis longus are anatomically far from the ulnar." }, "5": { "exist": true, "char_ranges": [ [ 101, 169 ] ], "word_ranges": [ [ 16, 27 ] ], "text": "The palmaris longus is medial, as is the flexor digitorum profundus." } }

{ "1": "Tendon of the flexor carpi ulnaris.", "2": "Tendon of the abductor pollicis longus.", "3": "Tendon of the deep flexor of the fingers.", "4": "Radial carpal flexor tendon.", "5": "Palmaris longus tendon." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en198_37466", "title": "Common flexor sheath of hand", "score": 0.019230769230769232, "content": "The common synovial sheath for the flexor tendons or the ulnar bursa is a synovial sheath in the carpal tunnel of the human hand. It contains tendons of the flexor digitorum superficialis and the flexor digitorum profundus, but not the flexor pollicis longus. The sheath which surrounds the flexor digitorum extends downward about halfway along the metacarpal bones, where it ends in blind diverticula around the tendons to the index, middle, and ring fingers. It is prolonged on the tendons to the little finger and usually communicates with the mucous sheath of these tendons. References External links https://web.archive.org/web/20070814124446/http://moon.ouhsc.edu/dthompso/namics/labs/wrist2.htm Upper limb anatomy" }, { "id": "wiki20220301en116_5094", "title": "Common flexor tendon", "score": 0.017879948914431672, "content": "The common flexor tendon is a tendon that attaches to the medial epicondyle of the humerus (lower part of the bone of the upper arm that is near the elbow joint). It serves as the upper attachment point for the superficial muscles of the front of the forearm: Flexor carpi ulnaris Palmaris longus Flexor carpi radialis Pronator teres Flexor digitorum superficialis See also Common extensor tendon References Tendons" }, { "id": "pubmed23n0066_4788", "title": "[Closed tendon injuries of the hand].", "score": 0.013968957871396896, "content": "Cases of subcutaneous tendon ruptures of the hand were compiled over a period of 10 years; the lesions were all traumatic rather than due to degenerative illness. The 914 injuries fall into two categories: 867 extensor and 47 flexor tendon ruptures. The localisation of the lesions is most often distal. The extensor tendon lesion is accompanied more often by a ruptured bony fragment; the distal flexor tendon is mostly torn-off bony fragment. The extensor tendon ruptures can be subdivided as follows: distal injuries of the extensor aponeurosis in the DIP joint (751 cases), IP joint (31), tractus intermedius (27), ext. carpi radialis longus (5) and brevis (1), ext. carpi ulnaris (6); proximal ruptures of the ext. pollicis longus (42), ext. digitorum communis II and indicis (1 each) and ext. carpi radialis longus and brevis (1 each). The flexor tendon lesions are as follows: distal injuries to flex. digitorum profundus (32 cases), flex. pollicis longus (9), and the opponens pollicis, which is classified under this heading (2). Proximal lesions to flex. pollicis longus (2) and flex. digitorum profundus and superficialis (1 each)." }, { "id": "article-22520_17", "title": "Hand Infection -- Treatment / Management", "score": 0.012776222526654356, "content": "Deeper infections more frequently require intravenous antibiotic treatment and prompt surgical management. In certain cases of flexor tenosynovitis, a trial of intravenous antibiotics under close inpatient observation may be attempted, provided the patient presents within 24 hours of symptom onset. [22] Typically, however, the treatment of choice for flexor tenosynovitis is incision and drainage of the flexor tendon sheath. [22] Incision and drainage of the flexor tendon sheath may be accomplished by passing an angiocatheter through a small proximal or distal incision on the digit. Depending on the presentation, however, a full open exposure may be required. [22] If untreated, thumb or index finger flexor tenosynovitis may spread to the deep thenar space or radial bursa, and the more ulnar digits may spread to the deep midpalmar space or ulnar bursa. [22] [25] The development of a “horseshoe abscess” is based upon similar connections, where infection communicates between the thumb and small finger flexor tendon sheaths in a potential space located between the pronator quadratus and flexor digitorum profundus tendons (i.e., Parona space). [22] [25]" }, { "id": "wiki20220301en011_122239", "title": "Median nerve", "score": 0.012666351415253664, "content": "Hand The median nerve enters the hand through the carpal tunnel, deep to the flexor retinaculum along with the tendons of flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus. From there, it is divided into recurrent muscular branch and digital cutaneous branch: The muscular branch (also known as recurrent branch) supplies the thenar muscles (opponens pollicis, abductor pollicis brevis, and superficial part of flexor pollicis brevis)" }, { "id": "wiki20220301en071_51383", "title": "Flexor pollicis longus muscle", "score": 0.01252948113207547, "content": "It arises also from the adjacent part of the interosseous membrane of the forearm, and generally by a fleshy slip from the medial border of the coronoid process of the ulna. In 40 percent of cases, it is also inserted from the medial epicondyle of the humerus, and in those cases a tendinous connection with the humeral head of the flexor digitorum superficialis is present. The fibers end in a flattened tendon, which passes beneath the flexor retinaculum of the hand through the carpal tunnel. It is then lodged between the lateral head of the flexor pollicis brevis and the oblique part of the adductor pollicis, and, entering an osseoaponeurotic canal similar to those for the flexor tendons of the fingers, is inserted into the base of the distal phalanx of the thumb." }, { "id": "pubmed23n0076_6102", "title": "[Extensor indicis muscle as a replacement for the abductor pollicis longus muscle. A case report].", "score": 0.012396845772969008, "content": "The abductor pollicis longus muscle is very important for the function of the thumb. Its deficit hinders grasping bigger objects. Therefore, the reconstruction of the APL tendon is important in chronic injuries. The interposition of a tendon graft is considered the best method. However, the muscle loses its contractility very quickly because of its small gliding amplitude. Consequently, this procedure is only usable in the first six to eight weeks after injury. Later the function of the abductor pollicis longus muscle can only be recovered by a tendon transposition. The described tendon transposition methods the palmaris longus tendon, the flexor carpi radialis tendon and the radial half of the extensor carpi radialis longus tendon--do not fulfill the requirements of a good tendon transposition. Functional considerations may make the extensor indicis muscle the best substitution for the abductor pollicis longus. There is no disturbance of the function of the index finger by loss of the extensor indicis muscle. Both the extensor indicis and the abductor pollicis longus are functional synergists and are under voluntary control of the brain. By mobilization of the extensor indicis, abductor pollicis longus strength can be approached. A difference exists in the gliding amplitude of both muscles. The gliding amplitude of the extensor indicis is 55 mm while that of the abductor pollicis longus is 28 mm. If the extensor indicis muscle is placed under moderate tension the gliding amplitudes are identical. The strength of the abductor pollicis longus is 0.092 kp/m. The strength of the extensor indicis is unknown.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en064_49096", "title": "Flexor carpi ulnaris muscle", "score": 0.012286240463036044, "content": "Action The flexor carpi ulnaris flexes and adducts at the wrist joint. Innervation The flexor carpi ulnaris is innervated by the ulnar nerve. The corresponding spinal nerves are C8 and T1. Tendon The tendon of flexor carpi ulnaris can be seen on the anterior surface of the distal forearm. On a person's distal forearm, just before the wrist, there are either two or three tendons. The tendon of the flexor carpi ulnaris is the most medial (closest to the little finger) of these. The most lateral one is the tendon of flexor carpi radialis muscle, and the middle one, not always present, is the tendon of palmaris longus. Function The muscle, like all flexors of the forearm, can be strengthened by exercises that resist its flexion. A wrist roller can be used and wrist curls with dumbbells can also be performed. These exercises are used to prevent injury to the ulnar collateral ligament of elbow joint." }, { "id": "wiki20220301en476_31809", "title": "Palmaris profundus muscle", "score": 0.012275622466705268, "content": "Palmaris profundus (also known as musculus comitans nervi mediani or palmaris bitendinous) is a rare anatomical variant in the anterior compartment of forearm. It was first described in 1908. It is usually found incidentally in cadaveric dissection or surgery. Structure Pirola et al. classified the muscle into subtypes depending on its origin: (1) from the radius, (2) from the flexor digitorum superficialis fascia, and (3) from the ulna. Though, other origins of the muscle were reported including the medial epicondyle of humerus, the palmaris longus and the flexor pollicis longus. It runs deep to the pronator teres and lateral to the flexor digitorum superficialis. Its tendon passes beneath the flexor retinaculum through the carpal tunnel before broadening out to insert to the deep part of palmar aponeurosis." }, { "id": "article-141378_7", "title": "Pyogenic Flexor Tenosynovitis -- Introduction -- Anatomy of Flexor Tendon Sheaths", "score": 0.012218045112781954, "content": "The flexor tendon sheaths for the index, middle, ring, and little fingers terminate at the level of the flexor digitorum profundus tendon insertion into the distal phalanx. The flexor tendon sheath ends at the flexor pollicis longus tendon insertion level in the thumb. Proximally, the flexor sheaths of the index, middle, and ring fingers extend to the A1 pulley at the level of the neck of the metacarpal bone. The sheath of the flexor pollicis longus tendon communicates with the radial bursa proximally. The little finger flexor sheath communicates with the ulnar bursa in about 80% of the population. [9] The radial and ulnar bursa are connected in 80% of people in the space of Parona, a potential space between the digital flexor tendons and the pronator quadratus in the volar distal forearm. This anatomic space allows a little finger or thumb infection to cause a horseshoe abscess. [10] [11]" }, { "id": "wiki20220301en071_51426", "title": "Palmaris longus muscle", "score": 0.012166202701309413, "content": "Clinical significance Use in tendon grafts The palmaris longus muscle is the most popular for use in tendon grafts for the wrist due to the length and diameter of the palmaris longus tendon, and the fact that it can be used without producing any functional deformities. When a tendon becomes ruptured in the wrist, the palmaris longus tendon may be removed from the flexor retinaculum and grafted to take the place of the ruptured tendon. The tendons most commonly replaced or supplemented by the palmaris longus tendon when ruptured are the long flexors of the fingers and the flexor pollicis longus tendon." }, { "id": "wiki20220301en011_153804", "title": "Flexor digitorum profundus muscle", "score": 0.011588048705617518, "content": "The flexor digitorum profundus is a muscle in the forearm of humans that flexes the fingers (also known as digits). It is considered an extrinsic hand muscle because it acts on the hand while its muscle belly is located in the forearm. Together the flexor pollicis longus, pronator quadratus, and flexor digitorum profundus form the deep layer of ventral forearm muscles. The muscle is named . Structure Flexor digitorum profundus originates in the upper 3/4 of the anterior and medial surfaces of the ulna, interosseous membrane and deep fascia of the forearm. The muscle fans out into four tendons (one to each of the second to fifth fingers) to the palmar base of the distal phalanx. Along with the flexor digitorum superficialis, it has long tendons that run down the arm and through the carpal tunnel and attach to the palmar side of the phalanges of the fingers." }, { "id": "article-36135_25", "title": "Anatomy, Shoulder and Upper Limb, Hand Extensor Pollicis Longus Muscle -- Surgical Considerations -- Tendon transfers", "score": 0.011178587494376968, "content": "Patients requiring surgical reconstruction of a ruptured extensor pollicis longus tendon may get a tendon transfer or a free tendon graft. The extensor indicis is commonly used for tendon transfer, while other tendons that are usable include the palmaris longus, extensor carpi radialis longus, extensor carpi radialis brevis, and abductor pollicis longus. While the palmaris longus tendon is avascular, a palmaris longus tendon transfer may be performed to preserve index finger extension power, which commonly decreases after a tendon transfer involving the extensor indicis. It is essential to make sure there is an appropriate amount of tension in the reconstructed tendon; if there is too much tension, the thumb will be hyperextended and will not be able to flex correctly. Without enough tension, there will be extension deficits. A surgical technique to approximate the appropriate tension is to lay the patient’s hand on the table, with the forearm pronated and the wrist in a neutral position, and measure the distance of the center of the patient’s thumbnail edge to the table. The distance should be 2 cm. If it is more or less the suturing holding together, the reconstruction should be removed and re-done to achieve appropriate tension in the reconstructed EPL so that the thumbnail edge remains 2 cm off the table. [25]" }, { "id": "wiki20220301en111_29396", "title": "Proper palmar digital nerves of median nerve", "score": 0.010894561342991837, "content": "In the palm of the hand the median nerve is covered by the skin and the palmar aponeurosis, and rests on the tendons of the flexor muscles. Immediately after emerging from under the transverse carpal ligament the median nerve becomes enlarged and flattened and splits into a smaller, lateral, and a larger, medial portion. The lateral portion supplies a short, stout branch to certain of the muscles of the ball of the thumb, viz., the abductor pollicis brevis, the opponens pollicis, and the superficial head of the flexor brevis, and then divides into three proper palmar digital nerves of median nerve (proper volar digital nerves): two of these supply the sides of the thumb, while the third gives a twig to the first lumbricalis and is distributed to the radial side of the index finger." }, { "id": "wiki20220301en286_2084", "title": "Mucous sheaths on back of wrist", "score": 0.010796108379537608, "content": "The mucous sheaths of the tendons on the back of the wrist are protective coverings for tendons in the wrist. Between the dorsal carpal ligament and the bones six compartments are formed for the passage of tendons, each compartment having a separate mucous sheath. One is found in each of the following positions: on the lateral side of the radial styloid process, for the tendons of the Abductor pollicis longus and Extensor pollicis brevis; behind the styloid process, for the tendons of the Extensores carpi radialis longus and brevis; about the middle of the dorsal surface of the radius, for the tendon of the Extensor pollicis longus; to the medial side of the latter, for the tendons of the Extensor digitorum communis and Extensor indicis proprius; opposite the interval between the radius and ulna, for the Extensor digiti quinti proprius; between the head and styloid process of the ulna, for the tendon of the Extensor carpi ulnaris." }, { "id": "wiki20220301en012_7682", "title": "Flexor carpi radialis muscle", "score": 0.010774061590758506, "content": "In anatomy, flexor carpi radialis is a muscle of the human forearm that acts to flex and (radially) abduct the hand. The Latin carpus means wrist; hence flexor carpi is a flexor of the wrist. Origin and insertion The flexor carpi radialis is one of four muscles in the superficial layer of the anterior compartment of the forearm. This muscle originates from the medial epicondyle of the humerus as part of the common flexor tendon. It runs just laterally of flexor digitorum superficialis and inserts on the anterior aspect of the base of the second metacarpal, and has small slips to both the third metacarpal and trapezium tuberosity. The tendon of the flexor carpi radialis is visible on the anterior surface of the forearm, just proximal to the wrist, when the wrist is flexed. It is the tendon seen most lateral, closest to the thumb." }, { "id": "article-30732_9", "title": "Anatomy, Shoulder and Upper Limb, Hand Ulnar Bursa -- Physiologic Variants", "score": 0.01073224043715847, "content": "The ulnar bursa typically originates at the pronator quadratus level and continues distally, terminating 1 to 3 cm proximal to the flexor tendon sheaths of digits 2-4. However, studies reveal that the ulnar bursa may communicate with the flexor tendon sheaths of digits 2, 3, and 4, with prevalence rates of 5.1%, 4%, and 3.5%, respectively. [7] Communication with the 5th digit's flexor tendon sheath is much more common, occurring in 50% to 80% of cases. [3]" }, { "id": "article-30732_1", "title": "Anatomy, Shoulder and Upper Limb, Hand Ulnar Bursa -- Introduction", "score": 0.010216856695729935, "content": "The synovial tendon sheath is a bursa that surrounds tendons as they pass through anatomic spaces. The ulnar bursa is the synovial tendon sheath enclosing the tendons of the medial 4 fingers' flexors as they pass through the carpal tunnel (see Image . Hand Bursae). It possesses 3 distinct invaginations that surround the structures of the carpal tunnel [2] : Deep layer: between the carpal bones and the flexor digitorum profundus tendons Intermediate layer: between the flexor digitorum profundus tendons and flexor digitorum superficialis tendons Superficial layer: superficial to the flexor digitorum superficialis tendons" }, { "id": "wiki20220301en085_19495", "title": "Abductor digiti minimi muscle of hand", "score": 0.010167396921694192, "content": "Variation In rare cases accessory fascicles of the abductor digiti minimi have been found arising from the antebrachial fascia, the radius, and the ulna. The abductor digiti minimi is the most variable hypothenar muscle, and might be joined by accessory slips from the tendon of the flexor carpi ulnaris, the flexor retinaculum, the fascia of the distal forearm, or the tendon of the palmaris longus. Occasionally, the muscle is partially inserted onto the fifth metacarpal bone. In case of polydactyly it may insert to the sixth finger instead, if there is one. Function It is an abductor of the little finger at the metacarpophalangeal joint. It is also possible that the muscle contributes to extension of the middle phalanx of the little finger through its connection to finger's extensor mechanism. It plays an important role when the hand is grasping large objects with outspread fingers." }, { "id": "wiki20220301en064_49097", "title": "Flexor carpi ulnaris muscle", "score": 0.00993223800241344, "content": "Variability The muscle can be doubled as accessory flexor carpi ulnaris muscle and is often accompanied by concomitant variants. Clinical significance Ulnar entrapment by the aponeurosis of the two heads of the flexor carpi ulnaris muscle may cause cubital tunnel syndrome. Tendon of flexor carpi ulnaris can be used for tendon transfer. Additional images References External links Muscles of the upper limb Forearm" }, { "id": "wiki20220301en085_57290", "title": "Flexor retinaculum of the hand", "score": 0.009900990099009901, "content": "The flexor retinaculum is continuous with the palmar carpal ligament, and deeper with the palmar aponeurosis. The ulnar artery and ulnar nerve, and the cutaneous branches of the median and ulnar nerves, pass on top of the flexor retinaculum. On the radial side of the retinaculum is the tendon of the flexor carpi radialis, which lies in the groove on the greater multangular between the attachments of the ligament to the bone. The tendons of the palmaris longus and flexor carpi ulnaris are partly attached to the surface of the retinaculum; below, the short muscles of the thumb and little finger originate from the flexor retinaculum. Function The flexor retinaculum is the roof of the carpal tunnel, through which the median nerve and tendons of muscles which flex the hand pass. Clinical significance" }, { "id": "article-30732_24", "title": "Anatomy, Shoulder and Upper Limb, Hand Ulnar Bursa -- Other Issues -- Deep Hand Infections", "score": 0.009900990099009901, "content": "During ulnar bursa endoscopic tenosynovectomy, a 3-4 mm skin incision is made at the ulnar palmar portal through the palmar aponeurosis. The ulnar palmar portal is the viewing portal. The trocar cannula is placed across the metacarpal necks, passing to the first webspace. The thumb is then abducted. An incision is made to create the first web portal at the tip of the trocar. Synovectomy is performed along the long flexor tendons between the thumb and index fingers. [17]" }, { "id": "wiki20220301en155_42353", "title": "Carpal tunnel", "score": 0.00980392156862745, "content": "Superficial to the carpal tunnel and the flexor retinaculum, the ulnar artery and ulnar nerve pass through the ulnar tunnel/Guyon's canal. Function Ten structures pass through the carpal tunnel, most of them flexor tendons (not the muscles themselves): flexor digitorum profundus (four tendons) flexor digitorum superficialis (four tendons) flexor pollicis longus (one tendon) Median nerve between tendons of flexor digitorum profundus and flexor digitorum superficialis The flexor carpi radialis (one tendon), is often incorrectly stated to travel within the carpal tunnel. More precisely, it travels within the fibers of the flexor retinaculum which forms the roof of the carpal tunnel, rather than running inside the tunnel itself." }, { "id": "pubmed23n0339_2232", "title": "Ultrasonic assistance in the diagnosis of hand flexor tendon injuries.", "score": 0.00980392156862745, "content": "In contrast to routine flexor tendon injuries, flexor tendon ruptures following blunt injury or re-ruptures following repair can be difficult to diagnose. The authors investigated the efficacy of using ultrasound to assist in the diagnosis. From 1996 to 1997, 8 patients underwent evaluation of the flexor tendons using an ATL HDI-3000 ultrasound machine with a high-resolution, 5 to 9-MHz hockey stick linear probe. Dynamic evaluation was performed in real time, simulating clinical symptoms. Six patients underwent surgical exploration. Sonographic diagnosis and intraoperative findings were correlated. Ultrasound was used to diagnose 3 patients with ruptured flexor digitorum profundus tendons. Mechanisms of injury included forceful extension, penetrating injury, and delayed rupture 3 weeks after tendon repair. Subsequent surgical exploration confirmed the ruptures and location of the stumps. Five patients had intact flexor tendons by ultrasound after forceful extension, penetrating injury, phalangeal fracture, crush injury, and unknown etiology. In 3 patients who underwent surgery for tenolysis, scar release, or arthrodesis, the flexor tendons were found to be intact, as predicted by ultrasound. The authors found ultrasound to be accurate in diagnosing the integrity of flexor tendons and in localizing the ruptured ends. They conclude that ultrasound is helpful in evaluating equivocal flexor tendon injuries." }, { "id": "wiki20220301en155_42352", "title": "Carpal tunnel", "score": 0.009708737864077669, "content": "Structure The carpal bones that make up the wrist form an arch which is convex on the dorsal side of the hand and concave on the palmar side. The groove on the palmar side, the sulcus carpi, is covered by the flexor retinaculum, a sheath of tough connective tissue, thus forming the carpal tunnel. On the side of the radius, the flexor retinaculum is attached to the scaphoid bone, more precisely its tubercle, as well as the ridge of trapezium. On the ulnar side, it is attached to the pisiform and hook of hamate. The narrowest section of the tunnel is located a centimetre beyond the mid-line of the distal row of carpal bones where the sectional area is limited to 1.6 cm2. The tendons of the flexor digitorum superficialis and profundus pass through a common ulnar sheath, while the tendon of the flexor pollicis longus passes through a separate radial sheath. The mesotendon shared by these tendons is attached to the radial and palmar walls of the carpal tunnel." }, { "id": "wiki20220301en011_153805", "title": "Flexor digitorum profundus muscle", "score": 0.0095941749651997, "content": "Along with the flexor digitorum superficialis, it has long tendons that run down the arm and through the carpal tunnel and attach to the palmar side of the phalanges of the fingers. Flexor digitorum profundus lies deep to the superficialis, but it attaches more distally. Therefore, profundus's tendons go through the tendons of superficialis, and end up attaching to the distal phalanx. For this reason profundus is also called the perforating muscle. The lumbricals of the hand arise from the radial side of its tendons." }, { "id": "pubmed23n1137_19247", "title": "Extensor digitorum muscle tendon to the index finger from the extensor carpi radialis brevis: a cadaveric case report.", "score": 0.009523809523809525, "content": "The forearm extensor compartment is known for its wide variability in terms of muscle origin, number of tendons and their distal insertion. The index finger on its dorsal aspect is the typical place of insertion of the two tendons of the extensor digitorum (ED-index) and of the extensor indicis. Being acquainted with their anatomy is of immense importance to orthopedic surgeons in the treatment of e.g., de Quervain's syndrome. The current report presents a rare finding of the ED-index tendon arising from the extensor carpi radialis brevis (ECRB). A routine dissection revealed their fused course from the lateral epicondyle of humerus, though separate from the extensor carpi radialis longus. The ED-index muscle belly separated from the ECRB, 119 mm distal to the lateral epicondyle. The distal insertion point of the ED-index was located radially to that of the extensor indicis. The deep branch of the radial nerve and the recurrent interosseous artery supplied the ED-index. No other musculotendinous variations were encountered neither on the ipsilateral nor the contralateral upper limb of the cadaver. This study presents in detail a tendon of the ED-index arising from the ECRB, aknowledge that can be applied namely in the lateral epicondylitis treatment or approach to the ulnar nerve at the level of the elbow. Extensive depiction of both the proximal and distal attachment points of the muscles, their course and dimensions is indispensable to attain the best patient outcomes and avoid iatrogenic injuries." }, { "id": "pubmed23n1163_16883", "title": "Acupotomy in the treatment of tenosynovitis of hand flexor tendons: A systematic review and meta-analysis.", "score": 0.009433962264150943, "content": "Acupotomy was used to treat tenosynovitis of hand flexor tendons (THFT) in China. But it's uncertain about the efficacy of acupotomy for THFT. We plan to evaluate the efficacy and safety about acupotomy therapy in the treatment of THFT through this review. The protocol about this review was registered in PROSPERO (registration number: CRD42022330568). We searched 6 databases from their respective inception dates to January 11, 2022. Studies searched was screened by our reviewers, and then the raw data was filtered out. We used RevMan 5.3 software to perform statistical analysis. 11 studies involving 828 patients were shortlisted. The experimental group showed obvious advantages compared with the control group, such as effective rate (odds ratio [OR] = 6.77, 95% CI [confidence intervals] = [3.89, 11.77], P &lt; .00001), cure rate (OR = 3.32, 95% CI = [1.81, 6.11], P = .0001) and Vas score (MD = -1.21, 95% CI = [-2.00, -0.42], Z = 3.01, P &lt; .003). According to the above results, Acupotomy is an effective and safe treatment for THFT. So it should be recommended for the treatment of THFT patients." }, { "id": "wiki20220301en071_51453", "title": "Adductor pollicis muscle", "score": 0.009345794392523364, "content": "From this origin the greater number of fibers pass obliquely downward and converge to a tendon, which, uniting with the tendons of the medial portion of the flexor pollicis brevis and the transverse head of the adductor pollicis, is inserted into the ulnar side of the base of the proximal phalanx of the thumb, a sesamoid bone being present in the tendon. A considerable fasciculus, however, passes more obliquely beneath the tendon of the flexor pollicis longus to join the lateral portion of the flexor pollicis brevis and the abductor pollicis brevis. Transverse head The transverse head (Latin: adductor transversus pollicis) is deeply seated. It is triangular, arising by a broad base from the lower two-thirds of the palmar surface of the third metacarpal bone; the fibers converge, to be inserted with the medial part of the flexor pollicis brevis and the oblique head into the ulnar side of the base of the proximal phalanx of the thumb." }, { "id": "article-22541_9", "title": "Hand Extensor Tendon Lacerations -- History and Physical -- Superficial Extrinsic Extensors", "score": 0.009345794392523364, "content": "Extensor carpi radialis longus (ECRL) Extensor carpi radialis brevis (ECRB) Extensor digitorum communis, (EDC) Extensor digiti minimi (EDM) Extensor carpi ulnaris (ECU)" }, { "id": "pubmed23n1096_10206", "title": "[De Quervain's tenosynovitis: Clinical aspects and diagnostic techniques].", "score": 0.009259259259259259, "content": "De Quervain's tenosynovitis is a tendon sheath inflammation of the musculus abductor pollicis longus (APL) and the musculus extensor pollicis brevis (EPB) in the first extensor compartment of the wrist. Typically, patients present with pain symptoms on the radial side of the wrist as a result of repetitive moments and consequent overload of the tendons. During physical examination, De Quervain's tenosynovitis is easily distinguishable from other wrist injuries. Early recognition is of utmost importance for treatment decisions due to the fact that it is very well treatable, especially in the acute phase. A multimodal approach with conservative management is the most effective. Surgical intervention is usually not necessary." }, { "id": "pubmed23n0574_13855", "title": "Management and functional outcomes of combined injuries of flexor tendons, nerves, and vessels at the wrist.", "score": 0.009174311926605505, "content": "A retrospective review of 42 patients with spaghetti wrist lacerations operated on by the author between June 1997 and May 2005 was completed. A total of 31 males and 11 females, average age of 17.1 years (range, 2-40 years), sustained spaghetti wrist injuries. The most frequent mechanisms of injury were accidental glass lacerations (55%), knife wounds (24%), and electrical saw injuries (11%). An average of 9.16 structures was injured, including 6.95 tendons, 1.4 nerves, and 0.8 arteries. The most frequently injured structures were median nerve (83%), flexor digitorum superficialis 2-4 tendons (81%), flexor digitorum profundus 2-4 tendons (66%), ulnar nerve and ulnar artery (57%), and flexor pollicis longus (40%). Combined flexor carpi ulnaris, ulnar nerve, and ulnar artery (ulnar triad) injuries occurred in 31%, while combined median nerve, palmaris longus, and flexor carpi radialis injuries (radial triad) occurred in 43%. Simultaneous injuries of both median and ulnar nerves occurred in 40.5%. Simultaneous injuries of both ulnar and radial arteries occurred in 14%. Neither artery was injured in 30.9%. Follow-up has ranged from 1 to 8 years, with an average of 46 months. Only four patients have been completely lost to follow-up. Range of motion of all involved digits (tendon function) was excellent in 34 patients, good in 3 patients, and poor in only 1 patient. Opposition was excellent in 31 patients, good in 5 patients, and poor in 2 patients. Intrinsic muscle recovery was subjectively reported to be excellent in 29 patients, good in 7, and fair to poor in 2 patients. Minor deformity (partial clawing) was reported in 4 patients and 1 patient has major deformity (total clawing). Sensory recovery was reported, excellent in 32 patients, good in 5 patients, and fair in only 1 patient." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 1322, 1446 ] ], "word_ranges": [ [ 245, 264 ] ], "text": "Wrong, he is a \"retentive\" patient and increasing O2 flow is highly likely to increase hypercapnia and, therefore, acidosis." }, "2": { "exist": true, "char_ranges": [ [ 893, 1195 ] ], "word_ranges": [ [ 168, 223 ] ], "text": "If we decide to do something, at present we might decide to use ventilation rather than theophylline, although with \"so little\" alteration of pH (and even more so if we think that this is a chronic patient who may have a baseline blood gas similar to the one presented to us) it may seem \"exaggerated\"." }, "3": { "exist": true, "char_ranges": [ [ 1487, 1641 ] ], "word_ranges": [ [ 273, 297 ] ], "text": "It is not a metabolic acidosis, the bicarbonate is not decreased, on the contrary, it is slightly increased trying to compensate the respiratory acidosis." }, "4": { "exist": true, "char_ranges": [ [ 1645, 1750 ] ], "word_ranges": [ [ 298, 315 ] ], "text": "He does not reach respiratory failure by definition (pO2 60), but he has hypercapnia and slight acidosis." }, "5": { "exist": true, "char_ranges": [ [ 1968, 2091 ] ], "word_ranges": [ [ 358, 378 ] ], "text": "At present and -as already mentioned- taking into account that there is no formal contraindication, it is not usually used." } }

{ "1": "Increase oxygen flow because he has acute respiratory acidosis and hypoxemia.", "2": "I would initiate noninvasive mechanical ventilation because he has acute hypercapnic respiratory failure with moderate respiratory acidosis.", "3": "I would add sodium bicarbonate to correct the acute metabolic acidosis.", "4": "The patient does not have respiratory insufficiency so he would continue with the same pharmacological regimen.", "5": "I would add intravenous aminophylline as a respiratory stimulant, since I appreciate hypoxemia and hypercapnia." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en049_36553", "title": "Non-invasive ventilation", "score": 0.01913919413919414, "content": "COPD The most common indication for acute non-invasive ventilation is for acute exacerbation of chronic obstructive pulmonary disease. The decision to commence NIV, usually in the emergency department, depends on the initial response to medication (bronchodilators given by nebulizer) and the results of arterial blood gas tests. If after medical therapy the lungs remain unable to clear carbon dioxide from the bloodstream (respiratory acidosis), NIV may be indicated. Many people with COPD have chronically elevated CO2 levels with metabolic compensation, but NIV is only indicated if the CO2 is acutely increased to the point that the acidity levels of the blood are increased (pH<7.35). There is no level of acidity above which NIV cannot be started, but more severe acidosis carries a higher risk that NIV alone is not effective and that mechanical ventilation will be required instead." }, { "id": "pubmed23n1056_10912", "title": "Nasal high-flow oxygen <i>versus</i> noninvasive ventilation in acute exacerbation of COPD: protocol for a randomised noninferiority clinical trial.", "score": 0.017645245800585605, "content": "Noninvasive ventilation (NIV) is considered as the first-line treatment for acute exacerbation of COPD (AECOPD) complicated by respiratory acidosis. Recent studies demonstrate a role of nasal high-flow oxygen (NHF) in AECOPD as an alternative treatment in patients intolerant to NIV or with contraindications to it. The study aimed to evaluate whether NHF respiratory support is noninferior compared to NIV in respect to treatment failure, defined as need for intubation or change to alternative treatment group, in patients with AECOPD and mild-to-moderate acute or acute-on-chronic hypercapnic respiratory failure. We designed a multicentre, prospective, randomised trial on patients with AECOPD, who have pH&lt;7.35 but &gt;7.25 and <iP</i <subaCO<sub2</sub</sub  &gt;45 mmHg, in whom NIV is indicated as a first-line treatment. According to power analysis, 498 participants will be required for establishing noninferiority of NHF compared to NIV. Patients will be randomly assigned to receive NIV or NHF. Treatment will be adjusted to maintain <iS</i <subpO<sub2</sub</sub between 88%-92% for both groups. Arterial blood gases, respiratory variables, comfort, dyspnoea score and any pulmonary or extrapulmonary complications will be assessed at baseline, before treatment initiation, and at 1, 2, 4, 6, 12, 24, 48 h, then once daily from day 3 to patient discharge, intubation or death. Given the increasing number of studies demonstrating the physiological effects of NHF in COPD patients, we hypothesise that NHF respiratory support will be noninferior to NIV in patients with AECOPD and mild-to-moderate acute or acute on chronic hypercapnic respiratory failure." }, { "id": "wiki20220301en010_32316", "title": "Respiratory failure", "score": 0.014370131614289551, "content": "Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise in arterial carbon dioxide levels is called hypercapnia. Respiratory failure is classified as either Type 1 or Type 2, based on whether there is a high carbon dioxide level, and can be acute or chronic. In clinical trials, the definition of respiratory failure usually includes increased respiratory rate, abnormal blood gases (hypoxemia, hypercapnia, or both), and evidence of increased work of breathing. Respiratory failure causes an altered mental status due to ischemia in the brain. The typical partial pressure reference values are oxygen Pa O2 more than 80 mmHg (11 kPa) and carbon dioxide Pa CO2 less than 45 mmHg (6.0 kPa). Cause" }, { "id": "pubmed23n0350_22852", "title": "Oxygen therapy during exacerbations of chronic obstructive pulmonary disease.", "score": 0.01349873843566022, "content": "Venturi masks (VMs) and nasal prongs (NPs) are widely used to treat acute respiratory failure (ARF) in chronic obstructive pulmonary disease (COPD). In this study, these devices were compared in terms of their potentiality to worsen respiratory acidosis and their capacity to maintain adequate (&gt; 90%) arterial oxygenation (Sa,O2) through time (approximately 24 h). In a randomized cross-over study, 18 consecutive COPD patients who required hospitalization because of ARF were studied. After determining baseline arterial blood gas levels (on room air), patients were randomized to receive oxygen therapy through a VM or NPs at the lowest possible inspiratory oxygen fraction that resulted in an initial Sa,O2 of &gt; or = 90%. Arterial blood gas levels were measured again 30 min later (on O2), and Sa,O2 recorded using a computer during the subsequent approximately 24 h. Patients were then crossed-over to receive O2 therapy by means of the alternative device (NPs or VM), and the same measurements obtained again in the same order. It was observed that both the VM and NPs improved arterial oxygen tension (p&lt;0.0001) to the same extent (p=NS), without any significant effect upon arterial carbon dioxide tension or pH. However, despite this adequate initial oxygenation, Sa,O2 was &lt; 90% for 3.7+/-3.8 h using the VM and for 5.4+/-5.9 h using NPs (p&lt;0.05). Regression analysis showed that the degree of arterial hypoxaemia (p&lt;0.05) and arterial hypercapnia (p&lt;0.05) present before starting O2 therapy and, particularly, the initial Sa,O2 achieved after initiation of O2 therapy (p&lt;0.0001) enabled the time (in h) that patients would be poorly oxygenated (Sa,O2 &lt; 90%) on follow-up to be predicted. These findings suggest that, in order to maintain an adequate (&gt; 90%) level of arterial oxygenation in patients with chronic obstructive pulmonary disease and moderate acute respiratory failure: 1) the initial arterial oxygen saturation on oxygen should be maximized whenever possible by increasing the inspiratory oxygen fraction; 2) this strategy seems feasible because neither the VM nor NPs worsen respiratory acidosis significantly; and 3) the Venturi mask (better than nasal prongs) should be recommended." }, { "id": "wiki20220301en040_1133", "title": "Respiratory acidosis", "score": 0.013095878277923639, "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": "wiki20220301en063_60916", "title": "Permissive hypercapnia", "score": 0.012684928340268145, "content": "Permissive hypercapnia is hypercapnia (i.e. high concentration of carbon dioxide in blood) in respiratory insufficient patients in which oxygenation has become so difficult that the optimal mode of mechanical ventilation (with oxygenation in mind) is not capable of exchanging enough carbon dioxide. Carbon dioxide is a gaseous product of the body's metabolism and is normally expelled through the lungs. In acute respiratory distress syndrome (ARDS), decreasing the tidal volume on the ventilator (usually 6-8 mL/kg) to 4-6 mL/kg may decrease barotrauma by decreasing ventilatory peak airway pressures and leads to improved respiratory recovery. Hypercapnia (increased pCO2) sometimes needs to be tolerated in order to achieve these lower tidal volumes. The permissive hypercapnia leads to respiratory acidosis which might have negative side effects, but given that the patient is in ARDS, improving ventilatory function is more important." }, { "id": "wiki20220301en358_3428", "title": "Medical gas therapy", "score": 0.012531328320802004, "content": "Patients with these conditions may suffer a range of symptoms including dyspnea (breathlessness), hypoxemia (below-normal oxygen content in the arterial blood) and eventually a weakening of the respiratory muscles due to exhaustion, which can lead to respiratory failure and require intubation and mechanical ventilation. Heliox may reduce all these effects, making it easier for the patient to breathe. Heliox has also found utility in the weaning of patients off mechanical ventilation, and in the nebulization of inhalable drugs, particularly for the elderly. Research has also indicated advantages in using helium–oxygen mixtures in delivery of anaesthesia. References Respiratory therapy Pulmonology Medical treatments Industrial gases" }, { "id": "pubmed23n0063_17765", "title": "Intermittent short-term negative pressure ventilation and increased oxygenation in COPD patients with severe hypercapnic respiratory failure.", "score": 0.012517248176621329, "content": "With the aim of testing a method that allows increasing concentrations of oxygen to be administered to patients with severe hypoxemia and hypercapnia while avoiding the risk of increasing respiratory acidosis, we studied 17 male patients with advanced chronic obstructive pulmonary disease (COPD) and severe hypercapnic respiratory failure. During 6 h and on one day only, all patients were given intermittent negative pressure ventilation (INPV) together with oxygenation starting at a concentration of 24 percent and increasing to 30 percent. Using this procedure, it was possible to raise arterial PaO2 to safe levels (from 47.2 +/- 3 mm Hg to 61.5 +/- 6 mm Hg, p less than 0.001) without increasing hypercapnia, and a significant drop in PaCO2 levels (from 74.4 +/- 9 mm Hg to 65.6 +/- 12 mm Hg, p less than 0.005) was even observed. One hour after INPV ended, the mean values of PaO2, PaCO2, oxygen saturation, and pH were also significantly better than prestudy values. We conclude that INPV and oxygen therapy with increasing oxygen flow could constitute an alternative option to intubation and mechanical ventilation in cases of severe hypercapnic respiratory failure due to advanced COPD." }, { "id": "InternalMed_Harrison_20795", "title": "InternalMed_Harrison", "score": 0.011862483969616259, "content": "The most important group of patients who benefit from a trial of NIV are those with exacerbations of COPD and respiratory acidosis (pH <7.35). Experience from several randomized trials has shown that, in patients with ventilatory failure characterized by blood pH levels between 7.25 and 7.35, NIV is associated with low failure rates (15–20%) and good outcomes (as judged by intubation rate, length of stay in intensive care, and—in some series—mortality rates). In more severely ill patients with a blood pH <7.25, the rate of NIV failure is inversely related to the severity of respiratory acidosis, with higher failure rates as the pH decreases. In patients with milder acidosis (pH >7.35), NIV is not better than conventional treatment that includes controlled oxygen delivery and pharmacotherapy for exacerbations of COPD (systemic glucocorticoids, bronchodilators, and, if needed, antibiotics)." }, { "id": "wiki20220301en159_7352", "title": "Alveolar–arterial gradient", "score": 0.011633587786259541, "content": "Because A–a gradient is approximated as: (150 − 5/4(P)) – at sea level and on room air (0.21x(760-47) = 149.7 mmHg for the alveolar oxygen partial pressure, after accounting for the water vapor), the direct mathematical cause of a large value is that the blood has a low , a low Pa, or both. is very easily exchanged in the lungs and low Pa directly correlates with high minute ventilation; therefore a low arterial Pa indicates that extra respiratory effort is being used to oxygenate the blood. A low indicates that the patient's current minute ventilation (whether high or normal) is not enough to allow adequate oxygen diffusion into the blood. Therefore, the A–a gradient essentially demonstrates a high respiratory effort (low arterial Pa) relative to the achieved level of oxygenation (arterial ). A high A–a gradient could indicate a patient breathing hard to achieve normal oxygenation, a patient breathing normally and attaining low oxygenation, or a patient breathing hard and still" }, { "id": "InternalMed_Harrison_20448", "title": "InternalMed_Harrison", "score": 0.011581797959282363, "content": "Oxygen Supplemental O2 should be supplied to keep arterial saturations ≥90%. Hypoxemic respiratory drive plays a small role in patients with COPD. Studies have demonstrated that in patients with both acute and chronic hypercarbia, the administration of supplemental O2 does not reduce minute ventilation. It does, in some patients, result in modest increases in arterial PCO2, chiefly by altering ventilation-perfusion relationships within the lung. This should not deter practitioners from providing the oxygen needed to correct hypoxemia." }, { "id": "wiki20220301en020_19466", "title": "Hypercapnia", "score": 0.011343323108158807, "content": "In many people a high causes a feeling of shortness of breath, but the lack of this symptom is no guarantee that the other effects are not occurring. A significant percentage of rebreather deaths have been associated with CO2 retention. The effects of high can take several minutes to hours to resolve once the cause has been removed. Diagnosis Blood gas tests may be performed, typically by radial artery puncture, in the setting of acute breathing problems or other acute medical illness. Hypercapnia is generally defined as an arterial blood carbon dioxide level over 45 mmHg (6 kPa). Since carbon dioxide is in equilibrium with carbonic acid in the blood, hypercapnia drives serum pH down, resulting in respiratory acidosis. Clinically, the effect of hypercapnia on pH is estimated using the ratio of the arterial pressure of carbon dioxide to the concentration of bicarbonate ion, . Tolerance" }, { "id": "wiki20220301en040_1128", "title": "Respiratory acidosis", "score": 0.01120647575658965, "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": "wiki20220301en142_15270", "title": "Pulmonary gas pressures", "score": 0.01120021384656509, "content": "The alveolar pO2 is not routinely measured but is calculated from blood gas measurements by the alveolar gas equation. Partial pressure of carbon dioxide Pathology The partial pressure of carbon dioxide, along with the pH, can be used to differentiate between metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. Hypoventilation exists when the ratio of carbon dioxide production to alveolar ventilation increases above normal values – greater than 45mmHg. If pH is also less than 7.35 this is respiratory acidosis. Hyperventilation exists when the same ratio decreases – less than 35mmHg. If the pH is also greater than 7.45 this is respiratory alkalosis. See also Alveolar-arterial gradient Diffusing capacity Pulmonary alveolus References Respiratory physiology" }, { "id": "wiki20220301en010_32319", "title": "Respiratory failure", "score": 0.010741250573561924, "content": "This type of respiratory failure is caused by conditions that affect oxygenation, such as: Low ambient oxygen (e.g. at high altitude) Ventilation-perfusion mismatch (parts of the lung receive oxygen but not enough blood to absorb it, e.g. pulmonary embolism) Alveolar hypoventilation (decreased minute volume due to reduced respiratory muscle activity, e.g. in acute neuromuscular disease); this form can also cause type 2 respiratory failure if severe. Diffusion problem (oxygen cannot enter the capillaries due to parenchymal disease, e.g. in pneumonia or ARDS) Shunt (oxygenated blood mixes with non-oxygenated blood from the venous system, e.g. right to left shunt) Type 2 Hypoxemia (PaO2 <8kPa or normal) with hypercapnia (PaCO2 >6.0kPa). The basic defect in type 2 respiratory failure is characterized by: {| class=\"wikitable\" |PaO2 || decreased (< )or normal |- | PaCO2 || increased (> ) |- | PA-aO2 || normal |- |pH || <7.35 |}" }, { "id": "InternalMed_Harrison_19946", "title": "InternalMed_Harrison", "score": 0.010643242238334263, "content": "Arterial blood gas testing is often helpful in assessing respiratory 1663 disease. Hypoxemia, while usually apparent with pulse oximetry, can be further evaluated with the measurement of arterial PO2 and the calculation of an alveolar gas and arterial blood oxygen tension difference ([A–a]DO2). Patients with diseases that cause ventilation-perfusion mismatch or shunt physiology have an increased (A–a) DO2 at rest. Arterial blood gas testing also allows the measurement of arterial PCO2. Hypercarbia can accompany severe airway obstruction (e.g., COPD) or progressive restrictive physiology, as in patients with neuromuscular weakness." }, { "id": "article-141285_35", "title": "Noninvasive Ventilation -- Clinical Significance -- Clinical Pearls", "score": 0.010425773736667249, "content": "Start treatment as early as possible When arterial pH is less than 7.35 and elevated PaCO2, it indicates the presence of acute or acute on chronic hypercapnia respiratory failure, which require admission to ICU In acute on chronic hypercapnia respiratory failure, the first goal is to correct arterial pH In chronic hypercapnic respiratory failure with arterial PaCO2more than 51 mmHg, the use of high-intensity pressure support is indicated. It should be targeted to correct CO2 toward normal or at least reduced by 20% from initial levels. When OSA is suspected, the EPAP  should be adjusted empirically (use the 10% rule of actual body weight) if no PAP titration was performed." }, { "id": "wiki20220301en020_52709", "title": "Oxygen therapy", "score": 0.010345178181078746, "content": "Careful titration of oxygen therapy should be considered in patients with chronic conditions predisposing them to carbon dioxide retention (e.g., COPD, emphysema). In these instances, oxygen therapy may decrease respiratory drive, leading to accumulation of carbon dioxide (hypercapnia), acidemia, and increased mortality secondary to respiratory failure. Improved outcomes have been observed with titrated oxygen treatment largely due to gradual improvement of the ventilation/perfusion ratio. The risks associated with loss of respiratory drive are far outweighed by the risks of withholding emergency oxygen, so emergency administration of oxygen is never contraindicated. Transfer from the field to definitive care with titrated oxygen typically occurs long before significant reductions to the respiratory drive are observed. Contraindications There are certain situations in which oxygen therapy has been shown to negatively impact a person's condition." }, { "id": "article-23259_20", "title": "Hypocarbia -- Treatment / Management", "score": 0.010155784138342278, "content": "Treatment of hypocapnia is targeted at treating the underlying pathology to reduce the respiratory rate if possible. Historically treatment involved rebreathing into a paper bag to increase alveolar CO2. However, this has been shown to increase undesirable outcomes including mortality, and is no longer recommended. In anxious patients, anxiolytics may be necessary. In an infectious disease, antibiotics targeting sputum or blood cultures are appropriate. In embolic disease, anticoagulation is necessary. Ventilator support may be necessary for patients with acute respiratory failure, acute asthma, or acute COPD exacerbation if they show signs of respiratory fatigue. In ventilator-controlled patients, it may be necessary to reevaluate their ventilator settings to reduce respiratory rate. If hyperventilation is intentional, monitor the arterial or venous blood gas values closely. In severe cases, pH may be directly reduced using acidic agents; however, this is not routinely performed. [11]" }, { "id": "wiki20220301en020_19470", "title": "Hypercapnia", "score": 0.010094110503946568, "content": "At higher concentrations of CO2, unconsciousness occurred almost instantaneously and respiratory movement ceased in 1 minute. After a few minutes of apnea, circulatory arrest was seen. These findings imply that the cause of death in breathing high concentrations of CO2 is not the hypoxia but the intoxication of carbon dioxide. Treatment The treatment for acute hypercapnic respiratory failure depends on the underlying cause, but may include medications and mechanical respiratory support. In those without contraindications, non-invasive ventilation (NIV) is often used in preference to invasive mechanical ventilation. In the past, the drug doxapram (a respiratory stimulant), was used for hypercapnia in acute exacerbation of chronic obstructive pulmonary disease but there is little evidence to support its use compared to NIV, and it does not feature in recent professional guidelines." }, { "id": "wiki20220301en001_270806", "title": "Heliox", "score": 0.009957705416170493, "content": "Patients with these conditions may suffer a range of symptoms including dyspnea (breathlessness), hypoxemia (below-normal oxygen content in the arterial blood) and eventually a weakening of the respiratory muscles due to exhaustion, which can lead to respiratory failure and require intubation and mechanical ventilation. Heliox may reduce all these effects, making it easier for the patient to breathe. Heliox has also found utility in the weaning of patients off mechanical ventilation, and in the nebulization of inhalable drugs, particularly for the elderly. Research has also indicated advantages in using helium–oxygen mixtures in delivery of anaesthesia. Diving uses Owing to the expense of helium, heliox is most likely to be used in deep commercial diving. It is also sometimes used by diving enthusiasts, particularly those using rebreathers, which conserve the breathing gas at depth much better than open circuit scuba." }, { "id": "pubmed23n0543_21095", "title": "[Non-invasive ventilation support in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD)].", "score": 0.009900990099009901, "content": "To verify that the use of noninvasive ventilatory support in acute exacerbation of chronic obstructive pulmonary disease leads to decreasing the number of deaths, shortening in-hospital stay and decreasing number of endotracheal intubations (ETI). The study was conducted at a respiratory department's ICU in 2002-2004. Patients hospitalized on ICU with acute exacerbation of COPD, respiratory acidosis and global respiratory failure were randomised into two groups. Patients in group A were treated by conservative medical therapy (oxygen, bronchodilator, corticosteroid), patients in group B received noninvasive ventilation with face mask. The parameters followed were: decrease in the number of deaths, shortening of ICU stay, reduction of ETI, faster improvement of breathing frequency, heart rate, pH, PaO2, PaCO2, lactate, dyspnoea symptom score and lung functions. Each group consisted of 30 randomised patients. There were 10 intubated patients in group A, as opposed to 3 in group B (N = 60; P = 0.034). Average length of ICU stay was 9.8 days in group A and 7.1 days in group B (N = 60; P = 0.756). Mortality rate was identical in both groups: 3 patients survived, 7 patients died. We found faster decrease of breathing frequency after one hour of noninvasive ventilation in group B (28.3 +/- 7.1 vs. 24.6 +/- 6.3, N = 59, p = 0.03). No difference was found in mortality rate. We observed decreasing of ETI rate with NIV. We found a tendency to shortening of ICU stay. There was faster improvement of breathing frequency after one hour of NIV." }, { "id": "pubmed23n0605_19715", "title": "[The influence of oxygen therapy on the hypercapnia in patients with chronic obstructive pulmonary disease].", "score": 0.00980392156862745, "content": "Oxygen therapy is a necessary therapeutic method in treatment of severe chronic respiratory failure (CRF), especially in phases of acute worsening. Risks which are to be taken into consideration during this therapy are: unpredictable increase of carbon dioxide in blood, carbonarcosis, respiratory acidosis and coma. The aim of this study was to show the influence of oxygen therapy on changes of arterial blood carbon dioxide partial pressure. The study included 93 patients in 104 admittances to the hospital due to acute exacerbation of CFR. The majority of the patients (89.4%) had chronic obstructive pulmonary disease (COPD), while other causes of respiratory failure were less common. The effect of oxygenation was controlled through measurement of PaO2 and PaCO2 in arterial blood samples. To analyse the influence of oxygen therapy on levels of carbon dioxide, greatest values of change of PaO2 and PaCO2 values from these measurements, including corresponding PaO2 values from the same blood analysis were taken. The obtained results show that oxygen therapy led to the increase of PaO2 but also to the increase of PaCO2. The average increase of PaO2 for the whole group of patients was 2.42 kPa, and the average increase of PaCO2 was 1.69 kPa. There was no correlation between the initial values of PaO2 and PaCO2 and changes of PaCO2 during the oxygen therapy. Also, no correlation between the produced increase in PaO2 and change in PaCO2 during this therapy was found. Controlled oxygen therapy in patients with severe respiratory failure greately reduces the risk of unwanted increase of PaCO2, but does not exclude it completely. The initial values of PaO2 and PaCO2 are not reliable parameters which could predict the response to oxygen therapy." }, { "id": "wiki20220301en198_22391", "title": "PCO2", "score": 0.009756291812679197, "content": "Medicine In medicine, the partial pressure of carbon dioxide in arterial blood is called or PaCO2. Measurement of in the systemic circulation indicates the effectiveness of ventilation at the lungs' alveoli, given the diffusing capacity of the gas. It is a good indicator of respiratory function and the closely related factor of acid–base homeostasis, reflecting the amount of acid in the blood (without lactic acid). Normal values for humans are in the range 35–45 mmHg. Values less than this may indicate hyperventilation and (if blood pH is greater than 7.45) respiratory alkalosis. Values greater than 45 mmHg may indicate hypoventilation, and (if blood pH is less than 7.35) respiratory acidosis. Aquatic Sciences" }, { "id": "wiki20220301en040_1132", "title": "Respiratory acidosis", "score": 0.009636046199301638, "content": "Acute respiratory acidosis: HCO3− increases 1 mEq/L for each 10 mm Hg rise in PaCO2. Chronic respiratory acidosis: HCO3− rises 3.5 mEq/L for each 10 mm Hg rise in PaCO2. The expected change in pH with respiratory acidosis can be estimated with the following equations: Acute respiratory acidosis: Change in pH = 0.08 X ((40 − PaCO2)/10) Chronic respiratory acidosis: Change in pH = 0.03 X ((40 − PaCO2)/10) Respiratory acidosis does not have a great effect on electrolyte levels. Some small effects occur on calcium and potassium levels. Acidosis decreases binding of calcium to albumin and tends to increase serum ionized calcium levels. In addition, acidemia causes an extracellular shift of potassium, but respiratory acidosis rarely causes clinically significant hyperkalemia. Diagnosis" }, { "id": "wiki20220301en041_18184", "title": "Glomus cell", "score": 0.009615384615384616, "content": "Function Glomus type I cells are chemoreceptors which monitor arterial blood for the partial pressure of oxygen (pO2), partial pressure of carbon dioxide (pCO2) and pH. Glomus type I cells are secretory sensory neurons that release neurotransmitters in response to hypoxemia (low pO2), hypercapnia (high pCO2) or acidosis (low pH). Signals are transmitted to the afferent nerve fibers of the sinus nerve and may include dopamine, acetylcholine, and adenosine. This information is sent to the respiratory center and helps the brain to regulate breathing." }, { "id": "pubmed23n0033_10717", "title": "[Indications and contraindications for oxygen therapy of respiratory insufficiency].", "score": 0.009523809523809525, "content": "After a critical review of the different opinions, the author differentiates the indications for oxygen treatment of respiratory insufficiency to subjective and objective based on his own experience following a clinical observation of 100 patients with exacerbated chronic respiratory insufficiency, subjected to dosed, controlled and continuous oxygen therapy. The most essential objective indication for oxygen treatment is the manifestation of hypoxemia degree without or with CO2 retention. According to hypoxemia manifestation, determined by PaO2 level, the indications are absolute (with PaO2 under 40 mm Hg), urgent (with PaO2 under 30 mm Hg) and relative (with PaO2 over 50 mm Hg). The application of oxygen treatment with PaO2 over 700 mm Hg as well as the so called \"preventive\" O2 treatment (with no hypoxemia) is improper with a view to possible harmful side effects of oxygen. Oxygen treatment is contraindicated in all patients with unfavourable ventilation response to oxygen treatment. In case of non-effective O2 treatment (unfavourable ventilation response resp.) mechanical ventilation must be turned to as well as in all cases with patients in respiratory coma." }, { "id": "InternalMed_Harrison_3790", "title": "InternalMed_Harrison", "score": 0.009478581120372165, "content": "The management of respiratory acidosis depends on its severity and rate of onset. Acute respiratory acidosis can be life-threatening, and measures to reverse the underlying cause should be undertaken simultaneously with restoration of adequate alveolar ventilation. This may necessitate tracheal intubation and assisted mechanical ventilation. Oxygen administration should be titrated carefully in patients with severe obstructive pulmonary disease and chronic CO2 retention who are breathing spontaneously (Chap. 314). When oxygen is used injudiciously, these patients may experience progression of the respiratory acidosis. Aggressive and rapid correction of hypercapnia should be avoided, because the falling PaCO2 may provoke the same complications noted with acute respiratory alkalosis (i.e., cardiac arrhythmias, reduced cerebral perfusion, and seizures). The PaCO2 should be lowered gradually in chronic respiratory acidosis, aiming to restore the PaCO2 to baseline levels and to provide" }, { "id": "wiki20220301en071_55445", "title": "Metabolic alkalosis", "score": 0.009433962264150943, "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": "pubmed23n0690_12123", "title": "[Noninvasive ventilation and acute respiratory failure].", "score": 0.009433962264150943, "content": "Noninvasive ventilation is effective in acute respiratory failure, in which drug therapy and administration of supplemental oxygen do not suffice and attempts are made to prevent the patient from ending up in invasive respirator therapy. The treatment is suited for acute respiratory failure for instance in cases of exacerbation of chronic obstructive pulmonary disease, in which a disturbance of pulmonary ventilation leads to the accumulation of carbon dioxide and to respiratory acidosis. Disadvantages associated with artificial airways are avoided, number of complications are reduced, hospitalization periods become shorter, mortality decreases and costs are saved." }, { "id": "wiki20220301en058_49663", "title": "Hyperoxia", "score": 0.0094038061254832, "content": "Diagnosis Treatment Oxygen supplementation is used to treat tissue hypoxia and to relieve arterial hypoxemia. High concentrations of oxygen are often given to patients with chronic obstructive pulmonary disease (COPD) or acute lung injury (ALI). Supplementing oxygen is known to cause tissue damage, with toxicity increasing with the increase of oxygen concentrations and exposure pressures. Unfortunately, the supplementation of oxygen is necessary if an individual is not able to obtain sufficient oxygen through respiration and perfusion. To decrease the chances of hyperoxia, the therapist should use the lowest concentration of oxygen required by an individual. At this time, there are no known alternatives to oxygen supplementation. See also References Oxygen Respiratory diseases Diving medicine" }, { "id": "wiki20220301en019_114897", "title": "Acidosis", "score": 0.009345794392523364, "content": "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. Arterial blood gases will indicate low pH, low blood HCO3, and normal or low PaCO2. In addition to arterial blood gas, an anion gap can also differentiate between possible causes. The Henderson-Hasselbalch equation is useful for calculating blood pH, because blood is a buffer solution. In the clinical setting, this equation is usually used to calculate HCO3 from measurements of pH and PaCO2 in arterial blood gases. The amount of metabolic acid accumulating can also be quantitated by using buffer base deviation, a derivative estimate of the metabolic as opposed to the respiratory component. In hypovolemic shock for example, approximately 50% of the metabolic acid accumulation is lactic acid, which disappears as blood flow and oxygen debt are corrected. Treatment" } ] } } }

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{ "1": "Digitalis intoxication due to pharmacokinetic interaction with verapamil.", "2": "Hypokalemia due to administration of thiazide and digoxin.", "3": "Pharmacodynamic interaction of beta-blocker, digoxin and verapamil.", "4": "Hypotensive effect of thiazide diuretic.", "5": "Cardiac arrhythmia due to verapamil." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en015_3353", "title": "Digoxin", "score": 0.019149715961150816, "content": "Digoxin can lead to cardiac arrhythmias when given with thiazides and loop diuretics. This is because co-administration of Digoxin with drugs such as thiazides and loop diuretics which can cause hypokalemia, low serum levels of potassium in the blood. This exacerbates the potential for cardiac arrythmias because the low levels of potassium reduces the amount of K+ at the ATPase pump and increase calcium levels too much which leads to these arrythmias. It can also cause visual disturbances as well as dizziness or fainting. Several other drugs associated with ADRs in concommitant use include verapamil, amiodarone, quinidine, tetracycline, and erythromycin." }, { "id": "pubmed23n0368_21088", "title": "[Unwanted drug interaction between anti-arrhythmic drugs and drugs used for heart failure].", "score": 0.017677937316658947, "content": "The appearance of adverse drug reactions may depend on the category of used drugs as well as on the coexistence of a pathological stage. Clinically important are: interactions of digitalis glycoside drugs leading to the occurrence or intensification of toxic symptoms characteristic for those drugs; interactions of antiarrhythmic drugs which may cause proarrhythmic effects and hypotension, and also interactions of nitrates resulting in lowering of the blood pressure. Quinidine, verapamil, nitrendipine, amiodaron, propafenone, captopril, spironolactone decrease renal clearance of digoxin, and amilorid/triamteren lower the extrarenal clearance of this drug. Thus the outcome of those concommitant therapies is the increase of digoxin serum concentration and appearance of toxic symptoms. Clinically dangerous, in the course of the antiarrhythmic therapy, is the increased risk of the arrhythmia appearance when two or more antiarrhythmic drugs are applied concomitantly. Antiarrhythmic drugs class IA (quinidine, disopyramide), class III (sotalol, amiodarone), class IV (calcium channel blockers) used at the same time with potassium depleters diuretics or beta-blocking agents result in the inhibition of repolarization and the increased duration of activation potential with the risk of developing arrhythmia of the torsade de pointes types. Nitrates interactions are mainly of the pharmacodynamic character. Most common adverse drug reaction, observed during the concomitant nitrates and another circulatory drug therapy, is excessive lowering of the blood pressure. These may lead to the decrease in the therapeutic efficacy of these combinations. Interactions of circulatory drugs are numerous, sometimes difficult to predict and they may lead to the intensification of the adverse drug reaction and lowering of their therapeutic efficacy." }, { "id": "pubmed23n0417_16942", "title": "An autopsy case of combined drug intoxication involving verapamil, metoprolol and digoxin.", "score": 0.017629698664181424, "content": "We present here a fatal poisoning case involving verapamil, metoprolol and digoxin. A 39-year-old male was found dead in his room, and a lot of empty packets of prescribed drugs were found near the corpse. The blood concentrations of verapamil, metoprolol and digoxin were 9.2 microg/ml, 3.6 microg/ml and 3.2 ng/ml, respectively. The cause of death was given as cardiac failure, hypotension and bradycardia due to a mixed drug overdose of verapamil, metoprolol and digoxin, based on the results of the autopsy and toxicological examination. We speculate that the toxicity of verapamil is potentiated by drug interaction with metoprolol and digoxin." }, { "id": "pubmed23n0105_4856", "title": "Calcium channel antagonists. Part IV: Side effects and contraindications drug interactions and combinations.", "score": 0.017324133793310333, "content": "With the correct selection of drug and patient, the calcium antagonists as a group can be remarkably effective at relatively low cost of serious side effects. Almost all side effects are dose related. Minor side effects include those caused by vasodilation (flushing and headaches), constipation (verapamil), and ankle edema. Serious side effects are rare and result from improper use of these agents, as when intravenous verapamil (or diltiazem) is given to patients with sinus or atrioventricular nodal depression from drugs or disease, or nifedipine to patients with aortic stenosis. The potential of a marked negative inotropic effect is usually offset by afterload reduction, especially in the case of nifedipine which actually has the most marked negative inotropic effect. Yet caution is required when even calcium antagonists, especially verapamil, are given to patients with myocardial failure unless caused by hypertensive heart disease. Drug interactions of calcium antagonists occur with other cardiovascular agents such as alpha-adrenergic blockers, beta-adrenergic blockers, digoxin, quinidine, and disopyramide. The most marked interaction with digoxin is that with verapamil, which may raise digoxin levels by over 50%. Combination therapy of calcium antagonists with beta-blockers is increasingly common, and is probably safest in the case of dihydropyridines. Other combinations being explored are those with angiotensin-converting enzyme inhibitors and diuretics." }, { "id": "pubmed23n0222_2932", "title": "Verapamil and digoxin: interactions in the rat.", "score": 0.016666666666666666, "content": "Verapamil and digoxin are often used in combination and clinical experience suggests that verapamil may increase digoxin toxicity. We have explored the effects of verapamil upon digoxin induced tachyarrhythmias and have undertaken a preliminary study of the influence of verapamil on digoxin pharmacokinetics in the rat. Anesthetized rats received 20 mg/kg of digoxin intraperitoneally followed by verapamil i.v., 0.3 mg/kg, in repeated doses either immediately after digoxin or only after the onset of digoxin induced arrhythmias. Digoxin alone produced prolonged paroxysmal atrial tachycardia in 88-100% of rats and verapamil converted 75% of rats to sinus rhythm and significantly reduced digoxin induced mortality. In a later study, rats were injected with 10 mg/kg verapamil i.p. twice a day for 7 days or only with saline. On the seventh day all the rats received 0.5 mg/kg of digoxin i.p. Eight hours later the animals were sacrificed and plasma, heart, brain, liver, kidney and muscle (diaphragm) digoxin concentration was measured by radioimmunoassay. Digoxin levels were twice as high in plasma, heart, liver and muscle of verapamil pretreated rats (p less than 0.01). Two types of verapamil - digoxin interactions are demonstrated in the above studies; one in which verapamil modifies digoxin induced arrhythmias and a second pharmacokinetic effect in which pretreatment with verapamil increases digoxin concentration in the plasma and in several tissues." }, { "id": "wiki20220301en020_110079", "title": "Verapamil", "score": 0.015944498539435248, "content": "Verapamil was approved for medical use in the United States in 1981. It is on the World Health Organization's List of Essential Medicines. Verapamil is available as a generic medication. Long acting formulations exist. In 2019, it was the 141st most commonly prescribed medication in the United States, with more than 4million prescriptions. Medical uses Verapamil is used for controlling ventricular rate in supraventricular tachycardia and migraine headache prevention. It is a class-IV antiarrhythmic and more effective than digoxin in controlling ventricular rate. Verapamil is not listed as a first line agent by the guidelines provided by JAMA in JNC-8. However, it may be used to treat hypertension if patient has co-morbid atrial fibrillation or other types of arrhythmia." }, { "id": "pubmed23n0299_14943", "title": "Effectiveness of verapamil-quinidine versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation.", "score": 0.015712888236732697, "content": "To determine the relative effectiveness of a verapamil-quinidine sequential combination versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation (PAF). This prospective, double-blind, randomized, controlled trial involved patients, aged 18 to 75 years, with new-onset (&lt; 48 hours) atrial fibrillation who presented to a community-based urban hospital with an annual ED census of 65,000. Exclusion criteria included ventricular response rate lower than 100 or higher than 200 beats/minute, allergy to study drugs, hypotension with evidence of end-organ hypoperfusion, and conduction abnormalities. Consenting patients were randomly assigned to receive rapid digitalization (1.0 mg over 2 hours) or i.v. verapamil (sequential 5-mg boluses up to 20 mg). After ventricular rate was controlled (&lt; 100 beats/minute), oral quinidine (200 mg) was initiated and repeated every 2 hours until conversion to normal sinus rhythm (NSR) occurred, until 1 g of quinidine was administered, or until adverse effects supervened. Heart rate, blood pressure, cardiac rhythm, time to conversion, and adverse effects were documented. Forty-four patients received the study drugs. Three were withdrawn, leaving 19 in the verapamil-quinidine (VER-Q) group and 22 in the digoxin-quinidine (DIG-Q) group. Sixteen patients (84%) in the VER-Q group and 10 (45%) in the DIG-Q group converted to NSR within 6 hours (P &lt; .02). Mean time to conversion (+/-SD) was 185 +/- 146 minutes for VER-Q and 368 +/- 386 minutes for DIG-Q patients (P = NS). Twelve VER-Q patients (63%) and 6 DIG-Q patients (27%) were discharged from the ED (P &lt; .05). Minor adverse effects were more common in the VER-Q group. No mortality or significant morbidity occurred. The sequential combination of verapamil and quinidine, in the doses studied, is an effective treatment for PAF and is superior to digoxin-quinidine. Digoxin should no longer be considered the treatment of choice for uncomplicated PAF." }, { "id": "pubmed23n0583_16813", "title": "Identification of severe potential drug-drug interactions using an Italian general-practitioner database.", "score": 0.015491452991452992, "content": "To analyze prescriptions in a general-practitioner database over 1 year to determine the frequency, the characteristics, and the monitoring of the severe potential drug-drug interactions (DDIs). We retrospectively analyzed the clinical records from 16 general practitioners in the Veneto region, an area in northern Italy. The study covered the period from January 1 to December 31, 2004. We selected all severe and well-documented interactions according to the book Drug Interaction Facts by David S. Tatro (Facts and Comparisons, St. Louis, MO, 2006). We grouped severe potential DDIs according to their specific potential risk, and for the most frequently interacting drug pairs, we investigated whether some specific tests had been prescribed by physicians for safety monitoring. During the study period, 16,037 patients (55% female) with at least one drug prescription were recorded, and a total of 185,704 prescriptions relating to 1,020 different drugs were analyzed. Ramipril was the most frequently prescribed drug followed by acetylsalicylic acid and atorvastatin. The final number of different types of severe potential DDIs was 119, which occurred 1,037 times in 758 patients (4.7% of the total number of patients). More than 80% of drugs involved in severe potential DDIs were cardiovascular drugs. Digoxin was the most frequently involved drug. Electrolyte disturbances, increase in serum digoxin levels, risk of hemorrhage, severe myopathy or rhabdomyolysis, and cardiac arrhythmias were the most commonly implicated potential risks. When considering patients using digoxin with loop or thiazide diuretics for more than 5 months, 72% had at least one test to monitor potential digoxin toxicity, whereas 28% had no tests. Sixty-four percent of patients using digoxin with amiodarone, verapamil, or propafenone had an ECG and/or digoxin monitoring, and 36% of them did not have any tests. The present study revealed that, in a group of Italian general practitioners, the risks of severe potential drug interactions are relatively low and the drugs concerned are few. Analyses of specific tests showed that physicians are generally aware of the potential risks caused by digoxin drug associations. However not all patients were closely monitored and this should be improved." }, { "id": "wiki20220301en293_5633", "title": "Management of atrial fibrillation", "score": 0.015277334185031407, "content": "Rate control Rate control is achieved with medications that work by increasing the degree of block at the level of the AV node, effectively decreasing the number of impulses that conduct down into the ventricles. This can be done with: Beta blockers (preferably the \"cardioselective\" beta blockers such as metoprolol, bisoprolol, atenolol) Calcium channel blockers (i.e. diltiazem or verapamil) Cardiac glycosides (i.e. digoxin) – have limited use, apart from in the sedentary elderly patient In addition to these agents, amiodarone has some AV node blocking effects (particularly when administered intravenously), and can be used in individuals when other agents are contraindicated or ineffective (particularly due to hypotension). Diltiazem has been shown to be more effective than either digoxin or amiodarone. Drugs used to control the rate of AF may cause side effects, especially fatigue and dyspnea. These are avoided by the more radical \"ablate and pace\" treatment (see below)." }, { "id": "pubmed23n0078_16259", "title": "Verapamil-digoxin interaction in chronic hemodialysis patients.", "score": 0.014961067853170189, "content": "Verapamil increases the serum-digoxin concentration (SDC) in digoxin treated normals due to a compromised renal and extrarenal clearance. In chronic hemodialysis patients (CHD-patients) treated with digoxin where the renal elimination is diminished, verapamil has been shown to cause substantial increases of SDC with risk of digoxin intoxication. The effect of verapamil treatment on SDC in 8 nearly anephric (Uvol less than 1 l/d) CHD-patients on digoxin treatment was assessed. The patients were continuously treated with verapamil for two periods of two weeks at two dosage levels, 120 mg/d and 240 mg/d, whereafter verapamil was withdrawn. SDC and serum-verapamil were measured weekly. The SDC increased from 1.1 mmol/l to 1.7 mmol/l (p less than 0.05, N = 7) during the first two weeks. Increasing the dose of verapamil to 240 mg/d did not cause a further increment in SDC; on the contrary, the mean SDC decreased. The SDC increments varied between 0 and 200% of baseline values. We conclude that verapamil treatment decreases digoxin clearance in CHD-patients and that the influence of verapamil on SDC in CHD-patients shows great interindividual variation with no close dose dependency and decreases to pretreatment level in 2-3 weeks." }, { "id": "pubmed23n0098_11924", "title": "The comparative effects of verapamil and a new dihydropyridine calcium channel blocker on digoxin pharmacokinetics.", "score": 0.014952667814113597, "content": "Conflicting conclusions have been reported about interaction of calcium channel blockers with digoxin. The effects of verapamil (240 mg/day) and a new dihydropyridine calcium channel blocker, isradipine (15 mg/day), on the pharmacokinetics of 1 mg intravenous digoxin were compared. All 24 volunteer subjects were healthy, male, nonobese, and aged 18 to 38 years. Groups of 12 subjects received each oral agent over 15 days, with collections of blood and urine for 72 hours after intravenous digoxin. Significant (P less than 0.05) reduction in nonrenal (7.01 +/- 1.97 to 4.00 +/- 1.86 L/hr) and total clearance (14.1 +/- 2.6 to 11.5 +/- 2.5 L/hr) were induced by verapamil, without change in renal clearance. A near-significant (P less than 0.1) increase in peripheral volume of distribution contributed to prolonged elimination half-life (23.1 +/- 4.4 to 34.3 +/- 9.7 hours). By contrast, isradipine caused only a 9% reduction in volume of distribution. Verapamil causes digoxin accumulation by reducing nonrenal elimination. No evidence of clinically relevant interaction of isradipine with digoxin was seen." }, { "id": "pubmed23n0135_17062", "title": "Effects of verapamil on pharmacokinetics and pharmacodynamics of digitoxin in patients.", "score": 0.014675697865353037, "content": "Investigations by various teams have shown that combined treatment with verapamil and digoxin may result in a marked increase in digoxin plasma concentrations, necessitating a reduction in the dose of digoxin. This is mainly due to an impairment of the renal digoxin excretion. Unlike digoxin, the excretion of digitoxin is independent of renal function. A prospective clinical study was therefore planned to investigate the influence of a daily dose of 240 mg of verapamil on pharmacokinetics and the cardiac effect of digitoxin after a single dose (n = 3) and under steady-state conditions (n = 10). While pretreatment with verapamil did not alter pharmacokinetics of digitoxin in the single-dose study, there was a slight rise of digitoxin plasma concentrations (an average of 35% in 8 out of 10 patients) following administration of verapamil for a period of 4 to 6 weeks. Renal excretion of digitoxin, however, was not changed significantly. Simultaneous with a rise of digitoxin plasma concentrations and until a new steady state was reached, PQ interval was prolonged and T wave flattening intensified. On the other hand, the antagonistic effect on contractility which was initially observed after verapamil administration was diminished. Based on these observations, it can be concluded that the risk of digitalis overdose after combined treatment with verapamil and digitoxin may be less pronounced than after digoxin, and that this glycoside can prove a valuable alternative." }, { "id": "pubmed23n0088_7313", "title": "Current concepts in the use of digitalis.", "score": 0.014516129032258063, "content": "After more than two centuries of administration of digitalis glycosides to patients with cardiac disease, empirical observation and tradition remain the basis for much of the clinical application of these drugs. Many questions remain, and the role of digitalis in the management of congestive heart failure and cardiac rhythm disturbances is changing with improvement in our understanding of the pathophysiology of these conditions and the availability of newer effective agents that may have less potential to cause life-threatening toxicity. Nevertheless, digitalis glycoside therapy is a familiar therapeutic intervention for the majority of physicians and remains appropriate in carefully selected patients. The development of digoxin-specific Fab fragments has led to improvement in treatment of advanced and refractory digitalis toxicity and opens up the possibility of improvement in diagnosis of less clinically obvious cases of digitalis intoxication. The role of digitalis glycosides in the management of supraventricular tachyarrhythmias and congestive heart failure in the presence of sinus rhythm should now be revised. In each of these clinical circumstances, alternative drugs or other modes of therapy have been developed that reduce the dependence of clinicians on digitalis as the sole or primary approach to management. In the immediate management of paroxysmal reentrant supraventricular tachyarrhythmias, verapamil has largely replaced digoxin as the drug of choice, although digoxin has an ancillary role, especially in patients with impaired ventricular function. In the management of patients with atrial fibrillation or atrial flutter with a rapid ventricular response, verapamil or diltiazem and beta-adrenergic-blocking drugs will effectively slow the ventricular response, thus reducing the likelihood of approaching the threshold of digitalis toxicity to achieve adequate rate control. In the treatment of patients with congestive heart failure and normal sinus rhythm, one must now recognize a subset of patients with diastolic rather than systolic dysfunction who are best treated by correcting underlying causes of left ventricular hypertrophy or ischemia rather than inotropic support with cardiac glycosides. Symptomatic patients with dilated ventricles and impaired contractile function should undergo correction of abnormalities of preload with vasodilators acting on the venous bed as well as diuretics, and reduction of elevated afterload with vasodilators that reduce arteriolar resistance and thus improve ventricular emptying.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "Pharmacology_Katzung_1205", "title": "Pharmacology_Katzung", "score": 0.01432748538011696, "content": "In patients with relatively low blood pressure, dihydropyridines can cause further deleterious lowering of pressure. Verapamil and diltiazem appear to produce less hypotension and may be better tolerated in these circumstances. In patients with a history of atrial tachycardia, flutter, and fibrillation, verapamil and diltiazem provide a distinct advantage because of their antiarrhythmic effects. In the patient receiving digitalis, verapamil should be used with caution, because it may increase digoxin blood levels through a pharmacokinetic interaction. Although increases in digoxin blood level have also been demonstrated with diltiazem and nifedipine, such interactions are less consistent than with verapamil." }, { "id": "pubmed23n0067_2422", "title": "Digoxin-verapamil interaction: reduction of biliary but not renal digoxin clearance in humans.", "score": 0.013867842218854756, "content": "The interaction between digoxin and verapamil was studied in six patients (mean age +/- SD, 61 +/- 5 years) with chronic atrial fibrillation. The effects of adding verapamil (240 mg/day) on steady-state plasma concentrations and renal and biliary clearances of digoxin were studied in a crossover manner. The biliary clearance of digoxin was determined by a duodenal perfusion technique. Verapamil induced a 44% increase in steady-state plasma concentrations of digoxin, from 0.80 +/- 0.24 to 1.15 +/- 0.40 nmol/L (p less than 0.01). The biliary clearance of digoxin decreased by 43%, from 187 +/- 89 to 101 +/- 55 ml/min (p less than 0.05), in the presence of verapamil, whereas the renal clearance was unaffected (153 +/- 31 versus 173 +/- 51 ml/min; difference not significant). Our results indicate that the main inhibitory effect of verapamil on digoxin elimination is on the biliary route." }, { "id": "pubmed23n0349_11250", "title": "P-glycoprotein system as a determinant of drug interactions: the case of digoxin-verapamil.", "score": 0.013618326118326118, "content": "Digoxin, which has a very narrow therapeutic window, is one of the most commonly prescribed drugs in the treatment of congestive heart failure. In some cases of atrial fibrillation digoxin is used in combination with verapamil. Verapamil can increase the plasma concentration of digoxin up to 60-90%. So far the precise mechanism of this pharmacokinetic drug-drug interaction is not known. Many studies suggest that verapamil reduces the renal clearance of digoxin. The energy-dependent membrane-bound transport enzyme, P-glycoprotein, may also be involved. Reports from oncology research show that verapamil can interact with P-glycoprotein as a modulator. Also taking into account that digoxin, like many anticancer drugs, is a substrate for P-glycoprotein, it is likely that P-glycoprotein modulation accounts for the digoxin-verapamil interaction. Current knowledge suggest that the non-competitive digoxin-verapamil interaction is due to inhibition of P-glycoprotein activity by verapamil resulting in a decreased renal tubular elimination of digoxin." }, { "id": "article-20623_87", "title": "Therapeutic Uses of Diuretic Agents -- Contraindications -- Drug-interactions", "score": 0.013550625135506252, "content": "Diuretic-induced hypokalemia can increase the risk of digitalis-induced arrhythmia. [163] Digoxin competes with K+ ions for its binding site on the Na+-K+-ATPase pump in the heart, and thus in diuretic-induced hypokalemia, the action of digoxin is unopposed, leading to fatal arrhythmias. [171] Although any diuretic causing hypokalemia can lead to this effect, loop diuretics carry the greatest risk when compared to other classes of diuretics, but as an individual agent, hydrochlorothiazide had the greatest risk. [172] Hence the combination of hypokalemia-inducible diuretics and digoxin can be dangerous and must be avoided. Similarly, clinicians must avoid using quinidine because thiazide-induced hypokalemia can potentiate its cardiovascular effects. [173]" }, { "id": "wiki20220301en321_3932", "title": "List of cardiac pharmaceutical agents", "score": 0.01329004329004329, "content": "Antiarrhythmic agents Type I (sodium channel blockers) Type Ia Ajmaline Procainamide Quinidine Type Ib Lidocaine Phenytoin Type Ic Encainide Flecainide Propafenone Type II (beta blockers) Bisoprolol Carvedilol Metoprolol Propranolol Type III (potassium channel blockers) Amiodarone Dofetilide Sotalol Type IV (slow calcium channel blockers) Diltiazem Verapamil Type V Adenosine Digoxin ACE inhibitors Captopril Enalapril Perindopril Ramipril Angiotensin II receptor antagonists Candesartan Eprosartan Irbesartan Losartan Telmisartan Valsartan Beta blocker (see above) Calcium channel blocker (see above) Antimineralocorticoid Eplerenone Finerenone Spironolactone Antiplatelet drug Abciximab Aspirin Cangrelor Clopidogrel Eptifibatide Prasugrel Ticagrelor Tirofiban Anticoagulant Apixaban Bivalirudin Dabigatran Edoxaban Enoxaparin Heparin Rivaroxaban Warfarin Fibrinolytics Alteplase Streptokinase Urokinase Diuretics" }, { "id": "pubmed23n0223_10294", "title": "Long-term oral treatment with high doses of verapamil in lone atrial fibrillation.", "score": 0.013086845657717113, "content": "It has earlier been shown that verapamil given intravenously or orally in sufficiently high single doses, may result in regular ventricular rhythm in patients with atrial fibrillation. We have analyzed whether this effect of verapamil can be utilized in long-term oral treatment. Eleven patients with lone atrial fibrillation were studied. Verapamil was given in gradually increasing doses from 40 mg three times a day to 320 mg three times a day, either alone or in combination with digoxin. Resting ECG was recorded and supine and standing blood pressures were measured on each dose level. When the patients were treated with verapamil alone, only a slight decrease in heart rate was noted, while during combined treatment with verapamil and digoxin a more marked heart rate decrease occurred with increasing doses of verapamil. The variation coefficient of the RR interval, a sign of ventricular regularity, decreased during verapamil treatment regardless of whether or not digoxin was also taken. A dose-dependent blood pressure decrease was noted during verapamil treatment. Side effects were common and led to discontinuation of the attempted protocol in all patients. Three patients were unexpectedly converted to stable sinus rhythm. Five patients improved subjectively, with a marked decrease in the sensation of palpitations during intake of increasing doses of verapamil. The study indicates that chronic oral treatment with verapamil may sometimes relieve the subjective sensation of palpitations in patients with atrial fibrillation. Side effects do, however limit the value of this mode of treatment in the majority of patients." }, { "id": "wiki20220301en047_73040", "title": "Proarrhythmia", "score": 0.013027248973497572, "content": "Atrial proarrhythmia Conversion of atrial fibrillation to flutter (usually VW type IC drugs or amiodarone). May be a desired effect. Increase of defibrillation threshold (a potential problem with VW type IC drugs) Provocation of recurrence (probably VW types IA, IC and III drugs). It is rare. Abnormalities of conduction or impulse formation Sinus node dysfunction, atrioventricular block (almost all drugs) Accelerate conduction over accessory pathway (digoxin, intravenous verapamil, or diltiazem) Acceleration of ventricular rate during atrial fibrillation (VW type IA and type IC drugs). Increased risk Presence of structural heart disease, especially LV systolic dysfunction. Class IC agents. Increased age. Females. Clinical pointers Class IA drugs Dose independent, occurring at normal levels. Follow QT interval, keep ms. Class IC drugs May be provoked by increased heart rate. Exercise stress tests after loading." }, { "id": "pubmed23n0134_689", "title": "Influence of verapamil on the digoxin-induced inotropic effect in guinea-pig isolated atria.", "score": 0.013013901212658975, "content": "The nature of the digoxin-verapamil interaction was explored \"in vitro\" by determining the effect of verapamil on digoxin-induced inotropism in isolated guinea-pig atria. Verapamil, at concentrations (2.10(-8)-3.10(-8)M) too low to have any significant effect on the amplitude or frequency of the basal contractile activity, reduced the inotropic action of digoxin in all experimental circumstances, i.e. in spontaneously beating atria from reserpine-treated or untreated animals, in electrically driven (at 1 Hz frequency stimulation) left atria. The results obtained suggest that a competitive antagonism exists between verapamil and digoxin. In spontaneously beating atria an apparently competitive antagonism was also observed between verapamil and ouabain. The interaction observed between cardiac glycosides and the Ca++ channel blocker suggests that Ca++ movements across the sarcolemma may influence the inotropic effect of digitalis or its toxicity." }, { "id": "wiki20220301en166_44933", "title": "WHO Model List of Essential Medicines", "score": 0.012899543378995433, "content": "Antianginal medicines Bisoprolol Glyceryl trinitrate Isosorbide dinitrate Verapamil Antiarrhythmic medicines Bisoprolol Digoxin Epinephrine (adrenaline) Lidocaine Verapamil Amiodaroneα Antihypertensive medicines Amlodipine Bisoprolol Enalapril Hydralazine Hydrochlorothiazide Lisinopril/amlodipine (lisinopril + amlodipine) Lisinopril/hydrochlorothiazide (lisinopril + hydrochlorothiazide) Losartan Methyldopa Telmisartan/amlodipine (telmisartan + amlodipine) Telmisartan/hydrochlorothiazide (telmisartan + hydrochlorothiazide) Sodium nitroprussideα Medicines used in heart failure Bisoprolol Digoxin Enalapril Furosemide Hydrochlorothiazide Losartan Spironolactone Dopamineα Antithrombotic medicines Anti-platelet medicines Acetylsalicylic acid (aspirin) Clopidogrel Thrombolytic medicines Alteplaseα Streptokinaseα Lipid-lowering agents Simvastatin Dermatological medicines (topical)" }, { "id": "wiki20220301en248_20376", "title": "Atrial fibrillation", "score": 0.01283532280836863, "content": "Rate control Rate control to a target heart rate of fewer than 110 beats per minute is recommended in most people. Lower heart rates may be recommended in those with left ventricular hypertrophy or reduced left ventricular function. Rate control is achieved with medications that work by increasing the degree of the block at the level of the AV node, decreasing the number of impulses that conduct into the ventricles. This can be done with: Beta blockers (preferably the \"cardioselective\" beta blockers such as metoprolol, bisoprolol, or nebivolol) Non-dihydropyridine calcium channel blockers (e.g., diltiazem or verapamil) Cardiac glycosides (e.g., digoxin) – have less use, apart from in older people who are sedentary. They are not as effective as either beta-blockers or calcium channel blockers. In those with chronic AF either beta blockers or calcium channel blockers are recommended." }, { "id": "wiki20220301en528_7698", "title": "List of side effects of digoxin", "score": 0.012804713096275813, "content": "Side effects due to other drug interactions Side effects can become more pronounced due to the drug interactions between digoxin and the following: Thiazide and loop diuretics, piperacillin, ticarcillin, amphotericin B, corticosteroids, and excessive laxative use. Amiodarone, some benzodiazepines, cyclosporine, diphenoxylate, indomethacin, itraconazole, propafenone, quinidine, quinine, spironolactone, and verapamil may lead to toxic levels and increased incidence of side effects. Digoxin plasma concentrations may increase while on antimalarial medication hydroxychloroquine. Patients taking digoxin should avoid taking hawthorn. Side effects due to dietary supplements Side effects can become pronounced due to the interactions of digoxin and these substances: licorice, aloe, and St. John's wort." }, { "id": "pubmed23n0099_2252", "title": "Comparative effects of verapamil and isradipine on steady-state digoxin kinetics.", "score": 0.01278772378516624, "content": "The effects on the steady-state digoxin pharmacokinetics of verapamil (240 mg/day) and a new dihydropyridine calcium channel blocker, isradipine (15 mg/day), were compared. Nineteen healthy white men, aged 23 to 40 years, ingested 0.25 mg digoxin tablets every 12 hours for two consecutive periods of 2 weeks. Each subject also received one of the calcium channel blockers during one of these periods, with agent and sequence randomized. Analyst-blind RIA serum digoxin determinations demonstrated that the nine subjects who received isradipine, 5 mg t.i.d., had a small increment in peak digoxin level from 2.3 +/- 0.6 to 2.9 +/- 0.7 ng/ml (p less than 0.05) but no significant change in steady-state level or AUC over 12 hours. By contrast, the 10 subjects who received verapamil, 80 mg t.i.d., showed significant increases in steady-state (0.9 +/- 0.1 to 1.3 +/- 0.2 ng/ml; p less than 0.001) and peak serum digoxin concentrations (2.5 +/- 0.7 to 3.6 +/- 0.8 ng/ml; p less than 0.001) and in AUC (15.7 +/- 1.7 to 23.6 +/- 2.9 ng . hr/ml; p less than 0.001). Neither calcium channel blocker reduced renal digoxin clearance. Verapamil increases digoxin levels without affecting renal clearance. Isradipine has no clinically important interaction with digoxin." }, { "id": "wiki20220301en015_3354", "title": "Digoxin", "score": 0.012410557881298061, "content": "Several other drugs associated with ADRs in concommitant use include verapamil, amiodarone, quinidine, tetracycline, and erythromycin. Overdose In overdose, the usual supportive measures are needed. If arrhythmias prove troublesome, or malignant hyperkalemia occurs (inexorably rising potassium level due to paralysis of the cell membrane-bound, ATPase-dependent Na/K pumps), the specific antidote is antidigoxin (antibody fragments against digoxin, trade names Digibind and Digifab). The mechanism of action for drugs such as Digibind and Digifab, used when adverse events occur with the use of digoxin, is that the FAB regions on the antibodies created against digoxin expedite the excretion of the drug into urine. Therefore, the amount of Digoxin in the body decreases quickly as it gets excreted rapidly. Pharmacology Pharmacodynamics" }, { "id": "wiki20220301en227_22992", "title": "Sodium channel blocker", "score": 0.012313153442968468, "content": "Indications for Class Ia agents are supraventricular tachycardia, ventricular tachycardia, symptomatic ventricular premature beats, and prevention of ventricular fibrillation. Procainamide can be used to treat atrial fibrillation in the setting of Wolff-Parkinson-White syndrome, and to treat wide complex hemodynamically stable tachycardias. Oral procainamide is no longer being manufactured in the US, but intravenous formulations are still available. While procainamide and quinidine may be used in the conversion of atrial fibrillation to normal sinus rhythm, they should only be used in conjunction with an AV node blocking agent such as digoxin or verapamil, or a beta blocker), because procainamide and quinidine can increase the conduction through the AV node and may cause 1:1 conduction of atrial fibrillation, causing an increase in the ventricular rate. Class Ia agents include quinidine, procainamide and disopyramide. Class Ib agents" }, { "id": "wiki20220301en035_40478", "title": "Amiloride", "score": 0.01219215567041654, "content": "Amiloride may be used in combination with a thiazide diuretic for treatment of high blood pressure or (less commonly) in combination with a loop diuretic for treatment of heart failure. The potassium-sparing effects of amiloride offset the low blood potassium (hypokalemia) that is often induced by thiazides or loop diuretics, which is of particular importance in people for whom maintaining a normal level of potassium is critically important. For example, people that are taking Digitalis (i.e. digoxin) are at higher risk for changes in heart rhythm if their potassium levels get too high. The 2017 clinical practice guidelines of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines list amiloride as a \"secondary\" oral antihypertensive, with minimal efficacy. For people with resistant hypertension, already taking a thiazide diuretic, an angiotensin converting enzyme inhibitor (ACE-i) or an angiotensin II receptor blocker (ARB), and a" }, { "id": "pubmed23n0551_2789", "title": "Verapamil versus digoxin and acute versus routine serial cardioversion for the improvement of rhythm control for persistent atrial fibrillation.", "score": 0.012117324209700988, "content": "The VERDICT (Verapamil Versus Digoxin and Acute Versus Routine Serial Cardioversion Trial) is a prospective, randomized study to investigate whether: 1) acutely repeated serial electrical cardioversions (ECVs) after a relapse of atrial fibrillation (AF); and 2) prevention of intracellular calcium overload by verapamil, decrease intractability of AF. Rhythm control is desirable in patients suffering from symptomatic AF. A total of 144 patients with persistent AF were included. Seventy-four (51%) patients were randomized to the acute (within 24 h) and 70 (49%) patients to the routine serial ECVs, and 74 (51%) patients to verapamil and 70 (49%) patients to digoxin for rate control before ECV and continued during follow-up (2 x 2 factorial design). Class III antiarrhythmic drugs were used after a relapse of AF. Follow-up was 18 months. At baseline, there were no significant differences between the groups, except for beta-blocker use in the verapamil versus digoxin group (38% vs. 60%, respectively, p = 0.01). At follow-up, no difference in the occurrence of permanent AF between the acute and the routine cardioversion groups was observed (32% [95% confidence intervals (CI)] 22 to 44) vs. 31% [95% CI 21 to 44], respectively, p = NS), and also no difference between the verapamil- and the digoxin-randomized patients (28% [95% CI 19 to 40] vs. 36% [95% CI 25 to 48] respectively, p = NS). Multivariate Cox regression analysis revealed that lone digoxin use was the only significant predictor of failure of rhythm control treatment (hazard ratio 2.2 [95% CI 1.1 to 4.4], p = 0.02). An acute serial cardioversion strategy does not improve long-term rhythm control in comparison with a routine serial cardioversion strategy. Furthermore, verapamil has no beneficial effect in a serial cardioversion strategy." }, { "id": "wiki20220301en191_20170", "title": "Outline of cardiology", "score": 0.012043428242737991, "content": "Ion channels Ion channels are responsible for cell membrane voltage, depolarization, and repolarization. These actions lead to conduction of signals down nerves and contraction of cardiomyocytes. Perhaps the most prominent manipulation of ion channels is through antiarrhythmic agents. These agents are commonly classified by the type of ion they manipulate and named the Vaughan Williams classification: Class I — Sodium channel blockers Class Ia — Fast sodium channels (quinidine, ajmaline, procainamide, disopyramide) Class Ib — Sodium channels (lidocaine, phenytoin, mexiletine, tocainide) Class Ic — Decrease conductivity (encainide, flecainide, propafenone, moricizine) Class II — Beta blockers (carvedilol, propranolol, esmolol, timolol, metoprolol, atenolol, bisoprolol) Class III — Potassium channel blockers (amiodarone, sotalol, ibutilide, dofetilide, dronedarone) Class IV — Calcium channel blockers (verapamil, diltiazem) Class V — Other (adenosine, digoxin, magnesium Sulfate)" }, { "id": "article-17675_67", "title": "Antiarrhythmic Medications -- Monitoring", "score": 0.011366327255505565, "content": "During the administration of beta-blockers, an electrocardiogram and heart rate monitoring are more useful than TDM. [52] Amiodarone is an excellent antiarrhythmic agent, but long-term use correlates with corneal opacities, thyroid problems, and lung infiltrates. Consequently, amiodarone is not the preferred geriatric population rather than young adults. Digoxin has a narrow therapeutic index. The therapeutic serum digoxin levels range is 0.5 to 2 ng/mL. Serum concentrations of cardiac glycosides require monitoring closely to avoid digitalis toxicity. Amiodarone, verapamil, quinidine, and diltiazem increase the serum levels of digoxin and can lead to toxicity. The recommendation is to reduce the digoxin dose by 25% to 50%, closely monitoring digoxin levels weekly for several weeks. Periodic electrolyte evaluation is a recommendation. Hypokalemia may make the patient more susceptible to digitalis toxicity. Healthcare professionals can reduce the morbidity of antiarrhythmic drugs with knowledge of the adverse drug reactions,pro-arrhythmic effects of specific antiarrhythmic drugs, and therapeutic drug monitoring. [53] [54]" }, { "id": "pubmed23n0778_5394", "title": "A comparison of verapamil and digoxin for heart rate control in atrial fibrillation.", "score": 0.011151960784313726, "content": "Atrial fibrillation (AF) is one of the most common types of sustained dysrhythmia and there are some disagreements about its treatment. The goals of AF treatment include the control of ventricular rate, the establishment of sinus rhythm and the prevention of thromboembolic events. In this study, the effect of verapamil was compared to digoxin on heart rate control in patients with AF. This descriptive study was conducted in an emergency department (ED) in Iran. Sixty patients with a new onset AF and rapid ventricular response receiving digoxin or verapamil were included and observed. Two thirty-patient groups receiving verapamil or digoxin were evaluated. The heart rate was significantly decreased in both groups (p = 0.002); however, the cardioversion was not noticed in both of them. The best rate control in verapamil and digoxin groups was observed after 5.9 mg (46.7%) and 0.6 mg (36.7%), respectively. Administration of verapamil in comparison with digoxin has no difference to control the heart rate in AF patients. It should be taken into consideration that prospective randomized studies should be conducted to identify the efficacy and select the best of these two drugs to treat AF patients." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 271, 373 ] ], "word_ranges": [ [ 38, 53 ] ], "text": "Small kidneys and hyperphosphatemia are features of chronic kidney disease (option 1 and 3 incorrect)." }, "2": { "exist": true, "char_ranges": [ [ 163, 270 ] ], "word_ranges": [ [ 22, 38 ] ], "text": "A family history of nephropathy could indicate the existence of a hereditary disorder (incorrect option 2)." }, "3": { "exist": true, "char_ranges": [ [ 271, 373 ] ], "word_ranges": [ [ 38, 53 ] ], "text": "Small kidneys and hyperphosphatemia are features of chronic kidney disease (option 1 and 3 incorrect)." }, "4": { "exist": true, "char_ranges": [ [ 0, 162 ] ], "word_ranges": [ [ 0, 22 ] ], "text": "Adequate corticomedullary differentiation is suggestive of no chronic parenchymal impairment, and is a frequent finding in acute renal failure (option 4 correct)." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Small sized kidneys.", "2": "Family history of nephropathy.", "3": "Elevated levels of phosphorus in blood.", "4": "Good ultrasound differentiation of renal cortex and medulla.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0699_19271", "title": "High chronic nephropathy detection yield in CKD subjects identified by the combination of albuminuria and estimated GFR.", "score": 0.014912280701754385, "content": "Epidemiological studies have shown that the burden of chronic kidney disease (CKD) is huge. CKD is a non-specific diagnosis, however, and it is hard to say which renal disorders comprise the body of CKD diagnosed on the strength of the combination of albuminuria and estimated glomerular filtration rate (eGFR) in epidemiological studies, or just how efficient such studies are in detecting chronic nephropathies. The INCIPE study identified 524 CKD cases (using the K/DOQI definition based on albuminuria and eGFR) in a random sample of 4000 Italians &gt;40 years old, 262 of whom were randomly chosen to be investigated in order to confirm their CKD and complete a diagnostic workup. We a priori defined diagnostic algorithms for 14 renal conditions based on personal family history, medical records, urine tests, kidney ultrasound with colour-Doppler and other tests. Among the subjects whose CKD was confirmed, a diagnosis of chronic nephropathy was reached in 68% of cases recognized as having either a specific (38%) or an undetermined (30%) kidney disease. Almost 50% of subjects with a specific chronic nephropathy had a diabetic or vascular renal disease. Abnormalities consistent with a chronic nephropathy were found in 50, 68, 70 and 100% of subjects with CKD Stages 1, 2, 3 and 4, respectively. Lone low eGFR and lone microalbuminuria were observed in 20 and 12%, respectively. In Caucasians &gt;40 years old with a confirmed CKD condition, (i) an impressive 68% of subjects have an underlying chronic nephropathy, so eGFR and albuminuria are very efficient in detecting renal diseases; (ii) in 32%, the only disclosed renal abnormalities were a glomerular filtration rate &lt;60 mL/min/1.73 m(2) or microalbuminuria; follow-up studies are needed to clarify whether these abnormalities do really identify a chronic nephropathy or just a cardiovascular risk condition." }, { "id": "wiki20220301en422_14318", "title": "Mesoamerican nephropathy", "score": 0.014658290500666285, "content": "Suspected disease: Estimated GFR (eGFR) < 60 ml/min/1.73m2 Absence of diabetes, hypertension, autoimmune disease, glomerular disease, congenital kidney disease, obstructive kidney disease as a clear cause of kidney disease (these comorbidities may be present but cannot account for disease development) Residing in a hotspot region Proteinuria < 2g/24h or 2g/g urine creatinine Likely disease: All of the above, plus eGFR < 60 ml/min/1.73m2 on 3 month or longer repeat measurement Relative hypokalemia and/or hyperuricemia Kidney ultrasound with loss of corticomedullary differentiation or bilateral small kidney size, without cystic disease or large stone burden Kidney biopsy showing primary tubulointerstitial disease without alternative cause of kidney disease in evidence" }, { "id": "pubmed23n0894_15796", "title": "Renal Morphology, Clinical Findings, and Progression Rate in Mesoamerican Nephropathy.", "score": 0.014472455648926238, "content": "Mesoamerican nephropathy (MeN) is a chronic kidney disease affecting rural inhabitants in Central America. We have previously described the renal morphology in 8 patients from El Salvador. To confirm the renal pathology, we have studied kidney biopsies from patients with MeN in Nicaragua. Follow-up urine and blood samples from both biopsy studies were collected to investigate the natural history. Case series. In the kidney biopsy study, 19 male sugarcane workers in Nicaragua with suspected MeN were investigated with questionnaires, kidney biopsies, and blood and urine analysis. Inclusion criteria were age 20 to 65 years and plasma creatinine level of 1.13 to 2.49mg/dL or estimated glomerular filtration rate (eGFR) of 30 to 80mL/min/1.73m<sup2</sup. Exclusion criteria were proteinuria with protein excretion &gt; 3g/24 h, uncontrolled hypertension, diabetes mellitus, or other known kidney disease. In the follow up-study, blood and urine from the kidney biopsy study in Nicaragua (n=18) and our previous biopsy study of MeN cases in El Salvador (n=7) were collected 1 to 1.5 and 2 to 2.5 years after biopsy, respectively. Renal morphology, clinical, and biochemical characteristics, change in eGFR per year. eGFR was calculated using the CKD-EPI creatinine (eGFR<subcr</sub), cystatin C (eGFR<subcys</sub), and creatinine-cystatin C (eGFR<subcr-cys</sub) equations. In the kidney biopsy study, participants had a mean eGFR<subcr</sub of 57 (range, 33-96) mL/min/1.73m<sup2</sup. 47% had low plasma sodium and 21% had low plasma potassium levels. 16 kidney biopsies were representative and showed glomerulosclerosis (mean, 38%), glomerular hypertrophy, and signs of chronic glomerular ischemia. Mild to moderate tubulointerstitial damage and mostly mild vascular changes were seen. In the follow up-study, median duration of follow-up was 13 (range, 13-27) months. Mean change in eGFR<subcr</sub was -4.4±8.4 (range, -27.7 to 10.2) mL/min/1.73m<sup2</sup per year. Most patients had stopped working with sugarcane cultivation. 3 biopsy specimens had 4 or fewer glomeruli. This study confirms the renal morphology of MeN: chronic glomerular and tubulointerstitial damage with glomerulosclerosis and chronic glomerular ischemia. Follow-up data show that eGFRs, on average, deteriorated." }, { "id": "wiki20220301en023_76153", "title": "Assessment of kidney function", "score": 0.014359900654775343, "content": "The most relevant assessments in a renal ultrasound are renal sizes, echogenicity and any signs of hydronephrosis. Renal enlargement usually indicates diabetic nephropathy, focal segmental glomerular sclerosis or myeloma. Renal atrophy suggests longstanding chronic renal disease. Chronic kidney disease stages Risk factors for kidney disease include diabetes, high blood pressure, family history, older age, ethnic group and smoking. For most patients, a GFR over 60 (mL/min)/(1.73 m2) is adequate. But significant decline of the GFR from a previous test result can be an early indicator of kidney disease requiring medical intervention. The sooner kidney dysfunction is diagnosed and treated the greater odds of preserving remaining nephrons, and preventing the need for dialysis." }, { "id": "wiki20220301en019_111575", "title": "Glomerular filtration rate", "score": 0.013526570048309178, "content": "Chronic kidney disease stages Risk factors for kidney disease include diabetes, high blood pressure, family history, older age, ethnic group and smoking. For most patients, a GFR over 60 mL/min/1.73m2 is adequate. But significant decline of the GFR from a previous test result can be an early indicator of kidney disease requiring medical intervention. The sooner kidney dysfunction is diagnosed and treated the greater odds of preserving remaining nephrons, and preventing the need for dialysis." }, { "id": "wiki20220301en019_111576", "title": "Glomerular filtration rate", "score": 0.012448245805186315, "content": "The severity of chronic kidney disease (CKD) is described by six stages; the most severe three are defined by the MDRD-eGFR value, and first three also depend on whether there is other evidence of kidney disease (e.g., proteinuria): 0) Normal kidney function – GFR above 90 mL/min/1.73 m2 and no proteinuria 1) CKD1 – GFR above 90 mL/min/1.73 m2 with evidence of kidney damage 2) CKD2 (mild) – GFR of 60 to 89 mL/min/1.73 m2 with evidence of kidney damage 3) CKD3 (moderate) – GFR of 30 to 59 mL/min/1.73 m2 4) CKD4 (severe) – GFR of 15 to 29 mL/min/1.73 m2 5) CKD5 kidney failure – GFR less than 15 mL/min/1.73 m2 Some people add CKD5D for those stage 5 patients requiring dialysis; many patients in CKD5 are not yet on dialysis. Note: others add a \"T\" to patients who have had a transplant regardless of stage." }, { "id": "pubmed23n0602_11132", "title": "[Estimation of glomerular filtration rate in primary care: prevalence of chronic kidney disease and impact on referral to nephrology].", "score": 0.012375412204972396, "content": "Data were collected in 18.922 patients attending Primary Care Centers in Alcañiz (Spain), mean age 59,96 +/- 17 years, 42,9 % males and 57,1 % females. The prevalence of eGFR was: stage 3 (30-59 ml/min/1,73 m2) 15,7 %; stage 4 (15-29 ml/min/1,73 m2) 0,6 %; stage 5 no dialysis (GFR &lt; 15 ml/min/1.73 m2) 0,1 %. This prevalence increased with age and 32 % of patients attending Primary Care services over 65 years presented a eGFR &lt; 60 ml/min/1,73 m2. Of the total patients with eGFR &lt; 60 ml/min/1,73 m2, 26 % had normal serum creatinine levels. Protocol implementation could implied for the Renal Unit an increase in the number of patients, specially the oldest ones. This study documents the substantial prevalence of significantly abnormal renal function among patients at Primary Care level and the importance of Primary Care collaboration in their early identification and appropriate management." }, { "id": "wiki20220301en019_111573", "title": "Glomerular filtration rate", "score": 0.012309108164850018, "content": "Normal ranges The normal range of GFR, adjusted for body surface area, is 100–130 average 125 mL/min/1.73m2 in men and 90–120 ml/min/1.73m2 in women younger than the age of 40. In children, GFR measured by inulin clearance is 110 mL/min/1.73 m2 until 2 years of age in both sexes, and then it progressively decreases. After age 40, GFR decreases progressively with age, by 0.4–1.2 mL/min per year. Decreased GFR A decreased renal function can be caused by many types of kidney disease. Upon presentation of decreased renal function, it is recommended to perform a history and physical examination, as well as performing a renal ultrasound and a urinalysis. The most relevant items in the history are medications, edema, nocturia, gross hematuria, family history of kidney disease, diabetes and polyuria. The most important items in a physical examination are signs of vasculitis, lupus erythematosus, diabetes, endocarditis and hypertension." }, { "id": "wiki20220301en025_100442", "title": "Chronic kidney disease", "score": 0.012162339365329138, "content": "Chronic kidney disease (CKD) is a type of kidney disease in which there is gradual loss of kidney function over a period of months to years. Initially there are generally no symptoms; later, symptoms may include leg swelling, feeling tired, vomiting, loss of appetite, and confusion. Complications include an increased risk of heart disease, high blood pressure, bone disease, and anemia. Causes of chronic kidney disease include diabetes, high blood pressure, glomerulonephritis, and polycystic kidney disease. Risk factors include a family history of chronic kidney disease. Diagnosis is by blood tests to measure the estimated glomerular filtration rate (eGFR), and a urine test to measure albumin. Ultrasound or kidney biopsy may be performed to determine the underlying cause. Several severity-based staging systems are in use." }, { "id": "wiki20220301en025_100455", "title": "Chronic kidney disease", "score": 0.011751275852806876, "content": "The glomerular filtration rate (GFR) is derived from the serum creatinine and is proportional to 1/creatinine, i.e. it is a reciprocal relationship:the higher the creatinine, the lower the GFR. It reflects one aspect of kidney function: how efficiently the glomeruli - the filtering units - work. Normal GFR is 90-120 mLs/min. The units of creatinine vary from country to country. But since the glomeruli make up <5% of the mass of the kidney, the GFR does not indicate all aspects of kidney health and function. This can be done by combining the GFR level with the clinical assessment of the person, including fluid status, and measuring the levels of hemoglobin, potassium, phosphate and parathyroid hormone (PTH)." }, { "id": "wiki20220301en090_31250", "title": "Phosphate nephropathy", "score": 0.01172882946281961, "content": "Diagnosis Phosphate nephropathy can be diagnosed via different types of assessment, most of which are also used to detect acute kidney injury and chronic kidney disease. Most phosphate nephropathy incidents are diagnosed weeks or months after taking OSP, due to its clinical silence. For example, these assessments include the measurement of serum phosphorus with an elevation of more than 3 mmol/L, the finding of an elevated serum creatinine level and a decrease in glomerular filtration rate (GFR), urine microscopy for crystallization detection, the image of calcium phosphate crystals deposited through CT scanning, urinalysis, renal biopsy specimens with histochemical staining for calcium phosphate. These assessments are generally carried out within the laboratory environment, in which longer waiting time is required to attain the results." }, { "id": "wiki20220301en019_111565", "title": "Glomerular filtration rate", "score": 0.01153588195841717, "content": "Modification of Diet in Renal Disease (MDRD) formula Another formula for calculating the GFR is the one developed by the Modification of Diet in Renal Disease Study Group. Most laboratories in Australia, and the United Kingdom now calculate and report the estimated GFR along with creatinine measurements and this forms the basis of diagnosis of chronic kidney disease. The adoption of the automatic reporting of MDRD-eGFR has been widely criticised. The most commonly used formula is the \"4-variable MDRD\", which estimates GFR using four variables: serum creatinine, age, ethnicity, and gender. The original MDRD used six variables with the additional variables being the blood urea nitrogen and albumin levels. The equations have been validated in patients with chronic kidney disease; however, both versions underestimate the GFR in healthy patients with GFRs over 60 mL/min. The equations have not been validated in acute renal failure. For creatinine in μmol/L: For creatinine in mg/dL:" }, { "id": "wiki20220301en023_76154", "title": "Assessment of kidney function", "score": 0.01134545760713985, "content": "The severity of chronic kidney disease (CKD) is described by six stages; the most severe three are defined by the MDRD-eGFR value, and first three also depend on whether there is other evidence of kidney disease (e.g., proteinuria): 0) Normal kidney function – GFR above 90 (mL/min)/(1.73 m2) and no proteinuria 1) CKD1 – GFR above 90 (mL/min)/(1.73 m2) with evidence of kidney damage 2) CKD2 (mild) – GFR of 60 to 89 (mL/min)/(1.73 m2) with evidence of kidney damage 3) CKD3 (moderate) – GFR of 30 to 59 (mL/min)/(1.73 m2) 4) CKD4 (severe) – GFR of 15 to 29 (mL/min)/(1.73 m2) 5) CKD5 kidney failure – GFR less than 15 (mL/min)/(1.73 m2) Some people add CKD5D for those stage 5 patients requiring dialysis; many patients in CKD5 are not yet on dialysis. Note: others add a \"T\" to patients who have had a transplant regardless of stage." }, { "id": "wiki20220301en043_69821", "title": "Diabetic nephropathy", "score": 0.011116755236011253, "content": "It is recommended that diabetics have their albumin levels checked annually, beginning immediately after a diagnosis of type 2 diabetes and five years after a diagnosis of type 1 diabetes. Medical imaging of the kidneys, generally by ultrasonography, is recommended as part of a differential diagnosis if there is suspicion of urinary tract obstruction, urinary tract infection, kidney stones or polycystic kidney disease. Conformation kidney biopsy should only be performed if non-diabetic kidney disease is suspected. Urine analysis in patients with diabetic kidney disease is often bland. In cases of severely increased microalbuminuria, hematuria might be present. fat bodies might be present in patients who develop nephrotic-range proteinuria. Staging To stage the degree of damage in this (and any) kidney disease, the serum creatinine is determined and used to calculate the estimated glomerular filtration rate (eGFR). Normal eGFR is equal to or greater than 90ml/min/1.73 m2." }, { "id": "wiki20220301en023_76150", "title": "Assessment of kidney function", "score": 0.010640891675374433, "content": "There are several different techniques used to calculate or estimate the glomerular filtration rate (GFR or eGFR). The above formula only applies for GFR calculation when it is equal to the Clearance Rate. The normal range of GFR, adjusted for body surface area, is 100–130 average 125 (mL/min)/(1.73 m2) in men and 90–120 (mL/min)/(1.73 m2) in women younger than the age of 40. In children, GFR measured by inulin clearance is 110 (mL/min)/(1.73 m2) until 2 years of age in both sexes, and then it progressively decreases. After age 40, GFR decreases progressively with age, by 0.4–1.2 mL/min per year. Estimated GFR (eGFR) is now recommended by clinical practice guidelines and regulatory agencies for routine evaluation of GFR whereas measured GFR (mGFR) is recommended as a confirmatory test when more accurate assessment is required." }, { "id": "wiki20220301en019_111574", "title": "Glomerular filtration rate", "score": 0.010328917473522319, "content": "A urinalysis is helpful even when not showing any pathology, as this finding suggests an extrarenal etiology. Proteinuria and/or urinary sediment usually indicates the presence of glomerular disease. Hematuria may be caused by glomerular disease or by a disease along the urinary tract. The most relevant assessments in a renal ultrasound are renal sizes, echogenicity and any signs of hydronephrosis. Renal enlargement usually indicates diabetic nephropathy, focal segmental glomerular sclerosis or myeloma. Renal atrophy suggests longstanding chronic renal disease. Chronic kidney disease stages" }, { "id": "wiki20220301en001_68250", "title": "Autosomal dominant polycystic kidney disease", "score": 0.010026737967914439, "content": "Prognosis In ADPKD patients, gradual cyst development and expansion result in kidney enlargement, and during the course of the disease, glomerular filtration rate remains normal for decades before kidney function starts to progressively deteriorate, making early prediction of renal outcome difficult. The CRISP study, mentioned in the treatment section above, contributed to build a strong rationale supporting the prognostic value of total kidney volume (TKV) in ADPKD; TKV (evaluated by MRI) increases steadily and a higher rate of kidney enlargement correlated with accelerated decline of GFR, while patient height-adjusted TKV (HtTKV) ≥600 ml/m predicts the development of stage 3 chronic kidney disease within 8 years." }, { "id": "wiki20220301en043_69809", "title": "Diabetic nephropathy", "score": 0.009900990099009901, "content": "Diabetic nephropathy, also known as diabetic kidney disease, is the chronic loss of kidney function occurring in those with diabetes mellitus. Diabetic nephropathy is one of the leading causes of chronic kidney disease (CKD) and end-stage renal disease (ESRD) globally. Protein loss in the urine due to damage to the glomeruli may become massive, and cause a low serum albumin with resulting generalized body swelling (edema) and result in the nephrotic syndrome. Likewise, the estimated glomerular filtration rate (eGFR) may progressively fall from a normal of over 90 ml/min/1.73m2 to less than 15, at which point the patient is said to have end-stage renal disease. It usually is slowly progressive over years." }, { "id": "pubmed23n0662_5474", "title": "[Chronic kidney disease in the source documentation of the outpatient clinic Department of Nephrology. Part II. Comparison of the three different methods of glomerular filtration rate estimation].", "score": 0.009900990099009901, "content": "The aim of the study was to compare three methods of GFR estimation as simplified MDRD formula, Cockcroft-Gault formula and 24 hour urine collection used in evaluation of kidney function. The study was conducted at the outpatient clinic and enclosed 1183 patients aged between 17 and 98 years (mean 64.7) with creatinine level &gt;120 micromol/l and/or creatinine clearance &lt;90 ml/min/1.73 m2, described in detail in part I. After calculation we obtained different mean GFR values adequately to the method: 38.4 +/- 15.13 ml/min/1.73 m2 (simplified MDRD formula), 44.51 +/- 20.59 ml/min/1.73 m2 (Cockcroft-Gault formula) and 45.63 +/- 25.55 ml/min/1.73 m2 (24-h urine collection). Results of the GFR assessment were different according to the applied method of calculation. The smallest data dispersion was observed in GFR values calculated based on abbreviated MDRD formula and the highest when obtained based on to the 24-hour urine collection. The GFR values obtained based on 24 hour urine collection showed positive correlations with BMI (p&lt;0.01), hemoglobine (p&lt;0.01), hematocrite (p&lt;0.01), diastolic blood pressure (p=0.01), albumin (p=0.041), iron (p=0.03), AIAT activity (p=0.01), and negative with age (p&lt;0.01), phosphate (p&lt;0.01), alkaline phosphatase activity (p=0.039), parathormone (p=0.03), potassium (p&lt;0.01) and magnesium (p&lt;0.01). In the group of patients with GFR values below 30 ml/min in comparison with patients with GFR values above 30 ml/min, in all three methods of GFR estimation it was shown significantly higher values of phosphate, potassium, age, and lower hemoglobin, hematocrite. It was shown also in the group with GFR below 30 ml/min values estimated based on Cockcroft-Gault formula and 24 hour urine collection significantly lower BMI." }, { "id": "pubmed23n0059_9368", "title": "[A study of serum phosphorus and renal phosphate excretion in children of different age groups].", "score": 0.00980392156862745, "content": "To further elucidate the data of high serum phosphorus concentration reported for foreign children, this study compared the values of serum phosphorus concentration in ethnic Chinese children with foreigners' results, and investigated the potential causes of high serum phosphorus concentration. This study included 33 healthy term male neonates from 2-3 days to 5-7 days old, 1,094 children of 6-18 years old (elementary school-senior high school) and 62 adults. A total of 1,189 persons were studied. Value of serum phosphorus concentration showed no significant difference between boys and girls, and no age dependency; there was notable change in serum phosphorus concentration in growing children of different ages. The mean values of serum phosphorus concentration of neonates aged 2-3 days and 5-7 days (7.20 mg/dl and 7.65 mg/dl, respectively) were the highest; boys aged 6-11 years 5.15-5.50 mg/dl and girls aged 6-11 years 5.14-5.28 mg/dl were the second; boys aged 12-18 years 4.31-4.94 mg/dl and girls aged 12-18 years 4.44-4.96 mg/dl were the lowest. These findings are similar to the conclusions of foreign reports that the older the subjects of the study, the less their serum phosphorus concentration. The maximal transport rates of tubular phosphate reabsorption were determined from a Walton-Bijvoet nomogram using the side-rule method they recommend. The renal phosphate threshold concentration of neonates aged 2-3 days 8.41 mg/100 ml GFR and 5-7 days 7.76 mg/dl GFR was also the highest; boys aged 6-11 years 5.84-6.32 mg/dl GFR and girls aged 6-11 years 5.82-6.10 mg/dl GFR and 5.44-6.10 mg/dl GFR was the second; adult males 3.51 mg/dl GFR and adult females 3.62 mg/dl GFR was the lowest. Increased intestinal absorption of phosphorus, low GFR and low clearance of phosphorus might be the contributing factors to cause high serum phosphorus concentration. Although high renal phosphate threshold capacity is important, increased absorption of phosphorus by G-I tract seems to be another factor in accordance with the need of phosphorus of the growing body cells." }, { "id": "wiki20220301en184_18873", "title": "Renal Association", "score": 0.009711779448621553, "content": "The Renal Association established the UK Renal Registry (UKRR) in 1995. The UKRR team manage data collection, analysis and reporting on approximately 8,000 new patients, 67,000 existing patients on RRT and on about 500,000 patients with an AKI each year. Data collated from renal centres and hospital laboratories is used to improve the care of patients with kidney disease across the UK. In 2005 the association published, together with the RCP of London, national guidelines on the diagnosis and management of chronic kidney disease (CKD), which led to the routine reporting of the estimated glomerular filtration rate (eGFR) by most National Health Service laboratories." }, { "id": "pubmed23n0662_5473", "title": "[Chronic kidney disease in the source documentation of the outpatient clinic Department of Nephrology. Part I. Causes of renal failure and characteristics of the studied population].", "score": 0.009708737864077669, "content": "During the last years the incidence of chronic kidney disease (CKD) is permanently increasing and has become a global social and economical problem in the world as well as in Poland. The aim of the study was the retrospective analysis of medical records of patients with renal failure under supervision at the outpatient clinic, Department of Nephrology, University Hospital in Cracow. The study population enclosed 1183 patients (640 men and 543 women) aged between 17 and 98 years (mean 64.7) with creatinine concentration &gt;120 micromol/l and/or creatinine clearance &lt;90 ml/min/1.73 m2. Hemoglobin, iron, creatinine, urea, sodium, potasium, calcium, phosphate, magnesium, PTH, uric acid, albumin, total protein, bilirubin, glucose, total cholesterol, LDL and HDL cholesterol, triglicerydes concentration and values of hematocrite, MCV, HbA1, as well as alkaline phosphatase, AspAT, AIAT activity were estimated based on standard laboratory methods. Creatinine clearances were evaluated based on 3 different methods: simplified MDRD formula, Cockcroft-Gault formula and 24-h urine collection. Mean creatinine concentration in the studied population was 172.8 micromol/l (1.95 mg/dl). Hypertension was diagnosed in 65% of patients. In spite of treatment, more than half of the patients (51.9%) have increased systolic blood pressure and above 1/3 (35%) increased diastolic blood pressure. Mean hemoglobin concentration was 13.02 g/dl; more than 12% of patients had decreased hemoglobin below 11 g/dl. Mean values of parameters discovering calcium-phosphate metabolism were: calcium--2.33 mmol/l, phosphate--1.23 mmol/l and parathormon--169.3 pg/ml. Increased value of total serum cholesterol level was noted more than half of the patients (56.5%). Significant positive correlations were found between GFR calculated based on Cockcroft-Gault formula and BMI, hemoglobin, hematocrite, serum iron, diastolic blood pressure, total and LDL serum cholesterol, triglicerydes level, as well as AIAT activity and % values of HbA1c and negative with age, serum potassium, phosphorus, PTH and uric acid." }, { "id": "pubmed23n1059_4860", "title": "Assessment of serum electrolytes and kidney function test for screening of chronic kidney disease among Ethiopian Public Health Institute staff members, Addis Ababa, Ethiopia.", "score": 0.009615384615384616, "content": "Chronic kidney disease (CKD), which is characterized by its asymptomatic nature until an end stage, is one of the most common public health problems in the world. Thus, a regular checkup, especially for those individuals with high risk groups is inevitably important, and the screening has been done with laboratory findings. However, in developing countries, including Ethiopia screening for CKD are rarely done, and it is becoming common to hear sudden death from the kidney failure. Therefore, we aimed to screen serum electrolyte levels and estimated glomerular filtration rate (eGFR) among Ethiopian Public Health Institute (EPHI) staff members for an early detection of CKD and to identify the factors associated with it. A cross-sectional study was conducted from July 1 to October 28, 2018 among EPHI staff members. The level of serum creatinine and electrolytes were measured using COBAS 6000 analyzer. Then, eGFR was calculated using MDRD and CKD-EPI equations. Data analysis were done using SPSS version 20, and the factors associated with the outcome variable were assessed using logistic regression. P values &lt; 0.05 were considered as statistically significant. This study found that 3.6 and 1.9% of the study participants were at CKD stage II by MDRD and CKD-EPI equations, respectively. Out of the total study participants, 9.5% had hyperkalemia (serum potassium level &gt; 5.0 mmol/L) and 8.5% had hypocalcemia (serum calcium level &lt; 2.15 mmol/L). An older age (P = 0.006), high BMI (P = 0.045) and previous history of CVDs (P = 0.033) were found to be significantly associated factors with reduced glomerular filtration rate. Nine percent of the study participants were obese, 6.1% had family history of kidney failure, 18% self-reported history of hypertension, 3.4% diabetic and 5.3% had CVDs. About 51.2% of the study participants were males, and the majorities, (66%) of the study participants were found to be alcohol consumers. The prevalence of a stage II kidney disease was relatively low and none of the participants was under serious kidney disease (GFR &lt; 60 mmol/min/1.73m<sup2</sup). An older age, high BMI and previous history of CVDs were significantly associated with reduced GFR. Hyperkalemia and hypokalemia were the major electrolyte disorders in the study participants." }, { "id": "pubmed23n0626_19410", "title": "[One-year follow-up of renal function in endemic nephropathy families].", "score": 0.009523809523809525, "content": "Endemic nephropathy is familial, chronic tubulointerstitial disease with an insidious onset and asymptomatic, slow progressive course. The present study was undertaken with the aim to find out whether new persons with renal disorders can be detected among members of endemic families in the village of Sopić (Kolubara River region, Serbia). The study involved 44 members of five endemic families without history of renal disorders. Objective survey and laboratory analyzes that enabled determination of kidney functions (creatinine clearance, proteinuria, urine specific gravity and osmolality, fractional sodium excretion (FENa), the rate of tubular phosphate reabsorption (TRP), urine N-acetil-D-glycosaminidase and intestinal alkaline phosphatase) were done in all examined persons three times during the 6-month intervals. At the first examination, hypertension was detected in 23 (52%) person, decreased creatinine clearance in two and proteinuria in 10 persons included in the study. In addition, proteinuria and tubular disorders were detected in 6, hypertension, proteinuria and/or tubular disorders in 9 persons. The analysis of the results obtained by three check-ups undertaken during one year showed that proteinuria and tubular disorders appeared intermittently in half of the examined endemic family members. All persons with detected renal disorders required further examination in order to establish accurate diagnosis of renal disease. Three check-ups performed at six-month intervals in the members of five endemic families detected various renal disorders including renal hypofunction. Regular systematic check-ups of endemic families could enable early detection of the disease and early initiation of measures for slowing down chronic renal disease progression." }, { "id": "wiki20220301en002_195626", "title": "Dialysis", "score": 0.009433962264150943, "content": "Chronic indications Chronic dialysis may be indicated when a patient has symptomatic kidney failure and low glomerular filtration rate (GFR < 15 mL/min). Between 1996 and 2008, there was a trend to initiate dialysis at progressively higher estimated GFR, eGFR. A review of the evidence shows no benefit or potential harm with early dialysis initiation, which has been defined by start of dialysis at an estimated GFR of greater than 10 ml/min/1.732. Observational data from large registries of dialysis patients suggests that early start of dialysis may be harmful. The most recent published guidelines from Canada, for when to initiate dialysis, recommend an intent to defer dialysis until a patient has definite kidney failure symptoms, which may occur at an estimated GFR of 5–9 ml/min/1.732. Dialyzable substances" }, { "id": "pubmed23n0361_13624", "title": "[Secondary hyperparathyroidism as a cause of delayed functioning of renal graft. Reports of two cases].", "score": 0.009433962264150943, "content": "Parathormone (PTH) exerts vasomodulatory effect. In patients with severe hyperparathyroidism (HPTx) post transplant (Tx) PTH level decreases slowly and this could be a reason of delayed graft function. Case 1: 19 years old female; 2 years of CAPD-renal Tx lost after 8 years--6 years on hemodialysis (HD), clinical symptoms of severe HPTx (iPTH &gt; 1300 pg/ml). Elective parathyroidectomy was cancelled as patient received the second graft. Then she was oliguric and required regular HD from the 4th day after Tx. We observed increasing resistance index (RI) and finally no diastolic blood flow in graft USG-Doppler scan. Ten days after Tx, the patient was revised surgically and renal biopsy was performed. No pathology but slight ATN was found. At the same time iPTH level was 1225 pg/ml. Plasmapheresis (PF) was introduced, decreasing iPTH level to 850 pg/ml, 995 pg/ml, and 345 pg/ml respectively. After the second PF urine output increased (to 600 ml). Serum creatinine level decreased from 7.3 to 1.3 mg/dL within the next 10 days. Actually (5 months post Tx) graft function remains stable (creatinine 1.2 mg/dl). The level of iPTH at the second month after Tx was 756 pg/ml, at 4th month--439 pg/ml. Case 2: M.P. 20 years old female initially on HD, then Tx, lost after 5 months because of FSGS recurrence--again HD therapy. She developed severe secondary HPTx (iPTH level &gt; 1300 pg/ml). Planned parathyroidectomy was cancelled as she received a second transplant. After Tx she was anuric for 5 weeks and was treated with HD. She had high RI index in repeated USG-Doppler scans, blood flow in renal cortex was deceleration. Repeated renal biopsy showed no pathology and PF therapy was introduced. After the first PF the patient started to urinate, after the 5th--the urine output was 1000 ml. Overall 10 PFs were done. Now, 13 months after Tx, graft function is satisfactory (creatinine level 2.1 mg/dL). The level of iPTH in 4th month after Tx was 772 pg/ml, in 10th month--631 pg/ml. We suggest that disturbances in graft blood flow were influenced by high level of iPTH, decreased successfuly by PF therapy." }, { "id": "wiki20220301en025_100458", "title": "Chronic kidney disease", "score": 0.009392299558375318, "content": "Protein in the urine is regarded as an independent marker for worsening of kidney function and cardiovascular disease. Hence, British guidelines append the letter \"P\" to the stage of chronic kidney disease if protein loss is significant. Stage 1: Slightly diminished function; kidney damage with normal or relatively high GFR (≥90 ml/min/1.73 m2) and persistent albuminuria. Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Stage 2: Mild reduction in GFR (60–89 ml/min/1.73 m2) with kidney damage. Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Stage 3: Moderate reduction in GFR (30–59 ml/min/1.73 m2):. British guidelines distinguish between stage 3A (GFR 45–59) and stage 3B (GFR 30–44) for purposes of screening and referral." }, { "id": "wiki20220301en085_59102", "title": "Contrast-induced nephropathy", "score": 0.009345794392523364, "content": "Decreased kidney function European guidelines classify a pre-existing decreased kidney function to be a risk factor of contrast-induced nephropathy in the following cases: Estimated glomerular filtration rate (eGFR) < 45 ml/min/1.73 m2 of body surface area before intra-arterial administration with first-pass renal exposure (not passing lungs or peripheral circulation before kidneys), or in the intensive care unit eGFR < 30 ml/min/1.73 m2 before intravenous administration or intra-arterial administration with second-pass renal exposure Known or suspected acute kidney injury To calculate estimated GFR from creatinine, European guidelines use the CKD-EPI formula in adults ≥ 18 years, and the revised Schwartz formula in children. Swedish guidelines recommends no specific formula in children because of lack of evidence, but on the other hand recommends GFR based on cystatin C rather than creatinine in those with abnormal muscle mass or liver failure or cirrhosis." }, { "id": "pubmed23n0696_615", "title": "Rare tubulopathy - primary hypophosphatemic rickets (case report).", "score": 0.009345794392523364, "content": "Primary hypophosphatemic rickets is a rare disorder caused by inborn defect of renal tubular reabsorbtion and usually manifested in childhood and infancy with stunted growth and deformities of lower limbs. Patient 12 years old, female, was born to healthy parents, at 41 weeks of gestation by normal delivery and had a normal birth weight and length. She had one healthy sibling (male). Psychomotor development until the age of 2 years was normal. Since the age of 2 years deformation of legs and difficulties with walking have been observed. The Patient was consulted by Pediatric Orthopedist, Nephrologists and Endocrinologist. The blood biochemical findings revealed normal pH, normal calcium (CA), potassium (K), sodium (Na) concentrations, very low phosphate (P) with markedly elevated alkaline phosphatase (AP) and slightly elevated parathyroid hormone (PTH) concentration; urine test indicated impaired tubular function: mild glucosuria, proteinuria, and markedly increased phosphaturia. Phosphate tubular reabsorbtion (PTR) was 52%, phosphate/creatinine clearance 0,52, renal threshold phosphate concentration (TmP/GFR) 0,25 mmol/l. Genetic tests results not available yet. the diagnosis of phosphate diabetes made on the basis of clinical-laboratory data. The therapy with Inorganic phosphate (50-100mg/kg/d) and 1,25(OH)D3 40-50 ng/kg/d had been started. Childs walking abilities improved with treatment, the deformation of legs decreased, but O-legs and other skeletal deformations are still remarkable. Auxological parameters are not satisfactory. Physical growth is below the normal range (height SDS -3,78); the patient's predicted height less than target height. Biochemical monitoring performed regularly under the treatment, serum phosphate remains below normal, serum ALP is still elevated. This case is in line with other publications and indicates the difficulty to achieve normal phosphate levels and normal growth without an additional treatment with growth hormone. At this stage of the disease, the question of referring to the growth hormone therapy is being considered aimed to improve the growth tendencies. It is possible that orthopedic surgery is also needed in the future." }, { "id": "wiki20220301en085_59103", "title": "Contrast-induced nephropathy", "score": 0.009259259259259259, "content": "Roxana Mehran score The Roxana Mehran score is a clinical prediction rule to estimate probability of nephropathy (increase ≥25% and/or ≥0.5 mg/dl in serum creatinine at 48 h): Risk Factors: Systolic blood pressure <80 mm Hg - 5 points (if systolic BP less than 80 mmHg for at least one hour requiring inotropic support) Intra-arterial balloon pump - 5 points Congestive heart failure, counting as NYHA class III (marked limitation in activity due to symptoms, even during less-than-ordinary activity) or worse, or history of pulmonary edema - 5 points Age >75 y - 4 points Hematocrit level <39% for men and <35% for women - 3 points Diabetes mellitus- 3 points Contrast media volume - 1 point for each 100 mL Decreased kidney function: Serum creatinine level >1.5 g/dL - 4 points or Estimated Glomerular filtration rate (online calculator) 2 for 40–60 mL/min/1.73 m2 4 for 20–40 mL/min/1.73 m2 6 for < 20 mL/min/1.73 m2" }, { "id": "pubmed23n0481_19568", "title": "[Over 55 years-old live-related donor kidney transplants: a report of 12 cases].", "score": 0.009259259259259259, "content": "To evaluate the risk factors of the over 55-year-old donor and the safety and efficacy of the donor, and the recipient with the immediate and long-term of the kidney. The living-related donor kidney transplantation in 15 cases was performed in our unit from October 1999 to April 2002. Of these, 12 donors were over 55 with age ranging from 55 to 73 years-old and mean age of 62, 75 years. 5 donors were male and 7 were female. Father in 5 cases and 6 and 1 were mother and grandmother, respectively. The donors were evaluated depending on general state of health, hypertension, diabate and important organa in condition; and renal function by creatinine (Cre), creatinine clearance (Ccr), Glomerular filtration rate (GFR), B ultrasound and renal arteriograph prior to operation. The all receipients with ages ranging from 14 to 46 years with end-stage renal diseases (ESRD) from and their mean age was 32.9 years. The donor' left nephrectomy was performed in 10 cases and right nephrectomy in 2. Warm-ischemia time was from 70 s to 170 s (mean time, 92 s). Cold-ischemia time was from 60 minutes to 120 minutes and mean 84 minutes. The follow-up is from 12 to 42 months and mean 20, 84 months. All the 12 donors were perfectly recovered during operation and postoperation. During their 11-day stay in the hospital no complications was observed. The donor' creatinine was raised to about 12 to 34 micro mol/L (mean, 22 micro mol/L). One recipient died from lung infection at 28 days postoperative and 1 died due to liver failure with normal graft function after transplanted 6 months and yet one recipient with delayed graft function had recovered by 12 times dialysis. The remain recipient had a better recovered. Aged (&gt;or= 55 years-old) donor renal transplantation can be carried out as the poor supply of can be used kidney but must to controled the indication and the prepare to be accomplished seriously." }, { "id": "pubmed23n0659_16767", "title": "Glomerular filtration rate in examined population of Bosnian Posavina - region of Balkan Endemic Nephropathy.", "score": 0.009174311926605505, "content": "Balkan endemic nephropathy (BEN) is chronic tubulointersticial nephritis of unknown aetiology characterized by an insidious onset and gradual progression to end stage renal disease (ESRD). Endemic regions of Bosnia and Herzegovina are Posavina and Semberija, sited at basin of Sava River. In BEN, just like in other chronic renal diseases (CKD), glomerular filtration rate (GFR), is assumed a marker of overall renal function. The aim of this study was to compare GFR in examinees of endemic and non-endemic region for BEN, and between examinees with and without risk factors for BEN within endemic region. Study included 603 inhabitants of Bosnian Posavina, out of whom 386 (65%) from endemic (Domaljevac) and 217 (36%) from non-endemic (Svilaj) village, and it was performed in two phases. The first phase encompassed obtaining anamnestic data (demographic, personal and family history), measurement of arterial blood pressure, and urine dipstick testing (specific gravity, pH, proteins, leukocytes, glucose, ketones, and microalbuminuria). In the second phase, besides repeated urine dipstick test, laboratory blood testing and abdominal ultrasound, with special attention to urinary tract, was also performed. We have compared GFR between examinees of endemic and non-endemic regions for BEN, and between examinees with and without family burden for BEN within endemic region, using MDRD formula for calculating GFR, with cut-off value (5th percentile) based on result of studies performed in European Caucasians in screening for CKD and for establishing stages of CKD in BEN. Medical was used for statistical testing. Out of total number of examined inhabitants (603), 145 examinees were included in the second phase. After exclusion of 17 diabetic patients, 94 (73%) examinees from endemic and 34 (27%) examinees from non-endemic region remained. In the endemic region there were 46 (49%) examinees with and 48 (51%) without family burden for BEN. Overall GFR in examined groups was within physiologic range. There was not statistically significant difference in calculated GFR between examinees of endemic and non-endemic regions for BEN (Mann-Whitney test p=0.104; Fisher's test p=1), neither between examinees with and without family burden for BEN within endemic region (Mann-Whitney test p=0,7393; Fisher's test p=0,263). Overall GFR in examined groups was within physiologic range. There wasn't statistically significant difference in calculated GFR between examinees of endemic and non-endemic regions for BEN, neither between examinees with and without family burden for BEN within endemic region. GFR, no matter how accurately calculated and estimated, does not represent significant biomarker for diagnosis, especially early diagnosis, of BEN, until maybe its overt advanced form." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 9, 222 ] ], "word_ranges": [ [ 1, 36 ] ], "text": "The patient presents a good general condition with a recently diagnosed hepatocarcinoma, not giving him any type of treatment other than symptomatic and supportive at this stage would not be the right thing to do." }, "2": { "exist": true, "char_ranges": [ [ 223, 287 ] ], "word_ranges": [ [ 36, 45 ] ], "text": "TACE would not be indicated because of extrahepatic involvement." }, "3": { "exist": true, "char_ranges": [ [ 393, 522 ] ], "word_ranges": [ [ 64, 85 ] ], "text": "both with systemic treatment (indicated because it is metastatic) and the correct answer is 4, for all the reasons given therein." }, "4": { "exist": true, "char_ranges": [ [ 393, 522 ] ], "word_ranges": [ [ 64, 85 ] ], "text": "both with systemic treatment (indicated because it is metastatic) and the correct answer is 4, for all the reasons given therein." }, "5": { "exist": true, "char_ranges": [ [ 288, 358 ] ], "word_ranges": [ [ 45, 56 ] ], "text": "Transplantation would also not be done if he has extrahepatic disease." } }

{ "1": "Symptomatic and supportive treatment, since he presented an advanced hepatocarcinoma with vascular invasion and metastasis.", "2": "Transarterial chemoembolization (TACE), since the treatment increases survival in patients with advanced hepatocarcinoma.", "3": "Systemic chemotherapy with doxorubicin iv since he presents disseminated disease but he is in good general condition.", "4": "Treatment with oral sorafenib, since this is a patient with good general condition, Child A and advanced stage hepatocarcinoma BCLC-C.", "5": "The appropriate treatment is liver transplantation as it is the only procedure that completely eliminates the primary tumor and avoids future complications of cirrhosis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0684_5381", "title": "Complete response for advanced liver cancer during sorafenib therapy: case report.", "score": 0.014601253052989274, "content": "Hepatocellular carcinoma (HCC) is the fifth most common neoplasia in the world. In the past, treatment of advanced HCC with conventional antineoplastic drugs did not result in satisfactory outcomes: recently, in this patient population the oral multikinase inhibitor sorafenib has been able to induce a statistically significant improvement of overall survival. Similarly to other anti-angiogenic drugs employed in other tumour types, also sorafenib seldom induces the dimensional tumour shrinking usually observed with conventional cytotoxic drugs: data gathered from studies carried out with sorafenib and other competitors under development do not report any complete response in HCV-induced HCC. An 84-year old man with a long-lasting history of chronic HCV hepatitis was referred to our Institution for an ultrasonography investigation of a focal hepatic lesion. To better characterize the liver disease and clearly define the diagnosis of the focal hepatic lesion, the patient was hospitalized in our department. Laboratory and instrumental investigations confirmed the clinical picture of HCV-related liver cirrhosis and identified a hepatic lesion of about 6 cm featuring infiltrating HCC with thrombosis of the portal trunk. Due to the advanced stage of the disease, therapy with sorafenib 400 mg bid was started. Right from one month after the treatment was started, a reduction of alpha-fetoprotein level was observed which, by the third month, turned down within the normal limits. In addition the CT scan showed 50% reduction of the neoplastic lesion along with canalization of the portal trunk. At the sixth month the normalization of the alpha-fetoprotein level at the lower limit of normality was confirmed and the MRI showed complete disappearance of the neoplasia. In addition a reduction of a metallo-proteinase serum level was observed. At the twelfth month a further MRI confirmed complete response had been maintained. At present the patient is in a follow-up program to evaluate the duration of the complete response. This case is worth mentioning since, to the best of our knowledge, it represents the first evidence of complete response to sorafenib in an elderly patient with advanced HCV-related HCC." }, { "id": "wiki20220301en542_17370", "title": "Ultrasonography of liver tumors", "score": 0.013979416809605488, "content": "Ultrasound monitoring of TACE therapy (transarterial chemoembolization) Transarterial chemoembolization (TACE) is part of palliative therapies for HCC used in intermediate stages of the disease. It consists of selective angiographic catheterization of the hepatic artery and injection of chemotherapeutic agents (usually adriamycin, but other molecules are currently the subject of clinical trials), followed by embolization of hepatic artery with gelfoam, alcohol or metal rings. A similar procedure is transarterial embolization but without chemotherapeutic agents injection, used in the treatment of hypervascular liver metastases. These therapies are based on the predominantly arterial vasculature of HCC and hypervascular metastases, while the remaining liver parenchyma has a dual vascular intake, predominantly portal. Their efficacy is high only for lesions who are hyperenhanced during arterial phase. The role of US is" }, { "id": "wiki20220301en290_19088", "title": "Milan criteria", "score": 0.013740995928593798, "content": "one lesion smaller than 5 cm; alternatively, up to three lesions, each smaller than 3 cm no extrahepatic manifestations no evidence of gross vascular invasion Under current OPTN/ONUS guidelines, patients with cirrhosis and HCC who meet these criteria may be considered for transplantation. Depending on the treatment algorithm, additional factors such as advanced liver disease (as classified by Child-Pugh score) or evidence of portal hypertension may also affect suitability for transplantation." }, { "id": "wiki20220301en542_17334", "title": "Ultrasonography of liver tumors", "score": 0.013493866424352567, "content": "Ultrasound is useful in HCC detection, stadialization and assessing therapeutic efficacy. In terms of staging related to therapy effectiveness, the Barcelona classification is used which identifies five HCC stages. Curative therapy is indicated in early stages, which include very early stage (single nodule <2 cm), curable by surgical resection (survival 50-70% five years after surgical resection) and early stage (single nodule of 2–5 cm, or up to 3 nodules <3 cm) which can be treated by radiofrequency ablation (RFA) and liver transplantation. Intermediate stage (polinodular, without portal invasion) and advanced stage (N1, M1, with portal invasion) undergo palliative therapies (TACE and sorafenib systemic therapy) and in the end stage only symptomatic therapy applies." }, { "id": "wiki20220301en011_154486", "title": "Hepatocellular carcinoma", "score": 0.013480392156862746, "content": "Transcatheter arterial chemoembolization (TACE) is performed for unresectable tumors or as a temporary treatment while waiting for liver transplant (\"bridge to transplant\"). TACE is done by injecting an antineoplastic drug (e.g. cisplatin) mixed with a radio-opaque contrast (e.g. Lipiodol) and an embolic agent (e.g. Gelfoam) into the right or left hepatic artery via the groin artery. The goal of the procedure is to restrict the tumor's vascular supply while supplying a targeted chemotherapeutic agent. TACE has been shown to increase survival and to downstage HCC in patients who exceed the Milan criteria for liver transplant. Patients who undergo the procedure are followed with CT scans and may need additional TACE procedures if the tumor persists. As of 2005, multiple trials show objective tumor responses and slowed tumor progression, but questionable survival benefit compared to supportive care; greatest benefit is seen in people with preserved liver function, absence of vascular" }, { "id": "pubmed23n0349_6981", "title": "Adrenal metastasis from hepatocellular carcinoma (HCC): report of 3 cases.", "score": 0.013415067519545132, "content": "Although autopsy reports show that the adrenal gland is the second most common organ of hematogeneous metastasis from hepatocellular carcinoma (HCC), paradoxically there is found to be a very scarce number of the adrenal metastasis in clinical practice. We have recently experienced rare patients with right adrenal metastasis from HCC. Case 1: A 51 year-old man with a 5-year history of chronic hepatitis was admitted with hematemesis to Nippon Medical School Hospital. CT revealed a main tumor associated with a few daughter tumors in the hepatic posterior segment and in addition another tumor located between the right hepatic lobe and right kidney. The diagnosis of HCC with a right adrenal gland metastasis was made, and hepatectomy and right adrenalectomy was performed. Twenty months after operation he was alive and free of disease. Case 2: A 78 year-old man underwent resection of the lateral segment of the left hepatic lobe for HCC. Twelve months later, recurrent foci in the residual liver were found and those were treated with transarterial embolization (TAE). Right adrenal metastasis was found on CT 26 months after hepatectomy. TAE was done for the hepatic recurrent tumors and adrenal metastasis. Twelve months after, he survived in good condition. Case 3: A 47 year-old man presented with liver cirrhosis with a long history. He was diagnosed as having HCC with multiple intrahepatic metastases and was treated with TAE 4 times. Follow-up CT revealed right adrenal metastasis. TAE was done for hepatic recurrent tumor and right adrenal metastasis. Three months later the patient died of liver failure." }, { "id": "wiki20220301en542_17358", "title": "Ultrasonography of liver tumors", "score": 0.013390487854664217, "content": "The effectiveness of screening programs is proved by an increase in detection rate of HCC <2 cm (from <5% in the 90s in Europe to > 30% today in Japan) with curative therapy options. The main problem of ultrasound screening is that, in order to be cost-effective, it should be applied to the general population and not in tertiary hospitals. This raises the importance of the operator and equipment dependent part of the ultrasound examination. The efficiency of such a program is linked to the functional liver parenchyma of the cirrhotic patient. Therefore, some authors argue that screening should be excluded in patients with etiologies that prevent curative treatment or in patients with advanced liver disease (Child-Pugh class C). After curative therapies (surgical resection, local ablative therapies) continuing ultrasound screening is recommended first at 1 month then at 3 months intervals after the therapy to assess the effectiveness of therapy and to detect other nodules." }, { "id": "wiki20220301en544_13977", "title": "Bland embolization", "score": 0.013119755911517924, "content": "The majority of patients with HCC have underlying liver disease with resultant cirrhosis. Patients with normal liver function and, presumably, normal hepatic parenchyma may undergo resection of 75% to 80% of their liver without developing postoperative hepatic failure. Patients with underlying liver disease require a greater volume of liver remnant to maintain hepatic function, thus, tumors that might normally be resectable in patients with normal liver parenchyma may not be resectable in the presence of cirrhosis. The Child-Pugh nominal liver staging system is the most accurate in predicting survival of patients with unresectable HCC treated with TACE and TAE. Patients with Child-Pugh class C cirrhosis may be more likely to die of their underlying liver disease than of their HCC and are unlikely to tolerate arterial embolization well and therefore, embolization therapy is only indicated in patients with Child A or B cirrhosis." }, { "id": "wiki20220301en011_154474", "title": "Hepatocellular carcinoma", "score": 0.012903993102012904, "content": "Important features that guide treatment include: size spread (stage) involvement of liver vessels presence of a tumor capsule presence of extrahepatic metastases presence of daughter nodules vascularity of the tumor MRI is the best imaging method to detect the presence of a tumor capsule. The most common sites of metastasis are the lung, abdominal lymph nodes, and bone. Prevention Since hepatitis B and C are some of the main causes of hepatocellular carcinoma, prevention of infection is key to then prevent HCC. Thus, childhood vaccination against hepatitis B may reduce the risk of liver cancer in the future. In the case of patients with cirrhosis, alcohol consumption is to be avoided. Also, screening for hemochromatosis may be beneficial for some patients. Whether screening those with chronic liver disease for HCC improves outcomes is unclear." }, { "id": "InternalMed_Harrison_7062", "title": "InternalMed_Harrison", "score": 0.012800097991180794, "content": "Resection Liver transplantation (CLT/LDLT) Curative treatments (30%) 5-yr survival: 40–70% Randomized controlled trials (50%) Median survival 11–20 months Symptomatic treatment (20%) Survival <3 months PEI/RF TACE Sorafenib Advanced stage (C) Portal invasion, N1, M1, PST 1-2 Intermediate stage (B) Multinodular, PST 0 Very early stage (0) Single <2 cm carcinoma in situ Single Portal pressure/ bilirubin Normal Increased Associated diseases No Yes 3 nodules ˜3 cm Stage 0 PST 0, Child-Pugh A Early stage (A) Single or 3 nodules <3 cm, PST 0 PST End stage (D) Stage D PST >2, Child-Pugh C Stage A-C PST 0–2, Child-Pugh A–B HCC" }, { "id": "pubmed23n0826_2598", "title": "Diagnosis and treatment of hepatocellular carcinoma: An update.", "score": 0.012720077531901148, "content": "Hepatocellular carcinoma (HCC) is one of the most common malignancies leading to high mortality rates in the general population; in cirrhotic patients, it is the primary cause of death. The diagnosis is usually delayed in spite of at-risk population screening recommendations, i.e., patients infected with hepatitis B or C virus. Hepatocarcinogenesis hinges on a great number of genetic and molecular abnormalities that lead to tumor angiogenesis and foster their dissemination potential. The diagnosis is mainly based on imaging studies such as computed tomography and magnetic resonance, in which lesions present a characteristic classical pattern of early arterial enhancement followed by contrast medium \"washout\" in late venous phase. On occasion, when imaging studies are not conclusive, biopsy of the lesion must be performed to establish the diagnosis. The Barcelona Clinic Liver Cancer staging method is the most frequently used worldwide and recommended by the international guidelines of HCC management. Currently available treatments include tumor resection, liver transplant, sorafenib and loco-regional therapies (alcoholization, radiofrequency ablation, chemoembolization). The prognosis of hepatocarcinoma is determined according to the lesion's stage and in cirrhotic patients, on residual liver function. Curative treatments, such as liver transplant, are sought in patients diagnosed in early stages; patients in more advanced stages, were not greatly benefitted by chemotherapy in terms of survival until the advent of target molecules such as sorafenib. " }, { "id": "wiki20220301en220_29197", "title": "Metastatic liver disease", "score": 0.012645369202746254, "content": "Diagnosis Hemoglobin decrease Liver function test: ALP elevated, bilirubin elevated, albumin decrease Carcinoembryonic antigen for colorectal secondaries Ultrasound scan CT scan Biopsy under ultrasound control Treatment Treatment can consist of surgery (hepatectomy), chemotherapy and/or therapies specifically aimed at the liver like radiofrequency ablation, transcatheter arterial chemoembolization, selective internal radiation therapy and irreversible electroporation. For most patients no effective treatment exists because both lobes are usually involved, making surgical resection impossible. Younger patients with metastases from colorectal cancer confined to one lobe of the liver and up to 4 in number may be treated by partial hepatectomy. In selected cases, chemotherapy may be given systemically or via hepatic artery." }, { "id": "InternalMed_Harrison_7083", "title": "InternalMed_Harrison", "score": 0.012581518395471884, "content": "PEI/RFA/MWA Single lesion <5 cm Child’s A/B Tumor progression Transplant TACE/90Yttrium/ New agent trials Multifocal >5 cm Child’s A/B Sorafenib/Palliative care hormonal therapies Child’s C Bilirubin ˜2 Metastases Neoadjuvant bridge therapy RFA/TACE/90Yttrium Living donor transplant Suitable donor UNOS + criteria Ablation candidate Resection/RFA Non-cirrhotic Child’s A Single lesion No metastases Transplant candidate Transplant evaluation 1 lesion <5 cm 3 lesions all less than 3 cm Child’s A/B/C; AFP <1000 ng/mL No gross vascular invasion Not suitable for surgery Medical evaluation Comorbid factors 4 lesions Gross vascular invasion LN (+) or metastasis HCC diagnosed Cadaver donor wait list Yes Sorafenib/New agent clinical trials FIGURE 111-2 Hepatocellular carcinoma (HCC) treatment algorithm. The initial clinical evaluation is aimed at assessing the extent of the tumor and the underlying functional compromise of the liver by cirrhosis. Patients are classified as having resectable" }, { "id": "InternalMed_Harrison_7080", "title": "InternalMed_Harrison", "score": 0.01218590041879944, "content": "Most HCC patients have two liver diseases, cirrhosis and HCC, each of which is an independent cause of death. The presence of cirrhosis usually places constraints on resection surgery, ablative therapies, and chemotherapy. Thus patient assessment and treatment planning have to take the severity of the nonmalignant liver disease into account. The clinical management choices for HCC can be complex (Fig. 111-2, Tables 111-5 and 111-6). The natural history of HCC is highly variable. Patients presenting with advanced tumors (vascular invasion, symptoms, extrahepatic spread) have a median survival of ∼4 months, with or without treatment. Treatment results from the literature are difficult to interpret. Survival is not always a measure of the efficacy of therapy because of the adverse effects on survival of the underlying liver disease. A multidisciplinary team, including a hepatologist, interventional radiologist, surgical oncologist, resection surgeon, transplant surgeon, and medical" }, { "id": "wiki20220301en290_19087", "title": "Milan criteria", "score": 0.011991085161816871, "content": "In transplantation medicine, the Milan criteria are set of criteria applied in consideration of patients with cirrhosis and hepatocellular carcinoma (HCC) for liver transplantation with intent to cure their disease. Their significance derives from a landmark 1996 study in 48 patients by Mazzaferro et al which showed that selecting cases for transplantation according to specific strict criteria led to improved overall and disease-free survival at a four-year time point. These same criteria have since been adopted by the Organ Procurement and Transplantation Network (OPTN) in the evaluation of patients for potential transplantation.The threshold Milan criteria are as follows: one lesion smaller than 5 cm; alternatively, up to three lesions, each smaller than 3 cm no extrahepatic manifestations no evidence of gross vascular invasion" }, { "id": "pubmed23n0822_10865", "title": "[A case of advanced hepatocellular carcinoma successfully treated by liver resection after complete response induced by sorafenib administration].", "score": 0.011869952659426343, "content": "A 50-year-old man presented to our hospital with the chief complaint of right hypochondriac pain and a palpable tumor. Advanced hepatocellular carcinoma (HCC) and chronic hepatitis B infection were diagnosed and treated by twice-repeated transcatheterarterial chemoembolization (TACE) followed by administration of entecavir. Two months after the last TACE, alpha-fetoprotein(AFP)and protein induced by vitamin K absence or antagonistII (PIVKA-II) levels had elevated, and multiple small early enhancing nodules were detected on computed tomography(CT)scan. Based on his age and liver function (Child-Pugh score A5), a full dose of sorafenib (800 mg/day) was administered. The sorafenib dose was decreased after one month to 400mg/day because of hand-foot syndrome. Following sorafenib administration, the lesions shrank markedly, and complete response (CR) according to modified Response Evaluation Criteria In Solid Tumors(mRECIST)was achieved within 4 months. Six months after sorafenib treatment was begun, recurrent HCC was detected in segment 6, near the previously treated lesion. The decreased size of the main tumor and normalization of AFP levels allowed curative surgical resection. The patient was discharged 5 days after surgery and is currently treated with a half dose of sorafenib. Thirteen months after surgery, a small early enhancing lesion is visible on postoperative CT scan, but AFP and PIVKA-II levels are still keeping in a normal range. This case demonstrates that if sorafenib treatment is effective, then subsequent surgical treatment can be reconsidered in patients with advanced HCC responding to this combined therapy." }, { "id": "wiki20220301en011_154473", "title": "Hepatocellular carcinoma", "score": 0.011778884416854265, "content": "Staging BCLC Staging System The prognosis of HCC is affected by the staging of the tumor and the liver's function due to the effects of liver cirrhosis. A number of staging classifications for HCC are available; however, due to the unique nature of the carcinoma to fully encompass all the features that affect the categorization of the HCC, a classification system should incorporate tumor size and number, presence of vascular invasion and extrahepatic spread, liver function (levels of serum bilirubin and albumin, presence of ascites, and portal hypertension) and general health status of the patient (defined by the ECOG classification and the presence of symptoms). Of all the staging classification systems available the Barcelona Clinic Liver Cancer staging classification encompasses all of the above characteristics. This staging classification can be used to select people for treatment." }, { "id": "wiki20220301en409_32061", "title": "Liver support system", "score": 0.011771439948235528, "content": "Goals of MARS Therapy Recovery and prevention of re-transplantation • Prolong survival time and stabilize the patient to receive a re-transplant if the above goal is not achieved MARS Therapy Indication Primary graft dysfunction Hepatic encephalopathy ≥ II Increased intracranial pressure Renal dysfunction or hepatorenal syndrome. Progressive intrahepatic cholestasis Treatment Schedule: 3 to 5 eight-hour treatment sessions on consecutive days Continuous treatment with hemodynamic instability (in any case, treatment kit must be replaced every 24 hours) MARS in liver Failure after Liver Surgery Etiology: Liver Resection in hepatocellular carcinoma Transarterial Chemoembolization (TACE) Partial resection in living donor transplantation Other surgical interventions Goals of MARS Therapy Recovery until hepatic regeneration MARS Therapy Indication Hepatic encephalopathy ≥ II Renal dysfunction or hepatorenal syndrome. Progressive intrahepatic cholestasis" }, { "id": "InternalMed_Harrison_7114", "title": "InternalMed_Harrison", "score": 0.01170670037926675, "content": "Tumors of the Liver and Biliary Tree 552 tumor regrowth. Second, the Sorafenib HCC Assessment Randomized Protocol (SHARP) phase III trial of sorafenib versus placebo for unresectable HCC showed that survival could be significantly enhanced in the treatment arm with only 2% of the patients having tumor response but 70% of patients having disease stabilization. This observation has led to a reconsideration of the usefulness of response and the significance of disease stability. Third, HCC is a typically highly vascular tumor, and the vascularity is considered to be a measure of tumor viability. As a result, the Response Evaluation Criteria in Solid Tumors (RECIST) have been modified to mRECIST, which requires measurement of vascular/ viable tumor on the CT or MRI scan. A partial response is defined as a 30% decrease in the sum of diameters of viable (arterially enhancing) target tumors. The need for semiquantitation of tumor vascularity on scans has led to the introduction of" }, { "id": "wiki20220301en544_13978", "title": "Bland embolization", "score": 0.01152832674571805, "content": "When evaluating a patient for embolization, both the severity of the underlying liver disease and the extent of the tumor being treated should be considered. In 1999, Llovet et al, proposed the Barcelona Clinic Liver Cancer (BCLC) staging classification as a means of both classifying patients and linking their stage to a specific treatment. Although selective embolization of a solitary well circumscribed HCC in a patient with Child Class B cirrhosis might be well tolerated, embolization of a hemi-liver in a Child A patient with multifocal hepatoma involving more than 75% of the liver and with portal vein tumor thrombus may result in hepatic failure and severe death." }, { "id": "wiki20220301en078_39765", "title": "Sorafenib", "score": 0.010491044016771634, "content": "Liver cancer At ASCO 2007, results from the SHARP trial were presented, which showed efficacy of sorafenib in hepatocellular carcinoma. The primary endpoint was median overall survival, which showed a 44% improvement in patients who received sorafenib compared to placebo (hazard ratio 0.69; 95% CI, 0.55 to 0.87; p=0.0001). Both median survival and time to progression showed 3-month improvements; however, there was no significant difference in median time to symptomatic progression (p=0.77). There was no difference in quality of life measures, possibly attributable to toxicity of sorafenib or symptoms related to underlying progression of liver disease. Of note, this trial only included patients with Child-Pugh Class A (i.e. mildest) cirrhosis. Because of this trial sorafenib obtained FDA approval for the treatment of advanced hepatocellular carcinoma in November 2007." }, { "id": "pubmed23n0289_9778", "title": "[Long-term survival of patients with inoperable hepatocarcinoma, treated with interventional radiology].", "score": 0.010103329506314582, "content": "Survival rates in untreated patients with unresectable HCC are rather disappointing. Our study was aimed at assessing long-term survival in the patients submitted to combined transarterial chemoembolization (TACE) and percutaneous ethanol injection (PEI). We treated 223 patients, but long-term follow-up is available in 143 of them only. Eighty-seven of 143 patients had Child's A liver cirrhosis, 45 had Child's B and 6 Child's C. Five patients did not have cirrhosis. Eighty-seven patients had single lesions--45 of them &lt; 5 cm and 42 &gt; 5 cm. Fifty-six patients had multiple/diffuse lesions. All patients underwent TACE while PEI was performed in selected patients with single or double lesions. Survival rates were calculated with the life-table analysis by Kaplan and Meyer. Follow-up was 1-72 months (median: 28 months). At 1, 3 and 5 years, the overall survival rates were 72%, 34.5% and 16.4%, respectively. The survival rates at 1, 3 and 5 years in single lesions &lt; 5 cm were 90.4%, 52.1% and 34.8%, respectively, vs. 69.4%, 37.4% and 18.7% in lesions &gt; 5 cm and 58.8%, 12.5% and 0% in multiple/diffuse lesions. In conclusion, the long-term results of the radiologic treatment of unresectable HCC are comparable with surgical results obtained in selected cases." }, { "id": "wiki20220301en169_28464", "title": "Liver cancer", "score": 0.009944775692504015, "content": "Hepatocellular carcinoma Partial surgical resection is the recommended treatment for hepatocellular carcinoma (HCC) when patients have sufficient hepatic function reserve. 5-year survival rates after resection have massively improved over the last few decades and can now ranges from 41 to 74%. However, recurrence rates after resection can exceed 70%, whether due to spread of the initial tumor or formation of new tumors . Liver transplantation can also be considered in cases of HCC where this form of treatment can be tolerated and the tumor fits specific criteria (such as the Milan criteria). In general, patients who are being considered for liver transplantation have multiple hepatic lesions, severe underlying liver dysfunction, or both." }, { "id": "pubmed23n0845_18807", "title": "[Successful Multimodal Treatment for Aggressive Extrahepatic Metastatic Hepatocellular Carcinoma - A Case Report].", "score": 0.009900990099009901, "content": "A 38-year-old man underwent right hepatectomy for a huge hepatocellular carcinoma(HCC)in the right hepatic lobe. Four months later, recurrent and metastatic disease were observed in the remnant liver and right lung, respectively. We performed a hepatectomy for the recurrent lesion because transcatheter arterial chemoembolization (TACE) was not effective. After surgery, we initiated sorafenib treatment for the lung metastases. One year later, the lung metastases worsened and metastases were observed in the mediastinal lymph nodes, and both metastatic lesions were resected. Seven months later, para-aortic lymph nodal metastasis was observed and dissected. Three months later, metastasis to the supraclavicular lymph node was observed. We performed particle radiation therapy and a complete response was achieved. One year later, metastases in both lungs were observed and resected. Despite continued sorafenib administration throughout the clinical course, a metastasis to the left adrenal gland was observed. This lesion was extirpated because no other recurrent lesions were detected. At 4 years and 6 months after the first operation, no other recurrences have occurred. Currently, sorafenib is the initial drug of choice for HCC with extrahepatic metastases. It is possible to improve the prognosis of patients with HCC and extrahepatic metastases by applying surgical treatment during the course of sorafenib administration." }, { "id": "pubmed23n0085_10607", "title": "[Analysis of 293 cases of hepatocellular carcinoma of recent ten years--II. Diagnosis, therapy and prognosis].", "score": 0.00980392156862745, "content": "Two hundred and ninety-three cases of hepatocellular carcinoma (HCC) of recent ten years during 1979 and 1988 were analysed on its diagnosis, therapy and prognosis. Angiography was the most useful diagnostic method for the first 5 years. During recent 5 years and for the tumor with size less than 2 cm, however, ultrasonography was the best method. 24.7% cases showed negative AFP and only 42.5% cases showed the level over 400 ng/ml. According to the tumor occupying-rate at the diagnosis, the number of cases of E1 had increased annually, the other cases being unchanged. 88.6% cases had liver cirrhosis microscopically as being reported previously. As a therapy TAE was most frequently performed, followed by operation, arterial infusion of antitumor drugs et al. The prognosis of the patients depended on the tumor occupying-rate. For the case of E1, the prognosis was the best by the therapy of ethanol injection therapy, operation and TAE. For the cases with tumor of larger than E1, frequent TAE was the best. From these results we concluded that we must make efforts to find small tumors to get the good prognosis." }, { "id": "pubmed23n0072_9190", "title": "[Evaluation of non-surgical treatments of hepatocellular carcinoma--investigation of the cases with long and short survivals after treatment].", "score": 0.009708737864077669, "content": "One hundred and one cases of hepatocellular carcinoma (HCC) treated in Maebashi Red Cross Hospital from May 1984 to August 1987 were classified according to the therapy and progression of the disease and were investigated on their prognosis. Furthermore, \"long survived group\" in which, patients survived for more than one year were compared with \"short survived group\" in which patients died within one month after non-surgical treatment. In operated patients, the prognosis was the best, but the rate of operable cases was only 13.9%. In patients with stage IV, one year survival rate was significantly low. In patients with portal trunk invasion (Vp4), or with Child C that was the poorest functional reserve of the liver, one year survival rate was also significantly low in comparison with patients with other stages or other Child's classification. In HCC patients treated with transcatheter arterial embolization (TAE), the prognosis tended to be poor as stage and portal invasion progressed, but in regard to reserve function of the liver, the prognosis was not so poor in patients of Child C significantly as in cases of A or B. The comparisons between long and short survived group were as follows. a) In 17 cases belong to long survived group, mean survival period was 24 months and the longest one was 4 years and 10 months. On the other hand, in 10 cases belong to short survived group, mean survival period was 17 days, the shortest one was 3 days. b) The main reason of inoperability in long survived group was progression of the tumor. Complications such as diabetes mellitus, advanced age and rejection of treatment by the patient were the other reasons of in operability. In almost half of the patients in short survived group, the tumor progression and low functional reserve of liver were found in 4 patients. c) In short survived group, esophageal varices were more common and functional reserve of the liver was poorer than in long survived group. In short survived group, LDH and total bilirubin were significantly higher than those of long survived group, but there was no significant differences in transaminase value and ICG retention in 15 minutes. d) In short survived group, extent of the tumor in liver and portal invasion were advanced. Three cases of this group (30%) had distant metastasis. e) In long survived group, the main reason of death was hepatic failure. Renal failure, or pulmonary complications were also found in short survived group.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "wiki20220301en100_42448", "title": "Portopulmonary hypertension", "score": 0.009615384615384616, "content": "Portopulmonary hypertension (PPH) is defined by the coexistence of portal and pulmonary hypertension. PPH is a serious complication of liver disease, present in 0.25 to 4% of all patients suffering from cirrhosis. Once an absolute contraindication to liver transplantation, it is no longer, thanks to rapid advances in the treatment of this condition. Today, PPH is comorbid in 4-6% of those referred for a liver transplant. Presentation PPH presents roughly equally in male and female cirrhotics; 71% female in an American series and 57% male in a larger French series. Typically, patients present in their fifth decade, aged 49 +/- 11 years on average. In general, PPH is diagnosed 4–7 years after the patient is diagnosed with portal hypertension and in roughly 65% of cases, the diagnosis is actually made at the time of invasive hemodynamic monitoring following anesthesia induction prior to liver transplantation." }, { "id": "pubmed23n1091_5091", "title": "Complete Response of Hepatocellular Carcinoma with Macroscopic Vascular Invasion and Pulmonary Metastasis to the Combination of Drug-Eluting Beads Transarterial Chemoembolization and Huaier Granule: A Case Report.", "score": 0.009523809523809525, "content": "Hepatocellular carcinoma (HCC) associated with macroscopic vascular invasion and distant metastasis is an advanced-stage disease with an extremely poor prognosis and low survival rate. Therefore, there is an urgent need to develop novel therapeutic strategies to extend the lives of patients with advanced HCC. We represent a case of HCC with macroscopic vascular invasion and pulmonary metastasis responding dramatically to the combination treatment with drug-eluting beads transarterial chemoembolization (DEB-TACE) and Huaier granule. A 64-year-old man with hepatitis B virus (HBV)-induced liver cirrhosis was diagnosed with advanced HCC involved renal vein and inferior vena cava accompanied by pulmonary metastasis. The patient received three cycles of on-demand DEB-TACE from 9th September 2016 to 22nd August 2017 and combined with Huaier granule 20 g three times a day orally. Eight months following the treatment, complete response occurred with regression of HCC and vascular thrombus and disappearance of pulmonary metastasis. The levels of AFP had decreased from 8165.8ng/mL to within the normal range (1.7 ng/mL). This is the first case report of complete response of HCC to the combination treatment with DEB-TACE and Huaier granule. At the most recent follow-up, he remained in remission 36 months after cessation of treatment without clinical or imaging evidence of disease recurrence. The current overall survival is 54 months since the initial treatment. Data from this clinical case report suggest that the combination treatment with DEB-TACE and Huaier granule is a promising therapeutic option for advanced HCC with macroscopic vascular invasion and distant metastasis." }, { "id": "pubmed23n0040_8832", "title": "[Radiologic diagnosis of secondaries in the liver (author's transl)].", "score": 0.009523809523809525, "content": "A diagnosis of secondaries in the liver carries considerable weight in prognosis and treatment, particularly pre-operatively, so that a possibly unnecessary operation may be avoided. Among techniques available for screening for metastases of the liver scintigraphy plays an important part. Besides laboratory tests and clinical examination it is relatively efficient and does not burden the patient. But they often are incapable of providing a basis for therapeutic decisions. Radiologic techniques are unsuitable (13). Knowledge and proper interpretation of indirect signs will permit guidance at the right time. In essence they serve the radiologic proof of advanced metastatic growths. Space occupying processes in the liver are the main indication for angiography. This is certainly not a routine method but makes sense when trying to identify the nature of defects shown in scintigrams (10). Where a primary tumor is known, angiography will follow scintigraphy of the liver, the search technique of choice. While the two techniques are correctly positive in 75-90% for avascular secondaries, experience of numerous investigations confirms that vascular metastases can be recognized earlier in angiograms than in scintigrams. Only angiography provides specific information differentiating metastases from a heptoma. The additional proof of primary tumors of the pancreas is important. Angiography is essential for indication and planning of partial hepatectomy. The angiographic picture does not permit conclusions from the metastases as to site and identity of the primary tumor. Critical evaluation of the radiographic techniques for early recognition of secondaries in the liver suggests humility. Only by carefully combining the various techniques will it be possible to demonstrate secondaries in the liver earlier and more frequently." }, { "id": "pubmed23n0415_11190", "title": "Treatment of hepatocellular carcinoma: is there an optimal strategy?", "score": 0.009433962264150943, "content": "The incidence of hepatocellular carcinoma is increasing worldwide and now it accounts for as many as 1 million deaths annually, representing the third cause of cancer-related death. Surveillance programmes in the population at risk, namely cirrhotic patients, aim to detect tumours at an early stage when benefit from effective therapy may be provided. Patients with early tumours (single tumours measuring less than 5 cm or with less than 3 nodules measuring less than 3 cm in size) constitute the early stage category. These patients may be treated with surgical resection, transplantation, or percutaneous ablation, and the 5-year survival rate will exceed 50%. Patients with more advanced disease constitute the intermediate-advanced stage. Intermediate stage includes individuals without cancer-related symptoms and absence of vascular invasion and/or extrahepatic spread. They may achieve a 50% survival rate at 3 years that can be expanded by transarterial chemoembolization. Symptomatic patients with more advanced disease have a survival rate of less than 20% at 3 years. In this group of patients the efficacy of new agents should be assessed in phase II trials or randomized controlled trials versus no treatment to determine the impact of any therapy on survival. Finally, patients with end-stage disease with heavily impaired liver function (Child-Pugh class C) or severe physical impairment (performance status 3-4) die within 6 months and should receive only symptomatic treatment." }, { "id": "pubmed23n0254_18064", "title": "[Chemoembolization of hepatocarcinoma. Six years' experience].", "score": 0.009345794392523364, "content": "This study was aimed at retrospectively assessing the effectiveness of transarterial chemoembolization by reviewing our six years' experience. From January, 1988, to December, 1993, chemoembolization was performed in more than 400 patients. Of them, 321 patients with complete follow-up were selected. The treatment was retrospectively analyzed according to survival rates. The average survival of chemoembolized patients is 12 months after the first treatment session. Average survival rates in Child A, B and C patients were, respectively, 13.79, 11.2 and 6.01 months. The patients were also divided according to tumor spread and the results follow: patients with single localizations had 15.19 months' survival, those with multiple localization 12.06 and those with tumor spread had 9.51 months' survival. The patients were divided into two groups: complete chemoembolization (group A) and incomplete chemoembolization (group B). The average survival was 15.95 months for 160 group A patients and 10.11 months for 161 group B patients. As for the number of chemoembolization sessions, 123 patients underwent only one session, 112 patients two sessions, 70 patients three, 12 patient four and 4 patients five sessions--625 sessions in all. Chemoembolization was performed every 3-4 months and was always preceded by a CT exam. Our patients were compared with an untreated group where average survival was 6.32 months. The value of CT after the first treatment in predicting survival was also studied. Finally, the methods used in all treatment are reported on, together with the general results and those in the different classes of patients." }, { "id": "wiki20220301en542_17331", "title": "Ultrasonography of liver tumors", "score": 0.00932442641854547, "content": "Hepatocellular carcinoma (HCC) It is the most common liver malignancy. It develops secondary to cirrhosis therefore, ultrasound examination every 6 months combined with alpha fetoprotein (AFP) determination is an effective method for early detection and treatment monitoring for this type of tumor . Clinically, HCC overlaps with advanced liver cirrhosis (long evolution, repeated vascular and parenchymal decompensation, sometimes bleeding due to variceal leakage) in addition to accelerated weight loss in the recent past and lack of appetite." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 0, 231 ] ], "word_ranges": [ [ 0, 36 ] ], "text": "Metformin is an oral antidiabetic widely used in the treatment of type 2 diabetes mellitus. The best known side effects are gastrointestinal side effects and lactic acidosis; however, vitamin B 12 malabsorption, is less well known." }, "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": "Gliclazide.", "2": "Metformin.", "3": "Repaglinide.", "4": "Pioglitazone.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0786_15269", "title": "Prescribing of antidiabetic medicines to older diabetes type 2 patients in Lagos, Nigeria.", "score": 0.018532818532818532, "content": "The incidence of diabetes mellitus in older adults is increasing in Lagos and other parts of Nigeria but there is paucity of information on the use of medicines in this group of patients. A survey was therefore carried out to determine the prevalence of potentially inappropriate prescribing of antidiabetic medications to older diabetes adults in Lagos, Nigeria. A convenient sample of physicians working in seven health care facilities in Lagos were surveyed using a self-administered pre-tested questionnaire to determine the medications they often prescribed for diabetes patients older than 50 years, whether they consider dosage reduction in these patients, and the counselling information they provide to the patients. AGS 2012 Beer's criteria were used to determine potentially inappropriate medication (PIM) for the patients. Factors associated with the tendency to prescribe inappropriately were then evaluated using logistic regression analyses. Glibenclamide, metformin, and metformin/glimepiride combination were regularly prescribed by 45.64-87.25% of the physicians but gliclazide, pioglitazone, pioglitazone/metformin and pioglitazone/glimepiride combinations were prescribed occasionally by 41.61-61.74% of them. Majority of the physicians (87.25%) prescribe glibenclamide to the older patients and do not also always consider dosage reduction on account of older age. Some of these (30.2%) of these physicians equally prescribed chlorpropamide to the patients. Postgraduate qualification was the only significant factor associated with prescription of chlorpropamide (p &lt; 0.05). Inappropriate use of chlorpropamide and glibenclamide, and failure to consider dosage reduction on account of older age have been reported by physicians treating older diabetes patients in Lagos. This calls for continuous education of physicians in Lagos as well as in other parts of Nigeria to promote rational use of antidiabetic medications in the country." }, { "id": "pubmed23n1002_11305", "title": "Vitamin B12 deficiency and the knowledge and practice of physicians regarding screening for vitamin B12 deficiency among type 2 diabetic patients on metformin in selected hospitals in Riyadh, Saudi Arabia.", "score": 0.017355371900826446, "content": "The worldwide prevalence of diabetes is high including Saudi Arabia. One standard first-line treatment for diabetes is metformin, which was reported to increase the risk for vitamin B12 deficiency. We wanted to determine the prevalence of vitamin B12 deficiency in metformin-treated type 2 diabetes mellitus patients. We conducted a cross-sectional study at the diabetic clinics of four hospitals in Riyadh, Saudi Arabia. Type 2 diabetes mellitus patients who were on metformin for at least 1 year were included in the study. Associations between B12 deficiency and age, duration of type 2 diabetes mellitus (T2DM), duration of use and dosage of metformin, and use of proton pump inhibitors (PPIs) were determined. Of 363 T2DM patients, 206 (56.7%) were males and 157 (43.3%) were females, mean age was 53.72 ± 11.31 years, the mean duration of T2DM was 9.89 ± 7.32 years, and the mean duration of metformin use was 9.84 ± 7.29 years. There were 205 patients 56.5% who had a daily dose of 750 mg of metformin. The most commonly used oral hypoglycemic agent was gliclizide only in 138 (38.4%) of patients. There were 107 patients (29.5%) who were on PPIs. There were 210 patients (57.9%) who were on vitamin B12 supplementation, of which 111 (30.6%) had a daily dose of 200 mcg. The use of vitamin B12 supplement, duration of T2DM and duration of metformin use was significantly higher among females. The use of vitamin B12 supplement was significant among patients who were 46 years old and above. There were only 16 patients (4.4%) who had available serum vitamin B12 levels. Only 44.0% of the physician respondents know the current recommendation of American Diabetes Association on vitamin B12 screening and supplementation among diabetic patients, and 21.0% never prescribe vitamin B12 to their patients. Routine testing for serum vitamin B12 level is not practiced in our institution. A large percentage of physicians are not aware of the current recommendations of the American Diabetic Association (ADA) regarding vitamin B12 supplementation and screening. Thus, there is a need for doctors involved in the management of diabetes to keep abreast with guidelines and current recommendations and routinely monitor vitamin B12 levels particularly those who were on long-term takers of metformin and the elderly patients to optimize management of diabetes and its complications." }, { "id": "pubmed23n0370_21494", "title": "Meglitinide analogues in the treatment of type 2 diabetes mellitus.", "score": 0.01686176142697882, "content": "Type 2 diabetes mellitus is a complex heterogenous metabolic disorder in which peripheral insulin resistance and impaired insulin release are the main pathogenetic factors. The rapid response of the pancreatic beta-cells to glucose is already markedly disturbed in the early stages of type 2 diabetes mellitus. The consequence is often postprandial hyperglycaemia, which seems to be extremely important in the development of secondary complications, especially macrovascular disease. Therefore one of the main aims of treatment is to minimise blood glucose oscillations and attain near-normal glycosylated haemoglobin levels. Meglitinide analogues belong to a new family of insulin secretagogues which stimulate insulin release by inhibiting ATP-sensitive potassium channels of the beta-cell membrane via binding to a receptor distinct from that of sulphonylureas (SUR1/KIR 6.2). The pharmacokinetic and pharmacodynamic properties of repaglinide, the first drug of these new antihyperglycaemic agents on the market, and of nateglinide, which will be available soon, differ markedly from the currently used sulphonylureas [mainly glibenclamide (glyburide) and glimepiride]. Repaglinide and nateglinide are absorbed rapidly, stimulate insulin release within a few minutes, are rapidly metabolised in the liver and are mainly excreted in the bile. Therefore, following preprandial administration of these drugs, insulin is more readily available during and just after the meal. This leads to a significant reduction in postprandial hyperglycaemia without the danger of hypoglycaemia between meals. The short action of these compounds and biliary elimination makes repaglinide and nateglinide especially suitable for patients with type 2 diabetes mellitus who would like to have a more flexible lifestyle, need more flexibility because of unplanned eating behaviour (e.g. geriatric patients) or in whom one of the other first-line antidiabetic drugs, i.e. metformin, is strictly contraindicated (e.g. nephropathy with creatinine clearance &lt; or = 50 ml/min). Meglitinide analogues act synergistically with metformin and thiazolidinediones (pioglitazone and rosiglitazone) and can be also combined with long-acting insulin (NPH insulin at bedtime). Therefore, these drugs enrich the palette of antidiabetic drugs and make the treatment more flexible and better tolerated, which both add to better metabolic control and support the empowerment and compliance of the patient. However, this will only be the case if the patient and the diabetes care team are trained for this new therapeutic schedule and the healthcare system is able to pay for these rather expensive drugs." }, { "id": "pubmed23n0579_295", "title": "Induction of long-term glycemic control in type 2 diabetic patients using pioglitazone and metformin combination.", "score": 0.016064516129032258, "content": "To study the effects of pioglitazone and metformin combination in type 2 diabetics in achieving long-term optimal glycemic control. Patients whose duration of type 2 diabetes was less than 24 months were selected for the study. 373 such patients meeting the selection criteria were included in the study and were started on triple drug combination therapy. Three hundred seventy three (183 females and 190 males) patients were initiated on a triple drug combination of gliclazide 80 mg, tid, metformin 500 mg tid and pioglitazone 30 mg od. Once controlled, the doses of gliclazide were reduced if the blood glucose levels decreased. Those patients whose plasma glucose remained in the normal range for more than 6 months without the use of a sulphonylurea were considered to be in pharmacological remission. 48 patients were lost to follow up. At the beginning of the study the pre treatment biochemical parameters in these 325 diabetic patients at the time of enrolment were: average FBG of 209.44+/-73.82 mg/dl, PLBG 294.96+/-107.58 mg/dl, and HbA(1c) 11.21+/-3.85. The post treatment glycemic parameters were: FBG was 124.38+/-40.48 mg/dl (p &lt; 0.0001), and PLBG 162.32+/-54.33 mg/dl (p &lt; 0.001), average glycosylated hemoglobin was 6.45+/-2.17 (p &lt; 0.001). After using the triple drug combination pharmacological remission was achieved in 36.3 percent i.e. 118 (60 males and 58 females) patients. The average time required for achieving remission was 4 (+/-3.3) months in males and 5 (+/-4.02) months in females. 118 patients were maintained remission after 2 years of follow up. The average duration of remission is 27 (+/-2.66) months. There was an average weight gain of 2.56 +/- 1.32 kg in both the groups of patients in remission and those who could not achieve remission. In this study we have found that we could achieve long term glycemic control 'pharmacological remission' in 118 of the 325 patients i.e.36% of type 2 diabetic patients. Insulin sensitizers like pioglitazone along with metformin may induce long-term glycemic control in type 2 diabetic patients." }, { "id": "pubmed23n0672_3070", "title": "Drug utilization of oral hypoglycemic agents in a university teaching hospital in India.", "score": 0.015386343216531895, "content": "India has witnessed a rapidly exploding epidemic of diabetes in recent years and currently leads the world with the largest number of diabetic subjects in a single country. World Health Organization estimates that in 2000, 31.7 million individuals were affected by diabetes in India and these numbers will rise to 79.4 millions by the year 2030. In view of the above situation, drug utilization review of antidiabetic medicines in Indian healthcare settings has a valid significance to promote rational drug use in diabetics. The present study is aimed to determine the drug utilization patterns in type 2 diabetic patients on oral hypoglycemic agents in the Medicine Outpatient Department (OPD) and Inpatient Department (IPD) of Majeedia Hospital, a teaching hospital of Hamdard University, New Delhi. Patients with established type 2 diabetes (n = 218) visiting the OPD and IPD were interviewed using a structured questionnaire during the period January-May 2006. A majority of the type 2 diabetic patients in this setting were treated with multiple antidiabetic drug therapy. The most commonly prescribed antidiabetic drug class was biguanides (metformin) followed by sulphonylureas (glimepiride), thiazolidinediones (pioglitazone), insulin and alpha-glucosidase inhibitors (miglitol). As monotherapy insulin was the most common choice followed by metformin. The most prevalent multiple therapy was a three-drug combination of glimepiride  + metformin + pioglitazone. More than half of the type 2 diabetic patients showed poor adherence (compliance) to the prescribed therapy. This study strongly highlights the need for patient education or counselling on use of antidiabetic and concomitant drugs, monitoring of blood glucose and glycosylated haemoglobin (HbA1c) levels, diet control, and correction of diabetic complications. Metabolic control was poor and HbA1c monitoring was underutilized. Clinical monitoring of patients' adherence to prescribed treatments is recommended and measures should be taken to improve it." }, { "id": "wiki20220301en028_4298", "title": "ATC code A10", "score": 0.015026132404181184, "content": "A10BD Combinations of oral blood glucose lowering drugs A10BD01 Phenformin and sulfonylureas A10BD02 Metformin and sulfonylureas A10BD03 Metformin and rosiglitazone A10BD04 Glimepiride and rosiglitazone A10BD05 Metformin and pioglitazone A10BD06 Glimepiride and pioglitazone A10BD07 Metformin and sitagliptin A10BD08 Metformin and vildagliptin A10BD09 Pioglitazone and alogliptin A10BD10 Metformin and saxagliptin A10BD11 Metformin and linagliptin A10BD12 Pioglitazone and sitagliptin A10BD13 Metformin and alogliptin A10BD14 Metformin and repaglinide A10BD15 Metformin and dapagliflozin A10BD16 Metformin and canagliflozin A10BD17 Metformin and acarbose A10BD18 Metformin and gemigliptin A10BD19 Linagliptin and empagliflozin A10BD20 Metformin and empagliflozin A10BD21 Saxagliptin and dapagliflozin A10BD22 Metformin and evogliptin A10BD23 Metformin and ertugliflozin A10BD24 Sitagliptin and ertugliflozin A10BD25 Metformin, saxagliptin and dapagliflozin A10BD26 Metformin and lobeglitazone" }, { "id": "pubmed23n0482_3312", "title": "Treatment of type 2 diabetes with a combination regimen of repaglinide plus pioglitazone.", "score": 0.014718614718614718, "content": "The efficacy and safety of combination therapy (repaglinide plus pioglitazone) was compared to repaglinide or pioglitazone in 24-week treatment of type 2 diabetes. This randomized, multicenter, open-label, parallel-group study enrolled 246 adults (age 24-85) who had shown inadequate response in previous sulfonylurea or metformin monotherapy (HbA(1c) &gt; 7%). Prior therapy was withdrawn for 2 weeks, followed by randomization to repaglinide, pioglitazone, or repaglinide/pioglitazone. In the first 12 weeks of treatment, repaglinide doses were optimized, followed by 12 weeks of maintenance therapy. Pioglitazone dosage was fixed at 30 mg per day. Baseline HbA(1c) values were comparable (9.0% for repaglinide, 9.1% for pioglitazone, 9.3% for combination). Mean changes in HbA(1c) values at the end of treatment were -1.76% for repaglinide/pioglitazone, -0.18% for repaglinide, +0.32% for pioglitazone. Fasting plasma glucose reductions were -82 mg/dl for combination therapy, -34 mg/dl for repaglinide, -18 mg/dl for pioglitazone. Minor hypoglycemia occurred in 5% of patients for the combination, 8% for repaglinide, and 3% for pioglitazone. Weight gains for combination therapy were correlated to individual HbA(1c) reductions. In summary, for patients who had previously failed oral antidiabetic monotherapy, the combination repaglinide/pioglitazone had acceptable safety, with greater reductions of glycemic parameters than therapy using either agent alone." }, { "id": "pubmed23n0791_137", "title": "Prescription of oral antidiabetic drugs in K/DIGO chronic kidney disease stage 3 and 4: a single centre report.", "score": 0.014284340130819546, "content": "Evaluation of chronic kidney disease (CKD) is essential in order to prescribe properly oral antidiabetic drugs (OADs). The aim of our study was to report hypoglycemic drugs prescription to CKD in a cohort of type 2 diabetes mellitus (DM) outpatients. This survey included 1686 outpatients with type 2 DM treated with OADs who were not taking insulin evaluated by a team of diabetologists. Glomerular filtration rate (GFR) was calculated by the CKD-EPI formula and subjects were classified in the K/DIGO stages. Main clinical parameters were also evaluated. Patients were aged 68±10 years, 57.1% were males, Body Mass Index was 30±5 kg/m2, glycated hemoglobin 8±1%, systolic and diastolic blood pressure values were 138±15/80±9 mmHg. Serum creatinine was 1.03±0.35 mg/dL and GFR 71±21 mL/min/1.73 m2. In 504 patients (30%) GFR was lower than 60 mL/min/1.73 m2. The different treatment groups had different GFR and hypoglycaemic drugs were prescribed differently in the different K/DIGO stages. The majority of subjects in stage 3A and 3B were treated with repaglinide, however a significant percentage of them were treated with metformin and sulfonylureas. Nearly half of subjects with CKD stage 4 were treated with metformin and sulfonylureas. In this report we found that nearly one third of patients with type DM 2 had CKD and in a significant percentage of them OADs were prescribed even if they were in K/DIGO CKD stage 3 and 4." }, { "id": "pubmed23n0498_18918", "title": "Beneficial effects of triple drug combination of pioglitazone with glibenclamide and metformin in type 2 diabetes mellitus patients on insulin therapy.", "score": 0.013910422049956933, "content": "The thiazolidinediones are a class of antidiabetes medication that enhance the actions of insulin in muscle, liver, and adipose tissue. Data have been lacking on their use in combination with both sulfonylurea and metformin among patients of type 2 diabetes who are on insulin therapy secondary to failure of routine oral hypoglycemic drugs in controlling their diabetes. To determine the effects of pioglitazone in combination with sulphonylurea and metformin on diabetes control in patients being treated with insulin due to secondary failure of oral hypoglycemic agents. One hundred and twenty-four consecutive type 2 diabetes patients (mean age, 57.13 years) attending four centres in Mumbai, who were being treated with insulin were selected. They were switched on to triple drug combination of glibenclamide 5 mg, metformin 500 mg and pioglitazone 15 mg along with insulin. Study participants were required to have type 2 diabetes mellitus for atleast 5 years. Patients were excluded if they had any of the following: serum creatinine concentration greater than 1.5 mg/dl, alanine aminotransferase (ALT) level more than two times the upper limit of normal, symptomatic angina, cardiac insufficiency or history of myocardial infarction. Pioglitazone 15 mg with glibenclamide 5 mg and metformin 500 mg, significantly decreased hemoglobin HbA1c level from 11.5% to 7.32% (P &lt; 0.001), average fasting blood glucose from 194.8 mg/ dl to 124.06 mg/dl (p &lt; 0.01), average post-prandial blood glucose from 256.24 to 162.32 mg/dl (p &lt; 0.01). At 6 months, 43.35% of patients did not need to be continued on insulin. The total insulin requirement in 124 patients reduced by 71.81%. There were no significant side effects, liver enzymes were within acceptable levels, average weight gain was 2.23 kg, significant hypoglycemia was observed in 28 patients with two requiring hospitalisation, these patients were those who did not stick to follow-up schedules. With proper patient selection, pioglitazone with glibenclamide and metformin can be safely used in patients receiving insulin with good results." }, { "id": "wiki20220301en012_87344", "title": "Metformin", "score": 0.013852672750977835, "content": "Metformin was discovered in 1922. French physician Jean Sterne began the study in humans in the 1950s. It was introduced as a medication in France in 1957 and the United States in 1995. It is on the World Health Organization's List of Essential Medicines. Metformin is the most widely used medication for diabetes taken by mouth. It is available as a generic medication. In 2019, it was the fourth-most commonly prescribed medication in the United States, with more than 85 million prescriptions written for over 17 million patients. Medical uses Metformin is used to lower the blood sugar in those with type 2 diabetes. It is also used as a second-line agent for infertility in those with polycystic ovary syndrome. Type 2 diabetes The American Diabetes Association and the American College of Physicians both recommend metformin as a first-line agent to treat type 2 diabetes. It is as effective as repaglinide and more effective than all other oral diabetes mellitus type 2 drugs." }, { "id": "pubmed23n0403_2408", "title": "Patient perceptions of prandial oral therapy for type 2 diabetes.", "score": 0.013753662917099915, "content": "This survey was conducted to assess patient perceptions of glycemic control, convenience, and flexibility of a prescribed prandial oral therapy for type 2 diabetes mellitus. Questionnaires distributed by physicians yielded baseline responses from 3696 patients who were beginning repaglinide treatment. Data were analyzed from 1233 respondents who also completed follow-up questionnaires after 4 weeks of treatment. Among respondents, 60% were taking repaglinide with other antidiabetic agents in combination therapy; 59% were taking metformin, and 24% were taking troglitazone. Most respondents (84%) indicated that they were \"satisfied\" or \"very satisfied\" with repaglinide therapy, 92% wished to continue its use, and 60% believed that the treatment had improved their attitude toward taking antidiabetic medication. Patients perceived that fasting blood glucose levels were reduced during treatment, as was the incidence of hyperglycemia. Corresponding changes in perceived frequency of hypoglycemia during repaglinide treatment were minimal. Patient perceptions of prandial oral therapy with repaglinide were predominantly positive, due mostly to the perception that glucose control was achieved, with minimal perception of any increase in hypoglycemic episodes." }, { "id": "wiki20220301en104_17573", "title": "Alström syndrome", "score": 0.013656040928768202, "content": "Antibiotics: patients with lung problems will be prescribed antibiotics because they are more prone to infections like bronchitis. Oral diabetes medications: are taken by mouth to treat diabetes. Can be taken combined into a single pill, which may be more effective and convenient for people with diabetes. It is usually taken once or twice daily before meals. Some of these medications includes: Meglitinides (repaglinide and nateglinide): taken to stimulate the cells found in the pancreas to release insulin. These drugs are taken by mouth daily before each meal and could cause a drop in blood sugar. Metformin (biguanide): decreases the amount blood sugar being released by the liver and by stimulating the cells within muscles to take up blood sugar. Taken twice daily. Thiazolidinediones (rosiglitazone and pioglitazone): taken to help insulin work more efficiently in muscle and fat cells causing the liver to release less glucose. Is associated with heart failure." }, { "id": "wiki20220301en012_87409", "title": "Diabetes medication", "score": 0.013462217514124294, "content": "Sulfonylureas bind strongly to plasma proteins. Sulfonylureas are useful only in type 2 diabetes, as they work by stimulating endogenous release of insulin. They work best with patients over 40 years old who have had diabetes mellitus for under ten years. They cannot be used with type 1 diabetes, or diabetes of pregnancy. They can be safely used with metformin or glitazones. The primary side-effect is hypoglycemia. Typical reductions in glycated hemoglobin (A1C) values for second-generation sulfonylureas are 1.0–2.0%. First-generation agents tolbutamide acetohexamide tolazamide chlorpropamide Second-generation agents glipizide glyburide or glibenclamide glimepiride gliclazide glyclopyramide gliquidone Nonsulfonylurea secretagogues Meglitinides" }, { "id": "pubmed23n0981_24399", "title": "Diabetes and Aging: From Treatment Goals to Pharmacologic Therapy.", "score": 0.013338414634146343, "content": "Diabetes is becoming one of the most widespread health burning problems in the elderly. Worldwide prevalence of diabetes among subjects over 65 years was 123 million in 2017, a number that is expected to double in 2045. Old patients with diabetes have a higher risk of common geriatric syndromes, including frailty, cognitive impairment and dementia, urinary incontinence, traumatic falls and fractures, disability, side effects of polypharmacy, which have an important impact on quality of life and may interfere with anti-diabetic treatment. Because of all these factors, clinical management of type 2 diabetes in elderly patients currently represents a real challenge for the physician. Actually, the optimal glycemic target to achieve for elderly diabetic patients is still a matter of debate. The American Diabetes Association suggests a HbA1c goal &lt;7.5% for older adults with intact cognitive and functional status, whereas, the American Association of Clinical Endocrinologists (AACE) recommends HbA1c levels of 6.5% or lower as long as it can be achieved safely, with a less stringent target (&gt;6.5%) for patients with concurrent serious illness and at high risk of hypoglycemia. By contrast, the American College of Physicians (ACP) suggests more conservative goals (HbA1c levels between 7 and 8%) for most older patients, and a less intense pharmacotherapy, when HbA1C levels are ≤6.5%. Management of glycemic goals and antihyperglycemic treatment has to be individualized in accordance to medical history and comorbidities, giving preference to drugs that are associated with low risk of hypoglycemia. Antihyperglycemic agents considered safe and effective for type 2 diabetic older patients include: metformin (the first-line agent), pioglitazone, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists. Insulin secretagogue agents have to be used with caution because of their significant hypoglycemic risk; if used, short-acting sulfonylureas, as gliclazide, or glinides as repaglinide, should be preferred. When using complex insulin regimen in old people with diabetes, attention should be paid for the risk of hypoglycemia. In this paper we aim to review and discuss the best glycemic targets as well as the best treatment choices for older people with type 2 diabetes based on current international guidelines." }, { "id": "wiki20220301en023_21440", "title": "Pioglitazone", "score": 0.012643009501648246, "content": "Given previous experiences with the related drug troglitazone, acute diseases of the liver are regarded as a contraindication for pioglitazone. Side effects A press release by GlaxoSmithKline in February 2007 noted that there is a greater incidence of fractures of the upper arms, hands and feet in female diabetics given rosiglitazone compared with those given metformin or glyburide. The information was based on data from the ADOPT trial. Following release of this statement, Takeda Pharmaceutical Company, the developer of pioglitazone (sold as Actos in many markets) admitted that it has similar implications for female patients. The risk of hypoglycemia is low in the absence of other drugs that lower blood glucose." }, { "id": "pubmed23n0708_24378", "title": "Adulteration of herbal antidiabetic products with undeclared pharmaceuticals: a case series in Hong Kong.", "score": 0.01258670407606578, "content": "The current study aims to examine the problem of adulteration of herbal antidiabetic products with undeclared pharmaceuticals, including both registered and banned drugs. All cases involving use of adulterated herbal antidiabetic products referred to a tertiary centre for clinical toxicology analysis from 2005 to 2010 inclusive were retrospectively reviewed. The patients' demographic characteristics, clinical presentations, medical history, drug history and the analytical findings of the herbal antidiabetic products were studied. A total of 27 cases involving use of 29 adulterated herbal antidiabetic products were identified. Seventeen of the patients (63%) had clinical toxicities associated with the illicit products. Hypoglycaemia was the most common adverse effect, followed by lactic acidosis. Analysis of the 29 illicit herbal antidiabetic products revealed eight undeclared registered or banned oral antidiabetic agents, namely glibenclamide (n= 22), phenformin (n= 18), metformin (n= 6), rosiglitazone (n= 6), gliclazide (n= 2), glimepiride (n= 2), nateglinide (n= 1) and repaglinide (n= 1). Non-antidiabetic drugs were also detected in some products. Up to four adulterants were detected within the same product. Adulteration of herbal antidiabetic products with undeclared pharmaceuticals is a significant yet under-recognized problem. Patients taking these illicit products could be at risk of potentially fatal adverse effects. It is important to educate the public to avoid taking pCMs of dubious source. Effective regulatory measures should be put in place to address the problem." }, { "id": "pubmed23n0728_573", "title": "Managing diabetes in India: paradigms in care--outcomes and analysis in a comprehensive, clinical practice survey of Indian physicians.", "score": 0.01191352184729668, "content": "Diabetes continues to be a pandemic despite huge strides in the awareness and management of the condition. The incidence of diabetes has been projected to rise by almost 170% in most of the developing countries including India. Currently, about 50 million people suffer from diabetes in India with the figures expected to reach 87 million by the year 2030. To assess the management trends in India, a cross-section of doctors across all the major zones of the country were requested to answer a set of questions based on a case profile. Approximately 1000 doctors from all corners of India provided their feedback on various issues of diabetes management. The patient profile was that of an overweight 46-year-old Indian female with hypertension, diabetes and dyslipidaemia with a history of recurrent urinary tract infection (UTI). Almost 84.5% of doctors concurred with the diagnosis of metabolic syndrome for this patient. The awareness about diabetes being a comorbidity as well as a cause for recurrent UTI was high with 86% of doctors choosing diabetes as a cause for recurrent UTI. Around 94% of doctors chose metformin as the drug of choice for the management of this patient. A total of 74% of doctors chose the combination of metformin and sulfonylurea for the management of postprandial hyperglycaemia. Opinions were divided on the choice of drugs for the management of diabetes in a non-obese patient with 31% of doctors still choosing metformin as the drug of choice as per the American Diabetes Association 2009 guidelines and 66% of doctors choosing glimeperide as the first choice in a non-obese patient in concordance with the Association of Physicians of India/Indian College of Physicians (API/ICP) guidelines on diabetes. However, 95% of doctors unanimously chose metformin as the drug of choice in patients with abdominal obesity and diabetes. Almost 83% of doctors were aware that Indians have a genetic predisposition to diabetes due to an inherently smaller beta cell mass associated with insulin resistance. Majority of the physicians were also aware of the adverse effects of most of the antidiabetic drugs with 86% of the physicians identifying hydrochlorothiazide as the cause of worsening uric acid levels in diabetics, when used for the management of hypertension. Practice patterns in India generally conform to guidelines. The survey also demonstrated that majority of the physicians are aware of the different complexities associated with the management of diabetes." }, { "id": "wiki20220301en012_87422", "title": "Diabetes medication", "score": 0.011456996148908858, "content": "Generic Many anti-diabetes drugs are available as generics. These include: Sulfonylureas – glimepiride, glipizide, glyburide Biguanides – metformin Thiazolidinediones (Tzd) – pioglitazone, Actos generic Alpha-glucosidase inhibitors – Acarbose Meglitinides – nateglinide Combination of sulfonylureas plus metformin – known by generic names of the two drugs No generics are available for dipeptidyl peptidase-4 inhibitors (Januvia, Onglyza), the glifozins, the incretins and various combinations. Alternative Medicine The effect of Ayurvedic treatments has been researched, however due to methodological flaws of studies it has not been possible to draw conclusion regarding efficacy of these treatments and there is insufficient evidence to recommend them. References Further reading Anti-diabetic drugs" }, { "id": "wiki20220301en607_26383", "title": "Pioglitazone/glimepiride", "score": 0.010793399638336348, "content": "Medical uses In the United States pioglitazone/glimepiride is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are already treated with a thiazolidinedione and sulfonylurea or who have inadequate glycemic control on a thiazolidinedione alone or a sulfonylurea alone. In the European Union pioglitazone/glimepiride is indicated for the treatment of people with type 2 diabetes mellitus who show intolerance to metformin or for whom metformin is contraindicated and who are already treated with a combination of pioglitazone and glimepiride. References External links Anti-diabetic drugs" }, { "id": "wiki20220301en140_46083", "title": "Pioglitazone/metformin", "score": 0.010610528351138395, "content": "Pioglitazone/metformin, sold under the brand name Actoplus Met among others, is a fixed-dose combination anti-diabetic medication used to improve glycemic control in adults with type 2 diabetes. It contains pioglitazone, a thiazolidinedione, and metformin, a biguanide. Mechanisms Pioglitazone is a member of the thiazolidinedione class, it decreases insulin resistance in the periphery and in the liver resulting in increased insulin dependent glucose disposal and decreased hepatic glucose output. Metformin is a member of the biguanide class, improves glucose tolerance in patients with type 2 diabetes, lowering both basal and postprandial plasma glucose. Metformin decreases hepatic glucose production, decreases intestinal absorption of glucose and improves insulin sensitivity by increasing peripheral glucose uptake and utilization." }, { "id": "wiki20220301en023_21438", "title": "Pioglitazone", "score": 0.010015143171806167, "content": "Medical uses Pioglitazone is used to lower blood glucose levels in type 2 diabetes either alone or in combination with a sulfonylurea, metformin, or insulin. While pioglitazone does decrease blood sugar levels, the main study that looked at the medication found no difference in the main cardiovascular outcomes that were looked at. The secondary outcome of death from all causes, myocardial infarction, and stroke were lower. Pioglitazone has been found to reduce all-cause mortality in type 2 diabetic patients compared to other therapies, with a 60% reduction in mortality in those exposed to pioglitazone, compared to those never exposed. Another study found an all-cause mortality hazard ratio of 0.33 for pioglitazone after adjusting for >40 covariates, compared to insulin." }, { "id": "pubmed23n0383_7004", "title": "Repaglinide: a review of its therapeutic use in type 2 diabetes mellitus.", "score": 0.009900990099009901, "content": "Repaglinide, a carbamoylmethyl benzoic acid derivative, is the first of a new class of oral antidiabetic agents designed to normalise postprandial glucose excursions in patients with type 2 diabetes mellitus. Like the sulphonylureas, repaglinide reduces blood glucose by stimulating insulin release from pancreatic beta-cells, but differs from these and other antidiabetic agents in its structure, binding profile, duration of action and mode of excretion. In clinical trials of up to 1-year's duration, repaglinide maintained or improved glycaemic control in patients with type 2 diabetes mellitus. In comparative, 1-year, double-blind, randomised trials (n = 256 to 544), patients receiving repaglinide (0.5 to 4mg before 3 daily meals) achieved similar glycaemic control to that in patients receiving glibenclamide (glyburide) &lt; or = 15 mg/day and greater control than patients receiving glipizide &lt; or = 15 mg/day. Changes from baseline in glycosylated haemoglobin and fasting blood glucose levels were similar between patients receiving repaglinide and glibenclamide in all studies; however, repaglinide was slightly better than glibenclamide in reducing postprandial blood glucose in I short term study (n = 192). Patients can vary their meal timetable with repaglinide: the glucose-lowering efficacy of repaglinide was similar for patients consuming 2, 3 or 4 meals a day. Repaglinide showed additive effects when used in combination with other oral antidiabetic agents including metformin, troglitazone, rosiglitazone and pioglitazone, and intermediate-acting insulin (NPH) given at bedtime. In 1-year trials, the most common adverse events reported in repaglinide recipients (n = 1,228) were hypoglycaemia (16%), upper respiratory tract infection (10%), rhinitis (7%), bronchitis (6%) and headache (9%). The overall incidence of hypoglycaemia was similar to that recorded in patients receiving glibenclamide, glipizide or gliclazide (n = 597) [18%]; however, the incidence of serious hypoglycaemia appears to be slightly higher in sulphonylurea recipients. Unlike glibenclamide, the risk of hypoglycaemia in patients receiving repaglinide was not increased when a meal was missed in 1 trial. In conclusion, repaglinide is a useful addition to the other currently available treatments for type 2 diabetes mellitus. Preprandial repaglinide has displayed antihyperglycaemic efficacy at least equal to that of various sulphonylureas and is associated with a reduced risk of serious hypoglycaemia. It is well tolerated in a wide range of patients, including the elderly, even if a meal is missed. Furthermore, glycaemic control is improved when repaglinide is used in combination with metformin. Thus, repaglinide should be considered for use in any patient with type 2 diabetes mellitus whose blood glucose cannot be controlled by diet or exercise alone, or as an adjunct in patients whose glucose levels are inadequately controlled on metformin alone." }, { "id": "pubmed23n1058_25724", "title": "[Starting insulin or not? And if so, which basal insulin?]", "score": 0.009900990099009901, "content": "A 55-year-old patient with a BMI of 30 kg/m2 is referred for uncontrolled type 2 diabetes mellitus. His HbA1c-concentration is 71 mmol/mol, despite an initial 8% weight loss and treatment with metformin and glimepiride. The general practitioner proposes to start with insulin, but the patient refuses. We discuss whether there is a good alternative for insulin such as more weight loss and the addition of more drugs. Our patient then changes his mind and agrees to start insulin treatment. Basal insulin is usually recommended in cases like this.Since there are no significant differences between different types of available basal insulin, it seems reasonable to take price into account. Our patient achieved reasonable glucose control without weight gain using a combination of basal insulin and a GLP-1 receptor agonist." }, { "id": "wiki20220301en012_87388", "title": "Metformin", "score": 0.009823509823509824, "content": "It was withdrawn from the market in the UK and India in 2010, and in New Zealand and South Africa in 2011. From November 2011 until November 2013 the FDA did not allow rosiglitazone or metformin/rosiglitazone to be sold without a prescription; moreover, makers were required to notify patients of the risks associated with its use, and the drug had to be purchased by mail order through specified pharmacies. In November 2013, the FDA lifted its earlier restrictions on rosiglitazone after reviewing the results of the 2009 RECORD clinical trial (a six-year, open-label randomized control trial), which failed to show elevated risk of heart attack or death associated with the medication. Pioglitazone The combination of metformin and pioglitazone (Actoplus Met, Piomet, Politor, Glubrava) is available in the US and the European Union. DPP-4 inhibitors Dipeptidyl peptidase-4 inhibitors inhibit dipeptidyl peptidase-4 and thus reduce glucagon and blood glucose levels." }, { "id": "pubmed23n0574_19905", "title": "Effects of early use of pioglitazone in combination with metformin in patients with newly diagnosed type 2 diabetes.", "score": 0.00980392156862745, "content": "Type 2 diabetes is characterised by a progressive decline in HbA1c control over time. Early combination therapy, rather than sequential introduction of individual oral glucose-lowering agents, has been proposed to prevent this gradual rise in HbA1c. This observational study assessed the effect of early dual combination oral glucose-lowering therapies within 6 months of diagnosis in newly diagnosed, drug-naïve patients with type 2 diabetes. This was an observational, open-label, non-randomised study in newly diagnosed patients with type 2 diabetes, aged 35-70 years, with HbA1c levels &gt; 8.0% at diagnosis or &gt; 7.0% at the 3-6-month follow-up. Patients were allocated to dietary management alone if the HbA1c level was 7.0-8.0% at diagnosis. Metformin combined with gliclazide, repaglinide, or pioglitazone was given at diagnosis if the HbA1c was &gt; 8.0%. Similar treatments were introduced at 3-6 months if the HbA1c was &gt; 7.0%. Over a 3-year period, HbA1c was measured at 3-monthly intervals. All patients underwent regular dietetic review. Target HbA1c was &lt; or = 7.0%. 416 patients were considered eligible for inclusion, with a mean (+/- SD) age of 54.1 +/- 9.2 years, BMI of 33.5 +/- 6.1 kg/m2, and baseline HbA1c of 8.6 +/- 1.7%. A mixed model analysis of variance on the 178 patients who started with combination therapy, either immediately or after a 3-6 month period on diet, showed that metformin plus gliclazide, repaglinide, or pioglitazone was associated with a gradual increase in HbA1c values. Amongst those patients treated with the metformin/pioglitazone combination there was an estimated 0.1% increase in HbA1c/year. This was much less pronounced than the rises seen in HbA1c/year of 0.5% with the metformin/gliclazide and metformin/repaglinide combinations. This preliminary analysis of an observational, non-randomised, open-label ongoing study has shown that early use of combination therapy at time of diagnosis or within the first 3-6 months following diagnosis with metformin plus pioglitazone in newly diagnosed type 2 diabetes results in a slower deterioration in glycaemic control than that with metformin combined with either gliclazide or repaglinide. This may be due to the beta-cell protective properties of pioglitazone. These results need to be confirmed by further studies with a more robust design and methodology." }, { "id": "pubmed23n0809_19772", "title": "[A case of an elderly diabetic patient with dementia effectively treated with weekly exenatide].", "score": 0.00980392156862745, "content": "A 74-year-old man with diabetes mellitus since 64 years of age had been treated with glimepiride, metformin and alogliptin; however, his glycemic control remained poor, i.e., a casual blood glucose level of 318 mg/dl, HbA1c level of 10.6% and glycated albumin level of 24.9%. Although his blood glucose level improved with intensive insulin therapy, he exhibited dementia with an MMSE score of 9/30 and was unable to continue insulin injections by himself, thus rejecting his family's help. The extended-release form of the GLP-1 agonist exenatide (Bydureon(®)) was recently introduced in Japan. This new anti-diabetic agent enables the administration of once-weekly type 2 diabetes treatment that delivers a continuous dose of exenatide in a single weekly injection. We employed weekly exenatide therapy in combination with oral hypoglycemic agents in this case. The patient visited our outpatient clinic for injections every week, showing a remarkable improvement in his HbA1c level, from 10.7% to 7.1% in five months. Subcutaneous induration was the only side effect of weekly exenatide injection. Weekly exenatide therapy can be easily managed by other caregivers and is expected to be a useful treatment approach in elderly diabetic patients with dementia. " }, { "id": "wiki20220301en140_46084", "title": "Pioglitazone/metformin", "score": 0.009708737864077669, "content": "Indication Pioglitazone/metformin is indicated as an adjunct to diet and exercise: To improve glycemic control in patients with type 2 diabetes, or For patients who are already treated with a separate combination of pioglitazone and metformin, For patients whose diabetes is not adequately controlled with metformin alone, or For patients who have initially responded to pioglitazone alone and require additional glycemic control. Dosage and administration Use in pregnancy and lactation Pioglitazone/metformin should not be used during pregnancy unless the potential benefit justifies the potential risk to the fetus. There are no adequate and well-controlled studies in pregnant women with combination of pioglitazone and metformin or its individual components. It is not known whether pioglitazone and/or metformin are secreted in human milk. Because many drugs are excreted in human milk, pioglitazone/metformin should not be administered to a breastfeeding woman." }, { "id": "pubmed23n0831_1756", "title": "Getting to goal in newly diagnosed type 2 diabetes using combination drug \"subtraction therapy\".", "score": 0.009708737864077669, "content": "The treatment of newly diagnosed type 2 diabetes mellitus is diverse, with no clear consensus regarding the initial drug regimen or dosing to achieve optimal glycemic control. We treated 44 consecutive patients with newly diagnosed type 2 diabetes with maximally tolerated doses of pioglitazone 45 mg/day, metformin 1000-2000 mg/day, and repaglinide 1-4 mg before meals. The doses and drugs were subsequently decreased (\"subtraction therapy\") to achieve optimal glycemic control and minimize side effects. Three primary outcomes were measured: the short term HbA1c response, the long term HbA1c response, and the incidence of hypoglycemia. All 44 patients responded with a rapid, progressive decline in their HbA1c levels from 11.43±2.3% to 6.17±0.72% (101±25.1 mmol/mol to 44±7.9 mmol/mol) by three months, and remained stable thereafter. An HbA1c ≤7.0% (≤53 mmol/mol) was reached within 1-4 months in 42 of 44 patients, and in every patient by 12 months. Each patient's lowest HbA1c level, 5.65±0.6% (38±6.6 mmol/mol), was reached over 6.3±2.9 months. Patients with initial HbA1c levels &gt;10% (&gt;86 mmol/mol) (n=33) responded similarly as those with HbA1c levels &lt;10% (&lt;86 mmol/mol) (n=11). Combination drug therapy maintained HbA1c levels between 5.0 and 7.0% (31 and 53 mmol/mol) for up to 14.83 years. Only one clinically significant hypoglycemic event occurred during 261.08 person-years of follow-up. In our experience, combination drug \"subtraction therapy\" was safe and effective for treating all newly diagnosed type 2 diabetic patients." }, { "id": "wiki20220301en192_2025", "title": "Vitamin B12", "score": 0.009433962264150943, "content": "Metformin Reduced serum levels of vitamin B12 occur in up to 30% of people taking long-term anti-diabetic metformin. Deficiency does not develop if dietary intake of vitamin B12 is adequate or prophylactic B12 supplementation is given. If the deficiency is detected, metformin can be continued while the deficiency is corrected with B12 supplements. Other drugs Certain medications can decrease the absorption of orally consumed vitamin B12, including: colchicine, extended-release potassium products, and antibiotics such as gentamicin, neomycin and tobramycin. Anti-seizure medications phenobarbital, pregabalin, primidone and topiramate are associated with lower than normal serum vitamin concentration. However, serum levels were higher in people prescribed valproate. In addition, certain drugs may interfere with laboratory tests for the vitamin, such as amoxicillin, erythromycin, methotrexate and pyrimethamine. Chemistry" }, { "id": "pubmed23n1161_25623", "title": "Longitudinal assessment of the quality of life and patterns of antidiabetic medication use in patients with type 2 diabetes, Saudi Arabia perspective, DISCOVER study.", "score": 0.009345794392523364, "content": "Patients with type 2 diabetes nowadays have a wide range of new antidiabetic medications with better efficacy and safety. Physicians' attitude toward selecting antidiabetic medications to reach targeted glycemic control and better quality of life (QOL) has not been studied prospectively. The global DISCOVER study aims to comprehensively provide a real-world assessment of the treatment pattern changes for patients with type 2 diabetes, in addition to QOL assessment. The Kingdom of Saudi Arabia was one of the countries participating in the DISCOVER study program. This study is a part of the prospective, longitudinal multinational DISCOVER study conducted in 38 countries including Saudi Arabia, a country facing an epidemic of type 2 diabetes, recruited 519 adult patients with type 2 diabetes with a mean age of 52.4 ± 11 years, where, they were followed up for three years period, where 477 patients completed the follow-up period. The clinical, biochemical, and patient lifestyle data were assessed periodically during the study period. DISCOVER study is registered with ClinicalTrials.gov identifiers: NCT02322762. The most frequently used antidiabetic medications (ADMs) initially and during the follow-up were biguanides (metformin) and sulfonylureas (gliclazide, glibenclamide, glimepiride, glipizide, and glyclopyramide). Insulin (premix Insulin, basal insulin, and basal/bolus insulin) and dipeptidyl peptidase-4 (DPP-4) inhibitors (sitagliptin, vildagliptin, saxagliptin, and linagliptin) were the most frequent second and alternative of therapy. Other medications namely thiazolidinediones (TZds) (pioglitazone and rosiglitazone), incretins (exenatide and liraglutide), and Sodium-glucose co-transporter-2 (SGLT-2) inhibitors (canagliflozin) were used at a lesser rate. Drug availability, efficacy, and safety were the main determinants for choosing antidiabetic medications. The physical component score of the QOL had shown a significant decrease, while the mental component score has demonstrated an increase in QOL using SF36v2 Survey. There is an increasing trend of using of newly available ADMs, mainly DPP-4 inhibitors. The major limitation of ADMs use is related to efficacy, availability, and safety. This warrant taking all the measures to overcome these limitations through adopting a multidisciplinary team approach for close monitoring of the patients and any unfavorable side effects. Additionally, global insurance coverage for all patients with type 2 diabetes could be a solution for the drug availability factor." }, { "id": "pubmed23n0738_11529", "title": "Glimepiride: evidence-based facts, trends, and observations (GIFTS). [corrected].", "score": 0.009345794392523364, "content": "Type 2 diabetes mellitus is characterized by insulin resistance and progressive β cell failure; therefore, β cell secretagogues are useful for achieving sufficient glycemic control. Glimepiride is a second-generation sulfonylurea that stimulates pancreatic β cells to release insulin. Additionally, is has been shown to work via several extra pancreatic mechanisms. It is administered as monotherapy in patients with type 2 diabetes mellitus in whom glycemic control is not achieved by dietary and lifestyle modifications. It can also be combined with other antihyperglycemic agents, including metformin and insulin, in patients who are not adequately controlled by sulfonylureas alone. The effective dosage range is 1 to 8 mg/day; however, there is no significant difference between 4 and 8 mg/day, but it should be used with caution in the elderly and in patients with renal or hepatic disease. In clinical studies, glimepiride was generally associated with lower risk of hypoglycemia and less weight gain compared to other sulfonylureas. Glimepiride use may be safer in patients with cardiovascular disease because of its lack of detrimental effects on ischemic preconditioning. It is effective in reducing fasting plasma glucose, post-prandial glucose, and glycosylated hemoglobin levels and is a useful, cost-effective treatment option for managing type 2 diabetes mellitus." }, { "id": "InternalMed_Harrison_899", "title": "InternalMed_Harrison", "score": 0.009287193138124816, "content": "follow-up by the health care provider, possibly in the presence of a caregiver. Chlorpropamide has a prolonged half-life, particularly in older adults, and should be avoided because it is associated with a high risk of hypoglycemia. Metformin should be used with caution and only in patients free of severe renal insufficiency. Renal insufficiency should be assessed by a calculated glomerular filtration rate or, in very old patients who have reduced muscle mass, by a direct measure of creatinine clearance from a 24-h urine collection. Lifestyle changes in diet and exercise and a little weight loss can prevent or delay diabetes in high-risk individuals and are substantially more effective than metformin treatment. The risk of type 2 diabetes decreased by 58% in a study of diet and exercise, and this effect was similar at all ages and in all ethnic groups. The risk reduction with standard care plus metformin was 31%." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 221 ] ], "word_ranges": [ [ 0, 30 ] ], "text": "They describe a recent diagnosis of cerebral LOE with signs of intracranial hypertension (edema, midline deviation, papilledema). The associated headache is typically morning headache, with increasing ICP values at night." }, "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": "Predominance in the morning.", "2": "It does not change with effort.", "3": "Photophobia.", "4": "Sonophobia.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0882_3374", "title": "Chronic Headaches After a Concussion in an Obese 16-Year-Old Girl.", "score": 0.01565227861055927, "content": "Jennifer is a 16-year-old Latina girl who is new to your practice. During her first well visit, she mentions that she has had daily headaches for 2 years. They began after sustaining a concussion in a car accident. Typically, her headaches are bilateral and \"squeezing\"; they occur in the afternoons and last for a few hours. Her concussion also resulted in depressed mood, which has improved over time.When you ask if her headaches have changed recently, she says that they have been worse for the last few days. The quality and severity are unchanged; however, they now occur first thing in the morning, are worse when supine, and no longer remit. In the last 2 days, she has developed new-onset blurry vision, nausea, dizziness, photophobia, and sonophobia. Although she previously experienced sadness with her concussion, she now feels irritable. She has never used tobacco, alcohol, or drugs, and she takes no medications.On examination, her body mass index is above the 99th percentile. You note mild papilledema bilaterally. She has no focal neurological deficits. The remainder of her examination is normal.You send her to an emergency department. Her head computed tomography is normal. A lumbar puncture demonstrates an opening pressure of 32 cm H2O; she feels relief after the procedure. She is admitted with a diagnosis of benign intracranial hypertension and is started on acetazolamide. What is the differential diagnosis of chronic headaches in an obese adolescent? How should a busy community pediatrician manage Jennifer acutely? What follow-up care should Jennifer receive?" }, { "id": "pubmed23n0927_20057", "title": "Acute cerebellitis in adults: a case report and review of the literature.", "score": 0.012049062049062049, "content": "Acute cerebellitis is a rare disease with the majority of cases described in children. Little is known about the clinical characteristics and outcome in adults. A 37-year-old Caucasian woman presented with headache, nausea, and photophobia, and was diagnosed as having a migraine attack. Two days later, she subsequently returned with aggravated headache, dysarthria and horizontal nystagmus. Magnetic resonance imaging (MRI) showed a swollen cerebellum and hydrocephalus and the patient was diagnosed with acute cerebellitis. Cerebrospinal fluid (CSF) examination showed an elevated leukocyte count and protein. Blood serology showed the presence of immunoglobulin M and immunoglobulin G for both Epstein-Barr virus and cytomegalovirus. The patient was treated with dexamethasone and discharged to a rehabilitation center, where she fully recovered. We searched the literature for adult cases of acute cerebellitis. Including our patient, we identified 35 patients with a median age of 36 years. The etiology was unknown in 34% of cases. The most common clinical presentation consisted of headache, nausea/vomiting and ataxia. Six patients presented with only headache and nausea and subsequently returned with cerebellar signs. In 9 cases, the cerebellitis was complicated by hydrocephalus. Half of the patients ended up with neurological sequelae, while follow-up MRI was abnormal in 71%. Acute cerebellitis in adults is a rare disorder which mainly presents with headache, nausea/vomiting and ataxia. To diagnose cerebellitis, imaging of the brain (preferably MRI) is required and CSF examination may be necessary to narrow the differential diagnosis. The treatment depends on the widely diverse etiology, and treatment with steroids is recommended in the case of cerebellar oedema and hydrocephalus. Neurosurgical intervention may be necessary to prevent brain herniation." }, { "id": "article-22614_52", "title": "Migraine Headache -- Evaluation", "score": 0.011745472837022132, "content": "Acute severe headache, especially if it is the first or worst episode (discard subarachnoid hemorrhage) Abnormal neurologic examination, especially if there are unexplained symptoms or signs (confusion, stiff neck, papilledema, epilepsy) Non-typical characteristics Changes in the patient's typical features or patterns New episodes in older (> 50 years of age) or immunosuppressed patients Systemic or meningeal signs or symptoms (fever, weight loss, fatigue) New neurological symptoms or signs on examination Headache not responding to treatment Headache lasting > 72 hours A significant change in the frequency, pattern, or severity of headaches Severe headache pain (\"worst headache of life\") or headache causing awakening from sleep New-onset headache in patients with HIV infection or cancer Associated symptoms or signs suggestive of meningitis or stroke The commonly used acronym \"SNOOP\" can be used to aid in the determination of neuroimaging indications:" }, { "id": "article-22610_10", "title": "Acute Headache -- History and Physical", "score": 0.011389759665621734, "content": "What is the patient's medical history? Does the patient take new medications, or have they recently changed them? Does the patient take \"blood thinners\"? Is this the worst headache the patient has ever experienced? Was the pain maximal at the onset? Has the patient had any difficulty moving or speaking normally? Did the patient have nausea or vomiting? Does the patient have a fever? Does the patient have any changes in vision or hearing? Does the patient have eye pain? Does the patient have any neck or facial pain? Did the patient have a seizure? Does the patient have dizziness? Does the patient have any sensitivity to light? Does the patient feel generally weak? Is there a weakness in a specific area of their body? Has the patient traveled recently? Has the patient been around sick contacts? Is the patient less than six weeks postpartum? Does the patient have a history of immunosuppression or take immunosuppressive medication?" }, { "id": "pubmed23n0743_6115", "title": "Posterior reversible leukoencephalopathy syndrome presenting with global cerebral edema and herniation.", "score": 0.011267006802721087, "content": "We report a case of global cerebral edema and herniation due to Posterior Reversible Leukoencephalopathy Syndrome (PRES). Case report. A 37-year-old healthy female developed persistent severe occipital headache, and after 1 month of persistent headache, developed an episode of loss of consciousness. CT brain showed diffuse cerebral edema and effacement of the sulci and basal cisterns. Her initial neurological examination was nonfocal but with severe headache. Overnight, she acutely became unresponsive with fixed dilated pupils, tachycardia, and hypertension. She was intubated and treated with hypertonic saline and mannitol with improvement in her clinical status. Intracranial Pressure (ICP) monitor showed elevated ICPs to 37 mmHg which responded to mannitol. MRI brain showed diffuse vasogenic edema predominantly in the white matter without enhancement. Cerebral angiogram was unremarkable. Cerebrospinal fluid including infectious work-up was negative. With supportive care, her mental status improved. On her 3 month follow-up visit, she was asymptomatic and had returned to work. Repeat MRI brain at 3 months showed persistent white matter changes that subsequently resolved at 9 months. Although PRES is typically considered to have a benign clinical course, clinician should be aware that severe cases can present with global cerebral edema and associated complications including intracranial hypertension and herniation." }, { "id": "pubmed23n0513_12098", "title": "[Reversible posterior leukoencephalopathy syndrome: experience in 3 cases].", "score": 0.011261685174728652, "content": "We report 3 cases with reversible posterior leukoencephalopathy syndrome (RPLS) accompanied by eclampsia or hypertensive encephalopathy. RPLS may develop in patients who have eclampsia or hypertensive encephalopathy or who are immunosuppressed. The findings on neuroimaging are characteristic of subcortical edema without infarction. A 27-year-old primigravida developed eclampsia at 37 weeks of gestation. MRI was performed 4 hours after the onset. The FLAIR sequence delineated extensive hyperintense lesions in the temporal and occipital lobe bilaterally. MR angiography(MRA) performed 6 days after the onset of symptoms clearly demonstrated intracranial vasospasm. Follow up MRI and MRA were performed 3 weeks after the onset. The MRI showed slight residual hyperintensity in the occipital lobe. The MRA showed the disappearance of the vasospasm. A 39-year-old woman on the 8th postpartum day presented with thunderclap headache, which led to a search for SAH. She visited our hospital, whose high arterial blood pressure (220/110 mmHg) was observed. Both CT and MRA were normal. MRI revealed abnormalities in the parieto-occipital regions bilaterally. Treatment of hypertension led to resolution of the posterior leukoencephalopathy. A 38-year-old woman on the 11th postpartum day suddenly developed vertigo, visual disturbance and generalized convulsion. MRI was performed 7 days after the onset. The FLAIR sequence delineated extensive hyperintense lesions in the occipital lobe bilaterally. MRA clearly demonstrated diffuse intracranial vasospasm. MRA performed 3 weeks after the onset showed the disappearance of the vasospasm. In conclusion, our experience suggests that the MRI and MRA noninvasively provide valuable findings which are complementary in the diagnosis and follow-up examination of a brain edema and vasospasm in RPLS." }, { "id": "pubmed23n0973_2011", "title": "[Posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a case report].", "score": 0.009900990099009901, "content": "This case report concerns a 22-year-old woman who had been diagnosed with systemic lupus erythematosus (SLE). She had intermittent fever, butterfly erythema, photosensitivity, oral ulcers, and multiple arthralgia in the past seven years, but she did not adhere to regular treatments. The edema of the lower extremities and face aggravated in the recent two weeks, so she was admitted to our Department of Rheumatology and Clinical Immunology. Meanwhile, we found she had severe hypertension, the maximal blood pressure was 170/120 mmHg. The patient had high SLE disease activity (the disease activity index score was as high as 23) with blood involvement, acute renal insufficiency, multiple serous effusion and rash. After one week treatments of intravenous methylprednisolone 80 mg daily and other drugs, her conditions made some extent improvement. However, she suffered sudden epileptic attacks. No positive neuropathological signs were found, and the blood pressure was up to 190/130 mmHg before the onset of the seizures. Her cerebrospinal fluid (CSF) pressure was 330 mmH<sub2</subO, the CSF protein level was normal value, and the white blood cell count was 0 cell/mm<sup3</sup, with no signs of infection. Cranial MRI showed vasogenic edema at bilateral parietal, occipito-parietal regions, and centrum ovale. We prescribed drugs of decreasing intracranial pressure, intravenous drugs of decreasing blood pressure and midazolam for sedation, without corticosteroid impulse therapy. She recovered consciousness in the next day, without epilepsy recurrence. We eventually diagnosed it as posterior reversible encephalopathy syndrome (PRES), according to the history, laboratory results, imaging featuresand clinical outcome. PRES is a disorder of reversible subcortical vasogenic brain edema in patients with acute neurological symptoms (eg, seizures, encephalopathy, headache, and visual disturbances). PRES is mainly caused by blood pressure changes or endothelial injury, which lead to breakdown of the blood-brain barrier and subsequent brain edema. Most patients have a favourable prognosis. SLE complicated with PRES is not rare, especially in patients with disease activity, hypertension, lupus nephritis and/or renal insufficiency, and use of cytotoxic drugs, early recognition and appropriate treatment remain important. Brainstem involvement, intracranial hemorrhage, renal insufficiency and high disease activity of lupus are risk factors for poor prognosis." }, { "id": "pubmed23n0570_6517", "title": "Emergent headaches during pregnancy: correlation between neurologic examination and neuroimaging.", "score": 0.009900990099009901, "content": "Emergent evaluation of the pregnant headache patient requires rational selection of acute neuroimaging studies, yet guidelines do not exist. We investigated the demographic and clinical features that are predictive of intracranial pathologic lesions on neuroimaging studies in pregnant women with emergent headaches. We conducted a retrospective review of demographic factors, clinical features, and radiologic findings in a consecutive case series of 63 pregnant women emergently evaluated with a chief complaint of headache, including those with previous headache histories. Clinical data were abstracted from emergency department records, hospital course, and discharge summaries. Multivariate logistic regression analysis examined predictors of intracranial pathologic lesions on emergent neuroimaging studies. Multiparous African American women constituted 63% of the case subjects. Headaches were frequently accompanied by photophobia (59%), nausea (52%), vomiting (37%), and occasionally with fever (11%), meningismus (9%), or seizures (7%). A total of 43% of case subjects had abnormal neurologic examination findings. Emergent neuroimaging, including noncontrast head CT and MR imaging, revealed an underlying headache etiology in 27%, including cerebral venous thrombosis, reversible posterior leukoencephalopathy, pseudotumor, and intracranial hemorrhage. The odds of having intracranial pathologic lesions on neuroimaging were 2.7 times higher in patients with abnormal results on neurologic examination (P=.085). Emergent neuroimaging studies may reveal an underlying headache etiology in 27% of pregnant women. Further research with a larger sample size is needed to determine what clinical factors are predictive of a pathologic condition on neuroimaging studies." }, { "id": "pubmed23n0305_22028", "title": "[A 64-year-old woman with severe headache and progressive disturbance of consciousness].", "score": 0.00980392156862745, "content": "We report a 64-year-old woman who developed nausea, headache, and consciousness disturbance. She was well until four years before the onset of her neurologic illness when (April of 1990 at her 59 years of the age) she was found to have an early cancer in her anterior wall of the lower stomach. Subtotal gastrectomy was performed and the operative result was reported as curative. Four years after the surgery (December of 1994 at her 64 years of the age), she noted suboccipital headache and nausea which had become progressively worse and she was admitted to our service on May 24, 1995. On admission, she appeared chronically ill but general physical examination was unremarkable with normal vital signs. Neurologically she was alert and not demented, and the higher cerebral functions were intact. Cranial nerves were also unremarkable. She was able to walk in tandem and on heels. No motor weakness or ataxia was noted. Deep tendon reflexes were moderately increased, however, no Babinski sign was noted. Although she had headache, no meningeal signs were seen. Slight superficial and vibratory sensory loss was noted in both feet. Routine blood work was again unremarkable except for slight increase in CEA to 8.3 ng/dl (N &lt; 5 ng/dl). The opening pressure of lumbar CSF was 180 mm H2O and the CSF contained 39 cells/microliter, 79 mg of protein, and 10 mg/dl of glucose. Approximately half of the cells were atypical malignant cells. Plain CT was unremarkable, however, tentorial border showed enhancement after contrast infusion. FGS showed no malignant tumors in the stomach. She was treated with intravenous glycerol and whole brain radiation, however, she continued to complain of severe headache, and her sensorium started to be disturbed one month after the admission. Follow-up cranial CT scan revealed enlargement of the lateral and the third ventricles. Her consciousness progressively deteriorated and she became comatose three months after the admission. Repeated cranial CT scan showed enlargement of the ventricles, but no mass lesions were seen within the brain. She developed respiratory arrest on September 25 of the same year. She was discussed in a neurological CPC and the chief discussant arrived at the conclusion that the patient had a gastric cancer with meningeal seeding developing meningeal carcinomatosis. The cause of deep coma was ascribed to damage of cerebral cortical areas secondary to metastatic carcinoma cells and fibrinous materials in the surface of the brain. Postmortem examination revealed thickening and clouding of leptomeninges of the cerebral convexity. On histologic observation, patchy areas of fibrous thickening were seen in the cerebral leptomeninges; in such areas, adenocarcinomatous cells were seen scattered. The basal meninges were free of carcinoma cells, however, leptomeninges of the cerebellum and brain stem tegmentum contained scattered carcinoma cells. The lateral and the third ventricles were enlarged, however, insides of the brain were free of pathologies; the ependymal layer were intact. In the stomach no carcinoma cells were remaining. Pneumonic changes were seen in the right upper and the left lower lobes which appeared to be the direct cause of her death. No evidence of tentorial herniation was noted. The cause of her deep coma was not clearly determined, however, combination of hydrocephalus and cortical malfunction due to leptomeningeal carcinoma cell infiltration and fibrinous material accumulation appeared to have played a role." }, { "id": "pubmed23n0266_12832", "title": "Warning symptoms of sinister headache.", "score": 0.00980392156862745, "content": "Headache is a common complaint. In most patients, it is usually a problem of migrainous or tension-type headache. It is crucial that a physician is able to differentiate sinister causes of headache from the more benign ones. Six cases are presented to illustrate the fact that there are clues in the history to suggest a sinister cause of headache even though there are minimal or no neurological deficits on physical examination. At some point of time, these cases were examined by a senior physician but they were diagnosed as migrainous or tension-type headaches. The first case is a 41-year-old labourer with cryptococcal meningitis. He presented with severe headaches at a relatively late age. A 20-year-old female complained of the worst headache she ever had and this was due to a subarachnoid haemorrhage. The third case was a young woman with a large parietal meningioma. Her headaches had recently assumed a different character. The fourth case involved an investment manager who developed headaches with transient diplopia and projectile vomiting and investigations revealed an ependymoma. A shipyard worker complained of a constant headache which disturbed his sleep. Two weeks after medical consultation, the character of his headache changed and he developed diplopia in all directions of gaze. He succumbed to pituitary apoplexy. The final case is a 28-year-old woman who had a complicated migraine. CT scan of the brain showed a large arterio-venous malformation." }, { "id": "pubmed23n0253_17043", "title": "[A 57-year-old woman with gait disturbance, headache, character change, convulsion, and coma].", "score": 0.009708737864077669, "content": "We report a 57-year-old woman with progressive gait disturbance, headache, character change, convulsion and coma. She was well until 55 years of age, when she noted an onset of unsteady gait. At times she experienced transient weakness in her right hand, which was followed some difficulty in articulation. She was admitted to our service for the work up on April 6, 1992. Neurologic examination at that time revealed an alert Japanese lady in no acute distress. She was oriented to all spheres, however, she was somewhat bradyphrenic and had some disturbance in recent memory. Higher cerebral functions appeared intact. The visual acuity and visual fields were normal as were the optic fundi. Pupils were round and isocoric reacting promptly to light. Ocular movement was full, however, horizontal nystagmus was noted upon right lateral gaze. The sensation of the face was intact. She showed right facial paresis of the central type. Hearing was intact. She showed slurred speech and some difficulty in swallowing. The tongue was deviated to the right. Her gait was wide based and unsteady; tandem gait was difficult, however, walking on toes and on heels were performed well. No cerebellar ataxia was noted, but she showed some clumsiness in her right hand. Deep reflexes were symmetric and normally reactive; plantar response was extensor bilaterally. Sensation was intact; no meningeal sign was elicited. Routine laboratory work up was unremarkable; the CSF was under a borderline pressure (180 mmH2O) and contained 39 mg/dl of protein and 59 mg/dl of sugar. Cranial CT scan revealed diffuse low density areas involving bilateral cerebral white matter as well as the brain stem; MRI revealed high signal intensity lesions in those areas; gadolinium enhancement was negative; cortical sulci were effaced and the anterior part of the left lateral ventricle was compressed without deviation of the midline structure. The patient was treated with steroid pulse therapy without effect. She was discharged for out patient follow up, however, she developed a convulsion which was followed by loss of consciousness, and was admitted again to our service. She had never gained consciousness after this episode, and remained in the state of akinetic mutism. Follow-up CT and MRI did not show much change, although the area of high signal density lesions slightly enlarged on June 1, 1993. Her clinical course was complicated by drug induced bone marrow suppression and nephrotic syndrome. She expired on September 8, 1993 after developing sudden drop of blood pressure and bradycardia.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0639_7601", "title": "A young man presenting with acute encephalopathy, hemiparesis, and headache.", "score": 0.009708737864077669, "content": "Familial hemiplegic migraine (FHM) is a rare type of migraine. Correct diagnosis is challenging for emergency physicians (EPs) due to its variable clinical picture, as well as its lack of diagnostic biological markers. To raise awareness among EPs regarding FHM's diverse clinical picture, and to highlight FHM's diagnostic criteria to facilitate an accurate and timely diagnosis of FHM in patients presenting to the emergency department (ED) with indicative symptomatology. A 24-year-old male student presented to the ED complaining of dizziness, general weakness, and blurred vision that had developed the previous night. The initial physical examination revealed drowsiness, slow speech production, and slight weakness with paresthesia in all limbs. Detailed communication with the patient's aunt revealed that he had experienced several similar attacks since the age of 12 years, and that there was also an extensive family history of the same symptoms. In addition, 2 h after arrival, the patient experienced severe throbbing headache, vomiting, severe dysphasia, and the weakness shifted to the right side. A computed tomography scan of the brain showed no anomalies. He was admitted with a tentative diagnosis of FHM. A diagnosis of FHM should be considered if the patient's clinical features include headache and weakness, with a family history of similar symptomatology. However, atypical symptoms of FHM may present as recurrent episodes of unexplained encephalopathy. Crucial elements for making an accurate and timely diagnosis of FHM include a detailed knowledge of weakness-related diseases and an ability to consider FHM in the differential diagnosis, as well as obtaining a thorough family history with repeated neurologic assessments." }, { "id": "pubmed23n0897_85", "title": "Posterior Reversible Encephalopathy Syndrome Causing Vision Loss After Endoscopic Endonasal Resection of Pituitary Adenoma.", "score": 0.009615384615384616, "content": "Posterior reversible encephalopathy syndrome (PRES) is characterized by headache, altered mental status, visual changes, and seizure combined with brain imaging consistent with cerebral edema without infarction. To the best of our knowledge, we report the first case of PRES after an endoscopic endonasal resection of a pituitary macroadenoma. A 59-year-old woman was diagnosed with a pituitary macroadenoma, for which she underwent endoscopic endonasal extracapsular resection. After an uneventful initial postoperative recovery, the patient experienced sudden onset of emesis, confusion, vision loss, and severe hypertension. Emergent computed tomography showed normal postoperative changes, with no signs of hematoma or infarction. Magnetic resonance imaging (MRI) showed fluid-attenuated inversion recovery changes in the posterior lobes and thalamus, consistent with PRES. Cerebral angiography showed no vascular abnormalities. Blood pressure control was the primary treatment modality. Within 10 days, the patient was neurologically intact except for right homonymous hemianopsia. Follow-up MRI showed resolution of the PRES with an area of infarction in the left occipital lobe. At 5 years follow-up, the patient reported minimal blurred vision. MRI showed encephalomalacia at the old infarct area, and her visual field testing was unremarkable. Although rare in neurosurgical patients, PRES must be considered in patients who develop acute vision loss and mental status changes associated with hypertension after surgery, including endoscopic endonasal surgery. PRES has the potential for significant neurologic morbidity, if not treated in a timely manner. Early recognition and treatment, with blood pressure control mainly, are therefore mandatory after a surgical complication, such as a postoperative hematoma, has been ruled out." }, { "id": "pubmed23n0104_2599", "title": "Post-epileptic headache and migraine.", "score": 0.009615384615384616, "content": "One hundred epileptic patients were questioned about their headaches. Post-ictal headaches occurred in 51 of these patients and most commonly lasted 6-72 hours. Major seizures were more often associated with post-epileptic headaches than minor attacks. Nine patients in this series of 100 also had migraine: in eight of these nine a typical, albeit a mild, migraine attack was provoked by fits. The post-ictal headache in the 40 epileptics who did not have migraine was accompanied by vomiting in 11 cases, photophobia in 14 cases and vomiting with photophobia in 4 cases. Furthermore, post-epileptic headache was accentuated by coughing, bending and sudden head movements and relieved by sleep. It is, therefore, clear that seizures provoke a syndrome similar to the headache phase of migraine in 50% of epileptics. It is proposed that post-epileptic headache arises intracranially and is related to the vasodilatation known to follow seizures. The relationship of post-epileptic headache to migraine is discussed in the light of current ideas on migraine pathogenesis, in particular the vasodilation which accompanies Leao's spreading cortical depression." }, { "id": "pubmed23n1093_21158", "title": "Glioblastoma Shortly after a Normal Conventional Brain Magnetic Resonance Imaging: A Report of Two Cases and Review of the Literature.", "score": 0.009523809523809525, "content": "Glioblastoma (GB) is the most common malignant tumor of the brain. Most of these tumors are primary or <ide novo</i GBs that manifest rapidly with initial presentations such as headache, new-onset epileptic seizure, focal neurological deficits, and altered mental status. The typical radiological features of GB include strong contrast enhancement, central necrosis, and edema with mass effect. Herein, we describe two cases of primary GB - two women aged 60 and 51 years who were diagnosed with GB 3.5 and 4 months, respectively, after their initial admission. These patients presented with right-sided headaches, and their neurological examination was within the normal limits. Their initial radiological investigations revealed no suspicious lesions, either on T1-weighted or T2-weighted magnetic resonance (MR) images. The 60-year-old patient was readmitted with persistent headache, and her T1-weighted MR images revealed a well-demarcated mass lesion in the right temporal lobe with strong contrast enhancement. Moreover, the T2-weighted MR images revealed closed sulci and swollen midline structures because of edema. The 51-year-old patient was readmitted with persistent headache, and her MR image revealed a mass lesion with heterogeneous contrast enhancement and necrosis on T1-weighted images and hyperintense areas with severe edema on T2-weighted images. The patients underwent craniotomy and gross total tumor resection. Notably, in both cases, the lesions were pathologically diagnosed as GB. Therefore, it should be borne in mind that only persistent headache could be a sentinel sign of GB before it becomes radiologically visible, thereby emphasizing the need for follow-up imaging studies at short intervals." }, { "id": "pubmed23n0864_1375", "title": "Linear headache: clinical characteristics of eight new cases.", "score": 0.009523809523809525, "content": "Linear headache (LH) has recently been described as a paroxysmal or continuous fixed head pain restricted in a linear trajectory of 5-10 mm in width, linking one endpoint in occipital or occipitocervical region with another endpoint in ipsilateral nasion or forehead region. For some patients, this headache had some features resembling migraine without aura. We made a prospective search of patients presenting with a clinical picture comprised under the heading of LH and we have accessed eight new cases. A detailed clinical feature of the headache was obtained in all cases to differentiate with cranial neuralgia, paroxysmal hemicrania, cervicogenic headache, nummular headache and migraine. The eight LH patients complained of a recurrent moderate to severe, distending, pulsating, or pressure-like pain within a strictly unilateral line-shaped area. The headache duration would be ranged from 1 h to 2 days or persistent for 1-6 months with recurrent worsening of headaches. For some patients, this headache had couple of features similar to that of migraine pattern, such as accompaniments of nausea, vomiting, and phonophobia, diziness, triggering factors of noise, bright night, resting after physical activity, fatigue, menstruation, and response to anti-migraine therapy. This description reinforces the proposal of LH as a new headache syndrome or a new variant of a previously known headache syndrome, probably of migraine." }, { "id": "wiki20220301en251_31181", "title": "New daily persistent headache", "score": 0.009438549955791336, "content": "Cranial autonomic nervous symptoms occur with painful exacerbations in 21%, and cutaneous allodynia may be present in 26%. In 2002, Li and Rozen conducted a study of 56 patients at the Jefferson Headache Center in Philadelphia and published the following results: 82% of patients were able to pinpoint the exact day their headache started. 30% of the patients, the onset of the headache occurred in correlation with an infection or flu-like illness. 38% of the patients had a prior personal history of headache. 29% of the patients had a family history of headache. 68% reported nausea. 66% reported photophobia. 61% reported phonophobia. 55% reported lightheadedness. Imaging and laboratory testing were unremarkable except for an unusually high number of patients who tested positive for a past Epstein-Barr virus infection. Diagnosis" }, { "id": "pubmed23n1109_12863", "title": "A Rare Case of Fatal Hemorrhagic Stroke in a Young Female with Early Mixed Connective Tissue Disease.", "score": 0.009433962264150943, "content": "Mixed connective tissue disease (MCTD) often presents as a slow progressive illness with low morbidity and mortality. Serious central nervous system disease is uncommon, and fatal outcomes are rarely seen. Here, we report a rare case of fatal hemorrhagic stroke in a 43-year-old female with a rapidly progressive MCTD. She presented to primary care with a history of headaches, visual disturbances, and unprovoked lower extremity swelling and pain. A rheumatological workup showed positive antinuclear (ANA) and ribonucleoprotein (RNP) antibodies. Magnetic resonance imaging (MRI) found a 12 mm hemorrhage along a cortical sulcus of the right frontal lobe, and a follow-up magnetic resonance angiography (MRA) and ophthalmological exam showed no definitive signs of vasculitis. Over the course of her workup, she developed swollen hands, Raynaud's syndrome, myalgias, and synovitis characteristic of evolving MCTD. The patient then began to experience severe headaches over one month. Repeat MRI was ordered, but never completed, and the patient presented to the emergency department (ED) with a severe, right-sided headache, and left-sided visual disturbance. In the ED, she began to display evidence of delirium and seizure activity and became unresponsive. A computerized tomography scan (CT) of the brain showed a right parietal lobe intraparenchymal hemorrhage approximately 5 × 3 × 5 cm in size with secondary mass effect including mid- and hind-brain herniation. Computerized tomography angiography (CTA) of the brain showed signs of large vessel vasculitis. A craniectomy was performed; however, the patient never regained consciousness and died several days later. Vasculitis, while rare in connective tissue diseases, should be aggressively assessed for and managed in patients with any early signs and symptoms of cerebrovascular involvement to prevent fatal outcomes." }, { "id": "pubmed23n0678_8915", "title": "Pattern of migraine headache in a group of Kurdish Iraqi patients.", "score": 0.009433962264150943, "content": "To study the pattern of migraine, and to show the effect of age and duration of illness on the evolution of migraine symptoms. A review of 200 migraine cases (attending the outpatient neurology clinic at Rezgary Teaching Hospital, and Kurdistan Private Neurology Clinic) was carried out during the period between October 2007 to May 2008. Case definition of migraine was according to the International Headache Society (IHS) criteria. The majority (77%) of the studied sample was female. The mean age (+/- SD) at onset was 22.33+/-9.52 years. The most common type of migraine observed was migraine without aura (72%). Different symptoms like phonophobia (92%), nausea (86.5%), photophobia (84%), vertigo (78%), scalp tenderness (75%), attacks of facial pallor (64%), sweating (57%), vomiting (50%), pain in the arms (39%), and pain in the chest (6%) was studied in relation to age at presentation and duration of illness in years. No significant association was found between the duration of illness and age at presentation and evolution of migraine symptoms. No significant association was found between the duration of illness and frequency of the attacks. Many migraine symptoms remain the same in each attack no matter the duration of illness and age at presentation, except for bouts of vomiting, which may be less common in younger patients." }, { "id": "wiki20220301en303_24568", "title": "Neuro-oncology", "score": 0.009345794392523364, "content": "Specific tumors Primary tumors 1. Malignant Astrocytomas Malignant astrocytomas are the most common primary brain tumors in adults. Malignant astrocytomas generate symptoms and signs by mass effect, local brain infiltration, tissue destruction, cerebral edema, and increased intracranial pressure. Headaches and seizures are the most frequent initial symptoms. Associated focal neurologic signs and symptoms occur depending on the anatomic location of the tumor. Confusion and mental status difficulties occur in patients with large tumors, those that cross the corpus callosum and those with a lot of associated edema. 2. Other Astrocytomas Tumors of presumed or known astrocytic lineage other than the malignant astrocytomas include a variety of tumors categorized by histology, location, age of onset, and natural history. 3. Oligodendrogliomas" }, { "id": "pubmed23n0396_9134", "title": "The clinical characteristics of new daily persistent headache.", "score": 0.009345794392523364, "content": "New daily persistent headache (NDPH) is a subtype of chronic daily headache. The literature on NDPH is scant and its true aetiology is unknown. A retrospective chart review was carried out from a computerized database at the Jefferson Headache Centre from August 1997 to May 2000 to identify patients with NDPH using the Silberstein et al. criteria. Forty women and 16 men were identified. Age of onset ranged from 12 to 78 years. The peak age of onset was the second and third decade in women and the fifth decade in men. Eighty-two per cent of patients were able to pinpoint the exact day their headache started. Onset occurred in relation to an infection or flu-like illness in 30%. A prior headache history was found in 38% of patients. A family history of headache was documented in 29%. The duration of daily headache ranged from 1.5 h to 24 h; 79% were continuous. Nausea occurred in 68% of patients, photophobia in 66%, phonophobia in 61%, and lightheadedness in 55%. Laboratory testing and neuroimaging in all patients was normal except for Epstein-Barr virus antibody titres, which were positive in 71% of seven patients tested, representing past infection. NDPH appears to be a female-predominant disorder, marked by a continuous daily headache with associated migrainous symptoms. Over 80% of patients could state the exact date their headache began. One-third of patients developed NDPH with a flu-like illness." }, { "id": "pubmed23n1028_26384", "title": "A Rare Case of Cerebral Amyloidoma Mimicking a Hemorrhagic Malignant Central Nervous System Neoplasm.", "score": 0.009259259259259259, "content": "Cerebral amyloidoma is a rare form of amyloidosis with a localized tumor like an amyloid deposition in the brain composed of insoluble fibrillary protein with cross beta-sheet conformation. Its usual presentation includes vision loss, seizures, behavioral changes, cognitive decline, and recurrent headaches. It has a benign course with a slow progression, and it is not associated with dissemination. We report a case of a 65-year-old Caucasian woman who presented with symptoms of progressively worsening cognitive dysfunction of six months' duration. From CT of the brain, it was found that she had a right frontal and left parietal hemorrhagic mass with a large amount of vasogenic edema and a midline shift. MRI showed heterogeneously enhancing hemorrhagic mass of 5.2 cm x 2.6 cm x 3.6 cm in size, with a satellite lesion. Initially, this was suspected to be a high-grade glioma vs. metastatic hemorrhagic lesions. She underwent stereotactic biopsy of the mass, and histopathology was consistent with cerebral amyloidoma with marked IgA lambda plasma cell differentiation. She did not have any evidence of systemic amyloidosis, and therefore, she is being clinically observed with a regular follow-up and annual CT surveillance. She has remained stable over the past two years, although she has residual cognitive dysfunction. Cerebral amyloidoma can mimic malignant central nervous system (CNS) neoplasms and should be considered as a differential of any single or multiple mass lesions occurring in the white matter region of the brain with a characteristic appearance of \"hyperdense lesions\" on CT. It is a benign disease with no metastatic potential that usually resolves entirely after resection." }, { "id": "pubmed23n0558_9714", "title": "Incidence and pattern of headache in cerebral venous thrombosis.", "score": 0.009259259259259259, "content": "Cerebral venous thrombosis (CVT) is a challenging condition because of the variability of clinical presentations. CVT can present at all ages, but is seen more in young and middle-aged women. CVT does not necessarily occur only when there is an obvious underlying etiology. In almost 30% of cases, the etiology cannot be established. CVT can present with an acute thunderclap headache, fever, seizures, focal deficits, impaired sensorium, or papilloedema. Headache is known to be the most frequently associated initial complaint, and is present in more than 80% of patients, but it is not always remembered that headache can be the sole presenting complaint of CVT and even when early papilloedema is absent. Headache can occur in isolation in up to 5% of CVT cases. There is no identifiable, uniform, recognizable pattern of headache in CVT, but this article discusses the \"Headache Profile\" that is seen more commonly in this setting with an illustration of one such case where the innocuous headache turned sinister. Magnetic resonance imaging with venography is the investigation of choice to diagnose CVT; computed tomography alone will miss a significant number of cases. One must keep in mind the possibility of CVT in every patient who presents with new-onset headache of any type, any severity, and in any location, particularly when there is worsening in spite of analgesics. Earlier the diagnosis, earlier the treatment, better is the outcome." }, { "id": "pubmed23n0704_16810", "title": "Atypical presentation in Rasmussen encephalitis: delayed late-onset periodic epileptic spasms.", "score": 0.009174311926605505, "content": "A five-and-a-half-year-old girl started experiencing progressive left hemiparesis at age two and a half years. At age five years and four months she started presenting clusters of asymmetric periodic epileptic spasms with no hypsarrhythmia. The ictal EEG showed periodic, constant and stereotyped complexes. Serial brain imaging revealed progressive atrophy of the right hemisphere with increased T2 signal on MRI. She underwent a right hemispherotomy, and histological examination showed signs of inflammation and features of focal cortical dysplasia (FCD). She has been seizure-free for 16 months. This case is unique in the following aspects: the presence of typical Rasmussen encephalitis features of progressive unilateral brain involvement without seizures, a delay of almost three years prior to seizure onset; an atypical seizure type presentation with periodic epileptic spasms and the presence of FCD associated with inflammatory changes. [Published with video sequences]." }, { "id": "pubmed23n1037_5127", "title": "Clinical predictors of significant intracranial computed tomography scan findings in adults experiencing headache disorder.", "score": 0.009174311926605505, "content": "Radiological assessments for adult headache disorder show significant intracranial findings in 2.5% to 10% of performed computed tomography scans (CT-scans), leading to an overuse consideration for CT-scan requests by physicians in headache-experiencing patients. Therefore, we undertook this study in order to determine predictors of significant intracranial CT-scan findings in adults experiencing headache disorder; in order to help physicians better select patients who need imaging, which would subsequently decrease the costs of headache disorder management and the useless irradiation rates. We carried out a cross-sectional study in the medical imaging departments of Yaounde Central Hospital and Douala Laquintinie Hospital, which are two teaching hospitals in Cameroon, over a period of five months. We consecutively and non-exhaustively included all consenting patients aged eighteen years and above, referred to the radiology department to perform a head CT-scan as aetiological workup of headache disorder, from either a traumatic or non-traumatic mechanism. Patients having a known brain lesion and those with a Glasgow coma scale less than thirteen were excluded. The clinical history of patients was taken and a complete physical examination was performed. Demographic data, clinical characteristics of the headache, results of neurological and physical examinations were collected and correlated to the results of head CT-scan. We enrolled 169 patients in the study, 56.2% were males, with a sex ratio of 1.3; sudden onset of headache increased by two the risk of discovering significant intracranial pathology (p = 0.032). Occipital and cervical location of headache, headache evolving by crisis, and recurrent paroxysmal headache were rather significantly correlated to no structural brain finding. An abnormal neurological examination with specifically abnormal stretch reflexes, aphasia, loss of consciousness, raised intracranial signs, weakness, and meningeal signs were predictive of structural intracranial pathology. Otorrhagia, epistaxis, and periorbital ecchymosis in addition were predictive in post-traumatic headaches. Abnormal results from neurological examination are the best clinical parameters to predict structural intracranial pathology on CT-scan in adult patients experiencing headache disorder. In case of post-traumatic headaches, in addition, otorrhagia, epistaxis, and periorbital ecchymosis are too highly predictive." }, { "id": "pubmed23n0930_8428", "title": "Treatment of the superior sagittal sinus and transverse sinus thrombosis associated with intracranial hemorrhage with the mechanical thrombectomy and thrombolytics: Case report.", "score": 0.00909090909090909, "content": "The superior sagittal sinus (SSS) and transverse sinus are the major dural sinuses that receive a considerable amount of venous drainage. The occlusion of them has been suggested to cause intracranial hypertension, hemorrhage, and lead to potentially fatal consequences. We reported a 35-year-old woman with headache presented to our emergency department with a decreased level of consciousness and epileptic seizures. The examination of speech, higher mental function, and cranial nerve were normal. Computed tomography (CT) demonstrated both subarachnoid and intraparenchymal hemorrhage and brain edema at the right temporal lobe accompanied by high density shadow in the right transverse sinus. Digital subtraction angiography (DSA) revealed extensive thrombosis of the SSS and bilateral transverse sinus. The SSS and transverse sinus thrombosis, accompanied by right temporal lobe hemorrhage, subarachnoid hemorrhage (SAH). An emergent mechanical thrombectomy by placed Solitair AB stent in the SSS, respectively, passed left and right sigmoid sinus-transverse sinus route. We removed the most clots, DSA revealed recanalization of the SSS and left transverse sinus was seen with normalization of the venous outflow, the occlusion of right transverse sinus was still present. There were 4 hours after patient back to neurosurgical intensive care unit (NICU), patient appeared anisocoria (R/L:4.0/2.5 mm), bilateral light reflexes disappeared, then we took a CT reexamination revealed intraparenchymal hemorrhage increased, brain edema was aggravated at the left temporal lobe, and mild midline shift. Subsequently, we performed decompressive hemicraniectomy and puncture the hematoma supplemented by B ultrasonic. Anticoagulation treatment was initiated 24 hours after surgery, and follow-up DSA showed gradually improved patency in the SSS and bilateral transverse sinus. Despite occlusion of the SSS and bilateral transverse sinus, patient's symptoms resolved after the operations and he was discharged without complications. The favorable clinical outcome after complete occlusion of the SSS and transverse sinus, accompanied by right temporal lobe hemorrhage, SAH has rarely been reported and it might be explained by our timely surgical intervention and development of compensatory cerebral collateral circulation." }, { "id": "article-22722_24", "title": "Hemiplegic Migraine -- Evaluation", "score": 0.009057609057609058, "content": "Brain imaging (CT or MRI head) during attacks is usually normal. In very few cases, cortical edema and cortical or meningeal enhancement may be seen in the hemisphere contralateral to the hemiparesis. [23] Susceptibility-weighted MRI during the acute phase might reveal a transient prominence of the cerebral veins corresponding to the neurologic deficit. [24] As transient hypoperfusion followed by hyperfusion is associated with migraine aura, hypoperfusion without infarction and hyperperfusion and vasodilatation can be observed (depending on the time of the imaging) in magnetic resonance perfusion-weighted imaging and angiography. Patients with FHM1 can have cerebellar atrophy. MRI head may show cortical hemispheric atrophy and cortical laminar necrosis in severe hemiplegic migraine cases. [25] Electroencephalography (EEG) is performed when there is a suspicion of alternate diagnoses like seizures. [22] Cerebrospinal fluid (CSF) may show nonspecific CSF pleocytosis in a few cases." }, { "id": "wiki20220301en320_24291", "title": "Reversible cerebral vasoconstriction syndrome", "score": 0.00905273937532002, "content": "Signs and symptoms The key symptom of RCVS is recurrent thunderclap headaches, which over 95% of patients experience. In two-thirds of cases, it is the only symptom. These headaches are typically bilateral, very severe and peak in intensity within a minute. They may last from minutes to days, and may be accompanied by nausea, photophobia, phonophobia or vomiting. Some patients experience only one headache, but on average there are four attacks over a period of one to four weeks. A milder, residual headache persists between severe attacks for half of patients. 1–17% of patients experience seizures. 8–43% of patients show neurologic problems, especially visual disturbances, but also hemiplegia, ataxia, dysarthria, aphasia, and numbness. These neurologic issues typically disappear within minutes or a few hours; more persistent symptoms may indicate a stroke. Posterior reversible encephalopathy syndrome is present in a small minority of patients." }, { "id": "article-22610_13", "title": "Acute Headache -- History and Physical", "score": 0.009022306990629406, "content": "S: Systemic illness (fever, cancer, pregnancy, HIV) N: Neurologic signs or symptoms (confusion, focal neurologic signs, seizures, papilledema) O: Onset is new or sudden (especially if age over 50) O: Other associated features (head trauma, drugs or toxins, headache awakens from sleep or worse with Valsalva, precipitated by coughing or exertion) P: Previous headache history with progression or change in characteristics" }, { "id": "pubmed23n1149_14679", "title": "Grade III solitary fibrous tumor/hemangiopericytoma: An enthralling intracranial tumor-A case report and literature review.", "score": 0.009009009009009009, "content": "Hemangiopericytomas account for less than 1% of all intracranial tumors. In 2016, World Health Organization (WHO) unified the two terms into a single medical condition known as solitary fibrous tumor/hemangiopericytoma (SFT/HPC). Our patient is an 80-year-old woman with a past medical history of sick sinus syndrome status post pacemaker placement. She presented to the emergency department with progressive headaches for one month duration. Her headaches worsened at night, waking her up from sleep. They also increased in intensity by bending forward. Review of systems was significant for bilateral lower extremity weakness accompanied by difficulty walking. The motor exam was remarkable for right upper and right lower extremity 3/5 weakness. The gait was ataxic. A Computed tomography scan of the head without contrast revealed a large dural-based right parietal hyperdense mass with surrounding edema, mass effect, and compression of the right lateral ventricle atrium. A right-to-left midline shift was also noted. Given the fact that our patient had a pacemaker, she was not a candidate for a brain MRI. Neurosurgery successfully resected the mass. Histopathological studies confirmed WHO grade III anaplastic solitary fibrous tumor/hemangiopericytoma. The patient was discharged on adjuvant radiation with imaging surveillance given the grade and the extent of resection. This case highlights a rare type of intracranial mass that resembles meningioma on imaging studies. It also illustrates that solitary fibrous tumor/hemangiopericytoma should be kept as a differential diagnosis for brain masses, given its aggressive nature, and its potential of metastasis and recurrence." }, { "id": "pubmed23n0400_1241", "title": "Sudden onset headache: a prospective study of features, incidence and causes.", "score": 0.009009009009009009, "content": "Sudden onset headache is a common condition that sometimes indicates a life-threatening subarachnoid haemorrhage (SAH) but is mostly harmless. We have performed a prospective study of 137 consecutive patients with this kind of headache (thunderclap headache=TCH). The examination included a CT scan, CSF examination and follow-up of patients with no SAH during the period between 2 days and 12 months after the headache attack. The incidence was 43 per 100 000 inhabitants &gt;18 years of age per year; 11.3% of the patients with TCH had SAH. Findings in other patients indicated cerebral infarction (five), intracerebral haematoma (three), aseptic meningitis (four), cerebral oedema (one) and sinus thrombosis (one). Thus no specific finding indicating the underlying cause of the TCH attack was found in the majority of the patients. A slightly increased prevalence of migraine was found in the non-SAH patients (28%). The attacks occurred in 11 cases (8%) during sexual activity and two of these had an SAH. Nausea, neck stiffness, occipital location and impaired consciousness were significantly more frequent with SAH but did not occur in all cases. Location in the temporal region and pressing headache quality were the only features that were more common in non-SAH patients. Recurrent attacks of TCH occurred in 24% of the non-SAH patients. No SAH occurred later in this group, nor in any of the other patients. It was concluded that attacks caused by a SAH cannot be distinguished from non-SAH attacks on clinical grounds. It is important that patients with their first TCH attack are investigated with CT and CSF examination to exclude SAH, meningitis or cerebral infarction. The results from this and previous studies indicate that it is not necessary to perform angiography in patients with a TCH attack, provided that no symptoms or signs indicate a possible brain lesion and a CT scan and CSF examination have not indicated SAH." }, { "id": "pubmed23n0901_13201", "title": "Status Epilepticus and Blindness in a Patient with Carfilzomib-Associated Posterior Reversible Encephalopathy Syndrome.", "score": 0.008928571428571428, "content": "Posterior reversible encephalopathy syndrome (PRES) is a neurological condition characterized by headaches, visual disturbances, and seizures. A magnetic resonance imaging (MRI) scan of an affected brain typically shows symmetrical white matter edema in the posterior cerebral hemispheres. The onset of PRES can constitute a medical emergency, especially when accompanied by status epilepticus. If promptly recognized and treated, the clinical syndrome and associated radiological findings are usually resolved in a matter of weeks or months. Carfilzomib is a proteasome inhibitor that is newly approved for relapsing myeloma in a patient who has received one or more lines of therapy. In this paper, we report on a 52-year-old female on carfilzomib for multiple myeloma who developed PRES following her second dose of treatment. She was admitted for chronic obstructive pulmonary disease (COPD) exacerbation, and while she was in the hospital, she developed a severe headache, blindness, and status epilepticus. A brain MRI showed signs consistent with PRES. After carfilzomib was discontinued, her symptoms resolved within three days. Unfortunately, the patient passed away shortly after being discharged, so there was no opportunity to perform a repeat MRI." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 635, 967 ] ], "word_ranges": [ [ 100, 148 ] ], "text": "It is evident, therefore, that the patient suffers from primary angular closure processes that possibly self-resolve when the triggering situation ceases, and not a true acute glaucoma attack. But these intermittent angular closures are contemplated within the spectrum of glaucoma due to primary angular closure (option 1 correct)." }, "2": { "exist": true, "char_ranges": [ [ 968, 1347 ] ], "word_ranges": [ [ 148, 205 ] ], "text": "Migraine, not being a Neurology question, can sometimes be a confounder in the usual clinic; however, patients are usually younger, or at least have a clear history of migraine, and, above all, they present symptomatologic worsening with intense sensory stimuli (photophobia and phonophobia), but symptoms are not worsened precisely in cases of dim lighting (option 2 incorrect)." }, "3": { "exist": true, "char_ranges": [ [ 1348, 1657 ] ], "word_ranges": [ [ 205, 251 ] ], "text": "Actinic keratitis occurs precisely in patients exposed to ultraviolet radiation that is not properly filtered before reaching the cornea; it is typical of welders (it is called welder's keratitis), skiers and other people with very intense light exposures and without adequate eye protection (wrong option 3)." }, "4": { "exist": true, "char_ranges": [ [ 1658, 2136 ] ], "word_ranges": [ [ 251, 332 ] ], "text": "Dry eye syndrome does not usually produce headache, and ocular discomfort does not go beyond the persistent discomfort that patients might define as pain because of its recently more studied neuropathic component. Some forms of dry eye may be worse in the evening but others are worse in the morning, and it depends mainly on the frequency of blinking. In addition, dry eye syndrome is an outdated term; nowadays it is preferred to speak of dry eye disease (incorrect option 4)." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Glaucoma due to primary angular closure.", "2": "Migraine.", "3": "Actinic keratitis.", "4": "Dry eye syndrome.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "InternalMed_Harrison_15519", "title": "InternalMed_Harrison", "score": 0.01123623498928696, "content": "acUte HemorrHagic conjUnctivitis Patients with acute hemorrhagic conjunctivitis present with an acute onset of severe eye pain, blurred vision, photophobia, and watery discharge from the eye. Examination reveals edema, chemosis, and subconjunctival hemorrhage and often shows punctate keratitis and conjunctival follicles as well (Fig. 228-2). Preauricular adenopathy is often found. Epidemics and nosocomial spread have been associated with enterovirus 70 and coxsackievirus A24. Systemic symptoms, including headache and fever, develop in 20% of cases, and recovery is usually complete in 10 days. The sudden onset and short duration of the illness help to distinguish acute hemorrhagic conjunctivitis from other ocular infections, such as those due to adenovirus and Chlamydia trachomatis. Paralysis has been associated with some cases of acute hemorrhagic conjunctivitis due to enterovirus 70 during epidemics." }, { "id": "pubmed23n1090_18188", "title": "Spontaneous filtering bleb with subsequent secondary glaucoma June consultation #1.", "score": 0.010621529209205324, "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": "wiki20220301en104_52423", "title": "One-Eye, Two-Eyes, and Three-Eyes", "score": 0.009886012570576329, "content": "Synopsis A woman had three daughters: The eldest only had single eye in the middle of her forehead, the second was common like ordinary people, the third was also common; but, she has two eyes on the sides of her head and a third in the middle of her forehead because she has three eyes. Her mother and sisters scorned Little Two Eyes because she was like other people and treated her badly, leaving her only their leftovers to eat. One day Little Two Eyes was sent to the field to tend to the goat, she sat down and cried as she had been given so little to eat and when she looked up a woman was standing beside her. The woman asked her why she was crying. Little Two Eyes explained and the wise woman told her to say to the goat Little goat, bleat. Little table, appear A beautifully spread table would stand before her, and Little Two Eyes could eat as much as she wanted. The woman then told Little Two Eyes that when she had had enough to eat she simply had to say Little goat, bleat." }, { "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": "wiki20220301en127_44706", "title": "Dry Your Eyes (TV series)", "score": 0.00980392156862745, "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": 0.009708737864077669, "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": "pubmed23n1004_9883", "title": "Ocular ischemic syndrome; A case report.", "score": 0.009708737864077669, "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": "pubmed23n0830_24397", "title": "Bilateral acute angle-closure glaucoma following treatment with topiramate for headache.", "score": 0.009615384615384616, "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": "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": "pubmed23n0762_17989", "title": "Topiramate-associated acute, bilateral, angle-closure glaucoma: case report.", "score": 0.009523809523809525, "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": "wiki20220301en044_31040", "title": "Charlie Slater", "score": 0.009523809523809525, "content": "On 2 March 2011, it was announced that Martin had recently returned to film two episodes. An EastEnders source told Digital Spy, \"Although they've had their ups and downs, Kat deeply regrets pushing Charlie away. The pair have a tearful reunion and there won't be a dry eye in the house.\" Jessie Wallace who plays Charlie's daughter Kat Moon, said that Charlie would help Kat come to terms with the fact that her baby is still alive, \"With what happened the night they thought Tommy died, things were still unresolved for them. Although they cleared the air before he left, things weren't right between them, so to have him back with her now makes it all the more special. It's also Charlie that makes Kat realise that she needs to bond with Tommy. He makes her see that she can do this.\" Martin returned for two episode's on 19 and 21 April 2011, with his return bringing in 10.31 million people to watch on 19 April and 8.43 million on 21 April." }, { "id": "pubmed23n0680_21006", "title": "Acanthamoeba keratitis due to genotype T11 in a rigid gas permeable contact lens wearer in Spain.", "score": 0.009433962264150943, "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": "pubmed23n0417_11180", "title": "Dry eyes. Eye series. 3.", "score": 0.009433962264150943, "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": "pubmed23n0995_23517", "title": "The Use of Topiramate for Weight Loss Causing Acute Glaucoma: A Case Report and Literature Review.", "score": 0.009345794392523364, "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": "wiki20220301en580_14136", "title": "The 3rd Eye (2017 film)", "score": 0.009345794392523364, "content": "10 years later, Alia is a hard-working professional and Abel is an edgy 15 year old teenager who still sees the ghosts of her childhood. When the sisters' parents die in a car accident, they are forced to leave their current home and return to their parents' old estate where Abel had been attacked years earlier. Alia has been dating a photographer named Davin for 8 months now who joins them at the estate. Abel's hallucinations worsen and she tells Alia that the ghost family that occupies the estate doesn't want them to live there. Alia, now excessively worried about Abel's mental health, decides to take her to a psychiatrist. Abel reveals that her mother had taken her to Bu Windu, a spiritual practitioner, and not a psychologist, when she was a kid. They go to Bu Windu who tells Alia about Abel's open third eye. Alia, who doesn't believe in the paranormal, mockingly asks Mrs. Windu to open her third eye. When her third eye is opened she starts witnessing a string of supernatural" }, { "id": "pubmed23n0829_15875", "title": "Unilateral Acute Closed-Angle Glaucoma After Elective Lumbar Surgery Reveals Multiple Intracranial Aneurysms. A Case Report and Discussion on Workup of Differential Diagnoses.", "score": 0.009259259259259259, "content": "The purpose of our paper is to present a case of a rare complication of posterior lumbar surgery. Our patient presented for elective lumbar decompression, which was complicated by durotomy. She then developed sudden headache and right eye pain once upright on postoperative day 2. Then on postoperative day 3, she developed a dilated nonreactive pupil with extraocular movements intact. A computed tomography scan of the head was negative for subarachnoid hemorrhage. Magnetic resonance angiography showed a possible right posterior communicating artery aneurysm. She was transferred to a tertiary center with a severe headache and a nonreactive pupil, raising concern for evolving third nerve palsy due to aneurysm. A cerebral angiogram was performed and showed multiple aneurysms. Aneurysm location did not explain the patient's symptoms, and ophthalmology was consulted. Elevated intraocular pressure was noted, and the patient was diagnosed with acute angle-closure glaucoma (AACG). Our patient was medically treated and subsequently underwent laser peripheral iridotomy. She has had improved vision and pupillary function at 1 month follow-up. The diagnosis is complicated by a durotomy, which led to cascade in the differential diagnosis to rule out intracranial pathology. Her age and home medications, which had sympathomimetic effects, placed her at increased risk, but lying prone in the dark under the drapes was likely the lead causative factor. In conclusion, a postoperative posterior spine patient with eye pain and changes in vision and pupils should be evaluated with AACG in mind due to the devastating consequences if left untreated or treatment is delayed. " }, { "id": "wiki20220301en127_44702", "title": "Dry Your Eyes (TV series)", "score": 0.009259259259259259, "content": "Dry Your Eyes was a Northern Irish sketch show which aired on BBC One NI in 2006, and was created by the Hole in the Wall Gang, the makers of one of Northern Ireland's most successful shows Give My Head Peace. The show was 'written' by Damon Quinn who also produced and appeared in the series. Writer Damon Quinn said \"It's a temporary move away from Give My Head Peace for us and is made up of a series of short series featuring new characters. We are delighted to be able to welcome on board actors Sharon Morwood, Martin McCann and Emma Little, which is a credit to BBC Northern Ireland in its commitment to bringing on local talent and promoting local comedy.\" A second series with a revamped cast - Diona Doherty, Michael Stranney, Niamh McAllister, Bernadette Brown, Cailum Carragher -will air in January 2022. Recurring sketches" }, { "id": "pubmed23n0724_10853", "title": "[A 56-year-old woman with adult-onset ophthalmoplegic migraine presenting with recurrent bilateral abducens nerve palsy].", "score": 0.009174311926605505, "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": "pubmed23n0088_3140", "title": "[Lacrimal hyposecretion in women working with video terminals].", "score": 0.009174311926605505, "content": "Tests of vision and lacrimal secretion were performed as part of a general medical check-up among women employed at video-terminals in a bank. The tests were taken by three groups of 100 employees each. The first group consisted of full-time (eight hours) employees, the second of those working part-time (the time spent at a video-terminal daily was never less than two hours of continuous work) and a third group of control subjects having different clerical jobs but working in the premises with video-terminals. Diminished lacrimal secretion was most often present among full-time workers (20 per cent). A statistically significant difference in lacrimal secretion was observed between the first and the second group of examinees. There was no significant difference between the second group and the controls." }, { "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": "wiki20220301en553_8137", "title": "The Gentlemen (2019 film)", "score": 0.00909090909090909, "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": "pubmed23n1065_23969", "title": "Neurotrophic keratitis in autoimmune polyglandular syndrome type 1: a case report.", "score": 0.009009009009009009, "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": "wiki20220301en131_9404", "title": "Third Eye Blind discography", "score": 0.009009009009009009, "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": 0.008928571428571428, "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": "wiki20220301en078_58401", "title": "The Eye (2002 film)", "score": 0.008928571428571428, "content": "The Eye, also known as Seeing Ghosts, is a 2002 Hong Kong-Singaporean horror film directed by the Pang brothers. The film spawned two sequels by the Pang brothers, The Eye 2 and The Eye 10. There are three remakes of this film, including Adhu, made in 2004 in Tamil, Naina made in 2005 in Hindi and The Eye, a 2008 Hollywood production starring Jessica Alba. Plot Blind since the age of five, 20-year-old Hong Kong classical violinist Wong Kar Mun undergoes an eye cornea transplant after receiving a pair of new eyes from a donor. Initially, she is glad to have her sight restored but becomes troubled when she starts seeing mysterious figures that seem to foretell gruesome deaths. The night before her discharge from the hospital, she sees a shadowy figure accompanying a patient out of the room and the next morning the patient is pronounced dead." }, { "id": "pubmed23n0477_8608", "title": "[Angle-closure glaucoma: important points in the diagnosis and follow-up].", "score": 0.008849557522123894, "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": "pubmed23n0490_529", "title": "[Work and video terminals: eye discomfort and blepharitis. Preliminary data].", "score": 0.008849557522123894, "content": "Blefaritis is one of the most common ocular disorders encountered in clinical practice. The clinical manifestation primarily occurs along the lid margin, and the predominant symptoms are itching and burning. In addition, the inflammation could cause a dysfunction of meibomian gland; this condition leads to ocular surface abnormalities. Objective of the present study was to determine if the Visual Display Terminals (VDT) work get worse the signs and symptoms of blefaritis in a group of 35 VDT operators. Results showed a correlation between burning, itching and corneal fluorescein staining and hour number a day of VDT work in the workers affected by blefaritis. The Authors concluded that VDT work can get worse the signs and symptoms of blefaritis." }, { "id": "pubmed23n0726_12720", "title": "Secondary Bilateral Angle Closure Glaucoma due to Topiramate.", "score": 0.008771929824561403, "content": "We examined a 39-year-old female with severe headache and blurred vision. She was on topiramate, 50 mg once a day for one week because of migraine. Periorbital edema, chemosis, myopia, high intraocular pressures, and shallow anterior chambers were present at the initial examination. Iridocorneal angles were closed, ultrasound showed choroidal effusions. We stopped topiramate and started antiglaucoma treatment. After one week the intraocular pressure was 10 mm Hg in both eyes without treatment. A new ultrasound showed no choroidal effusions. Topiramate has been associated with acute secondary angle closure glaucoma as an idiosyncratic reaction to the drug. Physicians prescribing topiramate need to alert patients of this potential sight-threatening idiosyncratic reaction." }, { "id": "wiki20220301en104_52425", "title": "One-Eye, Two-Eyes, and Three-Eyes", "score": 0.008771929824561403, "content": "The next day she went out again with the goat and left the scraps given to her. After a while, her sisters noticed this and told their mother. So Little One Eye was sent to go with Little Two Eyes when she drove the goat to pasture to see if someone was giving her food and drink. Little Two Eyes suspected this was the reason Little One Eye was accompanying her and so sang Little One Eye a song to make her one eye fall asleep. Little Two Eyes then summoned the table and ate as before. On returning home, Little One Eye told her mother that the fresh air made her so tired she fell asleep and that was why she did not see what Little Two Eyes had done, so the next day the mother sent Little Three Eyes to watch Little Two eyes when she went out with the goat. Little Two Eyes suspected that Little Three Eyes had been sent to watch her also, and so meant to sing her song to make her three eyes fall asleep but instead she sang a song to only make two of her eyes fall asleep. Little Three Eyes" }, { "id": "pubmed23n0981_1772", "title": "Premature Expression of Pseudoexfoliation Syndrome With Presenile Cataract in a 28-Year-Old Lady.", "score": 0.008695652173913044, "content": "We report a case of premature expression of pseudoexfoliation syndrome with presenile cataract in a 28-year-old lady with primary developmental glaucoma who had undergone glaucoma filtration surgery 26 years ago. We report a case of a 28-year-old Indian lady with progressive diminution of vision associated with photophobia in the left eye for 5 years and loss of vision in the right eye since childhood. She underwent glaucoma filtration surgery in the left eye at the age of 2 and was on 2 topical glaucoma medications when she presented to us. Refractive error was -17.00 D with -3.50 D @ 90-degree cylinder in the left eye. The right eye was phthisical. Left eye showed superior diffuse bleb, enlarged but clear cornea with superior Haab's striae, deep and quiet anterior chamber and patent surgical iridectomy at 1 o'clock position. There was diffuse iris atrophy with pseudoexfoliation at the pupillary ruff and over the anterior lens capsule. Lens showed grade 2 nuclear cataract. Intraocular pressure in the left eye was 23 mm Hg. Fundus examination showed 0.9 cupping with an inferior notch and diffuse pallor of the optic disc. Axial length of left eye was 31.44 mm. On the basis of these findings, she was diagnosed with primary developmental glaucoma and high myopia, status after glaucoma filtration surgery with presenile cataract and pseudoexfoliation in the left eye. The topical antiglaucoma medications were augmented. After 1 month, intraocular pressure in the left eye was reduced to 14 mm Hg. She was advised to continue topical glaucoma medications and regular follow-up. The present case is the first to describe the unusual presentation of pseudoexfoliation in a young individual along with presenile cataract. Simultaneous occurrence of pseudoexfoliation with cataract could be due to previous intraocular surgery, iris trauma, possible low-grade inflammation, and high myopia in a predisposed eye. The clinician should be aware that although a rare condition, pseudoexfoliation can occur in the young and may be associated with presenile cataract." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 0, 100 ] ], "word_ranges": [ [ 0, 16 ] ], "text": "It is a typical and frequent clinical picture in children. You are describing a contagious impetigo." }, "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": "Exudative erythema multiforme.", "2": "Contagious impetigo.", "3": "Infantile acne.", "4": "Pustular psoriasis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0793_12042", "title": "Infantile generalized pustular psoriasis: successful disease control with intermittent etretinate.", "score": 0.01913919413919414, "content": "Infantile generalized pustular psoriasis is a rare form of psoriasis and the best treatment is controversial. We experienced a 2-year-old female with erythema on her neck and axilla starting at 3 months of age. She presented with recurrent annular and geographic scaly erythema with a few pustules on the neck, precordium and axilla, but no fever. The histopathology revealed subcorneal neutrophilic infiltration and microabscesses without Kogoj's spongiform pustules. The initial diagnosis was subcorneal pustular dermatosis. However, she developed widespread geographic erythema and numerous pustules over her entire body with a fever when she got a cold. A second skin biopsy revealed monolocular pustules and Kogoj's spongiform pustules in the subcorneal layer. Etretinate was administrated after a diagnosis of pustular psoriasis was made and her condition improved gradually. The choice of treatment depends on patient age, general condition and the disease severity. " }, { "id": "pubmed23n0697_18549", "title": "Familial juvenile generalized pustular psoriasis: response to methotrexate.", "score": 0.018967997123336928, "content": "Two siblings with generalized pustular psoriasis were admitted to the hospital. Case 1: A 7-year-old girl presented with recurrent episodes of multiple pinhead-sized pustules all over her body since the age of 3. The current episode began a week prior to the onset of the lesions. On cutaneous examination, she had generalized erythema topped with tiny pustules, scales, and crusting (Figure 1A). A Gram stain performed from the pustule and cultures taken from the pus and blood were sterile. Histopathology of the pustule was suggestive of pustular psoriasis (Figure 2). Hemoglobin was 8.8 g%. Other hematologic, microbiologic, and radiologic investigations were normal. Treatment was started with methotrexate, to which she responded dramatically with reduction in appearance of new lesions, erythema, and scaling. After 4 weeks of treatment, there was almost 90% clearance of skin lesions. Case 2: A 3-year-old boy, brother of the patient in case 1, presented with similar complaints for the past week. The episode was preceded by high-grade fever. He had generalized erythema, scaling, and edema and multiple pinhead-sized pustules, some of which were arranged in an annular configuration (Figure 1B). All investigations, as in case 1, were normal except for hypocalcemia (Ca2+ = 8.8 g%) and generalized rarefaction on x-rays of both the ankle joints. Treatment was started with prednisolone (because of poor general condition) and methotrexate. Following therapy, significant improvement was evident with reduction in erythema and cessation of appearance of new pustules. The dose of prednisolone was gradually tapered after 3 weeks and then stopped." }, { "id": "pubmed23n0406_211", "title": "Acute generalized exanthematous pustulosis with erythema multiforme-like lesions.", "score": 0.018783068783068783, "content": "Acute generalized exanthematous pustulosis (AGEP) resembles generalized pustular psoriasis, but may manifest targetoid lesions, purpura, and blisters in addition to pustules. We describe a case of AGEP with erythema multiforme (EM)-like features in a 35-year-old woman who presented with acute onset of high fever and a strikingly polymorphic eruption consisting of numerous tiny pustules on erythematous bases, marked facial edema, oral and genital erosions, targetoid vesicular and purpuric lesions, pustules in string-of-pearl configuration and ring-like vesicles. The histology revealed, in addition to subcorneal pustules, vacuolar interface dermatitis with involvement of eccrine glands, and microabscesses in pilosebaceous structures. Systemic corticorsteroid and antibiotics were initiated, resulting in rapid resolution without recurrence. Recognition of EM-like lesions on a background of generalized pustular eruption could facilitate the diagnosis of AGEP and the institution of appropriate treatment." }, { "id": "wiki20220301en250_35953", "title": "Generalized pustular psoriasis", "score": 0.017427884615384616, "content": "Infantile and juvenile GPP is a rare disease in general, but even more so in children. In 2010, an article was published in Pediatric Dermatology by the Department of Dermatology, University of São Paulo. The report acknowledged that psoriasis is a relatively common skin condition in children, but \"the pustular variant is rare.\" Out of 1,262 cases of psoriasis in children, a \"0.6% rate of pustular variants\" was found. When GPP does occur in children, it usually appears during the first year of life. Khan et al. reported that in GPP patients ten or younger, less than 12% of cases are preceded by ordinary psoriasis. This differs greatly from GPP cases in adults, where 85% of GPP is preceded by typical psoriatic lesions." }, { "id": "pubmed23n0392_5517", "title": "Recurrent impetigo herpetiformis in a pregnant adolescent: case report.", "score": 0.016095934333718098, "content": "Impetigo Herpetiformis is a rare pustular dermatosis that typically occurs in pregnant women with unknown etiology. A 17 year old patient who developed Impetigo Herpetiformis for the second time in the 27th week of her 2nd pregnancy is presented. The patient improved with corticosteroids treatment but the lesions did not clear completely and had flare ups during stressful periods which brings us to conclusion that Impetigo Herpetiformis at least has a common pathway with Generalized Pustular Psoriasis in the pathogenesis as stress provoked exacerbations." }, { "id": "pubmed23n0709_4700", "title": "Ritodrine-induced pustular eruptions distinctly resembling impetigo herpetiformis.", "score": 0.014585414585414586, "content": "A 27-year-old nulligravida woman without a history of dermatosis was hospitalized for threatened preterm labor at 29 weeks' gestation; therefore, continuous infusion of ritodrine hydrochloride was started. At 31 weeks' gestation, erythematous plaques appeared and spread over the body surface; therefore, a topical steroid preparation was applied. At 32 weeks' gestation, the eruptions developed into irregular annular areas of erythema with multiple pustules accompanied by severe itching, and oral prednisolone treatment was started. Bacterial cultures of the pustules were negative, and a crural cutaneous biopsy revealed Kogoj's spongiform pustules. Based on the clinicopathological findings, the most likely diagnosis was impetigo herpetiformis, which causes cutaneous symptoms closely resembling pustular psoriasis in pregnant females without a history of psoriasis. To rule out ritodrine-induced pustular eruptions, the ritodrine infusion was stopped and treatment with an MgSO(4) preparation was started at 33 weeks' 3 days' gestation; however, the uterine contractions could not be suppressed. Because of the patient's highly edematous, severely painful feet, a cesarean section was performed the same day. Within several days of delivery, the eruptions began to resolve, and no recurrence was observed after treatment with oral prednisolone was stopped 31 days after delivery. On the basis of a positive patch test for ritodrine, we diagnosed pustular drug eruptions caused by ritodrine hydrochloride. Although ritodrine-induced pathognomonic cutaneous eruptions are rare, we would like to emphasize that ritodrine can cause drug-induced pustular eruptions distinctly resembling life-threatening impetigo herpetiformis." }, { "id": "wiki20220301en245_24146", "title": "Pustular psoriasis", "score": 0.014286955011290603, "content": "Generalized pustular psoriasis (GPP) is also known as (von Zumbusch) acute generalized pustular psoriasis in acute cases, and as impetigo herpetiformis during pregnancy. GPP is a rare and severe form of psoriasis that may require hospitalization. This form of psoriasis is characterized by an acute onset of numerous pustules on top of tender red skin. This skin eruption is often accompanied by a fever, muscle aches, nausea, and an elevated white blood cell count. Annular pustular psoriasis (APP), a rare form of GPP, is the most common type seen during childhood. APP tends to occur in women more frequently than in men, and is usually less severe than other forms of generalized pustular psoriasis such as impetigo herpetiformis. This form of psoriasis is characterized by ring-shaped plaques with pustules around the edges and yellow crusting. APP most often affects the torso, neck, arms, and legs. Diagnosis" }, { "id": "wiki20220301en250_35956", "title": "Generalized pustular psoriasis", "score": 0.014248366013071896, "content": "Case reports Case report 1 Von Zumbusch observed a male patient, who had had classic psoriasis for several years, and who then went through recurrent episodes of bright [erythema] and [edema], which became studded with multiple pustules. Von Zumbusch observed this patient through nine hospital admissions over 10 years. Case report 2 Hazarika gave a report of a 29-year-old woman with no family history of psoriasis, having had a normal first pregnancy, who presented with GPP in the twenty-eighth week of her second pregnancy. Steroid therapy caused a worsening of the symptoms. With cyclosporine the lesions cleared in 10–14 days, but new lesions appeared. The patient gave birth to a healthy baby in the thirty-eighth week of pregnancy. A month and a half after delivery, the woman presented with a psoriatic plaque on her leg." }, { "id": "pubmed23n0420_20309", "title": "[Kawasaki's disease with eruptive pustular and guttate psoriasis].", "score": 0.013844767910483145, "content": "Kawasaki's disease may have numerous atypical forms and these must be recognized in order to avoid delay of treatment. We report a case of psoriasis, first pustular and then guttate, occurring during Kawasaki's disease, and discuss a common pathophysiological mechanism. A 3 year-old boy was seen for a febrile exanthema suggestive of Kawasaki disease (bilateral conjunctivitis, red and fissured lips, palmoplantar erythema, scarlet fever-like rash and perineal desquamation) associated with pustular lesions. A biopsy specimen of a pustular area showed histological features consistent with the diagnosis of pustular psoriasis. No coronary abnormality was found. The child was treated with intravenous immunoglobulins (2 g/kg) and oral aspirin (60 mg/kg/d). All the symptoms disappeared and immediate follow-up was marked by the appearance of guttate psoriasis. Onset of psoriatic lesions during Kawasaki disease has been reported in 12 cases, either in acute phase or in immediate follow-up. Coronary complications have been found in 4 of 5 cases with acute psoriasis, suggesting a severe prognosis for this association. The hypothesis of a common pathophysiological mechanism is discussed with the intervention of a bacterial toxin acting as a superantigen and resulting in an strong activation of T-cells that leads to keratinocyte activation. The psoriatic lesions could hence be considered as a form of Köbner's phenomenon." }, { "id": "article-36078_19", "title": "Generalized Pustular Psoriasis -- History and Physical", "score": 0.01353526485220954, "content": "Impetigo herpetiformis represents widespread pustular psoriasis occurring in pregnancy. Onset is usually in the third trimester of pregnancy, but may be earlier, and has been documented in the first month of pregnancy and in the first day of the puerperium. The disease often persists until the child is born and may last after childbirth. It is characterized by salient features of generalized pustular psoriasis, usually starting from flexural surfaces as symmetrical, confluent areas of pustulation. The outbreak of lesions begins in the groin region and other flexures, with small pustules appearing on an inflamed skin. These spread radially, become dry in the center, or form plaques which may become widespread and leave a reddish brown pigmentation as they heal. The tongue, oral cavity, and even the esophagus may be involved, with erosions following pustules." }, { "id": "wiki20220301en250_35957", "title": "Generalized pustular psoriasis", "score": 0.013505402160864346, "content": "Case report 3 An eleven-year-old boy had an eight-year history of recurrent GPP. He suffered from \"fever, malaise and pain\". He was treated with acitretin, and improvement was seen in five weeks. Case report 4 In 1991, a case was reported of a man having plaque psoriasis and treating it with UV radiation at a tanning salon. After receiving a partial thickness burn from overexposure, he presented with annular pustular psoriasis, which cleared after 21 days, only to reoccur every 3 to 6 weeks for a year. Case report 5 A case report published in the Journal of Dermatological Treatment documents the successful use of adalimumab to control symptoms and induce relapse for 72 weeks. \"Adalimumab is ... approved for the treatment of moderate to severe rheumatoid arthritis ... and more recently for the treatment of psoriatic arthritis\". See also List of cutaneous conditions Psoriasis References External links Psoriasis" }, { "id": "pubmed23n0779_7052", "title": "Pustular psoriasis of pregnancy (impetigo herpetiformis)--case report.", "score": 0.013040523320023787, "content": "Impetigo herpetiformis is a rare dermatosis of pregnancy with typical onset during the last trimester of pregnancy and rapid resolution in the postpartum period. Clinically and histologically, it is consistent with pustular psoriasis. This similarity has led some authors to name the disease \"the pustular psoriasis of pregnancy\". We report the case of a patient who developed impetigo herpetiformis in two successive pregnancies." }, { "id": "wiki20220301en246_35122", "title": "Impetigo herpetiformis", "score": 0.012802327695944717, "content": "Impetigo herpetiformis is a form of severe pustular psoriasis occurring in pregnancy which may occur during any trimester. It is the only well known pustular psoriasis which is treated with steroids. See also Dermatoses of pregnancy List of cutaneous conditions Notes References External links Pregnancy-related cutaneous conditions Psoriasis Pathology of pregnancy, childbirth and the puerperium" }, { "id": "pubmed23n0332_3785", "title": "Generalized pustular psoriasis of pregnancy (impetigo herpetiformis).", "score": 0.012698288661405016, "content": "A 17-year-old woman had a sudden eruption of pustules in her intertriginous areas as well as of erythematosquamous plaques on the scalp, elbows, palms and soles in the third trimester of her first pregnancy. Histopathological evaluation of a biopsy revealed typical changes of pustular psoriasis with parakeratosis and abscesses of neutrophils (Kogoj's spongiform pustules). The diagnosis of pustular psoriasis was established by the typical clinical and histopathological findings. Laboratory parameters showed a highly elevated blood sedimentation rate, hypoferric anemia and decreased albumin levels. Serum concentrations of parathormone and its metabolites were normal. After systemic treatment with glucocorticosteroids and antibiotics, the lesions improved but did not clear. After delivery of a healthy boy, therapy was switched to retinoid photochemotherapy with isotretinoin and PUVA that resulted in rapid and complete clearing of the eruption. The coincidence of plaque-type psoriasis and a pustular eruption as described previously in impetigo herpetiformis supports the view that this dermatosis of pregnancy is a variant of generalized pustular psoriasis." }, { "id": "article-36078_10", "title": "Generalized Pustular Psoriasis -- Epidemiology -- Age at Onset", "score": 0.012366942428777141, "content": "The incidence peaks between 40 and 59 years of age, but infantile and juvenile cases are also reported. The age at onset tends to be earlier in those with pure generalized pustular psoriasis without plaque psoriasis." }, { "id": "wiki20220301en250_35954", "title": "Generalized pustular psoriasis", "score": 0.012348484848484848, "content": "According to the article by the University of São Paulo, mentioned above, \"The onset of childhood GPP is generally abrupt and accompanied by toxic features.\" The original acute episode usually lasts a few days, but \"repeated waves of inflammation and pustulation may follow.\" It is important that the disease is managed immediately in order to prevent life-threatening complications, such as infection or [sepsis]. Other complications include \"metabolical, hemo-dynamic, and thermoregulatory disturbances\" which occur as a result of \"alterations of the epidermal barrier.\" See Case Report 3 Circinate and annular This type of psoriasis appears as round lesions. It begins as discrete areas that become raised and swollen. Pustules appear at the edges of the round lesions, creating rings. The pustules then dry out and leave a trail of scale as the lesion grows. See Case Report 4" }, { "id": "wiki20220301en250_35976", "title": "Localized pustular psoriasis", "score": 0.01214752002153577, "content": "Localized pustular psoriasis presents as two distinct conditions that must be considered separate from generalized psoriasis, and without systemic symptoms, these two distinct varieties being pustulosis palmaris et plantaris and acrodermatitis continua. See also Psoriasis Skin lesion References Psoriasis" }, { "id": "wiki20220301en250_36080", "title": "Annular pustular psoriasis", "score": 0.012042875157629257, "content": "Annular pustular psoriasis is a rare variant of pustular psoriasis, having an annular, or circinate, lesion morphology that may appear at the onset of pustular psoriasis, with a tendency to spread and form enlarged rings. See also Psoriasis List of cutaneous conditions References External links Psoriasis" }, { "id": "article-36078_17", "title": "Generalized Pustular Psoriasis -- History and Physical", "score": 0.012007173116407205, "content": "Early onset plaque psoriasis may develop into pustular psoriasis after years, the cause usually being steroids or any other environmental factor or the onset maybe de novo , usually after an infection. In either form, the earliest symptom is burning sensation in the skin, which becomes dry and tender. These danger signs, not found in all cases, are followed by a sudden onset of high fever and severe malaise. Pre-existing lesions develop into minute pustules. Worsening of erythema occurs, and pustules spread to involve the previously normal skin, mostly the flexures and genital regions. Pustules may be in the form of discrete pustules, lakes of pus, circinate lesions, erythematous plaques covered with pustules, or a generalized erythroderma. Pustules appear in a series, and dried pustules start exfoliating. The nail changes include thickening and subungual areas of pus. The oral mucosa and tongue may also be involved. The disease process may resolve within a few days or weeks; psoriasis can revert back to its normal state or erythroderma can develop." }, { "id": "wiki20220301en250_35948", "title": "Generalized pustular psoriasis", "score": 0.01169874910882105, "content": "Generalized pustular psoriasis (GPP) is an extremely rare type of psoriasis that can present in a variety of forms. Unlike the most general and common forms of psoriasis, GPP usually covers the entire body and with pus-filled blisters rather than plaques. GPP can present at any age, but is rarer in young children. It can appear with or without previous psoriasis conditions or history, and can reoccur in periodic episodes. Signs and symptoms GPP presents as pustules and plaques over a wide area of the body. It differs from the localized form of pustular psoriasis in that patients are often febrile and systemically ill. However, the most prominent symptom, as described in the Archives of Dermatology, is \"sheeted, pinhead-sized, sterile, sub-corneal pustules\". The IPC roundtable adds that these pustules often occur either at the edges \"of expanding, intensely inflammatory plaques\" or \"within erythrodermic skin\"." }, { "id": "pubmed23n0521_11812", "title": "Impetigo herpetiformis: menstrual exacerbations for 7 years postpartum.", "score": 0.011604072996561757, "content": "Impetigo herpetiformis (IH) is a rare pustular dermatosis that shares striking clinical and histological similarities to generalized pustular psoriasis. The case of a 26-year-old primigravida with IH progressing in the 30th week of her pregnancy is presented. The peculiarity of our presentation relies on the reappearance of the disease postpartum. Monthly exacerbations during menstruation lasted for 7 years. Some probable clues regarding the pathogenesis of IH are suggested." }, { "id": "pubmed23n0841_25294", "title": "Elderly-Onset Generalized Pustular Psoriasis without a Previous History of Psoriasis Vulgaris.", "score": 0.011173358232181761, "content": "Generalized pustular psoriasis (GPP) is characterized by sudden fever and extensive erythema with pustules and occurs in patients with or without preceding psoriasis vulgaris. We report an 83-year-old man showing irregularly shaped erythema with pustules on the trunk and extremities. He initially had no fever and came to our clinic a few days after the onset of the skin lesions because of high fever and general malaise. We found an extension and new development of erythema and pustules on the whole body. The patient also manifested night delirium. Histological examination revealed neutrophil infiltration into the upper epidermis, which formed a spongiform pustule of Kogoj. Pustular fluid cultures were negative for bacteria. We diagnosed GPP without preceding psoriasis vulgaris. Mutation analysis revealed no significant mutations in IL36RN and CARD14. Previous reports indicated that onset of GPP at the age of 83 years is definitely rare. In older individuals, general disease characteristics include an atypical clinical course, an especially slow appearance and cure, and mental disorder. Our case also revealed such characteristics. Thus, it is necessary to be aware of the clinical course and mental problems in elderly patients with GPP. " }, { "id": "wiki20220301en248_42517", "title": "Erosive pustular dermatitis of the scalp", "score": 0.011083743842364532, "content": "Erosive pustular dermatitis of the scalp presents with pustules, erosions, and crusts on the scalp of primarily older Caucasian females, and on biopsy, has a lymphoplasmacytic infiltrate with or without foreign body giant cells and pilosebaceous atrophy. See also Skin lesion Cicatricial alopecia List of cutaneous conditions References Conditions of the skin appendages" }, { "id": "wiki20220301en004_124221", "title": "Psoriasis", "score": 0.010923616206081356, "content": "The five main types of psoriasis are plaque, guttate, inverse, pustular, and erythrodermic. Plaque psoriasis, also known as psoriasis vulgaris, makes up about 90% of cases. It typically presents as red patches with white scales on top. Areas of the body most commonly affected are the back of the forearms, shins, navel area, and scalp. Guttate psoriasis has drop-shaped lesions. Pustular psoriasis presents as small, noninfectious, pus-filled blisters. Inverse psoriasis forms red patches in skin folds. Erythrodermic psoriasis occurs when the rash becomes very widespread, and can develop from any of the other types. Fingernails and toenails are affected in most people with psoriasis at some point in time. This may include pits in the nails or changes in nail color." }, { "id": "wiki20220301en250_35951", "title": "Generalized pustular psoriasis", "score": 0.010855683269476373, "content": "Eugene M. Farber, MD and colleagues provide a description of von Zumbusch psoriasis in \"Pustular Psoriasis\", published in Cutis. They describe the pattern as having \"waves of widespread or universally fiery redness\". The affected areas are \"painful and tender\". Small sub-corneal pustules form, with sizes originally between 1 and 10 mm in diameter. These pustules may merge to form \"yellow-green lakes of pus\". The pustules dry out, and \"Waves of scarlatiniform [resembling scarlet fever] peeling follow, removing the desiccating pustules\". In regards to the onset, the von Zumbusch form may \"supervene on any previous pattern of psoriasis\". It also may or may not recur periodically. Generalized pustular psoriasis of pregnancy (Impetigo herpetiformis) This form of GPP tends to have symmetrical and grouped features. It usually onsets early in the third trimester of pregnancy, and generally persists until the child is born, but occasionally long after." }, { "id": "pubmed23n0018_3472", "title": "[Impetigo herpetiformis and PUVA-treatment (author's transl)].", "score": 0.01069023569023569, "content": "Report on a 20 years old pregnant woman, who fulfilled the criteria of the impetigo herpetiformis as well as later those of the pustular psoriasis Zumbusch in her clinical course. The impetigo herpetiformis is interpreted as a variant of the pustular psoriasis occurring during the pregnancy with lowered calcium-level, which increases the endogeneous eruption pressure. After negative attempts of treatment with Prednisolon, antibiotics, and later with Methotrexat an excellent therapeutic effect could be achieved by oral PUVA-treatment." }, { "id": "article-36078_18", "title": "Generalized Pustular Psoriasis -- History and Physical", "score": 0.010574152072711151, "content": "A rare subacute form represents generalized pustular psoriasis in infancy and early childhood. The disease starts as discrete areas of erythema which become elevated. Pustules appear peripherally on the advancing edge, becoming dry and shedding in the form of scales as the lesion gradually progresses. There are no accompanying systemic symptoms." }, { "id": "pubmed23n0075_16446", "title": "[Generalized pustular psoriasis in siblings].", "score": 0.009900990099009901, "content": "Generalized pustular psoriasis in siblings, 31-year-old male and 26-year-old female, is presented. In both cases, pustular lesions appeared in childhood and typical eruption of psoriasis vulgaris was not observed during their clinical course. Cholecystitis and chronic tonsillitis of the brother and periodontitis and chronic tonsillitis of the sister were considered to be possible provocative factors. HLA-A24, Bw52-, DR2, as the common HLA haplotype in our cases, was estimated." }, { "id": "wiki20220301en245_24144", "title": "Pustular psoriasis", "score": 0.009805924412665985, "content": "The term pustular psoriasis is used for a heterogeneous group of diseases that share pustular skin characteristics. Signs and symptoms Characteristics may vary according to the subtype of pustular psoriasis. For example, it can be localized, commonly to the hands and feet (localized pustular psoriasis), or generalized with widespread patches appearing randomly on any part of the body (generalized pustular psoriasis). However, all forms of pustular psoriasis share in common the presence of red and tender blotchy skin covered with pustules." }, { "id": "pubmed23n0973_7187", "title": "Psoriasis Vulgaris in Children - Case Presentation.", "score": 0.009708737864077669, "content": "A seven-year-old girl, with erythematous-squamous rash, was admitted to our clinic to decide upon the diagnosis and treatment, being transferred from a county hospital. Heredo-collateral antecedents - an aunt, related to her mother, with psoriasis. When admitted, the patient presented prominent non-pruriginous erythematous plaques, clearly marked and covered by thick, silvery-white scales, easily exfoliating, all over at the level of: scalp, earlobes, neck, torso, limbs, periungual, axillary and genital areas. The dermatological examination: psoriasis vulgaris in patches and plaques, a diagnosis also confirmed histopathologically. Using a local dermatologic treatment, the evolution was favorable, the patient initially presenting thick squamae, then, gradually, there occurred the psoriasis whitening. We presented this case since psoriasis is rarely met at this early age." }, { "id": "wiki20220301en250_35949", "title": "Generalized pustular psoriasis", "score": 0.009457933370976848, "content": "Causes Most cases of generalized pustular psoriasis present in patients with existing or prior psoriasis conditions. However, there are many cases of GPP that arise without a history of psoriasis. The Department of Dermatology of the University of São Paulo proposed a classification for these two conditions. Pso+ represents patients with a personal history of psoriasis and pso- represents patients with no history of psoriasis. They also identified a common factor among patients in each group: In the pso+ group, the most common precipitating factor is corticosteroid withdrawal. In the pso- group, the most common precipitating factor is infection. In a large portion of cases, the disease is brought on by some triggering factor. Through research and observation, many of these factors have been identified. The following table, from an article in Cutis, lists a few factors that have been observed as influential in the onset of GPP." }, { "id": "pubmed23n1018_23597", "title": "Human Orf: An Under-recognized Entity.", "score": 0.009433962264150943, "content": "Dear Editor, Orf, also called contagious ecthyma, contagious pustular dermatitis, sore mouth, or scabby mouth, is a highly contagious zoonotic disease which is caused by a double-stranded DNA virus, ORFV (Parapoxvirus genus of the family Poxviridae) (1). The infection is endemic to sheep and goats, and humans are infected either through direct transmission from active lesions on infected animals or through contact with fomites (2). Orf is an occupational hazard and the population at risk includes shepherds, butchers, farmers, wool shearers, and veterinarians (2,3). Professionals rarely seek medical attention as they are aware of its benign nature (4). A 59-year-old woman presented with two painful plaques involving the dorsal aspect of her right thumb and the first interdigital space of the left hand. On examination, targetoid appearance with a central umbilication surrounded by a violaceous bullous halo was observed (Figure 1). The patient had been raising goats on her farm that recently presented udder and perioral crusted lesions. She did not wear gloves while performing this task. A skin biopsy was performed and showed elongation of the rete ridges, edematous papillary dermis, and eosinophilic intracytoplasmic inclusions in vacuolated cells (Figure 2). A diagnosis of human orf was established and the patient was started on a topical antiseptic solution to prevent secondary infection. The lesions healed without scarring after 6 weeks. Orf is characterized by one or multiple nodules on the hands and fingers, but also on the feet, legs, neck, and face. After an incubation period of 3-7 days, the lesions evolve through six clinical stages (2-4): (1) maculopapular stage (days 1-7), with erythematous macules or papules; (2) target stage (days 7-14), with necrotic center and red outer halo; (3) acute stage (days 14-21), in which the nodule begins to weep; (4) regenerative stage (days 21-28), in which the nodule becomes dry; (5) papilloma stage (days 28-35), where the lesion become papilloma-like and forms a dry crust; (6) regression stage (after 35 days). The lesions may be accompanied by lymphangitis, lymphadenopathy, malaise, fever, erysipelas, and occasionally erythema multiforme and bullous pemphigoid (3). Orf is usually a clinical diagnosis (2-4). The characteristic clinical appearance and location of the lesions along with the history of contact with infected animals is sufficient to establish a diagnosis. The differential diagnosis includes milker's nodule, cutaneous anthrax, neutrophilic dermatosis, atypical mycobacterial infection, cutaneous leishmaniasis, pyogenic granuloma, keratoacanthoma, and fungal infection (4,5). Further investigations are performed only when the diagnosis is in doubt and include electron microscopy, virology, enzyme-linked immunosorbent assay, or PCR-based approaches (4). The histological findings depend on the stage of the lesion and include eosinophilic inclusion bodies, epidermal necrosis, vacuolated keratinocytes, a dense mixed dermal infiltrate, and delicate finger-like projections in the epidermis (6).There is no specific treatment since the disease resolves spontaneously within 6-8 weeks, but successful application of cryotherapy, topical imiquimod, and cidofovir has been reported without supporting evidence (4). Surgical debridement should be avoided because it prolonged the recovery period (5). For prevention, wearing nonporous gloves, washing after handling, and isolation of infected animals is effective (2,4). In the present case, the diagnosis of orf was established in a straightforward manner after a good clinical examination and occupational history, allowing us to reassure the patient on its benign nature. The knowledge of this diagnosis prevents multiple complementary investigations (blood tests, histopathology, skin cultures, PCR detection, and electron microscopy) and unnecessary overtreatment. Although a rare entity, the predominant hand involvement in professionals can have significant morbidity that reflects on their productivity and quality of life. This reinforces the need for using appropriate measures to prevent animal-to-human transmission." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 106, 556 ] ], "word_ranges": [ [ 18, 88 ] ], "text": "Since a prolonged and high-dose prednisone regimen will be established, it is advisable, in addition to the non-pharmacological preventive measures, to initiate treatment in any case to minimize the secondary loss of bone mass that occurs with the administration of glucocorticoids (and, above all, in the first months). Therefore, and for this reason alone, options 1, 2 and 5 would be discarded (the three of them have another conditioning factor)." }, "2": { "exist": true, "char_ranges": [ [ 106, 556 ] ], "word_ranges": [ [ 18, 88 ] ], "text": "Since a prolonged and high-dose prednisone regimen will be established, it is advisable, in addition to the non-pharmacological preventive measures, to initiate treatment in any case to minimize the secondary loss of bone mass that occurs with the administration of glucocorticoids (and, above all, in the first months). Therefore, and for this reason alone, options 1, 2 and 5 would be discarded (the three of them have another conditioning factor)." }, "3": { "exist": true, "char_ranges": [ [ 825, 947 ] ], "word_ranges": [ [ 130, 148 ] ], "text": "The option of associating a bisphosphonate could also be considered, but calcium supplementation is missing in proposal 3." }, "4": { "exist": true, "char_ranges": [ [ 557, 824 ] ], "word_ranges": [ [ 88, 130 ] ], "text": "In this context, and in the case of a person over 65 years of age, an appropriate attitude would be to administer calcium supplements (corticosteroids are osteopenizantes because they produce, among other mechanisms, a negative balance of this element) and vitamin D." }, "5": { "exist": true, "char_ranges": [ [ 106, 556 ] ], "word_ranges": [ [ 18, 88 ] ], "text": "Since a prolonged and high-dose prednisone regimen will be established, it is advisable, in addition to the non-pharmacological preventive measures, to initiate treatment in any case to minimize the secondary loss of bone mass that occurs with the administration of glucocorticoids (and, above all, in the first months). Therefore, and for this reason alone, options 1, 2 and 5 would be discarded (the three of them have another conditioning factor)." } }

{ "1": "Request DXA and wait for the result.", "2": "Assess absolute risk of fracture using the FRAX questionnaire without BMD and treat only if it is high.", "3": "Start treatment with bisphosphonates and vitamin D (800 IU/day).", "4": "Administer calcium supplementation (1g) and vitamin D (800 IU/day).", "5": "Assess for osteopenia on radiographs and treat if present." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0410_9186", "title": "A cost effectiveness analysis of calcium and vitamin D supplementation, etidronate, and alendronate in the prevention of vertebral fractures in women treated with glucocorticoids.", "score": 0.01783749803551784, "content": "To assess the relative costs and benefits of calcium and vitamin D supplements, cyclic etidronate, or alendronate in the prevention of vertebral fractures for women and with normal bone density and osteopenia who are about to initiate moderate dose glucocorticoid treatment. Using a decision analysis model, we evaluated the following patients: 4 hypothetical cohorts: 30-yr-old women with normal lumbar spine (LS) bone mineral density (BMD) (t score = 0), 50-yr-old women with borderline osteopenia (t score = -1), 60-yr-old women with moderate osteopenia (t score = -1.5), and 70-yr-old women with severe osteopenia (t score = -2) treated with a mean prednisone dose of 10 mg/day for one year. The main outcomes included the development of vertebral fractures 10 years after glucocorticoid treatment and at age 80 (life-time risk) and direct and indirect costs. At 10 years, calcium and vitamin D supplements decreased fracture rates by 30-50% at a minimal cost (US$800 or less per vertebral fracture avoided) or at a cost saving compared to no treatment for women with osteopenia (t score -1 to -2). Etidronate and alendronate are most cost effective in women with borderline osteoporosis (t scores of -1.5 and -2) in the 10 year analysis. In the life-time analysis, calcium and vitamin D treatment yielded a cost savings compared to no treatment for all groups with osteopenia. Etidronate decreased fracture rates further in all groups at a cost of less than $2,000 per fracture prevented. Alendronate reduced the fracture risk further at cost of $3,000-7,000 per fracture avoided. Calcium and vitamin D supplements and low cost bisphosphonate regimens such as cyclic etidronate decrease the life-time vertebral fracture risk at acceptable costs and should be considered when initiating glucocorticoid treatment for women who do not have osteoporosis." }, { "id": "pubmed23n0833_22449", "title": "[Bone protection in corticosteroid treated patients].", "score": 0.01709901351845086, "content": "The Piedmont Group of Clinical Nephrology compared the activity of 15 nephrology centers in Piedmont and Aosta Valley as regards bone protection in patients on corticosteroids therapy. Fracture prevalence shows great variability: in 4/15 centers (27%) no fractures were found, in 6/15 centers (40%) fractures were present in 1-4% of cases, in 1 center in 18% of patients. Clinical risk of fracture was based on sex, age and postmenopausal status in 11/14 of the centers (79%), history of fractures and bone disease in 4/14 centers (27%), smoking and alcohol consumption in 3 and 2 centers respectively, glucocorticoid dose and duration in 4, in children bone age and calcium phosphorus status. Dual energy X-ray absorptiometry was performed in 12 centers based on risk factors, in 8 (57%) DXA was performed during the follow-up, in 4 it was performed after 12 months and in 2 after 2-3 years. DXA is not prescribed in children. Only in one center, risk assessment is based on FRAX. Most of the patients are treated with vitamin D supplementation at a dose of steroids of 5 mg/d (80%). Calcium carbonate is used in 9 centers (60%), in two it is used only in the presence of low ionized calcium or bone mineral density. Bisphosphonates are used following AIFA prescription, in particular alendronate in all centers, risedronate in seven and denosumab in one. The analysis shows the great variability of the clinical and therapeutic approach regarding bone protection in patients on corticosteroids therapy, in Piedmont and Aosta Valley. " }, { "id": "pubmed23n1027_7405", "title": "Real-world effectiveness of osteoporosis treatment in the oldest old.", "score": 0.016270416850602258, "content": "We studied effectiveness of osteoporosis treatment in women older than 80 years, who often are not included in clinical trials. Treatments were as effective on bone density and fractures as in younger women. To study real-world effectiveness of osteoporosis treatment on BMD and fractures in the oldest old women (≥ 80 years) compared with women (60-79 years) in the clinical setting using Swedish health register data. National registers and data from DXA machines were used to study effectiveness of all available osteoporosis treatments in women 60-79 and ≥ 80 years using three approaches: (1) Total Hip BMD change up to 8 years after treatment start; (2) fracture incidence where patients served as their own controls, comparing the first 3 months after treatment start with the subsequent 12 months; and (3) comparison of fracture incidence post-fracture in women ≥ 80 years treated with osteoporosis treatment or calcium/vitamin D. Analysis 1: Total Hip BMD increased by up to 6.7% and 7.7% in women 60-79 and ≥ 80 years old, respectively. The mean increase in BMD was 1.1%-units per year in both age groups. Analysis 2: Relative to the 3-month baseline, fracture incidence decreased during the subsequent 12 months of treatment. Incidence rate ratios were estimated at 0.65, 0.74, 0.29, and 0.81 for any, hip, vertebral, and non-hip-non-vertebral fracture, respectively. Analysis 3: A 24-month incidence of any fracture in women ≥ 80 years given post-fracture osteoporosis treatment was lower (HR = 0.78) than in women given calcium/vitamin D, but treatment allocation was not random, with lower mortality (HR = 0.51) in patients receiving OP treatment. Osteoporosis medication in women &gt; 80 years in clinical practice likely works, and the magnitude of effect is similar to what was estimated in younger women. The choice between osteoporosis treatment and calcium/vitamin D after fracture in women ≥ 80 years is not random but appears associated with the patient's health status and presence of vertebral fractures, rather than the known risk profile of sustaining a fracture at a high age." }, { "id": "pubmed23n0760_8185", "title": "Management of osteoporosis in primary care before and after the result of densitometry: treatments in real practice versus the recommended by guidelines. CANAL study.", "score": 0.016190476190476193, "content": "To analyze the requirements for osteoporosis (OP) treatment of primary care physicians (PCP), before and after knowing the result of a bone densitometry (DXA). We studied 50 years older women from two Spanish health areas (Canary Islands and Alicante). The FRAX risk factors were collected and we reviewed the requirements for OP treatment before DXA and in the subsequent months (bisphosphonates, strontium, raloxifene/bazedoxifene, estrogens, parathyroid hormone). To evaluate the appropriateness of treatment we used published guidelines. A high risk for hip fracture was considered if FRAX ≥ 3% or the patient had a history of fragility fracture We included 339 women (mean age: 63 years). Before DXA, 14% of Canarias and 58% of Alicante were receiving treatment. Thirty seven percent of treated patients and 26% of the untreated patients had a high fracture risk before DXA. The average FRAX for a high risk of fracture and hip fracture was 5.6% and 2%, respectively. After DXA, the percentage of treated patients rose from 35 to 39%: increasing from 14 to 28% in the Canary Islands and decreasing from 58 to 51% in Alicante. Overall, treatment was received by 64% of patients with OP, 38% of patients with osteopenia and 15% of those with normal DXA. When the OP treatment guidelines were applied, we found that 7% needed treatment according to the most restrictive guidelines and 43% according to the most flexible guidelines. There is great variability in treatment for OP prescribed before after DXA between GP. A broad consensus guideline between different specialties is required to optimize clinical practice." }, { "id": "pubmed23n0978_8262", "title": "Suboptimal osteoporosis evaluation and treatment in older men with and without additional high-risk factors for fractures.", "score": 0.016083376222336594, "content": "We compared osteoporosis case-finding, evaluation and treatment in groups of Older Men and Older Women with age alone as a significant risk for fracture and Older Men with Higher Risk (older men additionally having previous hip fracture, corticosteroid use or androgen deprivation therapy). We studied 13,704 older men and women (≥70 years old) receiving care at a Veterans Affairs medical center from January 2000 to August 2010 whose 10-year hip fracture risk was assessed by limited FRAX score. The main outcome measures were the proportion of patients who had bone mineral density (by dual-energy X-ray absorptiometry [DXA]) and serum 25-hydroxy vitamin D (25-OH D) measurements performed, and calcium/vitamin D or bisphosphonates prescribed. The proportion of men with a 10-year hip fracture risk ≥3% with age alone as a risk was 48% and 88% in men aged 75-79 and ≥80 years, respectively. Compared with Older Women, fewer Older Men underwent DXA (12% vs 63%, respectively) and 25-OH D measurements (18% vs 39%), and fewer received calcium/vitamin D (20% vs 63%) and bisphosphonate (5% vs 44%) prescriptions. In Older Men with Higher Risk category, the proportion of men with 10-year hip fracture risk ≥3% ranged from 69% to 95%. Despite a higher risk and expectation that this group would have greater case detection and screening, few Older Men with Higher risk underwent DXA screening (27%-36%) and 25-OH D measurements (23%-28%), and received fewer calcium/vitamin D (40%-50%) and bisphosphonate (13%-24%) prescriptions. Considering the known morbidity and mortality, our findings underscore the need for improved evaluation and management of osteoporosis in older men at high risk for fracture." }, { "id": "pubmed23n0521_22427", "title": "Efficacy of risedronate in men with primary and secondary osteoporosis: results of a 1-year study.", "score": 0.015302089215132693, "content": "Osteoporosis is prevalent in men with an estimated one in eight men older than 50 years suffering from osteoporotic fracture, and a higher mortality rate after fracture among men compared with women. There are few approved therapies for osteoporosis in men. This observational study assesses the efficacy and safety of risedronate in the treatment of men with primary and secondary osteoporosis. A single-center, open label, randomized, prospective 1-year study was conducted in men with primary or secondary osteoporosis. Patients were randomized to risedronate (risedronate 5 mg/day plus calcium 1,000 mg/day and vitamin D 800 IU/day) or control groups (alfacalcidol 1 mug/day plus calcium 500 mg/day or vitamin D 1,000 IU/day plus calcium 800 mg/day). Bone mineral density (BMD) measurements, X-rays of the spine, a medical history and physical exam, and patient self-assessments of back pain were performed at baseline and 12 months. Blinded semi-quantitative fracture assessment was conducted by a radiologist. A total of 316 men with osteoporosis were enrolled in the trial (risedronate, n=158; control, n=158). At 1 year lumbar spine BMD increased by 4.7% in the risedronate group versus an increase of 1.0% in the control group (P&lt;0.001). Significant increases in BMD at the total hip and femoral neck were also observed with risedronate compared with the control group. The incidence of new vertebral fracture in the risedronate group was reduced by 60% versus the control group (P=0.028). Daily treatment with risedronate for 12 months significantly increased BMD at the lumbar spine, femoral neck and total hip and significantly reduced the incidence of new vertebral fractures. This is the first prospective, randomized, controlled trial to demonstrate a significant reduction in vertebral fractures in 1 year in men with primary or secondary osteoporosis." }, { "id": "pubmed23n0401_11011", "title": "[CBO guideline 'Osteoporosis' (second revision].", "score": 0.013900062572628945, "content": "Risk factors for osteoporotic fractures that can be used for case-finding according to the recent guidelines from the Dutch Institute for Health Care Improvement (CBO) include: a vertebral fracture, a fracture past the age of 50, a positive family history, low body weight, severe immobility and the use of corticosteroids. Measurement of bone mineral density (BMD) is only recommended for case-finding and not for population screening. Measurement of the BMD is advised in women &gt; or = 50 years of age with a fracture, women with a vertebral fracture regardless of age, women &gt; or = 60 years of age with three of the following risk factors, and women &gt; or = 70 years of age with two of the following risk factors: positive family history, low body weight and severe immobility. Persons with less than 1000-1200 mg calcium in their daily food who are using corticosteroids, persons with osteoporotic fractures and persons who are being treated with drugs for osteoporosis are eligible for calcium supplementation. Vitamin D supplementation is recommended for persons who do not come outdoors. For the drug treatment of osteoporosis in the first years after menopause, oestrogens, tibolone and raloxifene may be used. It is recommended that postmenopausal women with one or more osteoporotic vertebral fractures or an increased risk and a T-score below -2.5 be treated with a bisphosphonate. Patients who are expected to be treated with &gt; or = 15 mg prednisolone equivalent per day for more than 3 months and postmenopausal women and older men (&gt; or = 70) who will be treated with &gt; or = 7.5 mg prednisolone equivalent per day should be started on a bisphosphonate as soon as possible. Other patients who will be treated with &gt; or = 7.5 mg prednisolone equivalent per day should take a bisphosphonate if their Z-score is below -1 or their T-score is below -2.5." }, { "id": "pubmed23n1003_4945", "title": "Low rate of densitometric diagnosis and treatment in patients with severe osteoporosis in Colombia.", "score": 0.013863377941047843, "content": "Our study describes the clinical characteristics of patients with fragility fractures. It also shows there is a low knowledge about osteoporosis and its relation to fractures, in addition to the very poor adherence to medical advice and treatment. Osteoporosis is a systemic skeletal disease associated with an increased risk of fragility fractures and is a public health problem worldwide due to population aging. Early osteoporosis diagnosis and treatment is very important for reducing the incidence of fragility fractures and the resulting complications. Our study describes the clinical characteristics of patients with fragility fractures and their risk factors, evaluates the level of knowledge that patients have about osteoporosis, and follows-up on each case to establish if, after the fracture, a densitometric diagnosis was made and the patient received specific treatment in his outpatient follow-up through his health insurance plan. A descriptive cross-sectional study was carried out in a university hospital in Bogotá, Colombia. The data was collected by means of a questionnaire, administered to all patients admitted by the orthopedic emergency department with a diagnosis of fragility fracture. After discharge, a telephone follow-up was done every 3 months for 1 year, and patients were asked if they had already had the dual X-ray absorptiometry (DXA) scan and if they had begun osteoporosis treatment. A total of 111 patients with an average age of 74.4 years (± 11.3 years), of which 84 (75.6%) were women, all consulted for osteoporotic fracture at the orthopedic emergency department of the hospital. Hip fracture was the most frequent (51.4%), followed by vertebral (23.4%), wrist (22.5%), and humerus (4.5%) fracture. A total of 49.5% (n = 55) of the patients did not know what osteoporosis is; 58.6% (n = 65) did not know that fracture is the main complication of this disease, and 62.2% (n = 69) did not associate fractures with osteoporosis. All patients were educated about osteoporosis and the importance of diagnosing and treating it. Patients were given a medical order to have a DXA scan upon discharge; however, only 24.3% (n = 27) had the DXA scan in the first year of the fracture. A total of 33.3% (n = 37) received calcium plus vitamin D, and only 9.9% (n = 11) received osteoporosis treatment (7 bisphosphonate patients and 4 denosumab). No patient received osteoformative therapy. Our study shows that Colombian patients have little knowledge about osteoporosis and its relationship with fragility fractures. It also shows that densitometries are not done and, what is worse, patients with a diagnosis of fracture have limited access to treatment after discharge." }, { "id": "pubmed23n0309_8683", "title": "Osteoporosis: trials and tribulations.", "score": 0.013823857302118173, "content": "A 30-50% reduction in fracture risk produced by a drug is biologically \"worthwhile.\" The detection of this benefit, when truly present, is a challenge requiring large studies of 3-5 years' duration, because only a small number of women at risk actually sustain a fracture during this time. For example, in any year, fractures occur in 1-2 per 100 women approximately 65 years of age, 6-10 per 100 women approximately 75 years of age, and only 1-2 per 2,000 of the 15% of women &lt; 60 years of age with osteoporosis. An appreciation of this low annual event rate is important because (1) it helps patients to understand their illness, (2) it determines the power of clinical trials, (3) it underscores the large numbers of patients that must be treated to prevent one fracture, and (4) it underscores the need for safety, particularly in groups at low absolute risk of fracture; all are exposed to drug side effects, and the vast majority derive no benefit from treatment because they would not have had a fracture without it, despite being at risk. Few studies have met the design requirements needed to identify the antifracture efficacy of a drug when it really exists, namely, (1) large patient samples randomized to treatment or placebo for 3-4 years, (2) blinding throughout follow-up, (3) statistical analyses of preplanned comparisons using intention to treat, and (4) avoidance of statistical analyses of associations discovered by post hoc analyses. Moreover, (5) few studies have assessed long-term safety and quality of life. Consequently, the uncertainty regarding efficacy and safety of available treatments may be more of a problem of the design, execution, and interpretation of the clinical studies than of the drugs themselves. In the reduction of vertebral fracture risk, the greatest optimism exists for hormone replacement therapy (HRT) and the bisphosphonates. HRT reduces bone turnover, increases bone mineral density (BMD), and decreases vertebral fracture rates by approximately 40%, even in women &gt; 70 years of age. Reduction in hip fracture risk with HRT has been reported in observational studies. Two rigorously conducted studies provide credible evidence that the bisphosphonate alendronate reduces the risk of vertebral and hip fractures by approximately 40-50%. Etidronate, calcitonin, and 1,25-dihydroxyvitamin D3 may reduce risk of vertebral fracture; however, problems in study design leave uncertainty. Although 2 trials using fluoride suggest a reduction in fracture rates, the more rigorously conducted trials do not, despite having adequate power to do so. Calcium supplements are likely to slow bone loss, but reduction in fracture risk is uncertain. Vitamin D and calcium supplementation reduce risk of hip fracture in nursing home residents but not in community residents. There have been no studies of the efficacy of any treatment to prevent hip or vertebral fractures in men or in corticosteroid-related osteoporosis. The treatment of osteoporosis is becoming a reality. HRT and the bisphosphonates, particularly alendronate, appear to be the best options at present." }, { "id": "wiki20220301en001_33041", "title": "Osteoporosis", "score": 0.013332856734343724, "content": "Studies of the benefits of supplementation with calcium and vitamin D are conflicting, possibly because most studies did not have people with low dietary intakes. A 2018 review by the USPSTF found low-quality evidence that the routine use of calcium and vitamin D supplements (or both supplements together) did not reduce the risk of having an osteoporotic fracture in male and female adults living in the community who had no known history of vitamin D deficiency, osteoporosis, or a fracture. The USPSTF does not recommend low dose supplementation (less than 1 g of calcium and 400 IU of vitamin D) in postmenopausal women as there does not appear to be a difference in fracture risk. A 2015 review found little data that supplementation of calcium decreases the risk of fractures. While some meta-analyses have found a benefit of vitamin D supplements combined with calcium for fractures, they did not find a benefit of vitamin D supplements (800 IU/day or less) alone. While supplementation does" }, { "id": "pubmed23n0603_11585", "title": "3-year follow-up of 215 fracture patients from a prospective and consecutive osteoporosis screening program. Fracture patients care!", "score": 0.012125791594703512, "content": "Fractures can be prevented if osteoporosis is identified and treated. Starting in 2002, we have been using a screening program in which patients between 50 and 75 years of age with a wrist, shoulder, vertebral, or hip fracture are assessed by DEXA of the hip and spine and if osteoporotic or osteopenic, they are encouraged to see a doctor of their own choice. The patients receive documents containing information, the results of DEXA, and a letter to present to their doctor with suggestions regarding blood tests and treatment. Here we report the 3-year follow-up regarding compliance to the recommended treatment. A questionnaire was sent to fracture patients who participated in the initial screening study from November 2002 through November 2003. Questions included whether they had seen a doctor, whether treatment had been initiated, and their opinions about osteoporosis. 215 of the 236 patients answered the questionnaire, with a mean follow-up of 39 months. 76/87 of those with osteoporosis, 70/99 of those with osteopenia, and 11/29 of those with normal BMD had seen a doctor. Anti-resorptive treatment was prescribed to two-thirds of the osteoporotic patients, to one-sixth of the osteopenic patients, and to none of the patients with normal bone density. Calcium-vitamin D supplementation as monotherapy was given to one-third of the osteoporotic patients, to half of the osteopenic patients, and to half of the normal patients. Only a few osteoporotic patients, one-third of the osteopenic patients, and half of the normal patients received no treatment. Compliance to treatment was 80% over 3 years in those treated. Most patients felt that they could influence their skeletal health. Screening of fracture patients for osteoporosis effectively identifies patients with low bone mineral density and the patient can be trusted to seek appropriate medical advice for treatment of osteoporosis. Based on the bone scan diagnosis, the treatment that these patients received reflects current treatment guidelines well." }, { "id": "wiki20220301en159_33147", "title": "Senile osteoporosis", "score": 0.012051112579863407, "content": "Calcium and vitamin D3 intake from diet or supplementation are crucial in the ethiopathogenesis of this disease; therefore, the effective treatments should consist of non pharmacological methods (such as a modified diet with more calcium 1000–1500 mg/day and vitamin D3 intake of 600-800 IU/day, exercising, smoking cessation, and alcohol restriction), fall prevention, and individually chosen pharmacological intervention (antiresorptive agent like bisphosphonate or estrogen replacement therapy in women). Given bone fracture (hip, vertebrae, and colles) is a devastating complication of osteoporosis, vitamin D3 combined with calcium are used as primary prevention, along with alendronate, residronate, strontium and zoledronic acid which have proven efficacy in primary and secondary hip fracture prevention. The Institute of Medicine recommends a daily allowance of 800 IU of Vitamin D for people 70 and over, to get to a level of serum 25-hydroxyvitamin D (25OHD) of at least 20 ng/ml (50" }, { "id": "wiki20220301en363_22107", "title": "Abaloparatide", "score": 0.011884339026876509, "content": "Participants who completed 18 months of abaloparatide or placebo in the ACTIVE study were invited to participate in an extended open-labeled study - ACTIVExtend study (2012-2016). Subjects (n=1139) received additional 2 years of 70 mg of alendronate, Vitamin D (400 to 800 IU), and calcium (500–1000 mg) supplementation daily. Combined abaloparatide and alendronate therapy reduced significantly the incidence of vertebral and nonvertebral fractures. A clinical trial assessing the effectiveness of abaloparatide in altering spinal bone mineral density (BMD) in male subjects is expected to start in the first quarter of 2018. If successful, Radius Health aims to submit a sNDA to expand the use of abaloparatide-SC to treat men with osteoporosis. In addition to the injectable form of abaloparatide, a transdermal patch is also in development. Commercialization" }, { "id": "pubmed23n1045_23440", "title": "High rates of undiagnosed and untreated osteoporosis in postmenopausal women receiving medical services in the area of Upper Silesia.", "score": 0.01181454946266189, "content": "High social cost and high risk of disability make postmenopausal osteoporosis one of major public health problem in the 21<supst</sup century. The aim of this study was to assess frequency of undiagnosed and untreated osteoporosis in postmenopausal women in the Upper Silesia Region of Poland. Additionally, we compare estimation of the 10-year probability of major osteoporotic fractures (MOF) and hip fractures (HF) based on fracture risk assessment tool (FRAX) with and without bone mineral density (BMD). The survey included 450 postmenopausal women (age 65 ±11 years). A detailed questionnaire included demographic and anthropometric data, comorbidity, history of previous low-energy fractures, family medical history, and treatment for osteoporosis. The FRAX calculator was used to estimate the risk of MOF and HF. Osteoporosis was previously diagnosed in 23.7% women. Of those 70.2% were receiving vitamin D, 27% calcium preparations, 33% bisphosphonates, and 22% were untreated. Only 42.2% women with previous fractures had been diagnosed with osteoporosis and 42.8% received any treatment. 12.5% women with FRAX-BMD ≥ 10% had no risk factors of osteoporosis and &lt; 10% risk of MOF and HF in FRAX without BMD. Osteoporosis often remains undiagnosed and untreated in postmenopausal women. There is a great need to popularize FRAX without BMD calculator among physicians, especially GPs, as the risk calculation justify the implementation of antiosteoporotic therapy. Women with burden of risk factors of fractures and borderline FRAX without BMD values, should be referred to a densitometry examination, as having greater risk of fracture than shown by FRAX without BMD." }, { "id": "pubmed23n0527_5381", "title": "Anti-resorptive therapy for the prevention of postmenopausal osteoporosis : when should treatment begin?", "score": 0.010839079116512797, "content": "Osteoporosis is a condition associated with decreased bone strength and an increased fracture risk. It may be defined based on bone mineral density (BMD) with a T-score at the hip or spine of less than -2.5 standard deviations in young healthy individuals or from an osteoporotic fracture (i.e. a fracture occurring after low-energy trauma or no apparent trauma). Risk factors predisposing to fractures include: increasing age; female gender; low BMD; a prior fragility fracture; a family history of fragility fractures; low bodyweight; lack of estrogen in women (i.e. post menopause); corticosteroid use; smoking; a number of diseases; deficiency in calcium and vitamin D; an increased risk of falls (i.e. impaired vision); immobilization; and Caucasian race. The more risk factors that are present the higher the risk of fractures over the following 10 years. The need to initiate preventive therapy with anti-osteoporotic treatment increases steeply with the absolute fracture risk. Indications for referral for dual energy x-ray absorptiometry measurement of BMD include: age &gt;65 years; age &lt;65 years in postmenopausal women with any of the risk factors already mentioned; premature menopause (&lt;45 years); prolonged amenorrhea (&gt;1 year) in younger women; fragility fractures; and diseases or conditions known to lead to osteoporosis.Anti-resorptive therapies include calcium plus vitamin D, bisphosphonates (alendronate, etidronate, risedronate, ibandronate), selective estrogen receptor modulators (raloxifene), hormone replacement therapy, and calcitonin. Guidelines from several countries on when to initiate anti-resorptive therapy state that therapy may be started in patients with a prior fragility fracture (some guidelines state that in this situation no BMD measurements are necessary) or in patients with a T-score of less than -2.5 (some guidelines state that additional risk factors need to be present in this situation). Some guidelines state that anti-resorptive therapy may be initiated in patients with a T-score in the osteopenic range (from -1 to -2.5, i.e. not frank osteoporosis) in the presence of other risk factors. The cost effectiveness of anti-resorptive therapy increases with the absolute fracture risk. In some scenarios, treatment with bisphosphonates may be cost effective in a 50-year-old woman with an absolute hip fracture risk of &gt;or=1.1% over the next 10 years." }, { "id": "wiki20220301en286_22363", "title": "Canadian health claims for food", "score": 0.010690486897510322, "content": "In total, 63 897 individuals were analysed, most of whom were women (n=58 785 [92%]) with a mean age of 67.8 years (SD 9.7). In trials that reported fracture as an outcome (17 trials, n=52 625), treatment was associated with a 12% risk reduction in fractures of all types. In trials that reported bone-mineral density as an outcome (23 trials, n=41 419), the treatment was associated with a reduced rate of bone loss of 0.54% (0.35–0.73; p<0.0001) at the hip and 1.19% (0.76–1.61%; p<0.0001) in the spine. The fracture risk reduction was significantly greater (24%) in trials in which the compliance rate was high (p<0.0001). The treatment effect was better with calcium doses of 1200 mg or more than with doses less than 1200 mg (0.80 vs 0.94; p=0.006), and with vitamin D doses of 800 IU or more than with doses less than 800 IU (0·84 vs 0·87; p=0·03)." }, { "id": "pubmed23n1133_15884", "title": "The clinician's guide to prevention and treatment of osteoporosis.", "score": 0.01064039408866995, "content": "Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity." }, { "id": "pubmed23n0582_16977", "title": "The cost effectiveness of bisphosphonates for the prevention and treatment of osteoporosis: a structured review of the literature.", "score": 0.00980392156862745, "content": "Osteoporotic fragility fractures constitute a significant public health concern. The lifetime risk of any osteoporotic fracture is very high (40-50% in women and 13-22% in men). Fractures are associated with significant mortality and morbidity and represent a substantial economic burden to society. Bisphosphonates (alendronate, etidronate, risedronate and ibandronate) are indicated for the treatment and prevention of osteoporosis but are costly compared with other treatments, such as vitamin D and calcium. Our search identified 23 studies evaluating the cost effectiveness of bisphosphonate therapy for the treatment and prevention of fragility fractures; these studies were from five geographical areas and employed a variety of comparators and assumptions. We identified 11 studies investigating bisphosphonates in women with low bone mineral density (BMD) [T-score &gt;2.5 standard deviations {SDs} below normal {mean} peak values for young adults] and previous fractures, five studies investigating bisphosphonates in women with low BMD and no previous fracture, one study of bisphosphonates in women with osteopenia, five studies involving screening and two studies of bisphosphonates in special populations (women initiating corticosteroid treatment and men). In women with low BMD and previous fractures, bisphosphonate therapy was most cost effective in populations aged &gt; or =70 years and was unlikely to be cost effective in populations aged &lt; or =50 years. There was uncertainty concerning the cost effectiveness of bisphosphonates in such populations aged 60-69 years. In women with low BMD without previous fractures, treatment with alendronate or risedronate appeared to be cost effective across countries (UK, US, Denmark), but there was some uncertainty about the cost effectiveness of etidronate in patients in the highest age groups. Identifying risk factors for fractures through means such as spine radiographs to detect vertebral deformities improves the cost effectiveness of treatment. In women with osteopenia, alendronate therapy may be cost effective in women with a T-score of -2.4SD in the US. Screening for low BMD and treatment with alendronate or etidronate appears to be cost effective in postmenopausal women in general and in women with rheumatoid arthritis initiating corticosteroid therapy. Alendronate therapy without screening was also shown to be potentially cost effective in certain at-risk male populations, as well as in women initiating corticosteroid therapy after the age of 40 years. Decision makers in the US, UK and Sweden should consider funding the use of bisphosphonates for the prevention and treatment of osteoporosis in women aged &gt;70 years, particularly if they have other risk factors for fracture. Further studies are required to make more definitive conclusions in other countries and patient populations. Screening strategies for low BMD followed by bisphosphonate treatment should also be considered in the general female population aged &gt;65 years in the UK and US and in patients with rheumatoid arthritis initiating corticosteroid therapy." }, { "id": "pubmed23n0581_5826", "title": "[Glucocorticoids and osteoporosis].", "score": 0.009708737864077669, "content": "Treatment with glucocorticoids (GC) has no alternative in many medical disciplines for their anti-inflammatory and immunosuppressive effect. However, osteoporosis and the related fractures are a serious complication brought about by long-term GC therapy. The risk of fractures, especially of the vertebras and the ribs, becomes higher as early as in the first months of oral GC therapy. It grows in proportion to the daily dose of GC, and is present even if low doses are administered (2.5-7.5 mg of prednisone per day). Decreasing bone density (BMD) is not accountable for the higher risk of fractures in GC therapy and fractures occur with higher values of BMD than in primary osteoporosis. There is still no tool that we could use to quantify the changes in the bone quality and the increased risk of fracture in clinical practice. The principal mechanism by which GC induces osteoporosis is inhibition of bone formation caused by the suppression of osteoblastogenesis as well as the activity of functional osteoblasts, with accelerated osteocyte and osteoblast apoptosis. There are significant differences between individuals in terms of GC sensitivity, the reasons of which have not yet been explained. Prior to planned long-term GC therapy (&gt; 3 months) with daily doses higher than 2.5 mg of prednisone p.o. (or higher doses of inhaled GC), it is recommended to perform a densitometry exam using dual-energy X-ray absorptiometry (DXA) in the lumbar region of the spine and femoral collum to evaluate additional risk factors of osteoporosis and fractures for a more precise estimate of the risk of fracture in the specific patient. Sufficient intake of calcium (1,000-1,500 mg of elementary calcium per day) and of the vitamin D (800 IU per day) should be assured in all patients treated by GC. Endogenous production of sexagens should be evaluated and possible substitution therapy should be considered in premenopausal women and younger men. Today, bisphosphonates can be given to patients with a high risk of fracture, the effects of which in preventing the decrease of BMD and vertebral fractures have been documented in randomised clinical studies, even though the evaluation of the risk of fractures was not the primary endpoint of those studies. However, in view of the antiremodelling effect of bisphosphonates, it is clear that this therapy does not eliminate the cause of GC induced osteoporosis and drugs with stimulating effect on osteoblasts will certainly be preferred in the future. Very promising are the first clinical studies of injection parathormone (PTH 1-34) which stimulated bone formation in a continuing GC treatment." }, { "id": "pubmed23n0417_7740", "title": "Use of matched historical controls to evaluate the anti-fracture efficacy of once-a-week risedronate.", "score": 0.009708737864077669, "content": "Placebo controls are essential to assess anti-fracture efficacy of new osteoporosis therapies, but inclusion of a placebo arm in a subsequent clinical trial may be limited by practical or ethical considerations; in these cases, use of an historical control may be appropriate. A recent active-controlled study of risedronate 35 mg once a week demonstrated that this regimen produces increases in bone mineral density (BMD) that are comparable to those seen with the risedronate 5 mg daily dose, which has proven anti-fracture efficacy. To assess the anti-fracture efficacy of this new regimen, we have analyzed the fracture data collected in an active controlled study of risedronate dosing regimens (the Once-a-Week study) using matched historical control data from previous placebo-controlled trials. Women in the Once-a-Week study were matched for age, years since menopause, BMD, and prevalent vertebral fracture status, with placebo patients in the Vertebral Efficacy of Risedronate Therapy (VERT) trials forming an historical placebo group. We also constructed an historical active treatment group from the 5 mg daily arm of the VERT trials for comparison with the 5 mg daily and 35 mg once weekly treatment groups in the Once-a-Week study. Data were obtained from the risedronate 5 mg daily group (n=480) and 35 mg once-a-week group (n=485) in the Once-a-Week study and historical control groups representing daily placebo patients (n=114, matched from 993) and risedronate 5 mg daily patients (n=120; matched from 990) in the VERT studies. Patients received calcium supplementation (1000 mg daily); vitamin D was given if baseline serum 25-hydroxyvitamin D levels were low. Over 1 year, new vertebral fracture risk in the 35 mg once-a-week group was reduced by 77% relative to the historical placebo group (1.2% versus 5.0%; RR 0.23; 95% CI, 0.54 to 0.91, P=0.018), similar to the 1-year risk reduction observed in the VERT trials of risedronate 5 mg daily (61-65%). The incidence of new vertebral fractures in the three active treatment groups was similar: 1.7% in the historical risedronate 5 mg group, 1.5% in the risedronate 5 mg daily group from the Once-a-Week study, and 1.2% in the 35 mg once-a-week group. Risedronate 35 mg once a week appears as effective as the 5 mg daily dose in reducing the risk of new vertebral fractures in the first year of treatment. The use of appropriate historical control data provides an approach to the assessment of fracture effects in osteoporosis trials for which placebo-controlled data are not available." }, { "id": "pubmed23n0508_17961", "title": "[Trend of an osteoporosis curative medicine--Who uses what from when to when how?].", "score": 0.009615384615384616, "content": "About the point of which medicine to use how in the medical treatment of osteoporosis, the large-scale clinical trial performed in Europe and America has been arranging. Especially, about calcium, vitamin D, estrogen, and bisphosphonates medicine can be used now based on the evidence about them. The necessity of medical treatment for the patient diagnosed as osteoporosis according to the criteria established by osteoporosis congress is guaranteed. However, when considering the necessity for prevention of osteoporosis, we would like to know the view about medicating osteopenia group, but there are few bases that for the moment it is important. Moreover, \"up to when\" in the point whether medical treatment is required, we have to wait for the report of the clinical test of medicine medication over a long period of time which is performed now. However, it is foundations to continue medicine medication as much as possible now, if effective. Although it became clear in estrogen medical treatment that a risk is higher than a benefit by medication examination over a long period of time, as well as this, It is necessary to discuss the benefit and the economic effect of an osteoporosis curative medicine." }, { "id": "pubmed23n0920_9797", "title": "Weekly oral bisphosphonates over 2 years prevent bone loss in cardiac transplant patients.", "score": 0.009523809523809525, "content": "Heart transplantation (HTX) is an established therapy for end-stage heart disease. The aim of this study was to determine whether application of oral bisphosphonates is effective in preventing osseous complications after HTX. Thirty-three cardiac transplant recipients were treated with alendronate 70 mg/wk or risedronate 35 mg/wk in combination with 1000 mg calcium and 800 IU vitamin D. Markers of bone metabolism and dual-energy X-ray absorptiometry (DXA) were determined directly after HTX and 2 years later. Primary endpoints were changes in bone mineral density (BMD), markers of bone metabolism (osteocalcin, crosslaps), serum levels of the cytokines osteoprotegerin (OPG), receptor activator of NF kappa-B ligand (RANKL), and incidence of fractures. Eight patients presented with osteoporosis, and 16 patients with osteopenia by DXA without prevalent fractures. Over 2 years, the BMD improved in 2 patients from osteoporosis to osteopenia, and overall BMD remained stable, and fractures did not occur. In addition, the serum levels of OPG increased (P &lt; .0005), and the RANKL levels (P &lt; .001) as well as the RANKL/OPG-ratio decreased significantly (P &lt; .0005). The serum crosslaps showed no significant changes. The BMD showed a significant association with the increased 25-vitamin D levels only in females (P &lt; .001). In heart transplanted patients, weekly oral bisphosphonates in combination with calcium and vitamin D supplementation preserved bone mass, prevented uncoupling of bone resorption/formation and fractures. Bone density should be measured and adequately treated, that is, with regular bisphosphonates." }, { "id": "pubmed23n0589_16218", "title": "79-year-old post-menopausal woman with humerus fracture during teriparatide treatment.", "score": 0.009433962264150943, "content": "The patient, a 79-year-old woman with a history of osteoporosis, presented with acute back pain without trauma, three years ago. Spinal X rays showed a vertebral compression fracture at T7, and DXA indicated a T-score of -2.65 BMD at the total hip. The patient started treatment with alendronate 70 mg once a week, plus calcium and vitamin D supplementation. After two years, she presented new acute back pain, and spinal X-rays revealed new vertebral compression fractures at T8 and T11. In September 2004, she stopped alendronate therapy and began teriparatide 20 microg subcutaneously each day for 18 months, associated with a dose of 1200 mg/day of calcium and 880 IU/day of vitamin D. In July 2005, she fell and sustained a fracture of the left proximal humerus. She was treated with conservative therapy and continued teriparatide therapy. After 25 days of conservative management, left shoulder X-ray showed quick formation of fracture healing. In conclusion, although teriparatide is indicated for the treatment of severe osteoporosis and not to enhance fracture healing, there are many experimental data which indicate that it may be beneficial also in enhancing fracture healing." }, { "id": "pubmed23n0580_10044", "title": "A randomized study of the effect of 5-year and lifetime hip fracture risk information on physician recommendations for management of low bone density.", "score": 0.009433962264150943, "content": "Although risk prediction tools providing absolute fracture risk information are currently under development, little is known about US physicians' current thresholds for osteoporosis treatment or the potential effect of fracture risk information on treatment decisions. To investigate this, a random sample of US primary care physicians was surveyed. Treatment recommendations for 4 patient scenarios depicting postmenopausal women of varying ages, weights, and bone mineral density (BMD) were elicited. Physicians were randomly assigned to receive all scenarios with either a basic BMD report or an augmented BMD report containing 5-yr and lifetime absolute hip fracture risk estimates. Over 95% of physicians recommended prescription pharmacologic treatment of a 70-yr-old patient with osteoporosis. For 3 scenarios depicting women with T-scores of -1.01, treatment recommendations ranged from 30% to 44%. There were no statistically significant differences between physicians who received augmented and basic BMD reports, although those with augmented BMD reports were less likely to recommend prescription treatments. Physician specialty had inconsistent and small effects on recommendations. We conclude that nearly all of a random sample of US primary care physicians recommend pharmacologic treatment of osteoporosis, but a substantial minority also recommend treatment for patients who would not fit current guidelines. A BMD report including absolute hip fracture risk estimates did not change treatment recommendations." }, { "id": "wiki20220301en289_2170", "title": "Vitamin D", "score": 0.009396914446002805, "content": "Bone health In general, no good evidence supports the commonly held belief that vitamin D supplements can help prevent osteoporosis. Its general use for prevention of this disease in those without vitamin D deficiency is thus likely not needed. For older people with osteoporosis, taking vitamin D with calcium may help prevent hip fractures, but it also slightly increases the risk of stomach and kidney problems. A study found that supplementation with 800 IU or more daily, in those older than 65 years was \"somewhat favorable in the prevention of hip fracture and non-vertebral fracture\". The effect is small or none for people living independently. Low serum vitamin D levels have been associated with falls, and low bone mineral density. Taking extra vitamin D, however, does not appear to change the risk." }, { "id": "wiki20220301en480_12200", "title": "Vitamin D deficiency in Australia", "score": 0.009345794392523364, "content": "Infants, Children and Adults < 50 years: 5 μg/day (200 IU/day) Adults > 50 - < 70 years: 10 μg/day (400 IU/day) Adults > 70 years: 15 μg/day (600 IU/day) Treatment Day to day requirements of vitamin D are set around 800-1000IU to maintain healthy levels which in most cases can be provided by sun exposure. Increased amounts are required for individuals who are previously diagnosed as deficient. For those of moderate deficiencies, oral supplementation can be implemented into the diet at levels of 3000-5000 IU per day for a 6- to 12-week period continued by an ongoing reduced dose of 1000- 2000 IU per day to maintain stores in the body. Severe deficiency is treated through megadose therapy where patients are given doses around 100 000 IU to assist in raising stores faster to ensure physical health in restored to prevent further illness or disease. See also Vitamin D deficiency Vitamin D Sun exposure References Health in Australia Vitamin deficiencies" }, { "id": "pubmed23n0691_8774", "title": "Clinical question: What is the best approach to managing glucocorticoid-induced osteoporosis?", "score": 0.009345794392523364, "content": "Glucocorticoid-induced osteoporosis is common, and the resulting fractures cause significant morbidity and mortality. Rapid bone loss and increased fracture risk occur soon after the initiation of glucocorticoid therapy and are dose dependent. The increase in fracture risk is partly independent of bone mineral density, probably as a result of changes in bone material properties and increased risk of falling. Fracture risk can be assessed using the FRAX algorithm, although risk may be underestimated in patients taking higher doses of glucocorticoids. Because of the rapidity of bone loss and increase in fracture risk after the start of glucocorticoid therapy, primary prevention should be advised in high-risk individuals, for example older women and men, individuals with a previous fracture history and those with low bone mineral density. Bisphosphonates are the front-line choice for the prevention of fracture in the majority of glucocorticoid-treated patients, with teriparatide as a second-line option. Calcium and vitamin D supplements should be co-prescribed unless there is evidence of an adequate dietary calcium intake and vitamin D status." }, { "id": "pubmed23n0379_18321", "title": "Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis: 2001 update. American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis.", "score": 0.009259259259259259, "content": "Glucocorticoid-induced bone loss should be prevented, and if present, should be treated (Table 2). Supplementation with calcium and vitamin D at a dosage of 800 IU/day, or an activated form of vitamin D (e.g., alfacalcidiol at 1 microg/day or calcitriol at 0.5 microg/day), should be offered to all patients receiving glucocorticoids, to restore normal calcium balance. This combination has been shown to maintain bone mass in patients receiving long-term low-to-medium-dose glucocorticoid therapy who have normal levels of gonadal hormones. However, while supplementation with calcium and vitamin D alone generally will not prevent bone loss in patients in whom medium-to-high-dose glucocorticoid therapy is being initiated, supplementation with calcium and an activated form of vitamin D will prevent bone loss. There are no data available to support any conclusion about the antifracture efficacy of the combination of calcium supplementation plus an activated form of vitamin D. Antiresorptive agents are effective in the treatment of glucocorticoid-induced bone loss. All of these agents either prevent bone loss or modestly increase lumbar spine bone mass and maintain hip bone mass. While there are no randomized controlled trials of prevention of glucocorticoid-induced bone loss or radiographic vertebral fracture outcomes with HRT or testosterone, patients receiving long-term glucocorticoid therapy who are hypogonadal should be offered HRT. The bisphosphonates are effective for both the prevention and the treatment of glucocorticoid-induced bone loss. Large studies have demonstrated that bisphosphonates also reduce the incidence of radiographic vertebral fractures in postmenopausal women with glucocorticoid-induced osteoporosis. Treatment with a bisphosphonate is recommended to prevent bone loss in all men and postmenopausal women in whom long-term glucocorticoid treatment at &gt; or =5 mg/day is being initiated, as well as in men and postmenopausal women receiving long-term glucocorticoids in whom the BMD T-score at either the lumbar spine or the hip is below normal. While there is little information on the prevention or treatment of bone loss in premenopausal women, these women, too, may lose bone mass if they are being treated with glucocorticoids, so prevention of bone loss with antiresorptive agents should be considered. If bisphosphonate therapy is being considered for a premenopausal woman, she must be counseled regarding use of appropriate contraception. The therapies to prevent or treat glucocorticoid-induced bone loss should be continued as long as the patient is receiving glucocorticoids. Data from large studies of anabolic agents (e.g., PTH) and further studies of combination therapy in patients receiving glucocorticoids are eagerly awaited so additional options will be available for the prevention of this serious complication of glucocorticoid treatment." }, { "id": "pubmed23n0903_12221", "title": "[Adequacy of treatment for osteoporosis in primary prevention. Quantitative and qualitative study].", "score": 0.009259259259259259, "content": "Quantitative study: To assess the prevalence of inadequacy of treatment for osteoporosis in primary prevention (OPP) in women aged 60-74years. Qualitative study: To evaluate the diagnostic and treatment criteria of the OPP and it's variability in primary care physicians (PC) and specialists. Quantitative study: observational, cross-sectional and retrospective study. women aged 60-74years with active treatment for OPP (n=424) in May 2012. Inadequacy if they had ≤2 risk factors with a DXA or DXA T-score ≥-2.4. Qualitative study: Delphi technique (15items) and two rounds of consultation. March-April 2014. PC physicians, rheumatologists and orthopaedic surgeons (n=251). Random sampling. Quantitative study: degree of inadequacy is 63.4%. In 43.2% isn't mention a diagnosis of osteoporosis. In 82.3% there isn't mention of risk factors. bisphosphonate 40.3% and calcium +vitaminD 47.9%. Qualitative study: 23% respond to the first round, and of these 67% the second round. Items with higher agreement were the important of the evaluation of risk factors for diagnosis and bisphosphonates for treatment. Items with fewer consensuses were using the FRAX and densitometry and treatment with only calcium +vitaminD. The percentage of inadequacy is high. The degree of registration in medical history is low. The Delphi method is useful for detecting discrepancies between recommendations of clinical practice guidelines and results." }, { "id": "pubmed23n0928_18763", "title": "The Good and the Bad About the 2017 American College of Physicians Osteoporosis Guidelines.", "score": 0.009174311926605505, "content": "The American College of Physicians (ACP) published a set of guidelines on how to prevent fractures in men and women with low bone density or osteoporosis. As the population ages, the overall risk of fractures increases, thus burdening the health care system. These guidelines review current evidence for osteoporosis management, providing an update to the previous 2008 ACP's guidelines. The ACP put forth 6 recommendations addressing the complexities in osteoporosis management based on evidence available through October 2016 with a focus on bisphosphonates, calcium, vitamin D, and estrogen. Evidence was graded according to recommended strength by using the ACP standard methods. The ACP recommends anti-osteoporosis therapy with 1 of 3 bisphosphonates (alendronate, risedronate, or zoledronic acid) or denosumab in patients with osteoporosis, while excluding anabolic therapies, and recommends against raloxifene. Although bisphosphonates are the mainstay of treatment, anabolic therapy and raloxifene may be used in specific situations. Pharmacologic therapy is recommended for 5 years, oversimplifying length of therapy and failing to promote an individualized patient-centered care approach. Moreover, abrupt discontinuation of denosumab is associated with a decline in bone mineral density (BMD), which must be addressed. Routine monitoring of BMD by dual x-ray absorptiometry is not endorsed during treatment, which leads to underrecognition of management issues. Pharmacologic treatment with bisphosphonates for male osteoporosis is recommended, although therapies such as denosumab and teriparatide are excluded. Finally, the ACP recommends treatment for women aged ≥65 years at high risk for fracture with osteopenia after a discussion of patient preferences, fracture risk profile, and medications. Osteoporosis management is complex. The 2017 ACP guidelines address challenges faced by clinicians but oversimplify more complex issues. These are among a number of guidelines that are available for osteoporosis management, which may be used in combination with other sources to assist clinicians with diagnostic and management strategies." }, { "id": "pubmed23n0923_9955", "title": "Impact of an osteoporosis specialized unit on bone health in breast cancer survivals treated with aromatase inhibitors.", "score": 0.00909090909090909, "content": "Considering the increased fracture risk in early breast cancer patients treated with aromatase inhibitors (AI), we assessed the impact of a preventive intervention conducted by a specialized osteoporosis unit on bone health at AI treatment start. Retrospective cohort of postmenopausal women who started treatment with AI after breast cancer surgical/chemotherapy treatment and were referred to the osteoporosis unit for a comprehensive assessment of bone health. Bone densitometry and fracture screening by plain X-ray were performed at the baseline visit and once a year for 5 years. The final record included 130 patients. At AI treatment start, 49% had at least one high-risk factor for fractures, 55% had osteopenia, and 39% osteoporosis. Based on the baseline assessment, 79% of patients initiated treatment with bisphosphonates, 88% with calcium, and 79% with vitamin D. After a median of 65 (50-77) months, 4% developed osteopenia or osteoporosis, and 14% improved their densitometric diagnosis. Fifteen fractures were recorded in 11 (8.5%) patients, all of them receiving preventive treatment (10 with bisphosphonates). During the follow-up period, patients with one or more high-risk factors for fracture showed a greater frequency of fractures (15% vs. 3%) and experienced the first fracture earlier than those without high-risk factors (mean of 99 and 102 months, respectively; P=0.023). The preventive intervention of a specialized unit at the start of AI treatment in breast cancer survivors allows the identification of patients with high fracture risk and may contribute to preventing bone events in these patients." }, { "id": "pubmed23n0374_1152", "title": "An update on glucocorticoid-induced osteoporosis.", "score": 0.009009009009009009, "content": "In general, bone loss from glucocorticoid treatment occurs rapidly within the first 6 months of therapy. Glucocorticoids alter bone metabolism by multiple pathways; however, the bone loss is greatest in areas rich in trabecular bone. Preventive measures should be initiated early. It is the author's opinion that all subjects initiating treatment with prednisone at 7.5 mg or greater require calcium supplementation (diet plus supplement) at a dose of 1500 mg and vitamin D at a dose of 400 to 800 IU/d. If the patient is going to remain on this dose of glucocorticoid for more than 4 weeks, an antiresorptive agent should be started (e.g., estrogen, bisphosphonate, raloxifene). If a patient has established osteoporosis and is either initiating glucocorticoid therapy or is chronically treated with prednisone at 5 mg d or greater in addition to calcium and vitamin D supplementation, a potent antiresorptive agent (bisphosphonate) should be started. A bone mineral density measurement of either the lumbar spine or the hip may be helpful is assessing an individual's risk of osteoporosis, may improve compliance with treatment, and can be used to monitor the efficacy of the prescribed therapy. There is no reason to withhold treatment for glucocorticoid-induced bone loss until a bone mass measurement is taken, however. In motivated patients, a weight-bearing and resistance exercise program should be prescribed to help retain muscle strength and prevent depression. If hypercalciuria develops with glucocorticoid use, either thiazide diuretics or sodium restriction may be helpful. In patients who continue to lose bone or experience fracture's despite antiresorptive therapy while on glucocorticoids, bone-building anabolic agents (e.g., hPTH 1-34 or PTH 1-84) may be available someday soon." } ] } } }

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{ "1": "Conization.", "2": "Total hysterectomy without adnexectomy.", "3": "Pelvic radiotherapy with curative intent.", "4": "Repeat a more extensive biopsy.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0601_3853", "title": "[A falsely reassuring cervical smear in adenocarcinoma of the external os].", "score": 0.01838731443994602, "content": "3 women with only mild changes in cervical smears were later found to be suffering from cervical adenocarcinoma. The first patient was 53 years old. Her smears repeatedly showed Pap 3 with moderately atypical glandular cells. After 3 colposcopic examinations with biopsies and 2 loop electrosurgical excision procedures of the cervix which showed no histological signs of malignancy, diagnostic conization revealed an adenocarcinoma of the endocervix. She underwent a radical hysterectomy and chemoradiation because of positive pelvic nodes. The second patient was 30 years old and had persistent vaginal discharge and an enlarged cervix, but no cytological abnormalities. Colposcopy was unsatisfactory and the tissue obtained by loop electrosurgical excision was normal. Adenocarcinoma was diagnosed after conization. She was treated with radical hysterectomy and radiotherapy but died after one year. The third patient, aged 26, had a long history of slightly abnormal Pap smears and vulvar condylomata, and was referred with vaginal discharge. A severe abnormal smear with glandular atypia was followed by colposcopical biopsies and conization, which revealed an endocervical adenocarcinoma. She underwent radical hysterectomy. Adenocarcinoma is a rare type of cervical cancer: III cases out of 584 patients with cervical cancer in 2003 in the Netherlands. This neoplasm is more difficult to detect than cervical squamous cell carcinoma. Cervical cytology is not an effective tool for screening and diagnosis. Due to the localization, multifocality and diversity in its presentation, the assessment of cytology has a high false-negative percentage. Screening may be enhanced by combining cytology with testing for high-risk HPV types, notably type 18. If cervical cytology shows persistent atypical glandular cells with no conclusive histological result, then due to the endocervical localisation of the lesions adenocarcinoma can only be excluded by conization." }, { "id": "pubmed23n1044_8627", "title": "Recurrent vaginal intraepithelial neoplasia successfully treated with topical imiquimod: A case report.", "score": 0.01664259679526855, "content": "Vaginal intraepithelial neoplasia (VAIN) is a rare disease associated with human papillomavirus infection. High-grade VAIN is typically treated with either excisional or ablative therapy. However, recurrent VAIN lesions are common and these treatments cause vaginal scarring. Recent studies have indicated that 5% imiquimod is an effective treatment for VAIN. The present report describes a case of a woman diagnosed with recurrent VAIN 3 who was treated with a 5% topical imiquimod cream and achieved a complete response after excision and CO<sub2</sub laser vaporization. A 53-year-old, gravida 5, para 2 postmenopausal woman who was diagnosed with papillary squamous cell carcinoma by biopsy underwent conization, total abdominal hysterectomy and bilateral salpingo-oophorectomy. A histological examination revealed grade 3 cervical intraepithelial neoplasia with free surgical margins. At 3 years after the hysterectomy, the vaginal smear revealed atypical squamous cells, leading to a pathological diagnosis of VAIN 3. Partial vaginectomy was performed, and VAIN 3 was detected in the lesion with positive margins. At 4 months into follow-up, the vaginal smear revealed a high-grade squamous intraepithelial lesion (HSIL), and subsequent biopsy during colposcopy revealed a pathological diagnosis of VAIN 3. At 3 months after CO<sub2</sub laser vaporization, the vaginal smear revealed HSIL with suspected recurrence and imiquimod treatment was initiated. One sachet of 5% imiquimod cream (0.25 g) was placed in the entire vagina three times per week for 14 weeks with no apparent complications. At 3 years after the treatment, there has been no recurrence. This case demonstrated that topical imiquimod with careful follow-up is an effective treatment for VAIN and is well-tolerated. Further clinical evidence of the effectiveness and safety of imiquimod in patients diagnosed with VAIN is required." }, { "id": "pubmed23n0673_19999", "title": "Random biopsy after colposcopy-directed biopsy improves the diagnosis of cervical intraepithelial neoplasia grade 2 or worse.", "score": 0.01632680261228842, "content": "To evaluate the usefulness of additional random biopsies in the diagnosis of cervical intraepithelial neoplasia grade 2 (CIN 2) or worse (CIN 2+) after colposcopy-directed biopsy. A retrospective chart review was performed in 107 women with satisfactory colposcopy results after colposcopy-directed biopsy with random biopsy for abnormal cervical cytological evaluation at Soonchunhyang University Hospital between April 2008 and November 2009. Random biopsies were performed at the cervical squamocolumnar junction in lesion-free quadrants of the cervix. Loop electrosurgical excision procedure conizations were performed in 59 women. Age, referral cytology, lesion size, human papilloma virus (HPV) viral load, and HPV type were analyzed as possible indicators of lesion severity detected using random biopsy. The mean age was 39.3 years (range = 21-72 y), and 96 (89.7%) women were premenopausal. Sixty-three women had CIN 2+; of those, 8 (12.7%) were diagnosed using random biopsies: 6 had high-grade squamous intraepithelial lesions; 1 had low-grade squamous intraepithelial lesions; and 1 had atypical squamous cells of undetermined significance. Lesions diagnosed as CIN 2+ using random biopsies were significantly correlated with high-grade cytology (p &lt;.001) and lesion size (p &lt;.001) but not age (cutoff = 40 years), HPV viral load (cutoff = 300 relative light units; Hybrid Capture 2), or HPV genotype. Of 59 patients who underwent loop electrosurgical excision procedure conization, the disease severity of 9 (15.3%) cases was upgraded 1 or more grades, compared with the punch biopsy results. The detection of CIN 2+, particularly high-grade cytological abnormalities and large lesion size, can be increased by additional random biopsies after satisfactory colposcopy. Loop electrosurgical excision procedure conization can detect lesions not detected by punch biopsy." }, { "id": "pubmed23n0596_4783", "title": "Prognostic factors for the development of vaginal intraepithelial neoplasia.", "score": 0.014377470355731226, "content": "To identify risk factors for the appearance of vaginal intraepithelial neoplasia (VAIN). A total of 485 women with abnormal cytologies were followed over three years (2003-2006). They underwent cytolology and colposcopy, and testing for human papillomavirus virus (HPV) infection. If the colposcopy was atypical, a biopsy was performed. A total of 256 women were treated: 161 by cone biopsy, 103 by LLETZ, 12 by repeat conization, and 44 by total hysterectomy. In eight cases VAIN was diagnosed following hysterectomy. The average age at which VAIN appeared was 49.8 years (age range 39-61). Hysterectomy was indicated in two cases of cervical cancer, four cases of persistent high-grade cervical SIL, and two cases of recurrent high-grade cervical SIL. The mean time for the appearance of VAIN following hysterectomy was 3.8 years (range 1-9 years). Of these eight women, seven had HPV infections at high risk for carcinogenesis. Long-term follow-up cytology is necessary for women treated for high-grade SIL, even after hysterectomy, because of the increased risk of a primary vaginal VAIN lesion, especially in women with high-risk HPV infection." }, { "id": "pubmed23n0476_7552", "title": "Follow-up by combined cytology and human papillomavirus testing for patients post-cone biopsy: results of a long-term follow-up.", "score": 0.014143920595533498, "content": "The goal of this study was to evaluate the clinical implications of integrating human papillomavirus (HPV) testing into a long-term follow-up and management protocol for women postconization for high-grade cervical intraepithelial neoplasia (CIN2-3). Sixty-seven women were followed-up by Pap smears and HPV type and load testing (mean follow-up, 63 months; range, 50-72). Patients with persistent abnormal cytology on two consecutive smears and those with positive HPV test results (whatever their cytologic findings) were referred for colposcopy-directed biopsy. Patients histologically diagnosed with CIN2-3 and those with high-load HPV (whatever their histologic findings) underwent repeat conization or hysterectomy for residual disease. At follow-up, 29 (43.2%) women had positive cytology or positive HPV results and were referred for colposcopy. Eleven (37.9%) had high-grade cervical intraepithelial neoplasia or high-load HPV results and were further treated by reconization/hysterectomy. The respective positive predictive values of high-load HPV and low-grade squamous intraepithelial lesions were 100 and 60% for any CIN and 90 and 15% for CIN2-3. Only five of nine cases with a final diagnosis of CIN2-3 were originally identified by cytology: the other four were detected only by parallel evaluation by HPV testing. High-load HPV results with normal cytology or low-grade lesions harbored an 80% risk for CIN2-3. Adding HPV load assessment to the follow-up protocol of women postconization due to CIN2-3 lesions could help detect high-grade residual disease among low-grade lesions and normal cytology cases while concomitantly and safely bestowing the advantage of lowering the rates of colposcopic referrals and surgical procedures." }, { "id": "pubmed23n0590_65", "title": "[Management of CIN1].", "score": 0.014090796328454478, "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": "pubmed23n0001_6695", "title": "Carcinoma-in-situ of the cerivix treated with colposcopy guided epithelial conization. Report of a 4-7 year follow-up study.", "score": 0.013652036156928525, "content": "Twenty-five patients with the diagnosis of carcinoma-in-situ (CIS) of the cervix were treated with colposcopy guided epithelial conization. During the follow-up study of 4-7 years' duration, there was no recurrence of CIS in 20 of the 25 patients. Between 6 and 12 months after conization, 3 patients showed recurrence of CIS. Two of these patients were treated with further epithelial conization with no evidence of further recurrence 4 years after the second treatment. The third patient refused to accept further epithelial conization and modified radical hysterectomy was done without any evidence of residual tumour in the hysterectomy specimen. One patient showed stromal invasion in both colposcopically guided biopsy and bone biopsy. Modified radical hysterectomy specimen showed remnants of stromal invasion. One patient with Class IV smear failed to show any atypical transformation zone and cervicitis was proven on colposcopy guided biopsy following treatment with Flagyl. For two of the 25 patients, cytology was Class II and therefore failed to diagnose the pre-malignant condition; but colposcopy showed a grade 3 atypical transformation zone and the presence of CIS was confirmed histologically. Simultaneous use of cytology, colposcopy and colposcopically guided biopsy confirmed the diagnosis of CIS in all cases. The authors recommend colposcopically guided epithelial conization in younger patients, provided the malignant lesion is strictly intra-epithelial, and limited to the ectocervix. Routine follow-up with the aid of cyto-colposcopy remains the key factor in this schedule of therapy." }, { "id": "wiki20220301en249_5189", "title": "Bethesda system", "score": 0.012560564567095008, "content": "CIN 1 is the most common and most benign form of cervical intraepithelial neoplasia and usually resolves spontaneously within two years. Because of this, LSIL results can be managed with a simple \"watch and wait\" philosophy. However, because there is a 12–16% chance of progression to more severe dysplasia, the physician may want to follow the results more aggressively by performing a colposcopy with biopsy. If the dysplasia progresses, treatment may be necessary. Treatment involves removal of the affected tissue, which can be accomplished by LEEP, cryosurgery, cone biopsy, or laser ablation. HSIL: high-grade squamous intraepithelial lesion High-grade squamous intraepithelial lesion (HSIL or HGSIL) indicates moderate or severe cervical intraepithelial neoplasia or carcinoma in situ. It is usually diagnosed following a Pap test. In some cases these lesions can lead to invasive cervical cancer, if not followed appropriately." }, { "id": "pubmed23n0016_8773", "title": "[Recurrent carcinoma in situ of the uterine cervix (author's transl)].", "score": 0.012073452862926548, "content": "Among 228 patients who had previous treatment for carcinoma in situ of the cervix, most by hysterectomy, 3 recurrences in vaginal stumps were detected in women age 36, 46, and 56. In another case a carcinoma in situ of the cervix was found in a 25 year old patient who had a diagnostic and therapeutic conization because of desire for childbearing. The histology of the cone showed no residual carcinoma. Concommitent to the recurrent carcinoma in situ of the cervix a carcinoma of the vulva was detected. Recurrences of carcinoma in situ could occur because of incomplete resection of primary lesion. Wrong classification in the laboratory is possible if the invasion is missed on the microscopic examination and the case therefore receives the wrong treatment. Recurrences which are not true recurrences could arise from multicentric atypical foci of the squamous epitheleum of the -ower female genital tract. These considerations lead to the following recommendations: 1. When the suspected diagnosis carcinoma in situ of the uterine cervix is made a large enough cone biopsy which is appropriately marked is obtained and a complete microscopic examination of the cone must be obtained. 2. A hysterectomy with a large vaginal cuff is the treatment of choice. 3. A careful workup of the operative specimen in the microscopic laboratory is expecially essential. 4. A patient with such previous treatment for carcinoma in situ of the uterine cervix must be urged to continue with regular preventive examinations for cancer. The vaginal stump must be regularly re-examined both by colposcopy and by cytology." }, { "id": "pubmed23n0338_5532", "title": "[Therapeutic results of conization with diathermy].", "score": 0.009900990099009901, "content": "To assess the frequency, histological grade and time interval of residual and recurrent lesions after loop electrosurgical excision procedure and to analyse their associated risk factors. 288 patients treated by loop electrosurgical excision procedure between February 1991 and July 1995 were prospectively included in this study. They agreed to a postoperative cytological and colposcopic follow-up with a first visit between 3 and 6 months after excision, a second one between 9 and 15 months and a third one between 24 and 36 months. We used univariate and multivariate analyses to evaluate the association between clinical variables and residual or recurrent lesions. The pathologic diagnosis of the specimens included 21 normal cervices (7.3%), 35 CIN 1 (12.2%), 43 CIN 2 (14.9%), 180 CIN 3 (62.5%), 1 adenocarcinoma in situ (0.3%) and 8 microinvasive cancers (2.8%). The pathologist considered the excision complete in 244 cases (85%). Among the other 44 patients, 27 had involved endocervical margins, 17 involved exocervical margins but none had both margins involved. The mean postoperative follow-up +/- standard deviation was 39 +/- 13 months (range 24-68 months). Treatment failure, defined as the persistence or recurrence of a cervical lesion, was observed in 20 patients (6.9%) having a squamous cancer stage IB (n = 1), a CIN 3 (n = 15), an adenocarcinoma in situ (n = 1) or a CIN 1 (n = 1). In 6 cases the second treatment was performed before the first cytological and colposcopic visit because of an excision considered incomplete by the pathologist. Overall 19 out of the 20 treatment failures were diagnosed within the first two years of the follow-up. The endocervical localisation of the initial lesion (adjusted RR 13.7; 95% CI 1.3, 150.1; P &lt; 0.05) and incomplete excision (adjusted RR 9.1; 95% CI 3.0, 27.3; P &lt; 0.001) were the only independent risk factors for treatment failure. Residual or recurrent lesions occurs rarely after loop electrosurgical excision procedure. They are favoured by totally endocervical lesion and an incomplete excision. With the association of cytology and colposcopy, 95% of treatment failures can be detected in the first 2 postoperative years." }, { "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": 0.00980392156862745, "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": "pubmed23n0831_9564", "title": "Positive endocervical margins at conization: repeat conization or colposcopic follow-up? A retrospective study.", "score": 0.00980392156862745, "content": "The presence of residual cervical lesions was evaluated in patients submitted to repeat conization due to a finding of positive endocervical margins in a previous loop electrosurgical excision procedure (LEEP) specimen. In addition, the correlation between the presence of a residual lesion and risk factors for cervical cancer, and the use of repeat conization as first-choice treatment were analyzed. This retrospective study included 44 patients submitted to repeat cervical conization or total hysterectomy following a finding of affected endocervical margins in LEEP specimens. The risk factors analyzed in relation to the presence of residual lesions were age, smoking, cone depth, glandular involvement and the histopathology findings of cervical intraepithelial neoplasia (CIN) 1, CIN 2 or CIN 3/carcinoma in situ. The Chi-square test and the Mann-Whitney t-test were used, with significance defined at P &lt; 0.05. Residual lesions were found in 23/44 patients (52.3%), with 3/23 cases (13.0%) being compatible with invasive squamous cell carcinoma. Of the 23 patients, six (26.1%) were submitted to total hysterectomy, with one case being compatible with a moderately differentiated invasive squamous cell carcinoma. Two patients with a histopathology finding of CIN 3/carcinoma in situ in the previous LEEP specimen were diagnosed with invasive squamous cell carcinoma in the repeat conization specimen. Residual lesions were not significantly associated with the risk factors evaluated. In view of the high frequency of residual disease found when positive endocervical margins were found in LEEP specimens, the indication for repeat cervical conization rather than colposcopic follow-up is viable and justified. Indeed, since the presence of a residual lesion and its progression in the cervical canal are more difficult to screen and control, patients unable to comply with regular colposcopic follow-up could benefit from repeat conization when trying to avoid a potentially negative outcome." }, { "id": "pubmed23n0414_17888", "title": "Human papilloma virus testing in patient follow-up post cone biopsy due to high-grade cervical intraepithelial neoplasia.", "score": 0.009708737864077669, "content": "We evaluated the contribution of the human papilloma virus (HPV) load in planning follow-up and management of women post cone biopsy for high-grade cervical intraepithelial neoplasia (CIN2-3). Ninety-six suitable women were followed-up by Pap smears: two consecutive abnormal smears dictated referral for colposcopy-directed biopsy. Before colposcopy, HPV tests determined high-risk HPV DNA type and load (Hybrid Capture System type I). Patients histologically diagnosed with CIN1 or CIN2-3 underwent repeat conization or hysterectomy for residual disease. HPV load was compared to cytology for the detection of residual disease. At follow-up, 20/89 (22.4%) studied women had positive cytology reports of either low- (n = 11) or high-grade (n = 9) squamous intraepithelial lesion (SIL). Colposcopic biopsies diagnosed 9 CIN1 and 8 CIN2-3 cases. Residual disease was corroborated in 16/17 (94.1%) women and the status was readjusted based on cone biopsy/hysterectomy: CIN2-3 in 9 and CIN1 in 7. The positive prediction values for CIN2-3 residual disease with high-grade SIL, CIN2-3 on colposcopic punch biopsy, and high HPV load were 89, 100, and 100%, respectively. For CIN1 residual disease with low-grade SIL, CIN1 on colposcopic punch biopsy, and low and borderline HPV load, they were 54.5, 77.7, and 100%. The HPV load was a more accurate predictor for CIN1 or CIN2-3 on the cervical specimen in cases with low-grade SIL or CIN1 on colposcopic biopsy. Evaluating HPV loads after a positive cytology report may assist in triaging women post conization biopsy for CIN2-3 to appropriate treatment. Its high positive predictive value, specificity, and sensitivity for CIN1 and CIN2-3 and supplementary information could be especially pertinent for clinical management of low-grade SIL cases." }, { "id": "pubmed23n0079_16512", "title": "20-year experience of follow-up of the abnormal smear with colposcopy and histology and treatment by conization or cryosurgery.", "score": 0.009708737864077669, "content": "During the period 1967 to 1977, 1466 women with Pap smears suggesting cervical epithelial neoplasia (CIN) II or worse were evaluated by colposcopy, portio biopsy, and endocervical curettage. Women who had CIN III were treated first by conization and later by cryosurgery. Cytological diagnosis was inaccurate compared to colposcopical and histological diagnosis, with 27% having a worse histological diagnosis. In 22% of the cases histology was two degrees less or worse than suggested by cytology. Presence of atypical vessels was associated with invasive cancer in 17% of cases. A total of 635 patients were treated by conization. After an average follow-up of 10 years, the cure rate was 96% compared to 87% by cryosurgery (104 cases). Hysterectomy was, mainly because of old age, performed on 154 patients; the cure rate was 97%. Although most treatment failures occurred within the first 5 years, some were seen after as long as 15-20 years." }, { "id": "pubmed23n0236_7434", "title": "Diagnostic and therapeutic viewpoints on cervical intraepithelial neoplasia. 10-Year follow-up of a conization material.", "score": 0.009615384615384616, "content": "In 429 women with the diagnosis of cancer in situ (CIS), we found, during a follow-up time of 10 years, a relapse frequency of 5.3%; conization was the primary treatment in 414 cases, in 13 cases hysterectomy and radiotherapy in 2 cases. We found that the mean age was significantly higher (p less than 0.01) when the primary CIS lesion was localized in the cervix (36.8 +/- 10.5) compared to localization only on the portio (31.3 +/- 8.7). The risk of relapse was significantly higher (p less than 0.05) in patients where the primary cone had the lesion localized in the cervix compared to the patients where the primary cone had the lesion localized only to the portio. We found that the localization of PAD relapses appearing later compared to a high degree (about 65%) with the localization of the primary CIS lesion. Vaginal relapse was, generally speaking, twice as common when the primary CIS lesion was localized in the cervix compared to when it was localized on the portio alone. Alternative treatment methods to the conization operation are discussed and an increased individualization of CIS treatment is emphasized particularly with consideration to age and the localization of the CIS lesion." }, { "id": "pubmed23n0616_13070", "title": "European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, part 1.", "score": 0.009523809523809525, "content": "The current paper presents the first part of Chapter 6 of the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. It provides guidance on how to manage women with abnormal cervical cytology. Throughout this article the Bethesda system is used for cervical cytology terminology, as the European guidelines have recommended that all systems should at least be translated into that terminology while cervical intraepithelial neoplasia (CIN) is used for histological biopsies (Cytopathology 2007; 18:213-9). A woman with a high-grade cytological lesion, a repeated low-grade lesion or with an equivocal cytology result and a positive human papillomavirus (HPV) test should be referred for colposcopy. The role of the colposcopist is to identify the source of the abnormal cells and to make an informed decision as to whether or not any treatment is required. If a patient requires treatment the colposcopist will decide which is the most appropriate method of treatment for each individual woman. The colposcopist should also organize appropriate follow-up for each woman seen. Reflex testing for high-risk HPV types of women with atypical squamous cells (ASC) of undetermined significance with referral for colposcopy of women who test positive is a first option. Repeat cytology is a second possibility. Direct referral to a gynaecologist should be restricted to special circumstances. Follow-up of low-grade squamous intraepithelial lesion is more difficult because currently there is no evidence to support any method of management as being optimal; repeat cytology and colposcopy are options, but HPV testing is not sufficiently selective, unless for older women. Women with high-grade squamous intraepithelial lesion (HSIL) or atypical squamous cells, cannot exclude HSIL (ASC-H) should be referred without triage. Women with glandular lesions require particular attention. In a subsequent issue of Cytopathology, the second part of Chapter 6 will be presented, with recommendations for management and treatment of histologically confirmed intraepithelial neoplasia and guidance for follow-up of special cases such as women who are pregnant, postmenopausal or immunocompromised." }, { "id": "pubmed23n1098_2733", "title": "Post-Conization FIGO stage IA1 squamous cell cervical carcinoma; is hysterectomy necessary?", "score": 0.009523809523809525, "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": "pubmed23n0614_14145", "title": "Usefulness of repeat cytology at the time of first colposcopy.", "score": 0.009433962264150943, "content": "The value of repeat cytology in the detection of high-grade preinvasive or invasive disease was analyzed at the time of colposcopy in cases of patients with abnormal referral cytology. A series of 136 patients with squamous abnormalities in their referral cytology, who had undergone repeat cytology and for whom outcome had been established, were included in the study. Final diagnosis consisted of 27 negative results (20%), 37 cases of CIN1 (27%), 31 CIN2 (23%), 39 CIN3 (29%), and 2 (1%) cases of squamous cell carcinoma (SCC). Referral and repeat cytology suggestive of atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H), high-grade squamous intraepithelial lesion (HSIL) were findings significantly associated with a final diagnosis of CIN2 or worse. Sensitivity and positive predictive value of repeat cytology for the histological diagnosis of significant histological neoplasia (CIN2 or worse) were 81.9% and 77.6%, respectively. In women with referral cytology findings of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion (ASC-US/LSIL), repeat cytology was suggestive of HSIL in 20% of cases (11/54), and in 4% (2/54) biopsy was negative or CIN1, and the final diagnosis established by LLETZ was CIN3. Eight cases (10%) of HSIL in referral and repeat cytology in which biopsies were negative or insufficient were diagnosed as CIN3 or worse in the final diagnosis. Repeat cytology would have changed therapeutic management in 4 and 10%, respectively, of patients included as ASC-US/LSIL and ASC-H/HSIL in referral cytology." }, { "id": "pubmed23n0362_11264", "title": "[Conization with positive margins: what strategy should be adopted?].", "score": 0.009433962264150943, "content": "To define recommended treatment in cases of positive margins on cone biopsy specimens. This single-center retrospective study concerned 220 conizations performed between January 1996 and June 1998. The results of 70 conizations (31.8%) with positive margins were analysed. There were 32 cold knife conizations (mean age: 43 years) and 38 conizations by the loop electrosurgical excision procedure (mean age: 33 years). Mean depth of conization was 15.94 mm for cold knife conization and 10.08 mm for loop electrosurgical conization. Fifteen patients were excluded (5 with invasive cancer and 10 were lost to follow-up). This study included 55 patients with a mean 12-month follow-up. Six underwent hysterectomy for mini-invasion on the specimen or advanced age. Eleven underwent a second conization (followed by hysterectomy in 2 cases). The other 38 patients were submitted to simple surveillance with cervico-vaginal cytology and colposcopic examination. The rate of residual lesions (cervical intra-epithelial neoplasia: CIN 3) after conization with positive margin was 14.5% (n = 8). Residual persistent dysplasia is not present in all patients after conization with positive margins. Cytology and colposcopy allow detection of dysplasia, indicating the need for a second conization. In women with no desire for further pregnancy, systematic repeat surgery must be recommended." }, { "id": "article-22882_18", "title": "High-Grade Squamous Intraepithelial Lesion of the Cervix -- Treatment / Management", "score": 0.00942350332594235, "content": "Women aged 21 to 24 with HSIL cytology are recommended to undergo colposcopy. If CIN 2 or greater is not diagnosed on biopsy, it is recommended the patient follow up with cytology and colposcopy every 6 months for a 24-month period, as long as exams are adequate and reveal no squamous intraepithelial lesions (or at most LSIL). If HSIL cytology or a high-grade colposcopic lesion is found during this time, a biopsy should be performed. In patients where HSIL cytology persists for 24 months but no high-grade lesion is identified on biopsy, a diagnostic excisional procedure is recommended. If colposcopy is inadequate, CIN 3 is specified on biopsy, or CIN 2 or CIN 3 persists for 24 months, a diagnostic excisional procedure is recommended. If CIN 2 is specified on biopsy, observation for 12 months using both cytology and colposcopy every 6 months is recommended. This guideline exists because CIN 2 has a higher regression rate and less risk of progression to cancer than CIN 3, especially in younger women. Once the patient has 2 consecutive negative results on cytology and no evidence of a colposcopic abnormality, co-testing is recommended a year later. If negative, a second co-test is recommended after three years. If either co-test is abnormal, colposcopy is recommended." }, { "id": "pubmed23n0950_113", "title": "A Large Retrospective Study of 12714 Cases of LEEP Conization Focusing on Cervical Cancer That Colposcopy-Directed Biopsy Failed to Detect.", "score": 0.009345794392523364, "content": "Punch biopsy is important in the diagnosis of cervical cancer. However, it may fail to detect early cervical cancers. A retrospective study was performed in the largest academic women's hospital in China to demonstrate cervical cancer that colposcopy-directed biopsy failed to detect. <iMethods</i. Patients who were diagnosed with high-grade squamous intraepithelial lesion (HSIL), adenocarcinoma in situ (AIS), and persistent low-grade squamous intraepithelial lesion (LSIL) via colposcopy-directed biopsy and had further undergone loop electrosurgical excision procedure (LEEP) conization were included. These procedures were performed at Obstetrics and Gynecology Hospital of Fudan University from July 1, 2013, to December 31, 2016. In total, 5.98% (760/12714) of patients who underwent conization were diagnosed with invasive cervical cancer. Persistent LSIL (0.24%), HSIL (6.37%), and AIS (24.31%) were detected cancer by conization. Histological subtypes included squamous cell carcinoma (92.0%), adenocarcinoma (5.1%), adenosquamous carcinoma (1.8%), adenoid basal type carcinoma (0.9%), and small cell neuroendocrine carcinoma (0.1%). Cytology reports consisted of HSIL (45.4%), atypical squamous cells of undetermined significance (ASC-US) (16.1%), and LSIL (11.6%), and atypical squamous cells cannot exclude HSIL (ASC-H) (9.3%), squamous cell carcinoma (0.9%), AGC (atypical glandular cells, 0.9%), AIS (0.4%), and NILM (negative for intraepithelial lesion or malignancy, 15.4%). The sensitivity of high-risk human papillomavirus (hrHPV) screening (96.4%) was significantly higher than that of cytology (84.6%) (<iP</i &lt; 0.01), with sensitivity of cotesting at 99.8% and a ratio of double-negative results at 0.2%. The sensitivity of cytology and hrHPV screening of different cervical cancer histologic subtypes was also demonstrated. In this large retrospective study, we systematically reported the cytology, hrHPV, pathology, and stages of cervical cancer that colposcopy-directed biopsy failed to detect." }, { "id": "pubmed23n0364_18014", "title": "[Value of endocervical margin examination of conization specimens. Prospective study conducted on 150 patients].", "score": 0.009345794392523364, "content": "To assess the usefulness of frozen sections (FS) on endocervical margin in surgical conization or loop electrosurgical specimens. In a prospective study, 150 patients were treated from October 1995 to December 1997: 69 cases without FS, 81 cases with FS. CIN on frozen section resulted in an immediate additional resection. In the group without FS, 13 patients had involved endocervical margin by high-grade CIN (18.8%). Frozen section was impossible in a conization specimen that was too short. FS revealed 64 normal glandular epitheliums, seven squamous metaplasias in which two lesions were under-evaluated (being in fact CIN on permanent sections), eight high-grade CIN followed by additional resection in six cases and two invasive carcinomas. Endocervical margin on additionals section were always free of disease. The rate of failure was 2.6% among 77 cases. This rate corresponded to two under-evaluations. Invasive carcinoma and CIN without additional resection were excluded because frozen section only allowed a peroperative diagnosis. The average height of the cone and the rate of complications were similar. Repeat surgery was necessary in nine cases in the group without frozen section, in which five showed residual lesions, absent in the other group. The ultimate histological interpretation was never difficult after frozen section. This method permits reduction of cases with involved cone margin and residual lesions and, despite some limitations, it may be useful for surgical management." }, { "id": "pubmed23n0632_6871", "title": "The management of cervical intraepithelial neoplasia during pregnancy: is colposcopy necessary?", "score": 0.009259259259259259, "content": "The 2006 American Society for Colposcopy and Cervical Pathology Consensus guidelines state that it is acceptable to defer colposcopy until 6 weeks postpartum in pregnant patients with atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesion (LSIL) cytology. Therefore, we sought to determine the incidence of cervical intraepithelial neoplasia (CIN) 2,3 in pregnant patients referred to a university colposcopy clinic. A retrospective study identified all pregnant women with abnormal cytology referred to the University of Alabama at Birmingham colposcopy clinic between May 2005 and September 2007. After an institutional review board approval was obtained, demographic information, referral cytology, and histologic data were collected. The colposcopic impression was also obtained from the records. Six hundred twenty-five pregnant patients were identified. The mean age was 23 years (range, 14-44 years), the mean parity was 1 (range, 0-7), and the mean gestational age was 24 weeks (range, 4-39 weeks). The most common referral cytology was LSIL (41.0%), followed by ASC-US (34.1%), and high-grade squamous intraepithelial lesion (13.6%). One hundred thirty-eight patients (22%) underwent cervical biopsy at the time of initial colposcopy. Forty-three patients had CIN 1, 28 patients had CIN 2, and 23 patients had CIN 3. Forty-four patients (32%) had no evidence of CIN on biopsy. There were no cases of invasive cervical cancer identified. Of the 469 patients with ASC-US and LSIL cytology, 20 of 78 patients who had a cervical biopsy were diagnosed with CIN 2,3. Of the 128 patients with high-grade intraepithelial lesion or high-grade squamous intraepithelial lesion cytology, 31 of 60 patients who had a cervical biopsy were diagnosed with CIN 2,3. Repeat colposcopy in the third trimester was performed on 47 patients. Only 3 of 13 patients with a repeat biopsy had CIN 2,3. Pregnant patients with ASC-US or LSIL cytology rarely have colposcopically suspected CIN 2,3 at their initial colposcopy that warrants a cervical biopsy; therefore, it is reasonable to defer the initial colposcopy in patients with ASC-US and LSIL until at least 6 weeks postpartum." }, { "id": "pubmed23n0520_3152", "title": "Recurrent smear abnormalities where repeat loop treatment is not possible: is hysterectomy the answer?", "score": 0.009259259259259259, "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_16222", "title": "Verrucous carcinoma of the cervix: detection of carcinogenetic human papillomavirus types and their role during follow-up.", "score": 0.009174311926605505, "content": "Verrucous carcinoma is a rare variant of well-differentiated squamous cell carcinoma of the uterine cervix. Infection with high-risk human papillomavirus (HPV) is the main cause of intraepithelial and invasive neoplasias of the female genital tract, but the aetiology of verrucous carcinoma is still unknown. The aim of this study was to evaluate the presence of HPV in verrucous carcinomas of the cervix and to investigate the persistence and the role of high risk HPV types in follow-up. Three patients, with atypical cytologies, were observed. All the patients underwent cytology and colposcopy followed by direct biopsy. The Hybrid Capture II microplate method was used for molecular detection of pre-surgical low- and high-risk HPV types. HPV tests were performed during the follow-up, annually. The cytological findings revealed that atypical squamous cells \"cannot rule out high-grade lesion\" (ASC-H) in one case and high grade squamous intraepithelial lesion (H-SIL) in two cases. The HPV test detected high risk HPV types. Colposcopic findings showed cervical exophytic lesions. The histology revealed a well-differentiated verrucous carcinoma Ib stage, according to FIGO classification, in every case. Following radical hysterectomy, the post-operative course was uneventful. The mean follow-up time was 4.6 years. The follow-up HPV tests of the H-SIL patients were consistently negative as to cytological and colposcopical findings and no relapse was observed. At one-year follow-up the ASC-H patient who had shown postoperative histological features of koilocytosis associated with CIN2 and VAIN 3 had a persistence of high-risk HPV types with negative cytological and colposcopical findings. The HPV test was positive for two years and colposcopic and histological findings of VAIN degree 2 were revealed three years after surgery. Following vaginal laser CO2 vaporization the subsequently cytological and colposcopic checks were negative as was molecular detection of HPV. Follow-up colposcopy, cytology and molecular detection of HPV is recommended in all verrucous carcinoma patients since carcinogenic HPV DNA detection could represent a valuable diagnostic tool as an adjunct to cytology, for monitoring HPV infections with transforming potential." }, { "id": "pubmed23n0113_3776", "title": "The colposcopy and the cone biopsy in the diagnosis, treatment and follow-up of 81 cases of cervical intraepithelial neoplasia.", "score": 0.009174311926605505, "content": "A conization was performed on 81 patients with histological diagnosis of cervical intraepitelial neoplasia (CIN), whom and previously a rigorous colposcopic examination. 64 patients were younger than 35 years. The previous strict colposcopic examination determined that in none of the cases were the surgical margins of the cone biopsy affected: In 26 cases there was no correlation between the previous biopsy and the histological diagnosis of the cone biopsy. The latter was--higher in degree in 9 cases and, in addition to this, in the 23 histerectomies that were performed after the conization, 7 surgical specimens showed CIN in their histological study. The non-involved surgical margins--that could be obtained in those cases with a careful previous colposcopy,--can not guarantee the exeresis of all the CIN zones. The biopsy of an atypical zone, in a colposcopic extensive lesion, cannot be representative of the whole lesion. In the follow-up--5 years maximum and 1 year minimum--3 relapses had appeared and 9 pregnancies had been diagnosed, that had not showed an increase in the number of premature labours, nor in the cesareas-rate." }, { "id": "pubmed23n0347_5419", "title": "Colposcopy, cytology and histology in the diagnosis of squamous intraepithelial lesions of the cervix.", "score": 0.00909090909090909, "content": "To compare colposcopic findings to cytologic and histological diagnoses in women with colposcopic reports of ANTZ and/or HPV infection. Among 791 hospitalized women referred for colposcopic examination, colposcopy showed ANTZ grade 0-2 and/or HPV infection in 271 patients (34.26%). Only 153 were fully investigated by colposcopy, cytology (under colposcopic observation) and histology (target punch biopsy: 109 patients; surgical specimens of hysterectomy: 42 patients; conization: 2 patients). Cytological and histological diagnoses were reported according to the Bethesda System. 132/153 Pap smears were estimable for sampling adequacy; 44/63 resulted as normal and were histologically positive for LSIL [1]. Five LSIL-positive Pap tests were negative on histology (false negative and false positive rate of 33.33% and 3.78%). The pap test was diagnostic for intraepithelial neoplasia in 34/65 cases (53.3%) and for invasive cancer in 6/11 cases (54.5%). In 67/132 cases (50.8%) adequate-for-sampling Pap smears could not predict the exact diagnosis. On the other hand, 108/141 patients with colposcopic evidence of ANTZ/cancer showed histological SIL or invasive neoplasm (76.59%): ANTZ 1 was associated to LSIL and HSIL in 74.1% and 2.4%; ANTZ 2 to LSIL, HSIL and invasive cancer in 41%, 30.76% and 10.3%. Colposcopic suspicion of invasive cancer in 8 patients was histologically demonstrated in 7 (87.5%); colposcopic diagnosis of HPV infection was confirmed in 10/12 (83.4%). A better correspondance was shown between colposcopy and histology than between cytology and histology in the diagnosis of SIL. We suggest a routine colposcopy investigation for all patients admitted to a gynecological clinic and we believe it is very important to take Pap smears under colposcopic observation if colposcopy and cervical smears are performed in the same sitting." }, { "id": "pubmed23n0354_15029", "title": "Positive margins after conization and risk of persistent lesion.", "score": 0.00909090909090909, "content": "The aim of this study was to investigate a method to reduce the frequency of uterine reoperation with no persistent lesion and to identify factors predictive of persistent or recurrent lesions. Of 505 conizations performed by the same surgeon, 71 had positive margins (average patient age = 35.7 +/- 7.7 years). The patients underwent either immediate reoperation or monitoring with a Pap smear and colposcopy. Histologic assessment of the cervical cone after conization showed positive margins in 14.1% of cases [endocervical and exocervical margins affected in 50 of 505 (9.9%) and 21 of 505 (4.2%) cases, respectively]. Of 59 of these patients (83.1%) who underwent follow-up monitoring over an average of 35.2 months (range: 2.6-180. 8), 12 patients (average age: 40.8 +/- 6.4 years) underwent immediate hysterectomy and 47 (average age 34.0 +/- 7.4 years) benefited from monitoring first [secondary discovery of 19 persistent lesions within 6 months and 9 recurrences within 18 months on average (range: 8.8-48 months)]. Of the 9 patients with recurrent lesions, 7 underwent reintervention and 2 monitoring. Of the 19 patients with persistent lesions, 18 underwent reintervention and 1 monitoring. Normal histology was observed in 29.4% of patients undergoing secondary reoperation for an abnormal smear compared with 66.7% of patients undergoing immediate reoperation (P = 0.04). Severity of lesion and age of patients could not be used to predict the incidence of a persistent or recurring lesion. Seventy-nine percent of conizations had positive endocervical margins in patients with a recurring or persistent lesion compared with 48% in patients with normal follow-up (P = 0.03). Cytology and colposcopy follow-up in cases of positive conization margins may help to establish justification for the choice of reoperation, thereby limiting morbidity following repeated surgery." }, { "id": "pubmed23n0245_8263", "title": "Treatment of carcinoma in situ: evaluation of 1609 cases.", "score": 0.009009009009009009, "content": "In 1609 cases of carcinoma in situ, various methods of treatment were adopted: primary irradiation (22 cases), radical hysterectomy (11), simple hysterectomy (418), cervical amputation (83), ring biopsy with cervical curettage (63), and conization alone (1012). The outcome was related far less to the method of treatment than to the reliability of the primary diagnosis. If the latter was based only on colposcopically directed punch biopsies or cervical curettage, even with ring biopsy, 2.1% of patients died of cancer. In patients treated by hysterectomy, the vaginal approach resulted in 4 times fewer recurrences than did the abdominal approach, because of visualization of the extent of the lesions. Best results were obtained after conization with serial step-sectioning of specimens. Among 634 cases treated by conization with total removal of the lesion, there were no recurrences." }, { "id": "pubmed23n0993_6367", "title": "Abnormal Pap smear frequency and comparison of repeat cytological follow-up with colposcopy during patient management: the importance of pathologist's guidance in the management.", "score": 0.008928571428571428, "content": "Cervical cancer contributes to a significant global health burden with room for improvement of primary prevention methods. This study aimed to determine the prevalence of Turkish women with abnormal cytology and their management by comparing results from repeat cytological analysis with close follow-up and colposcopy. A retrospective evaluation of 8738 women who underwent Pap smears at a single institution during 2011 was performed. Either repeat cytological analysis or colposcopic biopsy was used for follow-up evaluation of women who had abnormal index cytology. From the 8670 women, 8259 of had normal cytology results (95.3%) and 411 women had abnormal cytology (4.7%) in the index Pap smear. The frequency of initial abnormal cytology was 65% (n=267), 27% (n=111), 3.4% (n=14), 2.4% (n=10), 1.9% (n=8), and 0.3% (n=1) for atypical squamous cell of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), ASC cannot exclude high-grade intraepithelial lesion (ASC-H), high-grade SIL (HSIL), atypical glandular cells (AGC), and invasive cancer, respectively. Of the 267 women with initial ASCUS, 108 (40.4%) underwent repeat cytology analysis, 84 (31.5%) underwent colposcopic biopsy, and 75 (28.1%) were lost to follow-up. On histopathology, 8.3% (n=7) of patients had cervical intraepithelial neoplasm 2 (CIN2) on colposcopy. Of 60 women with LSIL that underwent colposcopic biopsy, 13.3% (n=8) had CIN2/3. The results of the study suggest that routine cytological follow-up may be an appropriate method in the management of ASCUS instead of immediate colposcopy while immediate colposcopy cannot place repeat cytology for LSIL in developing countries." }, { "id": "pubmed23n0238_2076", "title": "Colposcopy, conization, and hysterectomy practices: a current perspective.", "score": 0.008928571428571428, "content": "Data from the provincial cytology program has shown a progressive increase in the number of cases of cervical carcinoma in situ detected in the general population and a doubling of disease rate in third decade women, with most of the cases now in the 25- to 29-year-old age group. The introduction of a colposcopy service has led to a significant decrease in the number of diagnostic conizations performed over a 5-year period. Conization was still used for therapy in a substantial number of women despite the availability of cryotherapy and laser surgery. Eighty-five percent of all patients undergoing cone biopsy had sever dysplasia or carcinoma in situ (CIN III) on pathological examination. In 25% of patients, the conization specimen revealed either dysplasia or carcinoma in situ extending to resection margins. During review of 2249 patients, 1174 were spared a conization and were treated by either hysterectomy, cryotherapy, or laser surgery. It would appear that, although colposcopy can reduce dramatically the number of diagnostic cone biopsies, conization will still be required for therapy in a substantial number of patients." }, { "id": "pubmed23n1006_1696", "title": "Post-hysterectomy rare collision vulva tumor with long-term human papilloma virus infection composed of squamous cell carcinoma of the labia major and adenosquamous carcinoma of bartholin gland: A case report.", "score": 0.008849557522123894, "content": "Post-hysterectomy collision tumors of the vulva has rarely been reported. Though long-term HPV infection may induce vulva tumor, but the relationship between HPV infection and collision vulva tumor is not clear. And there are no clear rules of the post-hysterectomy cancer surveillance for human papilloma virus (HPV) long-term infections. So here we first report a case of post-hysterectomy rare collision vulva tumor with long-term HPV infection composed of squamous cell carcinoma of the labia major and adenosquamous carcinoma of bartholin gland and hope to bring new direction to our future research. A 48-year-old woman with long-term HPV infection, 3 years after hysterectomy, gravida 3, para 2, was admitted to our hospital with complaints of a 4-month history of an itching vulva ulceration. An anabrosis was located on the surface of the solid mass of the bartholin gland at the posterior part of the right labium and the right inguinal lymph nodes were palpable. Result of the incisional biopsy of the ulcer area at local hospital was atypical squamous cells couldn't exclude high-grade squamous intraepithelial lesion (ASC-H). Subsequently more authoritative pathological consultation results suggested squamous cell carcinoma of the vulva. Post-hysterectomy collision vulva tumor with long-term HPV infection composed of squamous cell carcinoma of the labia major and adenosquamous carcinoma of bartholin gland. The extensive excision of the vulva, bilateral inguinal lymph nodes dissection, and local skin flap transposition surgeon was done to this patient. The final certificate diagnosis was: vulvar tumor T1bM0N0 composed of squamous cell carcinoma of the labia major and adenosquamous carcinoma of bartholin gland; HPV infection; post hysterectomy, and bilateral salpingectomy. The patient recovered well after surgery, and consequently received 6 courses of TC (paclitaxel + carboplatin) chemotherapy, and 9 months and 13 days followed up. So far patient recorded as complete response (CR). Collision vulva tumor occurred post-hysterectomy is extremely rare. It is most likely related to long-term HPV infection, which suggests us should to modify the manner of the post-hysterectomy cancer surveillance for HPV long-term infections. For patients with high-risk HPV infection, even if the cytology results are negative, we may should perform colposcopy and vulva biopsy more positively to prevent the disease from progressing into cancer. And the pathogenesis of relationship between HPV infection and collision vulva tumor is still need further investigation." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 298, 418 ] ], "word_ranges": [ [ 50, 72 ] ], "text": "As of 2017, the PETHEMA protocol for APL in low to intermediate risk patients (and/or over 70 years of age) is ATO+ATRA." }, "3": { "exist": true, "char_ranges": [ [ 812, 996 ] ], "word_ranges": [ [ 141, 173 ] ], "text": "One of the main causes of mortality in the induction of a promyelocyte is coagulopathy, but option 3 is totally incorrect. We could only mess things up even more by putting heparin!!!!" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "If asymptomatic, transretinoic acid (ATRA) will be initiated and controls in day hospital will be recommended.", "2": "Treatment with arsenic trioxide, ATRA and supportive therapy will be initiated.", "3": "It is a myeloblastic leukemia type M3, so chemotherapy and heparin treatment will be initiated to control disseminated intravascular coagulation.", "4": "Antibiotic treatment should be started. When the fever disappears, leukemia treatment should be started.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0807_4899", "title": "Postremission therapy in acute promyelocytic leukemia: room for improvement?", "score": 0.01889483065953654, "content": "A 29-year-old white man presented to the hospital with a 3-week history of fatigue, generalized weakness, gingival swelling and bleeding, and headaches. Laboratory work revealed WBC 30.4 k/μL, hemoglobin 7.9 g/dL, and platelets 16 k/μL. The WBC differential showed 64% blasts and 24% promyelocytes. Coagulation studies revealed prothrombin time (PT) 13.5 seconds, internationalized normalized ratio (INR) 1.3, fibrinogen 199 mg/dL, D-dimer greater than 1.0 μg/mL, and fibrin split products greater than 40 μg/mL. A bone-marrow aspirate with biopsy was performed, yielding the diagnosis of acute promyelocytic leukemia (APL), with t(15;17)(q23;q21.1) in all metaphases. Induction therapy commenced with daunorubicin, cytarabine (Ara-C), and all-trans retinoic acid (ATRA), and complete remission was documented 5 weeks later. PML-RARA fusion transcripts were still detected by reverse transcription polymerase chain reaction. He is now referred to you for consideration of postremission therapy in the setting of high-risk acute promyelocytic leukemia in first remission." }, { "id": "pubmed23n0530_16261", "title": "[Effect of all-trans retinoic acid on the newly diagnosed acute promyelocytic leukaemia: our experience].", "score": 0.018433571185864764, "content": "Acute promyelocytic leukaemia (APL) is characterised by the morphology of bias cells (M3), t(15;17) translocation, and coagulopathy combining disseminated intravascular coagulation (DIC) and fibrinolysis. Anthracy cline-cytosine arabinoside (Ara C) intensive chemotherapy yields a complete remission in 50 percent (%) to 80% of newly diagnosed APL patients. Failure to achieve complete remission results in fatal bleeding due to coagulopathy or fatal sepsis during the phase of aplasia. It has been recently shown that all trans retinoic acid (ATRA) selectively differentiates abnormal promyelocytes into mature granulocytes in APL, both in vitro and in vivo, and induced complete remission in 80% to 90% of the newly diagnosed patients. It has also been observed that therapy with ATRA rapidly improved coagulopathy, and induced no aplasia. However, in 30% of patients the treatment with ATRA as a single drug was associated with rapid increase in leukocytes and signs of \"ATRA syndrome\", which could have fatal outcome. Therefore the European study group initiated in 1991 a multicentre randomised trial comparing chemotherapy with daunorubicin Ara C (chemotherapy group) and ATRA combined to the same chemotherapy (ATRA group) in newly diagnosed APL patients, aged 65 years or less. Results of this study strongly suggest that ATRA should be incorporated in the front line therapy of newly diagnosed APL. The aim of our study was to confirm their results in our newly diagnosed patients. In our study we had 15 subsequently hospitalised patients with APL in whom diagnosis was made according to MIC classification, and who were treated with ATRA (Vesanoid-Hoffman La Roche) combined with chemotherapy according to the recommendation of the European study groups. The comparison of the effect of ATRA we has evaluated by the outcome of APL in 12 patients who received only combined chemotherapy in induction phase according to the Yu-AML-89 protocol 12 or 01-AM-86 protocol. Both protocols include daunorubicin and Ara C. In all patients MIC classification was performed. Characteristics of the patients included in the study with special emphasis to symptoms at presentation, are given in Table 1. Patients treated with ATRA plus chemotherapy received daily oral dose of ATRA 45 mg/m2 until the complete remission, or for a maximum of 90 days. After complete remission they received three courses of daunorubicin 60 mg/m2 for 3 days, and Ara C 200 mg/m2 for 7 days. However, course one was added to ATRA on day one of treatment of initial leukocyte counts were greater than 5 x 10(9)/L or rapidly started to increase to above 6 x 10(9)/L or more. Patients treated with chemotherapy received only in induction phase daunorubicin 45 mg/m2 for 4 days and Ara C 200 mg/m for 7 days as well as the intensive platelet support, heparin, fresh frozen plasma in those with bleeding. During the study haemostasis monitoring was performed in all patients. Complete remission was defined according to the criteria of the European study group. Early death was defined as a death during the therapy with ATRA or chemotherapy due to \"ATRA syndrome\", bleeding, aplasia, or resistant leukaemia. Statistical analysis was performed according to the Kruskal-Wallis test. Relevant haematological and pathobiological characteristics at presentation are shown in Table 2. It can be seen that there were no significant characteristic differences at presentation between ATRA group and chemotherapy group. The effects of the treatment are shown in Table 3. It can be seen that complete remission was achieved in 87% of patients receiving ATRA combined with chemotherapy and only in 42% of patients who received combined chemotherapy. This difference is significant (p &lt; 0.01). Duration of complete remission lasted for 14 months (median) in the patients receiving ATRA while only 5 months (median) in the patients who received combined chemotherapy. Fatal outcome in ATRA group occurred in 13% due to the \"ATRA syndrome\" and in 58% of the patients treated with combined chemotherapy due to bleeding. Table 4 shows four selected patients from ATRA group in whom complete remission was followed with disappearance of t (15;17), thus providint the evidence of the eradication of clonal abnormalities. It should be emphasised that 2 of 15 patients developed ATRA syndrome during the early phases of the treatment with a feature of cardiorespiratory distress. The therapy with steroid was unsuccessful. Nine of 13 patients in ATRA group had moderate side effects with no necessity to discontinue the therapy. Our clinical trial shows for the first time in our county a beneficial effect of ATRA in addition to chemotherapy compared with chemotherapy alone in newly diagnosed APL, thus comfirming the results of the European study group. The only flaw of in our study may come from the fact that the patients included in the study were not randomised and that for the comparison of the ATRA group were used previously treated patients with chemotherapy alone. However, we believe that this flaw has been overcome since uniform diagnostic procedure and particularly MIC classification were performed in all patients. In addition to that, all patients included in the trial were subjected to the analysis of haemostatic status as well as to precise biochemical studies, ECG and abdominal echography. It is interesting to note that in our study, similarity to the European study group, 13% of patients developed \"ATRA syndrome\". Therefore, it is recommended that further effort should be made in order to prevent this fatal and not yet resolved syndrome." }, { "id": "pubmed23n0866_3216", "title": "DIC Complicating APL Successfully Treated With Recombinant Thrombomodulin Alfa.", "score": 0.01837336704593342, "content": "An 8-year-old boy developed anorexia, fatigue, and fever. Laboratory examination revealed a high white blood cell (WBC) count of 145×10/μL with 97.5% abnormal promyelocytic cells that contained Auer bodies. Faggot cells were seen. He was diagnosed with acute promyelocytic leukemia. Later, a chromosome analysis showed 46,XY,t(15;17)(q22;q12). Promyelocytic Leukemia-retinoic acid receptor α-fused gene and chimeric mRNA were confirmed by fluorescence in situ hybridization and reverse transcriptase polymerase chain reaction, respectively. He was complicated with disseminated intravascular coagulation (DIC) and his fibrin and fibrinogen degradation product at the onset was 37.6 μg/mL. Human recombinant thrombomodulin (rTM) was started for DIC. After dexamethasone was administered at a dose of 8 mg/m to prevent all-trans retinoic acid syndrome on day 1, all-trans retinoic acid was started at a dose of 45 mg/m on day 4. Cytarabine (100 mg/m/d) and daunorubicin (45 mg/m/d) were started on day 9. The WBC count gradually increased to 270×10/μL on day 8, and then decreased beginning on day 9. DIC improved after the initiation of chemotherapy and only minor petechia was noted. DIC did not become worse even after rTM was stopped on day 8. The risk of DIC and bleeding is high in the early stage of treatment for acute promyelocytic leukemia, especially in patients with a high WBC count. In our patient, rTM may have prevented fatal DIC and made it possible to safely administer induction chemotherapy." }, { "id": "pubmed23n0282_16642", "title": "[Complete remission of acute promyelocytic leukemia accompanied by DIC in an elderly patient treated with all-trans retinoic acid].", "score": 0.01816545290892726, "content": "In this paper we report on a 74-year-old female patient who was suffering from acute promyelocytic leukemia (APL) and who, upon admission to our hospital on February 20, 1992, was also found to be stricken with disseminated intravascular coagulation (DIC). The DIC, however, was quickly arrested by administration of heparin and there was no exacerbation. Also, on admission her peripheral blood leukocyte count was 700/ul, but after oral administration of all-trans retinoic acid (ATRA) (45 mg/m/day) was begun on February 22, this count gradually increased and peaked at 35,200/ul on March 7. Some of these matured leukocytes revealed dysplastic features; some had Auer bodies. At this time cytogenetic analysis of bone marrow cells showed 46XX, t (15;17). The leukocyte count gradually decreased to 1,500/ul, and the dysplastic features disappeared. On March 21 her thrombocytes and reticulocytes began to increase, and she achieved complete remission when her abnormal karyotype disappeared on March 24. She suffered no severe complications such as infection or hemorrhage during treatment. We therefore suggest that ATRA is very effective for APL in elderly patients. It neither exacerbates DIC nor increases the risk of infection. In fact, when ATRA treatment is compared to the standard cytotoxic chemotherapy there is a reduced risk of infection." }, { "id": "pubmed23n0792_7774", "title": "[Analysis of empirical treatment for newly diagnosed acute promyelocytic leukemia combined with disseminated intravascular coagulation].", "score": 0.01780392156862745, "content": "This study was aimed to explore the clinical characteristics and optimal therapeutic methods for newly diagnosed acute promyelocytic leukemia (APL) combined with disseminated intravascular coagulation (DIC) so as to guide the clinical therapy. The clinical date and therapeutic outcome of 25 cases of APL combined with DIC treated from January 2008 to March 2013 in our department were analysed retrospectively. The 25 patients were given ATRA 20 mg orally twice a day and arsenic trioxide (ATO) 10 mg intravenously once a day to induce differentiation therapy, the chemotherapy was added after degranulation of promyelocytes. At the same time the platelets, fresh frozen plasma, fibrinogen, cryoprecipitate,prothrombin complex and amino methylbenzoic acid, low molecular weight heparin were given to treat DIC. According to the laboratorial examination of coagulation and fibrinolysis, the medication was adjusted.The white blood cell count, platelet level, prothrombin time (PT), partial thromboplastin time of plasma (APTT), fibrinogen level were detected, and the relation of those factors and age with bleeding severity was analyzed by multivariate manner. The results showed that among 25 patients with APL (low-risk 5 cases, intermediate risk 13 cases and high risk 7 cases), 22 cases combined with DIC, incidence of DIC was 88%. Out of 22 patients with DIC 21 patients (95.5%) were corrected, except 1 case death. After the first course of treatment, 23 cases (92%) gained complete remission (CR) with average CR time 31.8 ± 7.2 days. During the induction of CR, the average platelet transfusion level was 75.68 ± 55.88 U, the RBC level was 8.90 ± 5.69 U, the average level of fresh frozen plasma transfusion of APL patients with DIC was 21.92 ± 19.32 U. The recovery time of platelet level to normal was 29.3 ± 9.3 days, the recovery time of PT, APTT, FDP and fibrinogen to normal were 12.7 ± 9.5 days, 11.6 ± 8.6 days, 16.0 ± 9.3 days and 125.3 ± 85.3 days respectively. The multivariate analysis showed that WBC count at onset was &gt;10 × 10(9)/L and APTT was prolonged. These two factors were main reasons resulting in severe bleeding. It is concluded that the newly diagnosed APL always combined with DIC, therefore in the early phase of disease active transfusion of blood products, application of anti-coagulation and anti-fibrinolytic drugs as well as heparin should be performed; the coagulation function should be as soon as recovered to normal so as to early correct DIC. These measures can significantly decrease the mortality of APL patients resulting from DIC. The hyperleukocytosis and prolonged APTT are the main factors for severe bleeding." }, { "id": "pubmed23n0232_221", "title": "Acute promyelocytic leukemia with (15;17) translocation and chromosome no. 11 deletion (q23).", "score": 0.01763791763791764, "content": "The patient, a 76-year-old man, was referred with fever, large ecchymotic lesions and ulcerative laryngitis. Blood counts showed a hemoglobin of 11 g/100 ml, hematocrit of 31%, red blood cell count of 3.5 X 10(12)/1, white blood cell count of 6.8 X 10(9)/1 and platelet count of 16.0 X 10(9)/1. The differential count showed 17% neutrophils, 4% lymphocytes, 40% promyelocytes and 39% myeloblasts. The sternal marrow sample showed a marked hypercellularity. Of the cells, 80-85% were hypergranular promyelocytes, some of them showing bundles of Auer rods. No granulocytic maturation was observed. A few erythroblasts were present. A disseminated intravascular coagulation was observed (fibrinogen 0.85 g/l, factor V 18%, fibrin degradation products 640 mg/l). The serum creatinin was at 217 micromol/1 and the urea at 16.8 mmol/1. The treatment (daunorubicin, heparin, platelet transfusion) was unsuccessful and the patient died three days after entering hospital. The bone marrow karyotype by direct examination showed only normal metaphases (32 photographed). All the metaphases from the unstimulated blood 48-h culture (25 photographed) were clonal, showing the pattern 47,XY,del(11) (q23),t(15;17) (q24? q22?), +mar. The marker was '16 like' in size but its origin could not be determined (Figs. 1 and 2)." }, { "id": "pubmed23n0783_1213", "title": "Comparison of laboratory characteristics between acute promyelocytic leukemia and other subtypes of acute myeloid leukemia with disseminated intravascular coagulation.", "score": 0.01711402033204125, "content": "Acute promyelocytic leukemia (APL) is an acute myeloid leukemia (AML) subtype with distinctive cell morphology, molecular presentation, clinical course, and treatment. About 90% of APL patients present with hemorrhagic complications due to disseminated intravascular coagulation (DIC). When APL is suspected, all-trans retinoic acid (ATRA) treatment is recommended even before confirmation by molecular tests. Specific criteria for differentiating unconfirmed APL from other AML subtypes with DIC are currently lacking. We aimed to achieve the early diagnosis of APL from other AML types with DIC by restricting the DIC criteria. We retrospectively analyzed 29 patients newly diagnosed with AML accompanied by DIC from January 2005 to January 2013. Fibrin degradation products (FDP) (77.7 µg/mL vs. 23.7 µg/mL, p=0.026), D-dimer (7,376.2 ng/mL vs. 1,315.2 ng/mL, p=0.018), and TIBC (264.4 µg/dL vs. 206.8 µg/dL, P=0.046) were higher, while fibrinogen (133.8 mg/dL vs. 373.2 mg/dL, p&lt;0.001), WBC (14.988×10(9)/L vs. 70.755×10(9)/L, p=0.015), and ESR (7.1 mm/h vs. 50.0 mm/h, p &lt;0.001) were lower in APL patients than in the patients with other AML subtypes. FDP ≥27 µg/mL, D-dimer ≥2,071 ng/mL, and fibrinogen ≤279 mg/dL were our threshold values. These markers may be characteristic to APL and helpful in presumptive diagnosis. APL may be differentiated from other AML subtypes by core markers of DIC (FDP, D-dimer, and fibrinogen). We suggest that clinicians set new diagnostic thresholds by restricting the DIC criteria. These findings support the early initiation of ATRA, prior to confirmation by PML-RARA molecular testing." }, { "id": "pubmed23n1087_24691", "title": "Successful treatment of acute promyelocytic leukemia in a 92-year-old man using all-trans retinoic acid combined with oral arsenic: A case report.", "score": 0.0168928470455188, "content": "Acute promyelocytic leukemia is a special subtype of acute myeloid leukemia. The incidence of early death and complications is high. An oral regimen of all-trans retinoic acid combined with the realgar-indigo naturalis formula (RIF) without chemotherapy has provided a new strategy for the treatment of these patients. A 92-year-old male patient was admitted to the hospital due to fatigue and oral bleeding. He had no fever or lung infection. Routine blood test showed white blood cell count 1.0 ×109/L, hemoglobin 100 g/L, and platelets 21 × 109/L. Coagulation function indicated fibrinogen 1.02 g/L and D-dimer 2360 ng/mL. And 28% abnormal promyelocytes were observed in peripheral blood. A bone marrow morphologic, immunophenotypic, cytogenetic, and molecular examination was performed. Routine bone marrow examination showed active proliferation of nucleated cells, with promyelocytes accounting for 91%; immunophenotyping revealed an early myeloid cell population, accounting for approximately 82.4% of all cells. From February 15, 2020, 25 mg/m2 all-trans retinoic acid was orally administered daily. After the fusion gene result was obtained, oral administration of 60 mg/kg RIF daily began since February 18, 2020. The combination of the 2 agents was given until March 16, 2020. Oral administration of 25 mg/m2 retinoic acid daily began from March 20, 2020 for 2 weeks, and oral administration of 60 mg/kg RIF daily lasted for 4 weeks as the consolidation therapy. During the treatment, the proportion of promyelocytes in peripheral blood, white blood cell count, platelets, coagulation function, liver function, and QT interval were monitored. Oral retinoic acid and oral RIF were given without chemotherapy and the patient achieved bone marrow remission after 1 month, and molecular remission was achieved 2 months later. In the early stage of acute promyelocytic leukemia, combined thrombocytopenia and disseminated intravascular coagulation may develop. Platelet and fresh frozen plasma infusion were proactively given until platelets were stabilized above 30 × 109/L, and the coagulation function returned to normal. The regimen was safe and effective, and subsequent treatment did not require hospitalization, which helped to improve the patient's quality of life." }, { "id": "pubmed23n0814_24602", "title": "[An unusual cause of febrile neutropenia: brucellosis].", "score": 0.016281512605042014, "content": "Febrile neutropenia which is a common complication of cancer treatment, is one of the major causes of morbidity and mortality. Several gram-negative and gram-positive bacteria are responsible for infections in neutropenic patients, however the most common microorganisms are Escherichia coli and coagulase-negative staphylococci, in decreasing order. Although Brucella spp. infections are endemic in Turkey, brucellosis-related febrile neutropenia has only rarely been reported. In this report, a case of brucellosis-related febrile neutropenia in a patient with acute myeloblastic leukemia (AML) was presented. A 56-year-old male patient presenting with fever, petechiae/purpura, leukocytosis, thrombocytopenia, and anemia was admitted to our hospital. Laboratory studies revealed a hemoglobin level of 8.27 g/dl, leukocyte count of 77.100 k/ml, absolute neutrophil count of 200 k/ml, and platelets at 94.200 k/ml. The patient was diagnosed as AML-M1 and piperacillin/tazobactam was started as the first-line antibiotic therapy due to the febrile neutropenia. On admission, blood and urine cultures were negative. Once the fever was controlled, remission/induction chemotherapy was initiated. However, fever developed again on the eight day, and vancomycin was added to the therapy. Since the fever persisted, the antibiotic therapy was gradually replaced with meropenem and linezolid. However, fever continued and the patient's general condition deteriorated. Subsequently performed Brucella tube agglutination test revealed positivity at 1/320 titer and the microorganism grown in blood culture (Bactec 9050; BD, USA) was identified as B.melitensis by conventional methods. Rifampicin and doxycycline therapy was started immediately, however, the patient died due to septic shock. If the tests for brucellosis were performed earlier when response to second step antibiotic therapy lacked in this patient, it was assumed that mortality could be prevented by the prompt initiation of the appropriate treatment. Thus, since brucellosis is endemic in Turkey, it should be considered as a possible agent of febrile neutropenia especially in patients unresponsive to empiric antibiotherapy and appropriate diagnostic tests should be performed. " }, { "id": "pubmed23n0548_7830", "title": "Successful treatment of retinoic acid syndrome with dexamethasone: a case report.", "score": 0.0158033890157433, "content": "Retinoic acid syndrome (RAS) is the clinical syndrome that occurs after treatment of acute promyelocytic leukemia with all-trans-retinoic acid (ATRA). The patients experience fever, dyspnea, hypotension, respiratory distress, edema and weight gain. Chest x-ray will show pulmonary infiltrates and pleuropericardial effusion. The onset of this syndrome is usually 5-21 days after ATRA treatment when white blood cell counts are rising more than 10,000/cu.mm. The authors have reported a case of RAS. The patient was a 29-year-old man who had been working in a battery manufacturing factory for 7 years. He presented with easily bruising for one month. The initial blood test showed hematocrit of 36.2%, white blood cells count of 3,200/cu.mm with 28% neutrophils, 20% lymphocytes, 2% eosinophils and 50% promyelocytes and platelet of 20,000/cu.mm. Peripheral blood smear revealed numerous fragmented red blood cells. Bone marrow examination showed hypercellularity with abnormal promyelocytes of 95% and bone marrow cytogenetics was translocation of chromosome 15 and 17 [t (15;17)(q22;q12)]. The diagnosis was acute promyelocytic leukemia and the patient was treated with ATRA 45 mg/m2/day per oral starting on day 1 and intravenous idarubicin 10 mg/n2 on day 4, 5 and 6. On day 13, he had a body temperature of 39 degrees C and a dry cough. The white blood cells were rising to 7,400/cu.mm with 16% neutrophils. On day 18, he had oliguria, high grade fever, hypotension, cough with chest pain and white blood cells rose to 21,300/cu.mm with 65% neutrophils and rising of blood urea nitrogen and creatinine. Chest x-ray showed enlarged cardiac shadow with pleural effusion. Echocardiogram revealed moderate amount of pericardial effusion. The diagnosis of RAS was made and ATRA was withdrawn. Intravenous dexamethasone 4 mg every 6 hours and hemodialysis was started. The patient's symptoms improved dramatically and bone marrow examination was in complete remission. He was subsequently given cytarabine and idarubicin as consolidation. This patient had clinical manifestation consistent with RAS, which improved after prompt treatment." }, { "id": "pubmed23n0305_19231", "title": "[All-trans retinoic acid-induced myelomonocytoid differentiation in acute promyelocytic leukemia].", "score": 0.015667818420112, "content": "A 30-year-old man with a diagnosis of acute promyelocytic leukemia (APL) was admitted. Laboratory findings were as follows: WBC 32,900/microliter with 88% promyelocytes, Hb 10.4 g/dl, platelets 2.6 x 10(4)/microliter. Coagulation tests revealed DIC. Bone marrow was hypercellular with 91.8% promyelocytes which were strongly positive for peroxidase and positive for alpha-naphthyl butyrate esterase. Cytogenetic study revealed 46, XY, t(15;17) (q22:q11). He was treated with all-trans retinoic acid (ATRA) along with hydroxyurea (HU) and low-molecular weight heparin (LMH). Because his WBC increased to 93,700/microliter on day 6 of ATRA therapy, DCMP chemotherapy was given, while ATRA was withheld. He developed enterocolitis due to myelosuppression. ATRA was restarted along with granulocyte-colony stimulating factor (G-CSF). His WBC rose to 10,400/microliter with a marked, but temporary predominance of myelomonocytes both in peripheral blood and in bone marrow. These myelomonocytoid cells were positive for specific and nonspecific esterase double stainings. Then he entered complete remission. It was of interest that myelomonocytoid differentiation of APL cells was induced by ATRA. The etiology was discussed." }, { "id": "pubmed23n0064_21285", "title": "[Marked bone marrow necrosis preceding acute myeloblastic leukemia in childhood].", "score": 0.015483022477283597, "content": "A 3-year-old boy was transferred to our hospital because of fever, abdominal pain and severe systemic bone pain on October 16, 1989. Hematological examination showed hemoglobin 8.7 g/dl, white blood cell count 5300/microliters with 9% neutrophils and platelet count 5.5 x 10(4)/microliters. Bone marrow aspiration and biopsy revealed markedly necrotic cells. Blood chemistry showed transient elevation of CRP, serum LDH, FDP, FDP-Ddimer and fibrinogen. Tc99m pyrophosphate bone scanning showed multiple uptake spots in various bone. Although the sign of fever, abdominal pain and bone pain disappeared spontaneously after three weeks, anemia persisted. About two months later from bone marrow necrosis, abnormal cells appeared in the bone marrow. A diagnosis of AML (M3) was made and a combination chemotherapy started. This case is remarkable for elevation of acute phase protein in association with bone marrow necrosis." }, { "id": "pubmed23n0714_17965", "title": "Newly diagnosed acute promyelocytic leukemia.", "score": 0.0153276955602537, "content": "Acute promyelocytic leukemia (APL) represents a medical emergency with a high rate of early mortality. As a consequence, as soon as the diagnosis is suspected based upon cytologic criteria, it is necessary to start all- trans retinoic acid (ATRA) treatment without delay. For patients with newly diagnosed APL, induction therapy with ATRA plus anthracycline based chemotherapy is recommended. At present the combination of arsenic trioxide plus ATRA should be considered for patients who are not candidates for anthracycline-based therapy. For pediatric and adult patients with APL aged &lt; 60 years who achieve a CR with induction, I recommend 3 intensive courses of consolidation chemotherapy associated to ATRA, targeted on the basis of the risk group at diagnosis. In patients treated with a very intensive consolidation chemotherapy maintenance treatment can be omitted. However If a maintenance treatment has to be adopted I suggest the use of intermittent ATRA for 15 days every 3 months for a period of 2 years, rather than ATRA associated to chemotherapy. Moreover, taking into account the medical literature, a reduced dosage of ATRA ( 25 mg/m(2)) in pediatric patients and a consolidation chemotherapy of reduced intensity in elderly patients is recommended. Furthermore, in order to maximize survival, careful attention should be reserved to the coagulopathy and to the appearance of the differentiation syndrome. Finally, PCR for the PML/RARA fusion gene on a bone marrow specimen every three months for two years, and then every six months for additional three years are needed during the follow-up." }, { "id": "pubmed23n0682_7935", "title": "Acquired protein C deficiency in a child with acute myelogenous leukemia, splenic, renal, and intestinal infarction.", "score": 0.01502870651806822, "content": "We report the case of a 6-year-old boy diagnosed with acute promyelocytic leukemia (AML-M3V) when he presented with pallor, abdominal pain, anorexia, and fatigue. Induction chemotherapy was started according to the AML-BFM 98 protocol along with Vesanoid (ATRA, All-trans retinoic acid). On the sixth day of induction, he developed splenic and gallbladder infarcts. Splenectomy and cholecystectomy were performed while chemotherapy induction continued as scheduled. Four days later, he developed ischemic areas in the kidneys and ischemic colitis in the sigmoid colon. Hypercoagulation studies showed severe deficiency of protein C. Tests showed protein C 16% (reference range 70-140%), protein S 87% (reference range 70-140%), antithrombin III 122% (reference range 80-120%), prothrombin time 13.6 s (reference = 11.3), INR (international normalized ratio) 1.21, partial thromboplastin time 33 s (reference = 33), fibrinogen 214 mg/dl, D-dimer 970 μg/ml, factor II 98%, and that antinuclear antibody, antiphospholipid antibodies, mutation for factor II gene (G20210A), and mutation for Arg506 Gln of factor V were all negative (factor V Leiden). There was no evidence of clinical disseminated intravascular coagulation (DIC). He was treated with low molecular weight heparin and did well. He continues to be in complete remission 7 years later with normal protein C levels. Acquired protein C deficiency can occur in a variety of settings and has been reported in acute myelocytic leukemia. However, clinically significant thrombosis in the absence of clinical DIC, such as our case, remains extremely rare." }, { "id": "pubmed23n0299_14175", "title": "[CD2 and CD8 expression in acute promyelocytic leukemia].", "score": 0.01498917748917749, "content": "A 34-year-old man was admitted to our hospital for a headache in March, 1995. The patient's hemoglobin was 7.5 g/dl, platelet count was 1.8 x 10(4)/microliter and white blood cell (WBC) count was 12,400/microliters with 99% myeloblasts. Myeloblasts were agranular or hypogranular but electron microscopy revealed microgranules in cytoplasm, and a few faggots were observed. The bone marrow was hyperplastic due to myeloblasts and chromosomal abnormality was recognized: 46, XY, t(15; 17) (q22; q12). PML-RAR alpha with intron 3 breakpoint of the PML locus, and rearrangements of the T-cell receptor beta and gamma genes were detected. These cells were positive for CD2 (63%), CD8 (47%), CD13 (87%) and CD33 (99%). Microgranular variant type of acute promyelocytic leukemia (APL) was diagnosed. Disseminated intravascular coagulation (DIC) was also present. The patient was treated with enocitabine, daunorubicin, 6-mercaptopurine, dalteparin sodium, anti-thrombin III concentrates and gabexate mesilate with prophylactic frozen transfusions of fresh plasma and platelet transfusions for 5 days, but WBC count did not decrease and DIC did not improve. The patient died of cerebral hemorrhage 7 days after diagnosis of APL. APL with CD8 expression has never been reported. We suggest that therapy should be modified in this type of APL and conclusions concerning the most appropriate therapeutic strategy will depend on the results of treatment of similar cases in the future." }, { "id": "wiki20220301en090_18824", "title": "Acute myeloid leukemia", "score": 0.014640326591900897, "content": "Acute promyelocytic leukemia is treated with all-trans-retinoic acid (ATRA) and either arsenic trioxide (ATO) monotherapy or an anthracycline. A syndrome similar to disseminated intravascular coagulation can develop during the initial few days of treatment or at the time the leukemia is diagnosed, and treatment can be complicated by a differentiation syndrome characterised by fever, fluid overload and low oxygen levels. Acute promyelocytic leukemia is considered curable. There is insufficient evidence to determine if prescribing ATRA in addition to chemotherapy to adults that suffer from acute myeloid leukaemia is helpful. Consolidation Even after complete remission is achieved, leukemic cells likely remain in numbers too small to be detected with current diagnostic techniques. If no consolidation therapy or further postremission is given, almost all people with AML will eventually relapse." }, { "id": "pubmed23n0789_23195", "title": "Clinical features and treatment outcomes of pediatric acute promyelocytic leukemia in a Mexican pediatric hospital.", "score": 0.013458110516934046, "content": "Acute promyelocytic leukemia (APL) is a distinct type of acute myeloid leukemia (AML) characterized by chromosomal translocations involving the retinoid acid receptor α (RARA) gene on chromosome 17. APL is a relatively rare blood disease that is highly curable with current treatment strategies; however, patient outcomes are heterogeneous in countries with limited resources. Promyelocytic leukemia accounts for 20-25% of all AML cases in Latin American countries. We conducted a study from July 2007 to July 2012 and applied the IC-APL2006 protocol. This case study reports the results from eleven patients with AML M3 (five males and six females). In all cases, the diagnoses were made by aspirating bone marrow and evaluating the t(15:17) or t(11:17) transcript. In eight cases, the molecular biology-based diagnostics for the PLM-RARa transcript were positive, and they were negative in two cases. One patient was positive for the PLZF-RARa transcript. The mean WBC at the time of diagnosis was 10.1 x 10(9)/L, and the mean platelet count was 17.1 x 10(9)/L. The mean percentage of abnormal promyelocytes in the bone marrow aspirates was 68%. Of the eleven patients, four presented with disseminated intravascular coagulation. All of the patients began treatment with transretinoic acid (ATRA) (45 mg/m(2)/day), which led to 4 cases of ATRA syndrome. There were 2 relapses, and the patient died in one case. The remaining ten patients were alive after the median follow-up period of 33.6 months (range from 11 to 60 months). The authors report on a series of cases involving pediatric patients with AML M3 seen at a single institution; the patients were stratified and treated with a standard protocol to obtain satisfactory results. Although the number of patients is limited, the health outcomes are relevant. To our knowledge, this is the first series of pediatric APL patients in Mexico who were treated with the IC-APL2006 protocol." }, { "id": "pubmed23n0598_11863", "title": "Pediatric acute promyelocytic leukemia: all-transretinoic acid therapy in a Brazilian pediatric hospital.", "score": 0.013097713097713098, "content": "Acute promyelocytic leukemia (APL) is an uncommon form of pediatric acute nonlymphocytic leukemia. It is characterized by clinical (refractory coagulopathy), morphologic (promyelocytic differentiation arrest), and cytogenetic t(15;17) hallmarks. The introduction of all-transretinoic acid (ATRA) or tretinoin, a biologic response modifier, in its therapy was followed by dramatic improvement in its outcome. To show the results of APL treatment in our hospital, we reviewed the information about 15 patients less than 18 years old, newly diagnosed with APL between November 2002 and November 2006. The diagnosis was made upon examination of bone marrow aspirates. The clinical charts were searched for data regarding clinical presentation, diagnosis, initial response with induction therapy, toxicity of ATRA, and antracyclic drug (daunorubicin). The median age was 10 years; the male-to-female ratio was 2:1. Fourteen patients received induction chemotherapy. Thirteen achieved complete remission. Six patients showed signs of coagulopathy. Only 1 patient was diagnosed with ATRA syndrome. There was a death owing to sepsis before the beginning of the therapy and 2 relapses with death associated with the therapy discontinuation. Preliminary results are encouraging and confirm that ATRA is safe and efficacious as first choice therapy for APL." }, { "id": "pubmed23n0526_9444", "title": "Delayed recovery of normal hematopoiesis in arsenic trioxide treatment of acute promyelocytic leukemia: a comparison to all-trans retinoic acid treatment.", "score": 0.013055362898290564, "content": "To examine laboratory data including total blood cell count, leukocyte morphology and coagulation parameters during treatment for acute promyelocytic leukemia (APL) at a single institute, and compare the precise differences between all-trans retinoic acid (ATRA) and arsenic trioxide (As2O3) treatment. Sixteen patients with APL who were treated with ATRA or As2O3 alone and achieved complete remission (CR) were analyzed. ATRA 45 mg/m2/day was given orally until CR. As2O3 0.15 mg/kg/day was given intravenously until leukemic blasts and promyelocytes were eliminated from the bone marrow. All 7 patients in the ATRA-treated group were primary cases and all 9 patients in the As2O3-treated group were relapsed cases after the achievement of CR with the ATRA. There was no difference in the data before treatment between these two groups. The duration of leukocytopenia and neutropenia during As2O3 treatment was significantly longer than those of ATRA treatment. The nadir of leukocyte and neutrophil counts was observed later in the As2O3-treated group. Terminal neutrophil differentiation was observed more obviously in the ATRA-treated group. The red blood cell count and hemoglobin concentration decreased significantly at the end of As2O3 treatment and were lower than those of ATRA treatment. Platelets recovered earlier in the ATRA-treated group. Coagulation parameters were not significantly changed between the two groups. In comparison with ATRA treatment, the recovery of several components in the peripheral blood cells was delayed in As2O3 treatment. Therefore we should pay more and longer attention in As2O3 treatment." }, { "id": "pubmed23n0714_18512", "title": "Clinical bleeding events and laboratory coagulation profiles in acute promyelocytic leukemia.", "score": 0.012316294533227549, "content": "Bleeding is the leading cause of death for patients with acute promyelocytic leukemia (APL). Blood component transfusion to correct coagulopathy is the keystone in reducing bleeding. The benefit of fresh frozen plasma transfusion is unproven. Using laboratory profiles to predict bleeding is important guidance for the determination of transfusion policies in the treatment of APL. For 116 patients of APL, bleeding events were collected and correlated with various hematologic and coagulation parameters, including leukemic cell percentages, white blood cell (WBC) and platelet counts, prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen levels, and disseminated intravascular coagulation (DIC) scores. Overt DIC occurred in 77.6% of patients. Severity of DIC was associated with bone marrow leukemic cell percentages but unrelated to bleeding. Patients with bleeding had significantly higher WBC counts (26.73 ± 6.18 vs. 13.03 ± 3.03 per μL, P = 0.026) and more prolonged PT (4.85 ± 0.70 vs. 2.59 ± 0.28 s, P = 0.002) and APTT (3.98 ± 1.68 vs. 0.96 ± 0.93 s, P = 0.017). Fibrinogen levels, platelet counts, and leukemia cell percentages were not significantly different between bleeding and non-bleeding patients. PT is valuable in prediction of bleeding. Patients with PT ≧ 5 s had a relative risk of 6.14 for bleeding. Seven patients had severe bleeding before initiation of all-trans retinoic acid (ATRA). Patients with APL are susceptible to DIC and subsequent bleeding events. Prompt ATRA administration is crucial in preventing hemorrhagic events. High WBC counts, prolonged PT, and APTT are associated with clinical bleeding in our series. PT is the most accurate parameter in predicting bleeding. Based on these findings, supportive care should be directed toward correction of coagulopathy to prevent bleeding complications and fresh frozen plasma appears to be indicated for coagulopathy associated with APL." }, { "id": "pubmed23n0383_13591", "title": "Analysis of prognostic factors in newly diagnosed patients with acute promyelocytic leukemia: the APL92 study of the Japan Adult Leukemia Study Group (JALSG).", "score": 0.011744281045751634, "content": "All-trans-retinoic acid (ATRA) has been incorporated in front-line therapy for newly diagnosed acute promyelocytic leukemia (APL). We conducted a multicenter study of differentiation therapy with ATRA alone or in combination with chemotherapy followed by intensive postremission chemotherapy in patients with APL (the JALSG APL92 study), and analyzed prognostic factors to increase the cure rate in our subsequent trial. From 1992 to 1997, adult patients with newly diagnosed APL received oral ATRA 45 mg/m2 daily alone until complete remission (CR) if initial leukocyte counts were &lt; 3.0x10(9)/l, and ATRA daily plus daunorubicin (DNR) 40 mg/m2x3 days plus enocitabine (BHAC) 200 mg/m2x5 days if leukocyte counts were &gt; or =3.0 x 10(9)/l. If peripheral blasts exceeded 1.0x10(9)/l during therapy, DNRx3 days plus BHACx5 days was added. After CR was achieved, three courses of consolidation and six courses of maintenance/intensification chemotherapy were administered. Of 376 patients enrolled, 369 were evaluable (median age 46 years, range 15-86 years; median leukocyte counts 2.0x10(9)/l), and 333 (90%) achieved CR (94% of patients treated with ATRA alone, 88% with ATRA plus later chemotherapy, 89% with ATRA plus initial chemotherapy, and 86% with ATRA plus initial and later chemotherapy). At a median follow-up of 45 months, the predicted 6-year overall and event-free survival (EFS) rates for all patients were 65% and 52%, respectively. Favorable prognostic factors for CR were younger age, no or mild purpura, high serum total protein level, low lactate dehydrogenase level, and no or mild disseminated intravascular coagulation (DIC). Favorable prognostic factors for EFS were leukocyte counts &lt; 10.0x10(9)/l, mild DIC, and no sepsis during induction therapy. In the JALSG APL97 study, we intensified chemotherapy for patients with leukocyte counts &gt; or =3.0x10(9)/l, and are randomly testing whether further chemotherapy is required for APL patients with negative PCR for PML/retinoic acid receptor alpha in the maintenance phase." }, { "id": "article-24207_24", "title": "Leukemia -- Treatment / Management", "score": 0.011289473684210526, "content": "APL: APL patients typically present with bleeding diathesis with increased coagulation parameters (elevated PT, aPTT) and low fibrinogen. Peripheral smear shows a predominance of myeloid blasts with Auer rods. It is important to start the treatment with ATRA (all-trans-retinoic acid) when APL is suspected rather than awaiting confirmatory tests with FISH. ATRA advances arrested promyeloblasts into becoming mature granulocytes which can result in differentiation syndrome. [17] Differentiation syndrome is seen during 48 hours of ATRA initiation to even three weeks from starting therapy for APL. Patients have a fever, respiratory distress with acute pulmonary infiltration on imaging, and capillary leak resulting in edema. It can mimic sepsis, resulting in delaying the treatment with dexamethasone. The commonly accepted starting dosage is 10mg every 12 hours till improvement in symptoms and counts. [18] Other significant complication with ATRA includes raised intracranial pressure leading to headaches and significant vision changes from papilledema." }, { "id": "pubmed23n0289_17062", "title": "AIDA (all-trans retinoic acid + idarubicin) in newly diagnosed acute promyelocytic leukemia: a Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto (GIMEMA) pilot study.", "score": 0.0112081650543189, "content": "From March 1993 to October 1993, 20 consecutive, newly diagnosed acute promyelocytic leukemia (APL) patients from 13 Italian institutions entered in a pilot study named AIDA, combining all-trans retinoic acid (ATRA) with idarubicin (IDA). ATRA was administered orally beginning on the first day of induction at the dosage of 45 mg/m2/d until complete remission (CR), whereas IDA was administered intravenously at the dosage of 12 mg/m2/d on days 2, 4, 6, and 8 of the induction. Patients who achieved CR were consolidated with 3 courses of chemotherapy without ATRA; thereafter, they were followed up for molecular and hematologic CR. The median age was 35.3 years (range, 6.5 to 67.6 years); 8 patients were males and 12 females; 4 had the hypogranular variant of APL (M3v), and 4 (2 with M3v) presented with leukocyte counts &gt; or = 10,000/microL. Molecular analysis for the promyelocytic leukemia-retinoic acid receptor alpha (PML-RAR alpha) hybrid gene at diagnosis was performed in 16 patients by means of reverse transcription-polymerase chain reaction (RT-PCR) analysis, and all were RT-PCR+ for the hybrid gene. In the remaining 4 patients, the cytogenetic study showed the presence of the t(15;17). After a median time of 36 days (range, 28 to 52 days) 18 (90%) patients achieved CR; the remaining 2 patients died 12 and 34 days after diagnosis from myocardial infarction caused by fungal myocarditis and from massive hemoptysis, respectively. ATRA syndrome was observed in only 2 patients, and, after the prompt discontinuation of ATRA and initiation of dexamethasone, both recovered from the syndrome. However, after recovering, 1 patient achieved CR, whereas the other died at day 34 because of massive hemoptysis; other side effects were very limited. At recovery from the third consolidation course, only 3 of 14 (21.4%) tested patients were RT-PCR+ for the PML-RAR alpha hybrid gene. Of these, 2 relapsed shortly afterwards; however, in the last patient, the PML-RAR alpha disappeared at successive testing performed 2 months later. As of September 30, 1995, after a median follow-up period from diagnosis of 27 months (range, 24 to 31 months), the overall survival and event-free survival durations are 85% and 69%, respectively; moreover, 14 of 18 (78%) patients who achieved CR are still alive and in first molecular and hematologic CR. Of the 4 relapsed patients, 3 achieved a second CR with ATRA and, after further treatment, are now in molecular and hematologic CR after 4+, 16+, and 17+ months from the second CR. These results indicate that (1) the AIDA protocol is highly effective in treating APL; (2) after 3 consolidation courses, the majority of patients who achieved CR are RT-PCR- for the hybrid gene PML-RAR alpha; (3) the persistence of an RT-PCR positivity for the PML-RAR alpha hybrid gene after 3 consolidation courses is indicative of early relapse, thus these patients still require additional treatment. These results have prompted the Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto (GIMEMA) to initiate, in cooperation with the Associazione Italiana di Ematologia ed Oncologia Pediatrica and some European Organization for Research and Treatment of Cancer (EORTC) centers, a new multicentric clinical trial named AIDA LAP 0493 for the treatment of adult and pediatric APL patients. All patients are considered eligible if APL diagnosis is confirmed with molecular or cytogenetic studies for PML-RAR alpha hybrid gene or t(15;17) and are enrolled to receive the same induction and consolidation therapy of this pilot study. After consolidation, patients who are RT-PCR- for PML-RAR alpha hybrid gene are randomized to four arms, whereas patients who are RT-PCR+ after consolidation undergo, if eligible, an allogenic transplantation procedure." }, { "id": "wiki20220301en051_5938", "title": "Pancytopenia", "score": 0.010215392640570323, "content": "Diagnosis Pancytopenia usually requires a bone marrow biopsy in order to distinguish among different causes. anemia: hemoglobin < 13.5 g/dL (male) or 12 g/dL (female). leukopenia: total white cell count < 4.0 x 109/L. Decrease in all types of white blood cells (revealed by doing a differential count). thrombocytopenia: platelet count < 150×109/L. Treatment Treatment is done to address the underlying cause. To tide over immediate crisis Blood transfusion with packed red blood cells (PRBC) or platelet transfusion may be done. Sometimes there are obvious clinical clues to suggest underlying B12 deficiency for a cause of pancytopenia. In this selected cases even with severe anemia blood product transfusions can be avoided and vitamin B12 treatment itself suffice. In other situations like acute leukemia, Myelodysplastic syndrome, aplastic anemia etc. disease specific therapy is needed. References External links EID Journal (Volume 6, Number 6), CDC, December 2000." }, { "id": "wiki20220301en034_55861", "title": "Hairy cell leukemia", "score": 0.009753433208489388, "content": "Treatment Several treatments are available, and successful control of the disease is common. Not everyone needs treatment immediately. Treatment is usually given when the symptoms of the disease interfere with the patient's everyday life, or when white blood cell or platelet counts decline to dangerously low levels, such as an absolute neutrophil count below 1000 cells per microliter (1.0 K/μL). Not all patients need treatment immediately upon diagnosis." }, { "id": "wiki20220301en054_43457", "title": "Arsenic trioxide", "score": 0.009708737864077669, "content": "Uses Medical Arsenic trioxide is used to treat a type of cancer known as acute promyelocytic leukemia (APL). It may be used both in cases that are unresponsive to other agents, such as all-trans retinoic acid (ATRA) or as part of the initial treatment of newly diagnosed cases. This initial treatment may include combination therapy of arsenic trioxide with all-trans retinoic acid (ATRA). Effectiveness appears similar to Realgar/Indigo naturalis, which can be taken by mouth and is less expensive but is less available. In the 1970s, Chinese researcher Zhang Tingdong and colleagues discovered this use. It was approved for leukemia treatment in the United States in 2000. University of Hong Kong developed a liquid form of arsenic trioxide that can be given by mouth. Organoarsenic compounds, such as feed additives (roxarsone) and medication (neosalvarsan), are derived from arsenic trioxide." }, { "id": "pubmed23n0560_171", "title": "[Complete remission of acute promyelocytic leukemia resisting all-trans retinoic acid of one case treated by tanshinone II A].", "score": 0.009708737864077669, "content": "A 30 years-old man was administrated with dizziness and fatigue for half month, and the big toe on his left foot got the prolonged bleeding of wound complicated with fever 7 days before the admission. The physical examination (PE) discovered that the case suffered from the anemic appearance, lower part tenderness of sternum, petechiae and purpura on skin of lower extremities, and with remaining not to be remarkable. The examination of blood routine showed WBC 2.3 x 10(9)/L, Hb 60/L, BPC 34 x 10(9)/L and blasts 0. 85. The bone marrow smear indicated markedly the hypercellularity, promyelocytes 89% and strongly positive myeloperoxidase (MPO). The PT and APTT were prolonged, and the FDP and D-dimer were positive. The acute promyelocytic leukemia (APL) with DIC was diagnosed. The patient was administered with all-trans retinoic acid (ATRA) with dosage of 20 mg three times per day. After 14 week treatment, the patient did not get complete remission. Then the tanshinone II A was taken orally with 30mg twice each day. After 8 week treatment of tanshinone II A, the blood routine was restored to normal. Four weeks later, the bone marrow also became normally, and the patient got a complete remission (CR). After more than 3 months of consolidation therapy with tanshinone II A, the patient was relapsed. When the homoharringtonine and cytarabine (HA) were given, the patient was got CR again. Three years later, he was relapsed secondarily, and then died of intracranial hemorrhage. The tanshinone II A could induce CR of APL with ATRA resistance, no side effect was observed; there is a reoccurring possibility from consolidation therapy with tanshinone II A." }, { "id": "pubmed23n0780_13350", "title": "Co-expression of t(15;17) and t(8;21) in a Case of Acute Promyelocytic Leukemia: Review of the Literature.", "score": 0.009615384615384616, "content": "Additional chromosomal abnormalities in acute myelogenous leukemia have been identified as one of the most important prognostic factors. Favorable chromosomal changes such as t(8;21), inv(16), and t(15;17) are associated with higher rates of complete remission and event-free survival. Translocation (15;17) characterizes acute promyelocytic leukemia (APL) (French-American-British class M3) in almost all patients. Secondary chromosomal abnormalities are also present in approximately 23%-29% of patients with newly diagnosed APL. The prognostic implications of t(8;21) and other secondary cytogenetic aberrations in APL are reviewed here. We present a 47-year-old woman diagnosed with APL whose initial cytogenetic analysis included both t(8;21) and t(15;17). The initial induction chemotherapy included 3 days of idarubicin (12 mg/m2/day) and daily all-trans retinoic acid (ATRA; 45 mg/m2/day). At the sixth week of treatment, a control bone marrow biopsy was found to be normocellular, t(15;17) bcr3 and t(8;21) were negative, and t(15;17) bcr1 fusion transcripts were reduced from 5007 (1.78525699%) copies per 1 µg RNA to 40 (0.00062020%) with real-time quantitative polymerase chain reaction. Consolidation with 4 days of idarubicin (5 mg/m2/day), ATRA (45 mg/m2/day for 15 days), and cytarabine (1 g/m2/day for 4 days) was then started. However, the patient became pancytopenic and had neutropenic fever after consolidation treatment. Unfortunately, she died 3 months after the time of APL diagnosis, due to acute respiratory distress syndrome-like respiratory problems and multiorgan dysfunction requiring respiratory support and hemodialysis. None declared." }, { "id": "pubmed23n0260_6702", "title": "[Late and slow diagnosis of acute promyelocytic leukemias--the main cause of early death].", "score": 0.009615384615384616, "content": "Acute hypergranular promyelocytic leukemia (AML M3) belongs to malignant diseases leading very rapidly to death. Immediate treatment based on early diagnosis may cure one third of patients. The typical finding in peripheral blood of patients is pancytopenia with or without atypical promyelocytes. In published studies only 15-25% patients exhibit leukocyte counts above 10 x 10(9)/l. Five of our ten patients studied had leukocyte count above 10 x 10(9)/l. The difference might be in connection with late and slow diagnosis of AML M3. AML is not taken into consideration during medical examination even if the disease occurs in medical family. Thus we describe clinical signs of AML M3 that could be divided into three main groups: bleeding, infections and anemia. In patients with bleeding or anemia or with infections repeating within a short period or with an infection and concurrent signs of bleeding or anemia the complete blood cell count should be examined immediately. If blood cell count abnormalities are found the patient should be sent immediately to hematology unit for further examination and treatment. Early diagnosis enables to start \"differentiation therapy\" with all-trans retinoic acid that could be administered as monotherapy only in patients with leukocytes below 5 x 10(9)/l. Early diagnosis of AML M3 might ameliorate the fate of patients, since four of our five patients referred to us with elevated leukocyte counts expired in the first five days." }, { "id": "pubmed23n0272_8087", "title": "[Therapy of disseminated intravascular coagulation in acute promyelocytic leukemias. Apropos of 19 cases].", "score": 0.009523809523809525, "content": "To evaluate our experience in the treatment of disseminated intravascular coagulation (DIC) associated to AML-M3 with substitution therapy with or without heparin. The clinical records of 19 patients diagnosed of AML-M3 in the Hospital Juan Canalejo, in La Coruña, between 1986 and 1991 were revised. DIC was defined by abnormalities in one or more of the following: prothrombin time, activated partial thromboplastic time, thrombin time, fibrinogenaemia, fibrin/fibrinogen degradation products, D-dimers. The treatment given to 13 patients was only substitutive including platelets, fresh-frozen plasma, cryoprecipitates and antithrombin III. Low-dose sodium heparin (Kabi) in continuous intravenous infusion was associated to the treatment of the remaining 6 patients. With regard to the leukaemic therapy, most of the patients received daunorubicin, 2 mg/kg/day x 5 days, and AraC, 100 mg/Kg/day x 7 days. All patients showed haemorrhagic symptoms at diagnosis, and laboratory data of DIC were present in 11 cases (57%). The mean duration of DIC was 6.5 days for the patients receiving substitutive treatment and 9.5 days for those given heparin. Complete remission (CR) of the leukaemia was attained in 12 cases (63%); of the patients treated with heparin, 50% achieved CR whereas 75% of those receiving substitute therapy attained CR. The 24-months survival rate was 30% for the patients treated with substitutive therapy and 16% for those treated with heparin. The incidence of death associated to haemorrhage during induction therapy was 30% for the substitutive treatment group and 50% for the heparin group. Shorter duration of DIC, lesser rate of early death, higher CR rate and longer 2-year survival were found in those AML-M3 patients not receiving heparin." }, { "id": "pubmed23n0755_21996", "title": "Current routine practice and clinico-pathological characteristics associated with acute promyelocytic leukemia in Korea.", "score": 0.009433962264150943, "content": "Acute promyelocytic leukemia (APL) can be life threatening, necessitating emergency therapy with prompt diagnosis by morphologic findings, immunophenotyping, cytogenetic analysis, or molecular studies. This study aimed to assess the current routine practices in APL and the clinico-pathologic features of APL. We reviewed the medical records of 48 Korean patients (25 men, 23 women; median age, 51 (20-80) years) diagnosed with APL in 5 university hospitals between March 2007 and February 2012. The WBC count at diagnosis and platelet count varied from 0.4 to 81.0 (median 2.0)×10(9)/L and 2.7 to 124.0 (median 54.5)×10(9)/L, respectively. The median values for prothrombin time and activated partial thromboplastin time were 14.7 (11.3-44.1) s and 29 (24-62) s, respectively. All but 2 patients (96%) showed a fibrin/fibrinogen degradation product value of &gt;20 µg/mL. The D-dimer median value was 5,000 (686-55,630) ng/mL. The t(15;17)(q22;q12 and PML-RARA fusion was found in all patients by chromosome analysis and/or multiplex reverse transcriptase-polymerase chain reaction (RT-PCR), with turnaround times of 8 (2-19) d and 7 (2-13) d, respectively. All patients received induction chemotherapy: all-trans retinoic acid (ATRA) alone (N=11, 26%), ATRA+idarubicin (N=25, 58%), ATRA+cytarabine (N=3, 7%), ATRA+idarubicin+cytarabine (N=4, 9%). Since APL is a medical emergency and an accurate diagnosis is a prerequisite for prompt treatment, laboratory support to implement faster diagnostic tools to confirm the presence of PML-RARA is required." }, { "id": "pubmed23n0647_4761", "title": "Gangrenous cheilitis associated with all-trans retinoic acid therapy for acute promyelocytic leukemia.", "score": 0.009345794392523364, "content": "A 67-year-old Japanese woman who presented with erythema on the abdomen and pancytopenia was found to have acute promyelocytic leukemia (APL). A skin biopsy revealed invasion of APL cells. She was started on induction treatment with all-trans retinoic acid (ATRA) at 45 mg/m(2). On day 4, the leukemic cell number had increased to over 1.0 x 10(9)/L. Consequently, chemotherapy with idarubicin and cytarabine was initiated. On day 10, dryness of the lips appeared. The lower lip swelled and developed painful black eschars. A high fever was also present. Despite discontinuing ATRA on day 20 and administering antibiotics, an anti-fungal agent and valaciclovir, these signs did not improve. Histopathologically, the biopsied lip revealed infiltration of neutrophils and vasculitis. The patient was given ATRA on days 29 and 30 due to an increase in APL cell numbers, after which the gangrenous cheilitis extended over the whole lip. On day 49, the patient was started on re-induction treatment with arsenic trioxide. She achieved complete remission and the gangrenous cheilitis slowly healed over the following 8 weeks. Since the clinical features of the gangrenous cheilitis in this case were similar to those of ATRA-associated scrotal ulcers, it appears that activated neutrophils derived from differentiated APL cells may have caused the gangrenous cheilitis. Physicians should be alert to the development of gangrenous cheilitis during treatment with ATRA." } ] } } }

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{ "1": "Segmental resection of the affected colon.", "2": "Periodic endoscopic surveillance.", "3": "Local resection of the base of the polyp.", "4": "Sigmoidectomy plus lymphadenectomy.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0289_3681", "title": "[Our experience of 350 endoscopic polypectomies of the colon].", "score": 0.017879948914431672, "content": "The authors report their experience of the endoscopic removal of 350 polyps of the colon. Vegetating lesions of doubtful endoscopic appearance and nature were excluded from this study. Indications regarding intestinal cleaning and the most appropriate pharmacological preparation are given on the basis of personal experience. No patient had to be hospitalised and the colon was fully explored in all cases; the cecum was reached in 85% of cases. The maximum limit of endoscopic removal was 5 cm due to the greater risk of complications and presence of cancer on polyps. A total of up to 8 polyps were removed in a single session in cases of multiple polyposis. From 1986 to 1992 350 polypectomies were performed in 177 patients, of which 301 were adenoma (85.9%) and 49 mixed (14.1%). Adenomas were 80.5% tubular, 13.6% tubulo-villous and 4.3% villous. Cancer was found on polyps in 5 cases (1.6%). 146 polyps were found in the rectum (41.8%), 84 in the sigma (24%), 76 in the descending (21.7%), 21 in the transverse (6%), and 23 in the right colon (6.5%). Patients were aged between 3 and 81 years, and the most frequently affected age bracket was between 40-70 years. Follow-up consisted in checks at 6, 12 and 24 months in cases of adenoma and quarterly checks during the first year in the event of carcinoma in situ. The decision to use a diathermic loop or hot biopsy was made in relation to lesion size, reserving the former for polyps with diameters of over 8 mm. All polyps under 5 cm were removed and subjected to histological tests. No cases of early or late complications were reported in the 350 polypectomies performed. The authors indicate the criteria of choice which led to surgical resection of the first instance. In the event of in situ carcinoma, endoscopic removal is considered sufficient provided that it is radical. The following must be evaluated in the case of invasive carcinoma: tumor size, the degree of differentiation, lymphatic or vascular invasion and generic or specific risk factors linked to the individual patient." }, { "id": "pubmed23n0124_10287", "title": "Treatment of colonic polyps--practical considerations.", "score": 0.017820370663709804, "content": "The adenomatous colonic polyp, a neoplastic lesion, is the precursor of most if not all carcinomas of the colon and rectum. Confirmatory evidence is derived from epidemiological, histological and clinical data demonstrating a close parallelism between adenomas and cancer of the colon. Based on current knowledge, all colonic polyps should be removed to prevent the development of colonic cancer. However, since the risk of malignancy within an adenoma is related to its size, histology and the degree of dysplasia, practical considerations dictate that all polyps 1 cm in diameter or larger should be removed upon their detection by barium enema or colonoscopy since such adenomas are the ones most likely to contain malignancy. The endoscopic removal of colon polyps can be efficiently and safely accomplished when established principles of colonoscopy and electrosurgery are followed. This technique requires the proper equipment, a skilled endoscopy assistant, and an experienced endoscopist with the ability to adeptly perform colonoscopy, an understanding of the basic concepts of electrocautery and knowledge of the various structural configurations of colonic polyps. Colonoscopic polypectomy will avoid the need for surgical resection in most instances. Management of the malignant colonic polyp remains controversial. The patient with a sessile or pseudo-pedunculated polyp containing invasive cancer should undergo colonic resection. Surgery is not necessary for the majority of patients whose pedunculated adenomas contain invasive cancer, unless the malignancy is poorly differentiated, the cancer invades lymphatics or vascular channels, or tumour is seen at or near the resection margin. Surveillance colonoscopy after endoscopic polypectomy should be performed in most instances within one year to look for recurrent tumour, missed polyps or a metachronous adenoma. Subsequently, colonoscopy should be performed every two years in patients with multiple index polyps, and every three years after removal of a single index adenoma." }, { "id": "pubmed23n0489_9001", "title": "Endoscopic resection of large colorectal polyps.", "score": 0.01746031746031746, "content": "Endoscopic polypectomy is a common technique, but there are discrepancies over which treatment--surgical or endoscopic--to follow in case of polyps of 2 cm or larger. To analyse the efficacy and complications of colonoscopic polypectomy of large colorectal polyps. 147 polypectomies were performed on 142 patients over an eight-year period. The technique used was that of submucosal adrenaline 1:10000 or saline injection at the base of the polyp, followed by resection of the polyp using a diathermic snare in the smallest number of fragments. Remnant adenomatous tissue was fulgurated with an argon plasma coagulator. Lately, prophylactic hemoclips have been used for thick-pedicle polyps. Complete removal was defined as when a polyp was completely resected in one or more polypectomy sessions. Polypectomy failure was defined as when a polyp could not be completely resected or contained an invasive carcinoma. The mean patient age was 67.9 years (range, 4-90 years), with 68 men and 79 women. There were 74 sessile polyps, and the most common location was the sigmoid colon. The most frequent histology was tubulovillous. Most of the polyps (96.6%), were resected and cured. This was not achieved in four cases of invasive carcinoma, and a villous polyp of the cecum. All pedunculated polyps were resected in one session, whereas the average number of colonoscopies for sessile polyps was 1.35 +/- 0.6 (range, 1-4). The polypectomy was curative in all of the in situ carcinomata except one. As for complications, 2 colonic perforations (requiring surgery) and 8 hemorrhages appeared, which were controlled via endoscopy. There was no associated mortality. Endoscopic polypectomy of large polyps (&gt; or =2 cm) is a safe, effective treatment, though it is not free from complications. Complete resection is achieved in a high percentage, and there are few relapses. It should be considered a technique of choice for this type of polyp, except in cases of invasive carcinoma." }, { "id": "pubmed23n0006_12366", "title": "[Endoscopic resection of colonic polyps. A propos of 45 polypectomies].", "score": 0.016035959424163276, "content": "Endoscopic resection of polyps of the colon is, no doubt, a considerable therapeutic advance. It avoids surgical operation permits histological examination and makes simple biopsy unnecessary. It is indicated in the presence of pediculated polyps of a diameter or less than 3 cm, whatever the site of the polyp. Thus we were able to remove 45 polyps without complications. The method is not indicated in a large size polyp, sessile polyps or diffuse polyposis. The follow-up is still insufficient to assess : 1) the true risk of resection which can only be undertaken after long experience of colonoscopy ; 2) the frequency or recurrent adenomas. Endoscopic resection is at present the simplest method of detection and treatment of carcinoma in situ of the colon of which we observed four cases in our series. The problem of surgical reoperation is discussed." }, { "id": "pubmed23n0132_6056", "title": "[Endoscopic excision of malignant colorectal polyps. Study of a series of 82 cases].", "score": 0.016009221311475412, "content": "The management of malignant colonic polyps removed by endoscopic polypectomy is a controversial subject. We reported a series of 81 patients with 82 malignant polyps removed by endoscopic polypectomy between 1977 and 1984. 15 polyps contained carcinoma in situ and were treated by endoscopic polypectomy alone. 36 polyps contained superficial cancer; 35 were treated by EP alone; 1 was treated by endoscopic polypectomy and colectomy. 26 polyps contained invasive carcinoma and 2 were classified as polypoid adenocarcinomas. 19 had clear resection margins at polypectomy and seven had involved resection margins: 17 were treated by endoscopic polypectomy alone, 9 were treated by endoscopic polypectomy and colectomy. The patients were followed with colonoscopy. Follow-up has been 6 to 74 months (mean 32 months). The patients whose polyps were treated by endoscopic polypectomy alone, had had no evidence of recurrent tumor at the polypectomy site. Of the 12 patients undergoing colectomy, 4 had residual tumor at the polypectomy site. No patients had involved lymph nodes. There was no evidence of recurrence in any of these cases. Polyps containing contained carcinoma in situ and superficial cancer, polyps containing invasive carcinoma and clear resection margins can be treated with endoscopic polypectomy alone. Polyps with invasive carcinoma and involved resection margins should undergo segmental colonic resection. This approach must be weighed against the age of the patient, the medical status and the morbidity and mortality of the surgical procedure." }, { "id": "pubmed23n0039_7596", "title": "Definitive treatment of \"malignant\" polyps of the colon.", "score": 0.015159345391903532, "content": "There has been an unremitting rise in incidence of colonic cancer in this country with no recent improvement in cure rate. As a result the evolution of colorectal cancer has been the focus of considerable attention with an enlarging body of evidence pointing to the common neoplastic polyp as a precursor to malignancy. \"Neoplastic\" polyps include \"adenomatous polyps,\" \"villous adenomas\" and, lately recognized, \"villo-glandular polyps.\" Experience with endoscopic removal of over 2,000 colonic polyps (with no mortality) has introduced two questions of prime concern to the surgeon: (1) What constitutes clinical malignancy in a polyp? AND, (2) When should laparatomy supplant or follow endoscopic removal? Eight hundred and ninety-two consecutive adenomatous (tubular), villous, villoglandular (villo-tubular) and \"polypoid cancer\" polyps are analyzed, 855 of which have been followed for 6 months to 4 years. Support is offered to the concept that villous and tubular growth patterns are merely variants of a similar base disturbance in cell renewal. Superficial cancer (carcinoma-in-situ) occurred in 6.6% of neoplastic polyps and represents no threat if the polyp is completely removed. Only when the cancer penetrates the muscularis mucosae should it be regarded as \"invasive.\" The term \"malignant polyp\" should be reserved for this form. Invasive cancer was found in 5.0% of neoplastic polyps in this series. Only in this group need the question of further surgical intervention be raised. Major considerations influencing a decision for subsequent laparotomy are polyp size and gross morphology (i.e. sessile or pedunculated), histologic type (of the polyp and of the cancer itself), adequacy of clearance between depth of invasion and plane of polyp resection, and the patient's age and general condition. These are analyzed. Twenty-five of 46 patients with \"malignant polyps\" were subjected to abdominal exploration: 17 showed no residual cancer, whereas 8 (5 with recognized incomplete endoscopic removal) had tumor in the bowel wall. Of the remaining 21 patients, for whom endoscopic polypectomy alone was deemed appropriate, none have shown residual or recurrent cancer on clinical and endoscopic followup. Colonoscopy appears to be a most promising approach in terms of the goals of cancer programs, offering both prophylaxis and opportunity for treatment at a favorable stage of disease." }, { "id": "wiki20220301en126_26377", "title": "Colonic polypectomy", "score": 0.014611613876319759, "content": "Colonic polypectomy is the removal of colorectal polyps in order to prevent them from turning cancerous. Gastrointestinal polyps can be removed endoscopically through colonoscopy or esophagogastroduodenoscopy, or surgically if the polyp is too large to be removed endoscopically. The method used to perform colonic polypectomies during colonoscopy depends on the size, shape and histological type of the polyp to be removed. Prior to performing polypectomy, polyps can be biopsied and examined histologically to determine the need to perform polypectomy. Evaluation Prior to resection, assessment of the polyp should include: polyp size, morphology, location, and accessibility. If there are features that suggest of cancer is present in the polyp, then either endoscopic submucosal dissection or surgery should be considered. If the polyp appears benign, but the risk of progression to cancer is negligible, then resection is not necessary." }, { "id": "wiki20220301en016_102433", "title": "Polyp (medicine)", "score": 0.014245014245014245, "content": "While colon polyps are not commonly associated with symptoms, occasionally they may cause rectal bleeding, and on rare occasions pain, diarrhea or constipation. They are a concern because of the potential for colon cancer being present microscopically, and the risk of benign colon polyps becoming malignant over time. Since most polyps are asymptomatic, they are usually discovered at the time of colon cancer screening. Common screening methods are occult blood test, colonoscopy with a modern flexible endoscope, sigmoidoscopy ( usually with the older rigid endoscope), lower gastrointestinal series (barium enema), digital rectal examination (DRE), virtual colonoscopy or Cologuard. The polyps are routinely removed at the time of colonoscopy, either with a wire loop known as a polypectomy snare (first description by P. Deyhle, Germany, 1970), or with biopsy forceps. If an adenomatous polyp is found, it must be removed, since such a polyp is pre-cancerous and has a propensity to become" }, { "id": "pubmed23n0243_6433", "title": "Endoscopic polypectomy: inadequate treatment for invasive colorectal carcinoma.", "score": 0.014141613924050632, "content": "Endoscopic polypectomy has greatly decreased the necessity for transabdominal resection of adenomatous polyps of the colon and rectum. In addition, the routine removal of these presumed precancerous lesions may well decrease the incidence of colon cancer in these patients. However, some authors have proposed that endoscopic resection alone of certain pedunculated polyps containing invasive carcinoma is adequate treatment for these lesions. At Columbia-Presbyterian Medical Center this has not been our standard practice, and 729 patients who have undergone endoscopic removal of pedunculated adenomatous polyps of the colon and rectum during the past decade have been reviewed. Forty-seven (6.4%) of these patients had polyps containing carcinoma in situ for which no further resection was performed. Thirty-nine patients (5.3%) had polyps containing carcinoma which had invaded up to or through the muscularis mucosae and were, therefore, considered invasive carcinomas. In this latter group, 24 patients underwent colon resection and 15 underwent endoscopic polypectomy alone. Within the group undergoing resection, six patients (25%) had from one to two lymph nodes within the resected specimen containing metastatic cancer. In review of these lesions, all 24 were able to be resected with an intervening segment of uninvolved stalk. After analyzing the frequently quoted parameters of size, depth of invasion into the stalk, degree of differentiation and involvement of lymphatics within the polyp, it was not possible to predict which lesions would have lymph node metastases at the time of resection. Consequently, it is concluded that all patients with polyps containing invasive carcinoma should undergo standard colon resection if feasible, despite the technical ability to resect these lesions endoscopically with an \"adequate\" margin of uninvolved stalk. This will eliminate the possibility of undiagnosed Dukes' Stage C lesions, and potentially improve long-term survival rates within this group of patients with an otherwise poor prognosis." }, { "id": "wiki20220301en605_1636", "title": "Serrated polyposis syndrome", "score": 0.01365861685934093, "content": "If polyps are very numerous, very large, or their growth cannot be controlled with colonoscopy, then surgery may be necessary. When surgery is necessary, a total abdominal colectomy with ileorectal anastomosis should be considered to minimize the risk of colon cancer. If surgery is necessary and involvement of polyps is focal or largely confined to a particular section of bowel, then segmental resection may be considered. Segmental resection is also recommended for cancer. In most cases, the rectum is left in place. Any remaining segments of colon or rectum require annual surveillance with colonoscopy." }, { "id": "pubmed23n0725_15177", "title": "Polypectomy practices in a real life setting. Do we do enough for our patients? A review of 1061 colonoscopies.", "score": 0.013571954361428044, "content": "Endoscopic removal of colon polyps is the main tool in colorectal cancer prevention programs. Although several quality indicators and guidelines have been proposed, polypectomy practices are still subject to great variation among endoscopist and little data is available regarding polypectomy practices in real life settings. The records of the 1061 screening colonoscopies performed in 2010 in a tertiary care teaching hospital in Bucharest were reviewed and all colonoscopies where at least one polyp was detected were selected for analysis. The number of detected polyps, the resection rate and method used for polypectomy were studied and compared to colonoscopy quality indicators previously reported in literature. 941 polyps were detected in 395 patients. Invasive colorectal cancer was found in 42 patients. 548 polyps (58.23%) were removed endoscopically, with at least one polyp being resected in 283 patients (71.5%), resulting in a polypectomy rate of 26.67% in the entire study population. Cold forceps resection was the most commonly used method for the resection of polyps less than 5 mm in size, while for larger polyps hot snare was the preferred method. Concomitant invasive carcinoma and a larger number of polyps were predictive of incomplete removal of all detected polyps. Most quality indicators were met in our study group, with suboptimal performance regarding histological documentation of detected polyps and establishing a polyp-free colon." }, { "id": "pubmed23n0119_17080", "title": "Patient management after endoscopic removal of the cancerous colon adenoma.", "score": 0.013528138528138528, "content": "The subject of management of patients after endoscopic removal of cancerous adenomas is controversial. A retrospective review of 126 lesions in 121 patients who had had colonoscopic polypectomy of malignant lesions between 1971 and 1985 was used to determine the criteria for colon resection. Invasive cancer was identified in 80 patients, while 41 patients had carcinoma in situ. A synchronous colon cancer was found in five of the 121 patients. The patients who had carcinoma in situ had no evidence of residual tumor or metastatic disease on subsequent follow-up (colon resection in three patients and endoscopic surveillance in 38 patients). Of the 80 patients with invasive cancer, 44 had subsequent colon resection, and 34 of these had no evidence of tumor in the resected bowel or mesenteric lymph nodes. Ten patients had residual tumor, metastatic cancer to regional lymph nodes, or both. Each of the 10 had at least one of the following indications of inadequate resection or dissemination of disease to local lymph nodes (the first indication is a macroscopic evaluation, while the remaining four are all microscopic): incomplete excision, poorly differentiated tumor, invasion of the line of resection, invasion of the polyp stalk, and invasion of venous or lymphatic channels. Present recommendations for patient management after endoscopic removal of an invasive malignant adenoma should include colon resection with regional lymphadenectomy for patients with one or more of these five criteria. Patients without any of these risk factors should have early repeat endoscopic examination 3 months after initial polypectomy to evaluate the polypectomy site. Total colonoscopic examination is repeated at 1 year to ensure the surveillance program is begun with a colon without neoplasms." }, { "id": "pubmed23n0409_20812", "title": "Colonoscopic miss rates determined by direct comparison of colonoscopy with colon resection specimens.", "score": 0.013457556935817804, "content": "Colonoscopy is an effective method for discovery of adenomas and for colon cancer screening and prevention. Studies evaluating back-to-back colonoscopies have estimated significant miss rates but are limited by the lack of a definitive gold standard. Our study evaluated the sensitivity of colonoscopy compared with examination of surgically resected colon as a gold standard. This was a retrospective analysis of patients who had a portion of colon surgically removed and had lower endoscopy within 5 months. The focus of the review was not for the particular lesion for which the surgery was indicated but, rather, for the synchronous lesions in the portions of bowel that were removed. Sensitivity was determined by counting the number of lesions detected at colonoscopy compared with those found in the surgically resected segment. A total of 73 synchronous lesions were present in the resected segments of 156 patients. Colonoscopy detected 56 of 73 the lesions (sensitivity 76.7%: 95% CI = 67-86). Of the 17 missed lesions, 14 of 17 (82%, 95% CI = 64-100) were &lt; 1-cm polyps. Endoscopy overlooked one 1-cm adenoma in the ascending colon. Two cancers were missed, both in the same patient in whom endoscopy detected a sigmoid cancer but missed synchronous lesions in the cecal and ascending colon. Colonoscopy is an effective method of finding cancers and polyps, but it is associated with significant miss rates for polyps &lt;1 cm. The entire bowel should be carefully evaluated to exclude synchronous tumors in patients with known colorectal cancer. Further improvement of colonoscopic techniques and technologies is warranted." }, { "id": "pubmed23n0113_3451", "title": "[Malignant colonic polyps: is polypectomy adequate treatment?].", "score": 0.013378076062639821, "content": "The management of patients with endoscopically removed malignant intestinal polyps is controversial. The risk of residual disease should be assessed against the risk of a surgical operation. The authors report 35 cases of malignant polyps (5.5% of 641 colonoscopically removed adenomas). Sixteen patients had carcinoma in situ and received no further treatment and 19 had invasive carcinoma (sessile in 6, pedunculated in 13). Of these 19, 7 did not undergo surgery--because of old age in 2, minimal invasion in 3, a low rectal location in 1 and refusal in 1. Twelve patients (3 with sessile, 9 with pedunculated polyps) underwent a surgical resection, and residual disease was present in 3 (25%), 1 with positive nodes. Reported criteria of increased risk of residual disease--cancer in lymphatics or veins, incomplete excision, tumour at resection margin, sessile and villous tumours--were present in nine. All three patients with residual disease had microscopically involved margins of resection. The authors believe that the increased risk of recurrence justifies the risk associated with subsequent surgical resection unless the patient is otherwise a poor operative risk." }, { "id": "wiki20220301en016_102440", "title": "Polyp (medicine)", "score": 0.013211382113821137, "content": "Colon polyps as they grow can sometimes cause bleeding within the intestine, which can be detected by an occult blood test. According to American Cancer Society guidelines, people over 50 should have an annual occult blood test. People in their 50s are recommended to have flexible sigmoidoscopies performed once every 3 to 5 years to detect any abnormal growth which could be an adenomatous polyp. If adenomatous polyps are detected during this procedure, a colonoscopy is recommended. Medical societies recommend colonoscopies every ten years starting at age 50 as a necessary screening practice for colon cancer. The screening provides an accurate image of the intestine and also allows the removal of the polyp, if found. Once an adenomatous polyp is identified during colonoscopy, there are several methods of removal, including using a snare or a heating device. Colonoscopies are preferred over sigmoidoscopies because they allow the examination of the entire colon and can detect polyps in" }, { "id": "wiki20220301en126_26379", "title": "Colonic polypectomy", "score": 0.013193058421568957, "content": "Larger, pedunculated polyps Pedunculated polyps can be removed by snare polypectomy. When the polyp is identified, a polypectomy snare is passed over the polyp and around the stalk of the polyp. The loop of the snare is then tightened to grip the polyp stalk, and the polyp is pulled away from the wall of the colon. An electric current is then passed through the snare loop to cut through the polyp stalk, providing electrocautery at the same time. The polyp can then be retrieved using the snare or an endoscopy basket, and removed by withdrawing the colonoscope. Technique Polyps may be removed using cold biopsy forceps, cold snare polypectomy, hot biopsy forceps, hot snare polypectomy, endoscopic mucosal resection, or endoscopic submucosal dissection. Cold biopsy forceps may be used for small (diminutive) polyps 1-3 mm in size. Cold snare polypectomy has the advantage of avoiding the risk of delayed bleeding, postpolypectomy coagulation syndrome, and perforation." }, { "id": "wiki20220301en186_40076", "title": "Colorectal polyp", "score": 0.013061540628080551, "content": "Gallery NICE classification In colonoscopy, colorectal polyps can be classified by NICE (Narrow-band imaging International Colorectal Endoscopic): Treatment Polyps can be removed during a colonoscopy or sigmoidoscopy using a wire loop that cuts the stalk of the polyp and cauterises it to prevent bleeding. Many \"defiant\" polyps—large, flat, and otherwise laterally spreading adenomas—may be removed endoscopically by a technique called endoscopic mucosal resection (EMR), which involves injection of fluid underneath the lesion to lift it and thus facilitate endoscopic resection. Saline water may be used to generate lift, though some injectable solutions such as SIC 8000 may be more effective. Minimally invasive surgery is indicated for polyps that are too large or in unfavorable locations, such as the appendix, that cannot be removed endoscopically. These techniques may be employed as an alternative to the more invasive colectomy." }, { "id": "wiki20220301en014_100819", "title": "Colonoscopy", "score": 0.012433786912804896, "content": "Fecal occult blood is a quick test which can be done to test for microscopic traces of blood in the stool. A positive test is almost always an indication to do a colonoscopy. In most cases the positive result is just due to hemorrhoids; however, it can also be due to diverticulosis, inflammatory bowel disease (Crohn's disease, ulcerative colitis), colon cancer, or polyps. Colonic polypectomy has become a routine part of colonoscopy, allowing quick and simple removal of polyps during the procedure, without invasive surgery. Colon cancer screening Colonoscopy is one of the colorectal cancer screening tests available to people in the US who are 45 years of age and older. The other screening tests include flexible sigmoidoscopy, double-contrast barium enema, computed tomographic (CT) colongraphy (virtual colonoscopy), guaiac-based fecal occult blood test (gFOBT), fecal immunochemical test (FIT), and multitarget stool DNA screening test (Cologuard)." }, { "id": "wiki20220301en016_102434", "title": "Polyp (medicine)", "score": 0.012061174834897463, "content": "(first description by P. Deyhle, Germany, 1970), or with biopsy forceps. If an adenomatous polyp is found, it must be removed, since such a polyp is pre-cancerous and has a propensity to become cancerous. For certainty, all polyps which are found by any diagnostic modality, are removed by a colonoscopy. Although colon cancer is usually not found in polyps smaller than 2.5 cm, all polyps found are removed since their removal reduces the likelihood of future colon cancer. When adenomatous polyps are removed, a repeat colonoscopy is usually performed three to five years later." }, { "id": "article-19726_10", "title": "Colon Polyps -- Treatment / Management", "score": 0.012026549750334917, "content": "Colonic polypectomy is done during colonoscopy for diagnostic and therapeutic purposes using snare polypectomy with electrocautery for pedunculated polyps, or mucosal resection for sessile polyps. Total colectomy with ileorectal anastomosis or proctocolectomy ileal pouch anal anastomosis is done for prophylactic reasons for Familial Adenomatous Polyposis (FAP) and MUTYH-associated polyposis (MAP). They may also be done with persistent bleeding or when there are too many polyps. Guidelines for CRC screening recommend a colonoscopy starting at age 50 for the general population, earlier for at-risk patients, and to stop screening if life expectancy is less than ten years. Risk factors for colon cancer include polyp pathology (adenomatous, serrated, with high-grade dysplasia, with more than 25% villous histology), polyp more than 1 cm in diameter, polyps located in the proximal colon and the number of polyps more than three. Hence, a follow-up colonoscopy is recommended to be done in 10 years if no polyps or distal small hyperplastic polyps are found; in five years if there are small sessile serrated polyps with no dysplasia; in three years if they are large sessile serrated polyp(s) or with dysplasia or traditional serrated adenoma. Other guidelines include screening in five to ten years if one or two small tubular adenomas are seen; in three years if there are three to ten adenomas; in less than three years if there are more than ten adenomas; and in three years if at least one adenoma is ten mm in diameter or more. Alternatively, also screen in three years if one or more adenomas show villous features of any or with high-grade dysplasia. Colectomy is recommended in cases of resected polyps with high-risk features of malignancy (lower third of the submucosa invasion, indeterminate or positive resection margins, margin less than 1 mm, lymphovascular invasion, or poor differentiation) as there is a high incidence of lymph node metastasis. [13] [14]" }, { "id": "pubmed23n0574_19507", "title": "[Clinical aspects in polyps of the colon].", "score": 0.01195054945054945, "content": "The colonics polyps according to their number, size, location, age of presentation and mainly, according to their histology, have the potentiality of malignant degeneration, which makes of a continuous study and pursuit susceptible. To evaluate the relation between the histologic type of the colon polyps, its location, the degree of dysplasia, the size, its possible commitment by carcinoma, the age, sex and the handling that has occurred them, in a series of 684 patients of the National Institute of Enfermedades Neoplásicas (INEN) between the 1 of January from 1974 to the 31 of March of the 2004. The revision of clinical histories of 840 patients with the diagnosis of colon polyp was made who attended the service of Gastroenterology of the INEN between the 1 of January from 1974 to the 31 of March of 2004 and a card predesigned for each clinical history filled. The study is of observational, analytical type and of cross section. 1162 resecteds polyps evaluated themselves in this period. 156 patients by diagnosis related to cancer and familiar adenomatouspoliposis did not include themselves. The final sample was of 684 patients, in whom it was 1057 polyps. Other endoscopic findings were: internal hemorrhoids (172), colonic diverticulosis (50), anal fissure (4), and nonspecific ulcerative colitis (2). The statistical processing was made with program SPSS 12. For the qualitative variables the method of the Chi-square was used, for the quantitative variables analyzed the average, the rank and the variance. 1057 polyps extirpated, by means of the endoscopy polipectomy were 1016, with colectomy were 32 and with transanal resection without colectomy they 9. Within the histology of the 1057 polyps, 331 was briefed (31.3%) that were hyperplasic, 448 (42.4%) adenomas, 278 (26.3%) others and 35 (8.2%) adenocarcinomas on adenomas. The average age was of 50 years, was no significant difference with sex. The location but frequence of the adenomas was in the left colon (76.6%). Adenocarcinoma (carcinomas on adenomas), was present mainly in polyps villous type, with dysplasia severe and greater to 10 mm. Nevertheless, in smaller polyps of 5mm with dysplasia severe, was a polyp invaded by cancer, that represents the 0,8% of millimetric polyps. The made handling was mainly endoscopic, with 96% of the resected polyps this way, also slogan transanal resection and segmental colonic resection. The colectomy was necessary in 3% of all the made interventions, dysplasia severe or carcinoma was made in adenomatous polyps with, and in greater percentage in greater polyps of 20 mm (53%). The single polipectomy was sufficient in the level of invasion Haggitt 0. In patients with level of invasion Haggitt 1 and 2, the single polipectomy was the election treatment. On the other hand, in polyps with level of invasion Haggitt 3 and 4, the colectomy was the election treatment. One briefed two complications, one of perforation and peritonitis and another one of digestive hemorrhage loss (both: 0.29%), without mortality events. The Evaluation of colonic polyps in INEN is predominantly by endoscopy. The polyps are more frequent over the 50 years and have preferred location in the left colon. The carcinoma is more probable with severe dysplasia and greater size of the adenoma. All polyps, from the millimetric ones, including the hyperplasic, must be considered marks of neoplasia and extirpated in its totality." }, { "id": "Surgery_Schwartz_8557", "title": "Surgery_Schwartz", "score": 0.011698655176916047, "content": "if a lesion is discovered.Computed Tomography Colonography (Virtual Colonos-copy). Advances in imaging technology have created a num-ber of less invasive, but highly accurate tools for screening. CT colonography makes use of helical CT technology and three-dimensional reconstruction to image the intraluminal colon. At present, patients require a mechanical bowel preparation. The colon is then insufflated with air, a spiral CT is performed, and both two-dimensional and three-dimensional images are gener-ated. In the hands of a qualified radiologist, sensitivity appears to be as good as colonoscopy for colorectal cancers and polyps greater than 1 cm in size.103 Colonoscopy is required if a lesion is identified. CT colonography has also been used for imag-ing the proximal colon in cases of obstruction or if a colonos-copy cannot be completed in selected patients. Limitations of this technique include false-positive results from retained stool, diverticular disease, haustral folds, motion" }, { "id": "wiki20220301en016_102442", "title": "Polyp (medicine)", "score": 0.011608463566788862, "content": "It has been statistically demonstrated that screening programs are effective in reducing the number of deaths caused by colon cancer due to adenomatous polyps. The risk of complications associated with colonoscopies is approximately 0.35 percent, compared to a lifetime risk of developing colon cancer of around 6 percent. As there is a small likelihood of recurrence, surveillance after polyp removal is recommended. Endometrial polyp" }, { "id": "wiki20220301en016_102437", "title": "Polyp (medicine)", "score": 0.011588074720333994, "content": "There are three types of adenomatous polyp: Tubular adenomas (tube-like shape) are the most common of the adenomatous polyps; they may occur everywhere in the colon and they are the least likely colon polyps to develop into colon cancer Tubulovillous Villous adenomas are commonly found in the rectal area and they are normally larger in size than the other two types of adenomas. They tend to be non-pedunculated, velvety, or cauliflower-like in appearance and they are associated with the highest morbidity and mortality rates of all polyps. They can cause hypersecretory syndromes characterized by hypokalemia and profuse mucous discharge, and can harbor carcinoma in situ or invasive carcinoma more frequently than other adenomas." }, { "id": "wiki20220301en365_24183", "title": "Colon cancer staging", "score": 0.01134453781512605, "content": "Colon cancer staging is an estimate of the amount of penetration of a particular cancer. It is performed for diagnostic and research purposes, and to determine the best method of treatment. The systems for staging colorectal cancers depend on the extent of local invasion, the degree of lymph node involvement and whether there is distant metastasis. Definitive staging can only be done after surgery and histopathology of colorectal carcinoma. An exception to this principle would be after a colonoscopic polypectomy of a malignant pedunculated polyp with minimal invasion. Preoperative staging of rectal cancers may be done with endoscopic ultrasound. Adjunct staging of metastasis include abdominal ultrasound, MRI, CT, PET scanning, and other imaging studies." }, { "id": "wiki20220301en016_102438", "title": "Polyp (medicine)", "score": 0.010914355718899656, "content": "Risks The risks of progression to colorectal cancer increase if the polyp is larger than 1 cm and contains a higher percentage of villous component. Also, the shape of the polyps is related to the risk of progression into carcinoma. Polyps that are pedunculated (with a stalk) are usually less dangerous than sessile polyps (flat polyps). Sessile polyps have a shorter pathway for migration of invasive cells from the tumor into submucosal and more distant structures, and they are also more difficult to remove and ascertain. Sessile polyps larger than 2 cm usually contain villous features, have a higher malignant potential, and tend to recur following colonoscopic polypectomy. Although polyps do not carry significant risk of colon cancer, tubular adenomatous polyps may become cancerous when they grow larger. Larger tubular adenomatous polyps have an increased risk of malignancy when larger because then they develop more villous components and may become sessile." }, { "id": "wiki20220301en371_14823", "title": "Endoscopic mucosal resection", "score": 0.010889134725927854, "content": "For the colon and rectum Endoscopic mucosal resection and submucosal dissection are also highly effective methods for resection or large, non-malignant colorectal polyps and superficially (stage T1a) invasive colorectal cancers. The largest study of endoscopic mucosal resection by the Australian Consortium included 1000 cases and long term surveillance. After exclusion of 79 unresectable lesions, the remainder were treated by endoscopic mucosal resection. Overall 98.1% were disease free at the end of two rounds (typically at 6 and 18 months) of follow up. Endoscopic mucosal resection has been shown to be less expensive and safer compared to surgical resection of large, non-invasive polyps of the bowel. Endoscopic mucosal resection requires training to achieve proficiency. The Mayo Clinic Florida group reported that at least 100 procedures are needed to achieve proficiency. Many centers in the United States now offer high-quality, high-volume colorectal endoscopic mucosal resection." }, { "id": "pubmed23n0624_5108", "title": "Rapid progression of submucosal invasive micropapillary carcinoma of the colon in progressive systemic sclerosis: report of a case.", "score": 0.009900990099009901, "content": "A 71-year-old woman presented with hematochezia and narrowing of the stool. She suffered from progressive systemic sclerosis for 12 years and underwent home oxygen therapy due to pulmonary fibrosis and moderate pulmonary hypertension. Colonoscopy revealed a pedunculated, cauliflower-like polyp with a depressed surface in the sigmoid colon. The polyp was regarded as early colon cancer with possible submucosal invasion, and subsequent computed tomographic (CT) scans showed no evidence of lymph node involvement or distant metastases. Because of perioperative risks due to moderate pulmonary hypertension, she underwent an endoscopic resection of the early colon cancer. Pathological examination of the resected specimen of 20 mm diameter revealed the peculiar morphology of an adenocarcinoma with moderate lymphatic invasion. Immunohistochemical analysis for epithelial membrane antigen showed the specific 'inside-out growth pattern' indicative of invasive micropapillary carcinoma (IMPC). Taking the perioperative risks into consideration, she opted to undergo close follow-ups without an additional sigmoidectomy. At 6 months after the resection, the follow-up colonoscopy revealed a local recurrence of the colon cancer, and subsequent CT scans revealed multiple distant metastases including the lung, liver, lymph nodes and spleen. This is a rare case of a pure, submucosal IMPC of the colon. Furthermore, pure IMPC of the colon may represent a reliable predictor of lymphogenous and/or hematogenous metastases. Therefore, one should recommend an additional colectomy after endoscopic mucosal resection treatment when pathological findings confirmed IMPC of the colon and should continue a close follow-up for IMPC patients even when curative resections were performed at an early stage." }, { "id": "pubmed23n0064_8940", "title": "[Colonic polyps: clinical and practical implications].", "score": 0.00980392156862745, "content": "Among colorectal polyps, various forms of neoplastic or non-neoplastic lesions are distinguished by histology. Most accumulated knowledge suggests that the majority of cancer of the colon arise in pre-existing benign neoplastic polyps (adenoma-carcinoma sequence). Because of the risk of cancer being already present, all adenomatous polyps must be removed in toto. The carcinoma may occupy only a small area of the polyp, and therefore, forceps biopsies are inappropriate due to the sampling error. Since patients with polyps detected by rectosigmoidoscopy often have further polyps in the remaining part of the colon, complete examination of the whole colon is required. Follow-up examinations are indicated, because the risk of developing new polyps is high. Studies of the life history of the adenoma-carcinoma sequence suggest that interval of complete large-bowel follow-up may be about 5 years. The policy of polypectomy and follow-up examinations should be possible to prevent the development of colorectal cancer." }, { "id": "pubmed23n0074_3747", "title": "[Oncological supervision of patients after colonoscopic polypectomy].", "score": 0.009708737864077669, "content": "The high frequency of development of new adenomas in patients after colonoscopic polypectomy (30-50%) suggests the need for periodic control examinations of the whole large bowel. The diagnostic value of rectoscopy and routine diagnostic enema is limited and these methods are not suitable for periodic control of the bowel. An important method is fiberoptic sigmoidoscopy (FSS), but it is also insufficient because neoplasms are present frequently in proximal parts of the colon. The best method for evaluation of the whole colon is coloscopy, moreover, this method makes possible removal of the found polyps. In particular cases an alternative of coloscopy may be a combination of FSS and double contrast radiological examination of the colon. The frequency of control examinations of the large bowel depends primarily on the number of removed polyps. The patients after removal of a single polyp should undergo control examinations at intervals of 4-5 years. In cases with multiple adenomas removed during the first procedure or with one large adenoma (over 2 cm in diameter) should have control examinations repeated every 2-3 years." }, { "id": "pubmed23n0224_13772", "title": "Malignant colon polyps--cure by colonoscopy or colectomy?", "score": 0.009615384615384616, "content": "Although malignant sessile colon polyps usually require colectomy for proper treatment, the vast majority of malignant pedunculated polyps can be removed colonoscopically for cure. The author's experience with 83 consecutively encountered malignant polypoid lesions is reviewed and is the basis for the discussion herein. All 49 malignant pedunculated polyps were removed colonoscopically. Eight of these patients also underwent colectomy because of questionable or definite presence of cancer cells within the stalk portion of the polyp; no residual cancer was identified at the polypectomy site, and all lymph nodes were negative in these patients. Of 34 patients with malignant sessile polypoid lesions, 13 underwent colectomy because of obvious malignancy at colonoscopy. Twenty-one sessile lesions were removed colonoscopically; with malignancy documented, nine of the 21 patients underwent colectomy. Positive findings (either cancer at the polypectomy site or in lymph nodes) at surgery were identified in two of these nine patients. Colonoscopic polypectomy can be considered curative for malignant pedunculated polyps provided the stalk portion of the lesion is totally uninvolved with the malignant process, provided there is no lymphatic or vascular invasion, the malignancy is well differentiated, and follow-up endoscopic examination of the polypectomy site reveals no residual or recurrence. These four criteria must be satisfied in order to consider a malignant pedunculated polyp curatively removed by colonoscopic polypectomy alone. The risk of colectomy in patients satisfying these four criteria is believed to be greater than the risk of metastatic disease and death from this lesion. Colectomy is recommended for all patients with malignant sessile polypoid lesions, provided their general medical condition provides an acceptable operative risk. Although colonoscopic polypectomy is not recommended for obviously malignant sessile polyps, there are instances where sessile lesions are removed colonoscopically and found microscopically to contain focal or minute areas of invasive cancer. In certain of these patients, the risk of colectomy may exceed the risk of recurrence or metastasis, if the polypoid lesion has been totally removed colonoscopically and completeness of the polypectomy has been documented by follow-up colonoscopy. Each patient's clinical history, general condition, and histopathology must be reviewed individually by a clinician experienced in this field in order to reach a wise and proper decision regarding the potential need for colectomy, and limit colectomy to those patients in whom it is absolutely necessary." }, { "id": "pubmed23n0010_6929", "title": "A hard look at colonoscopy.", "score": 0.009523809523809525, "content": "The fiberoptic colonscope represents a significant diagnostic and therapeutic acheivement in the management of colonic disease. Despite some claims to the contrary, it is not universally simple, rapid, thorough, reliable, and inexpensive or without morbidity and mortality. Until these goals are achieved through future refinements, modifications, and new instrumentation, it is strongly recommended that the indications for colonscopy be sharply defined to include the following: (1) Investigation of colonic lesions seen on two successive or one air-contrast barium enema examination. Pedunculated polyps less than 1 cm in diameter can be observed. (2) Preoperative investigation of patients with demonstrable colorectal cancer (to rule out synchronous lesions). (3) Postoperative evaluation after colectomy for carcinoma where the anastomosis is above the reach of a sigmoidoscope. (4) Evaluation of patients with inflammatory bowel disease of the colon. (5) Investigation of persistent occult or gross rectal bleeding when anoscopy, sigmoidoscopy, and barium studies are negative. Patients who represent prohibitive surgical risks because of age or systemic disease should not be considered as candidates for colonoscopy without compelling indications. The decision to biopsy rather than remove or fulgerate a detected lesion must be left to the judgment and experience of the endoscopist. The morbidity that follows polypectomy or fulgeration of sessile lesions less than 0.5 cm in diameter probably exceeds the incidence of carcinoma." } ] } } }

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{ "1": "Its use is second choice when uricosurics have failed.", "2": "Its prolonged use is practically obligatory because there are tophi.", "3": "Its introduction should be delayed until the current attack has resolved with anti-inflammatory drugs or colchicine.", "4": "Its introduction should be gradual up to a dose that achieves a uricemia below 6 mg/dL.", "5": "In the first months of treatment it is advisable to associate low doses of colchicine to prevent new attacks." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0581_1612", "title": "Gout: an update.", "score": 0.017740429505135387, "content": "Arthritis caused by gout (i.e., gouty arthritis) accounts for millions of outpatient visits annually, and the prevalence is increasing. Gout is caused by monosodium urate crystal deposition in tissues leading to arthritis, soft tissue masses (i.e., tophi), nephrolithiasis, and urate nephropathy. The biologic precursor to gout is elevated serum uric acid levels (i.e., hyperuricemia). Asymptomatic hyperuricemia is common and usually does not progress to clinical gout. Acute gout most often presents as attacks of pain, erythema, and swelling of one or a few joints in the lower extremities. The diagnosis is confirmed if monosodium urate crystals are present in synovial fluid. First-line therapy for acute gout is nonsteroidal anti-inflammatory drugs or corticosteroids, depending on comorbidities; colchicine is second-line therapy. After the first gout attack, modifiable risk factors (e.g., high-purine diet, alcohol use, obesity, diuretic therapy) should be addressed. Urate-lowering therapy for gout is initiated after multiple attacks or after the development of tophi or urate nephrolithiasis. Allopurinol is the most common therapy for chronic gout. Uricosuric agents are alternative therapies in patients with preserved renal function and no history of nephrolithiasis. During urate-lowering therapy, the dose should be titrated upward until the serum uric acid level is less than 6 mg per dL (355 micromol per L). When initiating urate-lowering therapy, concurrent prophylactic therapy with low-dose colchicine for three to six months may reduce flare-ups." }, { "id": "pubmed23n0747_12930", "title": "Gout treatment: should we aim for rapid crystal dissolution?", "score": 0.01672194582642344, "content": "Monosodium urate crystal deposition in gout precedes the first attack and, while hyperuricaemia persists, it grows and expands to other sites. Fortunately, it is reversible and slowly dissolves when serum uric acid (SUA) is lowered below its saturation point of about 6.8 mg/dl and with certainty below 6 mg/dl. Crystals finally disappear from joints, taking longer in those patients with longer disease duration, probably because of a larger accumulated load of crystals. The SUA level achieved affects the velocity of crystal dissolution and tophi reduction. Accordingly, by deciding the SUA level cut-off point to be achieved by treatment we are determining the time of crystal disappearance and cure of gout. 6 mg/dl is the usual target level, but lower levels appear appropriate to us, particularly in certain situations." }, { "id": "pubmed23n0392_17935", "title": "[Summary of the Dutch College of General Practitioners' \"Gout\" Standard].", "score": 0.016601495506620018, "content": "The typical form of acute gout can be clinically diagnosed. The term 'complicated gout' is used if there are more than three acute attacks of gout per year, tophi or urate stones in the urinary tracts. In the case of recurrent probable acute gout, a diagnostic fine needle aspirate from the joint during an attack is indicated. First choice treatment of acute gout consists of NSAIDs. Colchicine is the second choice treatment and the third choice treatment consists of corticosteroids. Excessive alcohol use should be limited. Treatment of chronic gout depends on the uric acid excretion in the 24-hour urine. If the level of excretion is too low, the first choice should be benzbromarone, and if the uric acid output is too high, allopurinol should be the treatment of first choice. Increased fluid intake is recommended; maintenance treatment with colchicine is not advised. Consultation with or referral to a rheumatologist is indicated in the case of doubt about the diagnosis of 'acute gout' or 'complicated gout', or (suspected) bacterial arthritis and insufficient treatment effect." }, { "id": "pubmed23n0780_5394", "title": "Evaluating appropriate use of prophylactic colchicine for gout flare prevention.", "score": 0.016488651535380507, "content": "American College of Rheumatology and European League Against Rheumatism guidelines recommend colchicine to prevent gout flares in patients initiating and increasing uric acid–lowering therapy until serum uric acid is maintained at ≤6 mg/dl. We aimed to evaluate how well colchicine prescribing practices adhere to these guidelines and to examine factors associated with improved prescribing. Electronic medical records were reviewed for 126 patients with active colchicine prescriptions for prophylaxis of gout flares. Colchicine prescribing was defined as inappropriate if 1) no concurrent urate-lowering therapy was prescribed, 2) uric acid was not at goal and urate-lowering therapy had not been increased in the past 3 months, or 3) uric acid goals were met for &gt;1 year and flares had resolved in the absence of tophi. Colchicine use was considered inappropriate in 93 patients (73.8%). Thirty-four were prescribed no urate-lowering therapy, 50 were above the uric acid goal without urate-lowering therapy increase in the prior 3 months, and 9 were at the uric acid goal for &gt;1 year without flares or tophi. Patients appropriately prescribed colchicine were younger and were more likely to have been seen by a rheumatologist. Allopurinol dose and allergy, uric acid level, and renal function were similar in the 2 groups. We found a high prevalence of what we considered inappropriate prophylactic colchicine use, driven largely by failure to prescribe concurrent urate-lowering therapies or adequately increase these medications. Rheumatology consultation was associated with improved colchicine prescribing." }, { "id": "pubmed23n0639_16930", "title": "Gout--current diagnosis and treatment.", "score": 0.016465494620834426, "content": "Because of the changing dietary habits of an aging population, hyperuricemia is frequently found in combination with other metabolic disorders. Longstanding elevation of the serum uric acid level can lead to the deposition of monosodium urate crystals, causing gout (arthritis, urate nephropathy, tophi). In Germany, the prevalence of gouty arthritis is estimated at 1.4%, higher than that of rheumatoid arthritis. There are no German guidelines to date for the treatment of gout. Its current treatment is based largely on expert opinion. Selective literature review on the diagnosis and treatment of gout. Asymptomatic hyperuricemia is generally not an indication for pharmacological intervention to lower the uric acid level. When gout is clinically manifest, however, acute treatment of gouty arthritis should be followed by determination of the cause of hyperuricemia, and long-term treatment to lower the uric acid level is usually necessary. The goal of treatment is to diminish the body's stores of uric acid crystal deposits (the intrinsic uric acid pool) and thereby to prevent the inflammatory processes that they cause, which lead to structural alterations. In the long term, serum uric acid levels should be kept below 360 micromol/L (6 mg/dL). The available medications for this purpose are allopurinol and various uricosuric agents, e.g., benzbromarone. There is good evidence to support the treatment of gouty attacks by the timely, short-term use of non-steroidal anti-inflammatory drugs (NSAID), colchicine, and glucocorticosteroids." }, { "id": "pubmed23n0839_14448", "title": "Adherence to the 2012 American College of Rheumatology (ACR) Guidelines for Management of Gout: A Survey of Brazilian Rheumatologists.", "score": 0.01628327733264409, "content": "To describe the current pharmacological approach to gout treatment reported by rheumatologists in Brazil. We performed a cross-sectional survey study using an online questionnaire e-mailed to 395 rheumatologists, randomly selected, from among the members of the Brazilian Society of Rheumatology. Three hundred and nine rheumatologists (78.2%) responded to the survey. For acute gout attacks, combination therapy (NSAIDs or steroid + colchicine) was often used, even in monoarticular involvement, and colchicine was commonly started as monotherapy after 36 hours or more from onset of attack. During an acute attack, urate-lowering therapy (ULT) was withdrawn by approximately a third of rheumatologists. Anti-inflammatory prophylaxis (98% colchicine) was initiated when ULT was started in most cases (92.4%), but its duration was varied. Most (70%) respondents considered the target serum uric acid level to be less than 6 mg/dl. Approximately 50% of rheumatologists reported starting allopurinol at doses of 100 mg daily or less and 42% reported the initial dose to be 300 mg daily in patients with normal renal function. ULT was maintained indefinitely in 76% of gout patients with tophi whereas in gout patients without tophi its use was kept indefinitely in 39.6%. This is the first study evaluating gout treatment in a representative, random sample of Brazilian rheumatologists describing common treatment practices among these specialists. We identified several gaps in reported gout management, mainly concerning the use of colchicine and ULT and the duration of anti-inflammatory prophylaxis and ULT. Since rheumatologists are considered as opinion leaders in this disease, a program for improving quality of care for gout patients should focus on increasing their knowledge in this common disease." }, { "id": "pubmed23n0256_703", "title": "Prevention and management of gout.", "score": 0.015898050596176896, "content": "Gout is a common disease with a worldwide distribution. The major risk factor for the development of gout is sustained asymptomatic hyperuricaemia. Although pharmacological therapy of asymptomatic hyperuricaemia is not recommended, primary prevention of gout can be achieved through lifestyle changes including weight loss, restricting protein and calorie intake, limiting alcohol consumption, avoiding the use of diuretics in the treatment of hypertension, and avoiding occupational exposure to lead. The arthritis of gout can be readily managed with the use of nonsteroidal anti-inflammatory drugs (NSAIDs); systemic steroids or corticotrophin (adrenocorticotrophic hormone; ACTH) should be used in patients with contraindications to NSAIDs, or who are intolerant of them. Because of potential toxicity, colchicine should not be used to treat acute gout, but should be used in low dosage (0.6 to 1.2 mg/day) for prophylaxis of recurrent attacks of gout. The other cornerstone of prevention of recurrent gouty attacks is control of hyperuricaemia, which can be effectively accomplished with antihyperuricaemic therapy. The choice of agents, either uricosuric drugs or xanthine oxidase inhibitors, is based on the level of urinary uric acid excretion, renal function, age of patient, history of renal calculi and presence of tophi. Treatment and prevention of gout are exceedingly effective and patients can usually be managed by their primary care physician." }, { "id": "pubmed23n0066_11602", "title": "Drugs to lower uric acid levels. How to avoid misuse in gouty arthritis.", "score": 0.015737905695039803, "content": "Several points regarding the use of drugs to lower uric acid levels deserve emphasis. First, these agents are not useful in the management of acute gout. Second, all forms of the drugs should be initiated at low dose with gradual increments to achieve a serum uric acid level between 5 and 6 mg/dL. There are no data to support the widely presumed notion that dropping the uric acid level to a very low range (1 to 3 mg/dL) hastens resorption of tophi or improves joint function. Third, the uricosuric agents probenecid (Benemid) and sulfinpyrazone (Anturane) interact with a number of drugs, and both the patient and physician should be aware of this. Finally, and most important, careful and frequent monitoring is needed during the first several months of therapy with these drugs." }, { "id": "pubmed23n0374_9578", "title": "Treatment of chronic gout. Can we determine when urate stores are depleted enough to prevent attacks of gout?", "score": 0.015710872162485064, "content": "To determine if lowering of serum uric acid (SUA) concentrations below 6 mg/dl or longer duration of lowered SUA will result in depletion of urate crystals from the knee joints and prevent further attacks of gout. A prospective study was initiated 10 years ago at Philadelphia VA Medical Center to attempt to maintain SUA levels of patients with crystal proven gout at &lt; 6.0 mg/dl. We recalled all 57 patients who were available during 1999. Patients were divided into 2 groups: Group A, with SUA still &gt; 6 mg/dl, and Group B, with SUA &lt; or = 6 mg/dl. A knee joint aspirate was requested from all asymptomatic Group B patients and many in Group A. Aspirates were examined by polarized light microscopy for identification of crystals. There were no differences between the groups in age, sex, duration of gout, or serum creatinine. Group A (n = 38) had a mean of 6 attacks of gout for the recent year, those with tophi having the most frequent attacks. Among the 16 patients in this group who agreed to knee aspiration, monosodium urate (MSU) crystals were found in 14, although they were asymptomatic at the time. Nineteen patients (Group B) were able to maintain serum urate levels &lt; or = 6 mg/dl for &gt; 12 months. Nearly half of them had no attack of gout for 2 or more years, with a mean of 1 attack in the last year for the whole group. Three patients in whom tophi were found did not have major flares of gout within the past year. Knee joint aspiration was done on 16 asymptomatic patients. Seven (44%) still had MSU crystals present in their knees. Patients in this group who were taking prophylactic colchicine did not differ with respect to the character of synovial fluid from those who had discontinued it for up to several years, although the frequency of attacks was less in those who continued colchicine. A majority of patients were able to deplete urate crystal stores in their knee joint fluids when their SUA levels were kept to &lt; or = 6 mg/dl for several years. The mechanisms for persistence in some patients, and whether such crystals have clinical implications, are not known. Patients with chronic gout need serum urate concentrations to be kept low to prevent further attacks." }, { "id": "pubmed23n0910_14966", "title": "Images in clinical medicine: Tophi.", "score": 0.015358455378201963, "content": "Tophi (plural of tophus, Latin for \"stone\") are stone-like deposits of monosodium urate in the soft tissues, synovial tissues, or in bones near the joints. They are pathognomonic for gout, the most common inflammatory arthritis in the United States, with an estimated lifetime prevalence of 4%. It is usually the end result of loss of the balance between uric acid production and excretion. It can be found anywhere in the body especially in areas of friction or trauma. It is usually painless and rarely to present as the initial manifestation of gout. It is diagnosed mainly clinically. Imaging is mainly used to assess the complication like bony erosions. The American College of Rheumatology (ACR) guidelines currently indicate that urate-lowering therapy should be initiated in patients with the presence of tophi visible on examination or imaging (ACR Evidence A). First-line therapy for urate lowering remains the xanthine oxidase inhibitor allopurinol. The ACR currently recommends colchicine, 0.6 mg (or 0.5 mg) once or twice daily, or low dose NSAIDs should be continued to reduce gout flare incidence for six months after resolution of the tophus. Daily prednisone ≤10 mg has been endorsed as an acceptable second-line prophylactic agent. <bAbbreviations:</b ACR: American College of Rheumatology; NSAID: non-steroidal anti-inflammatory drug." }, { "id": "pubmed23n0318_11898", "title": "Managing problem gout.", "score": 0.015229885057471264, "content": "For the management of acute gouty arthritis, non-steroidal anti-inflammatory drugs (NSAIDs) are the drugs of choice. In recent years, the use of colchicine has declined because of its frequent adverse reactions, and its reduced efficacy when administered more than 24 hours after onset of an acute attack. Intra-articular corticosteroid therapy (e.g. methylprednisolone acetate) is indicated for the treatment of acute mono or oligoarticular gouty arthritis in aged patients, and in those with co-morbid conditions contraindicating therapy with either NSAIDs or colchicine. Oral corticosteroids (e.g. prednisone), and both parenteral corticotrophin (ACTH) and corticosteroids (e.g. intramuscular triamcinolone acetonide) are valuable, relatively safe alternate treatment modalities in those with polyarticular attacks. For the treatment of hyperuricaemia and chronic gouty arthritis, allopurinol is the preferred urate-lowering drug. Its toxicity in elderly individuals, those with renal impairment, and in cyclosporine-treated transplant patients can be minimised by adjusting the initial dose according to the patient's creatinine clearance. In those experiencing cutaneous reactions to allopurinol, cautious desensitisation to the drug can be achieved using a schedule of gradually increasing doses. The therapeutic usefulness of uricosuric drugs is limited by the presence of renal impairment, occurrence of intolerable side-effects, or concomitant intake of salicylates. They are particularly indicated in patients allergic to allopurinol and in those with massive tophi requiring combined therapy with both allopurinol and a uricosuric." }, { "id": "pubmed23n0904_1405", "title": "Treatment Options for Gout.", "score": 0.014561050513607964, "content": "1-2% of adults in Germany suffer from gout. Gout is one of the few rheumatological diseases that can be cured. It arises through the deposition of uric acid crystals in joints as a result of hyperuricemia. Painful redness and swelling of the affected joints are typical findings. Multiple pertinent guidelines and treatment recommendations have been published, but there is reason to believe that patients with gout are not always treated accordingly. This review is based on relevant publications from the years 2000-2016 that were retrieved by a selective search in the Cochrane and PubMed databases. In a person with normal renal function, asymptomatic hyperuricemia is not an indication for treatment to lower the serum uric acid level. The drugs of first choice for acute gouty arthritis are nonsteroidal antiinflammatory drugs (NSAID), corticosteroids, and colchicine. Treatment with xanthine oxidase inhibitors (XOI) or uricosuric drugs is indicated for patients with a recurrent or severe course; the target uric acid value is &lt;6 mg/dL. Long-term treatment should be initiated only after resolution of the acute attack. For patients with refractory gout, lesinurad (approved in February 2016) in combination with XOI is a new treatment option that can be considered. Comprehensive patient education and counseling is an important component of the treatment of patients with gout. Regular laboratory follow-up is necessary as well. The prevalence of gout is rising around the world. Patients with gout could benefit greatly from consistent implementation of the existing treatment guidelines and recommendations. In the future, controlled trials should be conducted to determine the best time to start treatment and the optimal target level for the serum uric acid concentration in terms of a risk/benefit analysis." }, { "id": "wiki20220301en015_140922", "title": "Colchicine", "score": 0.014467253176930596, "content": "Medical uses Gout Colchicine is an alternative for those unable to tolerate NSAIDs when treating gout. Low doses appear to be well tolerated and may reduce gout symptoms and pain (1.2 mg in one hour, followed by 0.6 mg an hour later). This low dose may have a similar effectiveness to NSAIDS (low quality evidence). At high doses, side effects (primarily diarrhea, nausea, or vomiting) limit its use, however may be effective against pain. In addition, there is preliminary evidence that daily colchicine (0.6 mg twice daily) may be effective as a long-term prophylaxis when used with allopurinol to reduce the risk of increased uric acid levels and acute gout flares, although adverse gastrointestinal effects may occur. For treating gout symptoms, colchicine is used orally with or without food, as symptoms first appear. Subsequent doses may be needed if symptoms worsen." }, { "id": "pubmed23n0817_25324", "title": "Diagnosis, treatment, and prevention of gout.", "score": 0.014403717088280848, "content": "Gout is characterized by painful joint inflammation, most commonly in the first metatarsophalangeal joint, resulting from precipitation of monosodium urate crystals in a joint space. Gout is typically diagnosed using clinical criteria from the American College of Rheumatology. Diagnosis may be confirmed by identification of monosodium urate crystals in synovial fluid of the affected joint. Acute gout may be treated with nonsteroidal anti-inflammatory drugs, corticosteroids, or colchicine. To reduce the likelihood of recurrent flares, patients should limit their consumption of certain purine-rich foods (e.g., organ meats, shellfish) and avoid alcoholic drinks (especially beer) and beverages sweetened with high-fructose corn syrup. Consumption of vegetables and low-fat or nonfat dairy products should be encouraged. The use of loop and thiazide diuretics can increase uric acid levels, whereas the use of the angiotensin receptor blocker losartan increases urinary excretion of uric acid. Reduction of uric acid levels is key to avoiding gout flares. Allopurinol and febuxostat are first-line medications for the prevention of recurrent gout, and colchicine and/or probenecid are reserved for patients who cannot tolerate first-line agents or in whom first-line agents are ineffective. Patients receiving urate-lowering medications should be treated concurrently with nonsteroidal anti-inflammatory drugs, colchicine, or low-dose corticosteroids to prevent flares. Treatment should continue for at least three months after uric acid levels fall below the target goal in those without tophi, and for six months in those with a history of tophi. " }, { "id": "wiki20220301en002_185649", "title": "Gout", "score": 0.014174972314507199, "content": "While it has been recommended that urate-lowering measures should be increased until serum uric acid levels are below 300–360 µmol/l (5.0–6.0 mg/dl), there is little evidence to support this practice over simple putting people on a standard dose of allopurinol. If these medications are in chronic use at the time of an attack, it is recommended that they be continued. Levels that cannot be brought below 6.0 mg/dl while attacks continue indicates refractory gout. While historically it is not recommended to start allopurinol during an acute attack of gout, this practice appears acceptable. Allopurinol blocks uric acid production, and is the most commonly used agent. Long term therapy is safe and well-tolerated and can be used in people with renal impairment or urate stones, although hypersensitivity occurs in a small number of individuals." }, { "id": "pubmed23n0716_8161", "title": "Diagnosis and treatment of gout in primary care.", "score": 0.014162077104642014, "content": "The prevalence of gout increases with age. Up to 7% of men &gt; 65 and 3% of women &gt; 85 have gout. Risk of gout increases significantly with increasing serum uric acid levels. Alcohol consumption and purine-rich foods such as red meat and seafood increase the risk of incident gout significantly. Loop and thiazide diuretics are also associated with increased risk. Gout is frequently associated with the metabolic syndrome. Dehydration, increasing creatinine levels, and surgery are also known to precipitate flares. Acute gout manifests as severe joint pain, of rapid onset, reaching maximal intensity within a few hours. Gout has a predilection for lower extremity joints. It often starts at the first metatarsophalangeal joint, a condition termed podagra. Other common sites of gouty flares include: tarsal and subtalar joints; ankle; knee; wrist; small joints of the hands; Achilles tendon; and olecranon bursae. The joint affected is usually hot, red, swollen and very painful. This is often associated with skin erythema. Identification of MSU crystals in the synovial fluid of an inflamed joint or from tophi allows a definite diagnosis of gout to be made. Hyperuricaemia does not confirm or exclude gout as most people with hyperuricaemia are asymptomatic, while serum uric acid levels tend to decrease during acute attacks. Short-acting NSAIDs should be used at maximal dose as first drug of choice if not contraindicated. In patients at risk of GI complications, co-prescription of a proton pump inhibitor or the use of COX-2 selective agents should be considered. Colchicine can be particularly useful in patients with heart failure in whom NSAIDs are contraindicated but should be avoided in patients with severe renal impairment. Joint aspiration and injection of intra-articular steroids is one of the most effective ways of treating acute monoarthritic gout. Uric acid lowering therapy is initiated if a patient suffers two or more attacks in one year. Many rheumatologists will start this therapy in hyperuricaemic patients whose first attack is very severe or in polyarticular gout." }, { "id": "pubmed23n0824_19774", "title": "Does starting allopurinol prolong acute treated gout? A randomized clinical trial.", "score": 0.014141414141414142, "content": "Traditionally, allopurinol is not initiated during an acute gout attack to avoid prolonging the painful arthritis. The 2012 American College of Rheumatology Guidelines for the Management of Gout suggest that urate-lowering therapy can be started during an acute attack, based on \"consensus opinion of experts, case studies, or standard of care.\" The aim of this study was to determine whether initiating allopurinol will adversely affect the resolution of acute, treated gout. We conducted a 28-day, placebo-controlled, double-blind study of allopurinol initiation in patients with acute gout. Patients with crystal-proven gout by arthrocentesis were enrolled if they presented to the rheumatology clinic with an acute gout attack within 72 hours from initial therapy. The patients were also required to meet at least 1 additional criterion for urate-lowering therapy including (1) the presence of gouty tophi, (2) more than 1 acute gout attack per year, (3) a history of nephrolithiasis, or (4) urate overproduction (&gt;1000 mg in 24-hour urine collection). Patients were excluded from the study if they had a glomerular filtration rate of less than 50 or liver function test of greater than 1.25 times the upper limit of normal. The treating physician determined therapy for the acute gout attack. Standard prophylaxis, with colchicine or nonsteroidal anti-inflammatory drugs, was prescribed. Allopurinol or placebo was initiated at 100 mg daily for the first 14 days and then increased to 200 mg daily for the next 14 days. The primary end point was protocol defined days to resolution of acute gout, incorporating patient-rated joint pain and physician examination. Secondary measures included Physician Global Assessment, patient-rated pain, adverse effects of therapy, and serum uric acid. Thirty-one patients (17 on placebo, 14 on allopurinol) completed the study. Both intent-to-treat and completer analyses showed only a statistically insignificant difference in days to resolution (15.4 days in the allopurinol group completers vs 13.4 days in the placebo group; P = 0.5). The secondary measures revealed that the acute phase of pain rapidly improved in both groups. We initiated allopurinol at low doses during an acute gout attack in patients who met criteria for starting urate-lowering therapy and did not have abnormal kidney or liver function. In this cohort, allopurinol did not prolong the acute, treated attack." }, { "id": "pubmed23n0283_18062", "title": "Gout: modern management of an ancient malady.", "score": 0.013878406708595387, "content": "If Dr. Sydenham could have benefited from today's therapy, he likely would not have had to endure thirty years of \"violent ... torture\" that gave birth to his most elegant and classic description of acute gout. The five key points to remember in management of the gouty spectrum are: (1) Establish the diagnosis as clearly as possible or as clearly as seems necessary under the clinical circumstances (i.e. arthrocentesis with crystal analysis to establish diagnosis is not always necessary with reliable patients when septic joint seems highly unlikely). (2) Treat acute attacks with NSAIDs alone or perhaps steroids--or rarely IV colchicine under special circumstances. (3) DO NOT START ALLOPURINOL OR PROBENECID DURING AN ACUTE FLARE OF GOUT--IT MAY MAKE THE EPISODE WORSE. (4) The pattern of disease over time (frequency and severity of attacks) determines whether or not one decides to use an agent such as allopurinol, probenecid, or prophylactic colchicine chronically once a patient is over the acute attack--the mere presence of increased uric acid and a single or rare gouty attack would not usually require any other than the appropriate acute therapy. (5) The presence of visible tophi, uric acid renal calculi and destructive gouty arthritis nearly always warrant uric acid lowering therapy." }, { "id": "pubmed23n0499_23622", "title": "Gout: a review of its aetiology and treatment.", "score": 0.013782051282051282, "content": "To review the current understanding of the causes and the management of gout. Publications on all peer-review literature from MEDLINE from 1965 to January 2004. Selected and evaluated by the author. Extracted and evaluated by the author. The underlying metabolic disorder in gout is hyperuricaemia. Most patients with hyperuricaemia remain asymptomatic throughout their lifetime. The phase of asymptomatic hyperuricaemia ends with the first attack of gouty arthritis or urolithiasis. The risk of gout and stone formation is increased with the degree and duration of hyperuricaemia. Drugs available for the treatment of acute gouty arthritis, such as non-steroidal anti-inflammatory drugs, selective cyclo-oxygenase 2 inhibitors, systemic corticosteroids, or colchicine, are effective. For periods between attacks, prophylactic therapy, such as low-dose colchicine, is effective. In those with recurrent attacks of more than two to three times yearly, a uric acid-lowering agent as a long-term therapy should be considered to avoid recurrence and the development of tophaceous gout. Effective management of gout can be achieved through better understanding of the causes of the condition, preventive measures as well as drug treatment." }, { "id": "pubmed23n0717_7376", "title": "Treatment of hyperuricemia, gout and other crystalline arthritidies.", "score": 0.013620689655172415, "content": "Gout is a very common joint disease which is due to chronic hyperuricemia and its related articular involvements. Yet it can be cured when appropriately managed. Comprehensive management of gout involves correct identification and addressing all causes of hyperuricemia, treating and preventing attacks of gouty inflammation (using colchicine NSAIDs, and/or steroids), and lowering serum urate (SUA) to an appropriate target level indefinitely. The ideal SUA target is, at a minimum, less than 6 mg/dL (60 mg/L or 360 μmol/L), or even less than 5 mg/dL in patients with tophi. The SUA target should remain at less than 6 mg/dL for long in all gout patients, especially until tophi have resolved. Patient education and adherence to therapy are key point to the optimal management of gout, aspects which are often neglected. Adherence can be monitored in part by continuing, regular assessment of the SUA level. More difficult cases of gout often need a combination of urate lowering therapy (ULT) for both refractory hyperuricemia and chronic tophaceous arthritis. Chronic tophaceous gouty arthropathy which do not respond adequately to optimized oral ULT might benefit from the use of pegloticase, when this is available in, for example, Italy and other European countries. By contrast, in calcium pyrophosphate (CPP) crystal deposition disease (CPPD), as evidenced by pseudo gout attacks or chronic polyarthritis, similar anti-inflammatory strategies have been recommended, but there have as yet been no controlled trials. Of note, there is no treatment for the underlying metabolic disorders able to control the CPPD. Management of crystal-induced arthropathies (CIA) depends not only on clinical expression, namely acute attacks or chronic arthropathy, but also on the underlying metabolic disorder. We will mainly focus on gout as an archetype of CIA." }, { "id": "wiki20220301en002_185651", "title": "Gout", "score": 0.013319148936170214, "content": "Probenecid appears to be less effective than allopurinol and is a second line agent. Probenecid may be used if undersecretion of uric acid is present (24-hour urine uric acid less than 800 mg). It is, however, not recommended if a person has a history of kidney stones. Pegloticase is an option for the 3% of people who are intolerant to other medications. It is a third line agent. Pegloticase is given as an intravenous infusion every two weeks, and reduces uric acid levels. Pegloticase is useful decreasing tophi but has a high rate of side effects and many people develop resistance to it. Using lesinurad plus febuxostat is more beneficial for tophi resolution than lesinural with febuxostat, with similar side effects. Lesinural plus allopurinol is not effective for tophi resolution. Potential side effects include kidney stones, anemia and joint pain. In 2016, it was withdrawn from the European market." }, { "id": "pubmed23n0298_20668", "title": "[How to select and use urate lowering agents for hyperuricemia].", "score": 0.01330532212885154, "content": "Two classes of urate lowering agents, i.e. uricosuric agents and allopurinol, are available for the treatment of hyperuricemia. To prevent the formation of urinary urate stones and possible damage to liver function, it is recommended to use uricosuric agents in those patients with underexcretion of urate, and allopurinol in those with overproduction. Urinary uric acid/creatinine ratio is a convenient index to determine these phenotypes. These agents should be started to prescribe from the minimal dose to prevent the gouty arthritis which is easily evoked in the first several months after the introduction of these agents. An uric acid level between 5.0 and 6.4 mg/dl had minimal occurence of gouty attack during the first six months of the drug therapy." }, { "id": "pubmed23n0712_18889", "title": "2011 Recommendations for the diagnosis and management of gout and hyperuricemia.", "score": 0.01322898458604799, "content": "Gout is a major health problem in the United States; it affects 8.3 million people, which is approximately 4% of the adult population. Gout is most often diagnosed and managed in primary care physician practices. Primary care physicians have a significant opportunity to diagnose and manage patients with gout and improve patient outcomes. Following publication of the 2006 European League Against Rheumatism (EULAR) gout guidelines, significant evidence on gout has accumulated and new treatments for patients with gout have become available. It is the objective of these 2011 recommendations for the diagnosis and management of gout and hyperuricemia to update the 2006 EULAR guidelines, paying special attention to the needs of primary care physicians, who manage most patients with gout. The revised 2011 recommendations are based on the Grading of Recommendations Assessment, Development, and Evaluation approach as an evidence-based strategy for rating quality of evidence and grading strength of recommendation in clinical practice. A total of 26 key recommendations for diagnosis (n = 10) and management (n = 16) were evaluated. Presence of tophus (proven or suspected) and response to colchicine had the highest clinical diagnostic value (likelihood ratio [LR], 15.56 [95% CI, 2.11-114.71] and LR, 4.33 [95% CI, 1.16-16.16], respectively). The key aspect of effective management of an acute gout attack is initiation of treatment within hours of onset of first symptoms. Low-dose colchicine is better tolerated than and is as effective as high-dose colchicine (number needed to treat [NNT], 5 [95% CI, 3-13] and NNT, 6 [95% CI, 3-72], respectively). For urate-lowering therapy, allopurinol in combination with probenecid was shown to be more effective than either agent alone (effect size [ES], 5.51 for combination; ES, 4.46 for probenecid; and ES, 2.80 for allopurinol). Febuxostat, also a xanthine oxidase inhibitor, has a slightly different mechanism of action and can be prescribed at unchanged doses for patients with mild-to-moderate renal or hepatic impairment. Febuxostat 40 mg versus 80 mg (NNT, 6 [95% CI, 4-11]) and 120 mg (NNT, 6 [95% CI, 3-26]) both demonstrated long-term efficacy. The target of urate-lowering therapy should be a serum uric acid level of ≤ 6 mg/dL. For patients with refractory and tophaceous gout, intravenous pegloticase is a new treatment option." }, { "id": "pubmed23n0629_4293", "title": "Febuxostat: a new treatment for hyperuricaemia in gout.", "score": 0.013052721088435373, "content": "Febuxostat is a new non-purine xanthine oxidase inhibitor that is more potent than allopurinol 300 mg daily. In two Phase III trials, significantly more febuxostat-treated gout patients met the primary endpoint [serum urate (sUA) &lt;6 mg/dl (&lt;360 mumol/l) at the last three visits] (48 and 53% with 80 mg; 65 and 62% with 120 mg), compared with those receiving allopurinol 300 mg (22 and 21%; P &lt; 0.001 in both studies). Febuxostat was more effective than allopurinol in the subset with impaired renal function; no dose adjustment is required in mild-to-moderate renal impairment. Long-term extension studies confirmed the efficacy and tolerability of febuxostat. In patients who achieved the sUA target of 6 mg/dl (360 mumol/l), the incidence of gout flares fell steadily and tophi resolved in many patients. The incidence of adverse events such as dizziness, diarrhoea, headache and nausea with febuxostat was similar to allopurinol. The incidence of cardiovascular side-effects (Antiplatelet Trialists Collaboration events) was numerically higher with febuxostat than with allopurinol, but this was not statistically significant. Co-administration of febuxostat with AZA or 6-mercaptopurine is not recommended. Prophylaxis (colchicine and/or NSAIDs) against acute attacks should be used for at least the first 6 months, since early mobilization flares were observed in the clinical trials. In conclusion, febuxostat is more effective than allopurinol 300 mg daily in reducing sUA levels &lt;6 mg/dl (360 mumol/l), the target recommended by EULAR, and offers a new option for the long-term treatment of gout." }, { "id": "pubmed23n0941_13257", "title": "[Treat to target in gouty arthritis].", "score": 0.012778904665314401, "content": "Gout is a crystal-induced, metabolically determined inflammatory rheumatic disease with increasing prevalence. In clinical practice, gout causes frequent diagnostic as well as therapeutic problems. The golden diagnostic standard is crystalographic analysis and evidence of monosodium urate crystals in the polarization microscope; if this is not available, the diagnosis can be established through a combination of clinical, laboratory and imaging techniques. The acute gouty attack must be treated by quick administration of anti-inflammatory medicines, with available alternatives being nonsteroidal antirheumatic drugs (NSA), colchicine and glucocorticoids. When the attack subsides, hypouricemic therapy is initiated which should combine the regimen and diet measures and pharmacological treatment. Recommendations for the treatment of gout were published by the EULAR and the Czech Society for Rheumatology. Recently a new strategy appeared known as Treat to target - T2T. This principle has been successfully used in the treatment of rheumatiod arthritis and spondyloarthritis. The publication is structured as four overarching principles and nine Recommendations. The recommendations emphasize long-term maintenance of serum levels of uric acid below 360 μmol/l as the basic gout-related target in all patients, and below 300 μmol/l for patients with tophies. It is recommended to administer prophylactic small doses of colchicine for at least 3-6 months on the commencement of hypouricemic therapy. The Recommendations further emphasize the need for regular monitoring of comorbidities and the kidney function. A separate recommendation is concerned with necessary education of patients and their motivation toward compliance with regimen measures and increased physical activity.Key words: colchicine - gouty arthritis - treat to target principle." }, { "id": "wiki20220301en035_11175", "title": "Lesch–Nyhan syndrome", "score": 0.012750180853629129, "content": "It is essential that the overproduction of uric acid be controlled in order to reduce the risk of nephropathy, nephrolithiasis, and gouty arthritis. The drug allopurinol is utilized to stop the conversion of oxypurines into uric acid, and prevent the development of subsequent arthritic tophi (produced after having chronic gout), kidney stones, and nephropathy, the resulting kidney disease. Allopurinol is taken orally, at a typical dose of 3–20 mg/kg per day. The dose is then adjusted to bring the uric acid level down into the normal range (<3 mg/dL). Most affected individuals can be treated with allopurinol all through life. No medication is effective in controlling the extrapyramidal motor features of the disease. Spasticity, however, can be reduced by the administration of baclofen or benzodiazepines." }, { "id": "article-22376_72", "title": "Gout -- Treatment / Management -- Prophylaxis For Acute Gout", "score": 0.012567727870218974, "content": "The subclinical joint inflammation in gout forms the basis for colchicine prophylaxis. An acute gout flare is the most common adverse effect of urate-lowering therapy. For prophylaxis, low-dose colchicine therapy is the first choice. It is commenced 1 or 2 weeks before using urate-lowering drugs and continued for up to 6 months after normalization of the uric acid levels or until the clinically visible tophi resolve. Low-dose NSAIDs and low-dose corticosteroids are rarely used. The recommended dosage of colchicine is 0.5mg once or twice daily in the absence of any renal or hepatobiliary compromises." }, { "id": "pubmed23n1030_24561", "title": "[Gout and Its Management in Clinical Practice].", "score": 0.012274394451102153, "content": "Gout and Its Management in Clinical Practice <bAbstract.</b Resolution of an acute attack is usually the prime objective in routine clinical management of gout. Crystal identification in synovial fluid by polarised light microscopy is considered the diagnostic gold standard. Imaging procedures such as high-resolution ultrasonography are also useful. Non-steroidal anti-inflammatory drugs, steroids and colchicine (not approved in Switzerland, available from pharmacies) are used to treat an acute gout attack. Just as important as the diagnosis and treatment of an acute attack is the long-term management of hyperuricaemia in order to prevent further gout attacks as well as possible renal, cardiac or metabolic complications. Therefore, patients with a confirmed diagnosis of gout should, apart from non-pharmacologic interventions, receive hypouricaemic therapy with a target uric acid level of &lt;360 µmol/l (&lt;6 mg/dl). Drugs of first choice are xanthine oxidase inhibitors. Achievement of the therapeutic objective should be periodically reviewed, adjusting therapy as necessary." }, { "id": "pubmed23n0559_20567", "title": "Management of gout in older adults: barriers to optimal control.", "score": 0.012012120337637978, "content": "Gout, a common inflammatory arthritis, can be diagnosed with absolute certainty. Gout results from the body's reaction to urate crystals deposited in tissues, and this pathophysiology is well understood. If used appropriately, available therapies can be entirely effective in not only treating the symptoms of gout, but also in eliminating the excess urate from the body, thereby eradicating the disease. Because of these facts, management of patients with gout should be successful. However, management of gout is particularly challenging in the elderly, even though the principles of management are the same for all age groups. The purpose of this article is to review these principles and discuss them as they pertain to the elderly. The classic gout attack is acute in onset, extremely painful and associated with marked swelling, warmth, erythema and tenderness of a single joint. However, the diagnosis of gout may be challenging in the elderly because atypical presentations are more common in this group. Treatment of acute gout involves the use of NSAIDs, colchicine, corticosteroids or corticotropin (adrenocorticotropic hormone). Unfortunately, co-morbid conditions such as chronic kidney disease, peptic ulcer disease and congestive heart failure may make the use of these agents dangerous or contraindicated. Thus, it is important to try to treat an acute flare of gout at the earliest sign, because the sooner treatment is initiated, the faster the inflammation will resolve. Urate-lowering agents include allopurinol and uricosuric agents. These also must be used judiciously in the elderly. However, if used at the lowest dose that maintains the serum urate level below 5.0-6.0 mg/dL, the excess urate in the body will be eliminated, acute flares will no longer occur and tophi will resolve. Gout is often seen in association with hypertension, excessive alcohol consumption, obesity and hypertriglyceridaemia. These conditions and the medications used to treat them may contribute to the hyperuricaemia. Treating these conditions and using medications that do not promote hyperuricaemia will aid in the management of gout. Despite the challenges that often complicate the management of gout in the elderly, an understanding of the pathophysiology of the disease and both the indications and limitations of the medications used should allow successful treatment." }, { "id": "pubmed23n0719_6951", "title": "Therapeutic perspectives on uricases for gout.", "score": 0.0119857133044852, "content": "Available recombinant uricases (rasburicase, pegloticase) are potent hypouricaemic agents for tophaceous gout, but their long-term use is in question. We have performed a literature review on uricases, using Scirus, PubMed, Science Direct, and several other search engines. We have also consulted the records of drug regulatory authorities and patents on uricases. Rasburicase (Fasturtec(®)) was approved in Europe for tumour lysis syndrome induced by chemotherapy, in a single daily infusion dose for a maximum of 7 days. A retrospective study (n=10) conducted in patients with gout and three clinical cases have shown that infusions spaced over time, over several months, ensure the control of serum uric acid and help to eliminate or significantly reduce the size of tophi. However, repeated gout attacks (despite colchicine) and hypersensitivity reactions (despite corticosteroids) have dampened enthusiasm for its use in gout. Pegloticase was recently approved by the Food and Drug Administration (FDA) for patients with chronic gout, refractory or intolerant to conventional hypouricaemic therapy. A 6 month study versus placebo showed that pegloticase (infused at 8 mg every 2 weeks), induced a significant decrease in plasma uric acid in about 40% of patients (associated with a tendency for tophi dissolution). However, the remaining patients were non-responders, which correlated with the formation of pegloticase antibodies and infusion reactions. Research efforts are needed to develop less immunogenic uricases. In conclusion, some uricases could have an important role in the treatment of gout, for instance as a first-line treatment and over a short period of several months in patients with severe and tophaceous gout to allow rapid tophi dissolution." }, { "id": "InternalMed_Harrison_26128", "title": "InternalMed_Harrison", "score": 0.011924083336093537, "content": "may be cost-effective after two attacks), serum uric acid levels (progression is more rapid in patients with serum uric acid >535 μmol/L [>9.0 mg/dL]), the patient’s willingness to commit to lifelong therapy, or the presence of uric acid stones. Urate-lowering therapy should be initiated in any patient who already has tophi or chronic gouty arthritis. Uricosuric agents such as probenecid can be used in patients with good renal function who underexcrete uric acid, with <600 mg in a 24-h urine sample. Urine volume should be maintained by ingestion of 1500 mL of water every day. Probenecid can be started at a dose of 250 mg twice daily and increased gradually as needed up to 3 g per day to achieve and maintain a serum uric acid level of less than 6 mg/dL. Probenecid is generally not effective in patients with serum creatinine levels >177 μmol/L (2 mg/dL). These patients may require allopurinol or benzbromarone (not available in the United States). Benzbromarone is another uricosuric drug" }, { "id": "wiki20220301en015_140949", "title": "Colchicine", "score": 0.011649652043287655, "content": "Colchicine is typically prescribed to mitigate or prevent the onset of gout, or its continuing symptoms and pain, using a low-dose prescription of 0.6 to 1.2 mg per day, or a high-dose amount of up to 4.8 mg in the first 6 hours of a gout episode. With an oral dose of 0.6 mg, peak blood levels occur within one to two hours. For treating gout, the initial effects of colchicine occur in a window of 12 to 24 hours, with a peak within 48 to 72 hours. It has a narrow therapeutic window, requiring monitoring of the subject for potential toxicity. Colchicine is not a general pain-relief drug, and is not used to treat pain in other disorders." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 251 ] ], "word_ranges": [ [ 0, 41 ] ], "text": "From what is described it is a macroprolactinoma as it is a pituitary tumor of more than one centimeter, which secretes prolactin and with an insufficiency of the rest of pituitary hormones. The first line treatment of choice is dopaminergic agonists," }, "2": { "exist": true, "char_ranges": [ [ 319, 484 ] ], "word_ranges": [ [ 52, 79 ] ], "text": "In this case, the cavernous sinus is pressured by the mass, so the surgical risk increases. Therefore, in this particular case, the surgical option seems more risky." }, "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": "Dopaminergic agonists.", "2": "Transsphenoidal surgery.", "3": "External radiotherapy or radiosurgery.", "4": "Treatment of hypogonadotropic hypogonadism with testosterone.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0400_4278", "title": "Gonadotropin-secreting pituitary tumor associated with hypersecretion of testosterone and hypogonadism after hypophysectomy.", "score": 0.0172002601720026, "content": "To review gonadotropin-secreting pituitary tumors and report the rare case of one of these tumors that caused high serum testosterone concentrations, followed by hypogonadism after hypophysectomy. A case report is presented of a 61-year-old man who had decreased vision in his left eye, found by computed tomography of the sella to be attributable to a soft tissue pituitary mass with upward extension that caused elevation and deviation of the optic chiasm. Endocrine and pathologic evaluations are presented, and the treatment and follow-up course are discussed. Endocrine evaluation revealed a serum follicle-stimulating hormone (FSH) of 72.48 mIU/mL, luteinizing hormone (LH) of 31.65 mIU/mL, prolactin of 26.42 ng/mL, and total testosterone of 15.24 ng/mL (all values higher than the normal ranges). A soft tissue mass (3.2 by 2.5 by 1.2 cm) with negative immunocytochemical staining for prolactin and growth hormone but positive staining for synaptophysin, FSH, and LH was removed. One month postoperatively, the patient's chief complaints were a decrease in penile size and erectile dysfunction. Endocrine evaluation revealed a decreased LH of &lt;0.3 mIU/mL, total testosterone of &lt;0.2 ng/mL, and FSH of 4.3 mIU/mL. Three months later with testosterone replacement therapy, testosterone levels normalized, LH was &lt;0.3 mIU/mL, and FSH was 3.9 mIU/mL. Thyroid function and adrenal function were normal before and after surgical intervention. This rare case indicates that gonadotropin tumors can produce a functional LH that can increase serum testosterone levels." }, { "id": "pubmed23n1149_8846", "title": "Sparsely Granulated Corticotroph Pituitary Macroadenoma Presenting With Pituitary Apoplexy Resulting in Remission of Hypercortisolism.", "score": 0.01646825396825397, "content": "Pituitary corticotroph macroadenomas, which account for 7% to 23% of corticotroph adenomas, rarely present with apoplexy. This report aimed to describe a patient with a sparsely granulated corticotroph tumor (SGCT) presenting with apoplexy and remission of hypercortisolism. A 33-year-old male patient presented via ambulance with sudden onset of severe headache and nausea/vomiting. Physical examination revealed bitemporal hemianopsia, diplopia from right-sided third cranial nerve palsy, abdominal striae, facial plethora, and dorsal and supraclavicular fat pads. Magnetic resonance imaging demonstrated a 3.2-cm mass arising from the sella turcica with hemorrhage compressing the optic chiasm, extension into the sphenoid sinus and cavernous sinus. Initial investigations revealed a plasma cortisol level of 64.08 (reference range [RR], 2.36-17.05) mcg/dL. He underwent emergent transsphenoidal surgery. Pathology was diagnostic of SGCT. Postoperatively, the following laboratory findings were found: (1) cortisol level, &lt;1.8 ug/dL (RR, 2.4-17); (2) adrenocorticotropic hormone level, 36 pg/mL (RR, 0-81); (3) thyroid-stimulating hormone level, 0.07 uIU/mL (RR, 0.36-3.74); (4) free thyroxine level, 1 ng/dL (RR, 0.8-1.5); (5) luteinizing hormone level, &lt;1 mIU/mL (RR, 1-12); (6) follicle-stimulating hormone level, 1 mIU/mL (RR, 1-12); and (7) testosterone level, 28.8 ng/dL (RR, 219.2-905.6), with ongoing requirement for hydrocortisone, levothyroxine, testosterone replacement, and continued follow-up. Corticotroph adenomas are divided into densely granulated, sparsely granulated, and Crooke cell tumors. Sparsely granulated pattern is associated with a larger tumor size and decreased remission rate after surgery. This report illustrates a rare case of hypercortisolism remission due to apoplexy of an SGCT with subsequent central adrenal insufficiency, hypothyroidism, and hypogonadism." }, { "id": "pubmed23n0476_17474", "title": "Medical therapy of macroprolactinomas in males: I. Prevalence of hypopituitarism at diagnosis. II. Proportion of cases exhibiting recovery of pituitary function.", "score": 0.014085151140988704, "content": "Hyperprolactinaemia frequently causes secondary hypogonadism through central suppression of gonadotropin secretion. Macroprolactinomas (&gt; 1 cm diameter) are more common in males and may additionally cause more generalised hypopituitarism. Recovery of the thyrotropic and/or corticotropic axes is well described following selective adenomectomy, but remains poorly defined in relation to medical (dopamine-agonist) therapy of macroprolactinomas. We therefore performed a retrospective examination of case records of male patients who had received medical therapy alone for macroprolactinoma between 1980-2001 (n = 35) and in whom tumor shrinkage was documented by interval pituitary imaging (reported throughout by a single neuroradiologist). Mean prolactin level at baseline was 59,932 mU/L (median 31,400; range 3,215-332,000); mean period of follow up was 4.2 years (median 2.6; range: 1.0-15). Defects of the following axes were evident at diagnosis: LH/FSH-testosterone (n = 27; 77%), TSH-T4 (n = 14; 41%-not including one case with pre-existing 1 degress hypothyroidism), ACTH-cortisol (n = 8; 23%). Overall, 14 men (40%) were deficient in 1 axis, seven (20%) in 2 axes and seven (20%) in 3 axes. Growth hormone secretory status was not systematically evaluated. In all but 6 patients, prolactin levels fell to normal or near-normal levels (mean 764 mU/L; median 260; range: &lt; 10-4,833). Of the patients in whom adequate reassessment had been performed, thyrotroph function recovered in 4/9, corticotroph function in 4/6 and gonadotroph function in 16/26 cases. In four cases (11%) previously described, development of visual impairment as a result of the chiasmal traction syndrome necessitated a dose reduction in medical therapy to allow a degree of controlled tumor re-expansion. The prevalence at diagnosis of TSH and ACTH deficiency in men with macroprolactinomas was 41% and 23%, respectively. Among eight patients with insufficiency of TSH and/or ACTH secretion who underwent complete interval reassessment over several years of treatment, recovery of at least one axis occurred in six cases (75%). This study highlights the importance of screening ACTH- and/or TSH-deficient men during dopamine agonist therapy in order to identify cases where hypopituitarism has resolved." }, { "id": "pubmed23n0051_4980", "title": "[Prolactin microadenoma in men. Study of 14 cases].", "score": 0.013092029264536002, "content": "Macroprolactinomas have been well documented in men over the past several years. By contrast, to the best of our knowledge, there have been no reports of microprolactinomas in men. We describe here 14 cases of microprolactinomas occurring in male patients (14 to 53 years old) and discovered on the basis of endocrine symptoms. Nine patients complained of impotence and/or decreased libido, 8 had gynecomastia with or without galactorrhea, 1 had undergone incomplete puberty. All patients had hyperprolactinemia (225 +/- 65 micrograms/l, mean +/- SEM, N less than 13 micrograms/l); plasma testosterone levels were low in 9 (162 +/- 33 ng/dl, mean +/- SEM; N = 308 - 876 ng/dl), while plasma luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels and their responses to LH-releasing hormone (LHRH) were normal in all cases. Among the 14 patients, 12 had no hypopituitarism and 2 had only partial corticotrope insufficiency; none had visual disturbances and only one complained of headaches. The sella turcica was normal in size and shape in 2 cases but a double floor and/or a thinner part of the floor was observed in 12. CT scan of MRI demonstrated in all cases an intrasellar microadenoma with a mean size of 7 mm (range, 3 to 10 mm) and no preferential localization. One patient was treated with bromocriptine, while the others underwent surgery via the transsphenoidal route. Immunocytochemistry demonstrated immunoreactive-prolactin (IR-PRL) cells in all the adenomas. Surgery resulted in normalization of plasma PRL in 11 of the 13 patients and in lowering PRL levels in the others 2.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "article-23268_2", "title": "Hypogonadism -- Introduction", "score": 0.011617157648218909, "content": "Nintey-five percent of the total testosterone in males is synthesized in the Leydig cells of the testis. Defects, whether acquired or congenital, that interefere with interactions in the hypothalamic-pituitary-testicular axis can cause male hypogonadism It is essential to distinguish between primary hypogonadism (which originates in the testes) and secondary hypogonadism (which originates in the hypothalamus or pituitary). Symptoms highly suggestive of hypogonadism include decreased spontaneous erections, decreased nocturnal penile tumescence, decreased libido, and reduced testicular volume. The normal range for early morning testosterone in a male is between 300 ng/dL to 1000 ng/dL [1] . Hypogonadism is diagnosed when the morning serum testosterone level is less than 300 ng/dL. However, clinical judgment can be exercised in the diagnosis of hypogonadism for patients with persistent symptoms of testosterone deficiency despite having testosterone levels are in the normal range [2] . Of note, total testosterone less than 405.9 ng/dL is below the fifth percentile [3] . Elderly males should aim for testosterone levels between 500 and 800 ng/dL while young adults should aim for testosterone levels between 600 and 900 ng/dL." }, { "id": "wiki20220301en026_104860", "title": "Hypogonadism", "score": 0.011408769825403172, "content": "Normal total testosterone levels depend on the man's age but generally range from 240 to 950 ng/dL (nanograms per deciliter) or 8.3-32.9 nmol/L (nanomoles per liter). According to American Urological Association, the diagnosis of low testosterone can be supported when the total testosterone level is below 300 ng/dl. Some men with normal total testosterone have low free or bioavailable testosterone levels which could still account for their symptoms. Men with low serum testosterone levels should have other hormones checked, particularly luteinizing hormone to help determine why their testosterone levels are low and help choose the most appropriate treatment (most notably, testosterone is usually not appropriate for secondary or tertiary forms of male hypogonadism, in which the LH levels are usually reduced)." }, { "id": "article-27251_25", "title": "Pituitary Cancer -- Evaluation -- Laboratory Tests", "score": 0.011259212082613046, "content": "Hyposecretory adenomas are tumors that cause the hyposecretion of hormones from the pituitary gland and can involve one or more hormones. Hyposecreting tumors require measuring levels of multiple hormones such as thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), free T4, total testosterone (in men), and cortisol. Hypogonadotropic hypogonadism requires magnetic resonance imaging (MRI) of the brain at the time of diagnosis to rule out a pituitary tumor as the underlying etiology. Confirmatory testing with stimulatory testing follows basic laboratory testing, and these tests are specific to the hormone of interest. [27] [28] [29]" }, { "id": "article-23503_32", "title": "Male Infertility -- Pathophysiology -- Prolactinoma", "score": 0.011209170217082572, "content": "Prolactin levels in men are normally quite low. When elevated, they suggest a possible prolactin-secreting pituitary tumor.  Such tumors may cause infertility, hypogonadism (low testosterone), gynecomastia, galactorrhea, and possibly a reduction of the peripheral visual fields due to compression of the optic chiasm. Prolactin levels above 150 mcg/L are suggestive of this condition, while a level above 300 mcg/L is pretty much diagnostic. An MRI or CT scan of the sella should be done for confirmation. Dopamine agonists, such as cabergoline and bromocriptine, are generally used as medical therapy to suppress prolactin secretion, and many men will then normalize their testosterone levels and sperm counts. Surgical therapy with a trans-sphenoidal resection of the prolactinoma is successful in 80% to 90% of cases, but the tumors often recur.  Surgery is usually reserved for patients with visual field loss and in those where medical therapy is unsuccessful or not well tolerated. [34]" }, { "id": "wiki20220301en381_28806", "title": "Gonadotropin-releasing hormone insensitivity", "score": 0.010867202782003912, "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": "pubmed23n1012_20108", "title": "The Testosterone Effect on Metabolic and Urologic Outcomes in Patients with Nonfunctioning Pituitary Macroadenomas and Hypogonadotropic Hypogonadism.", "score": 0.010749928714000571, "content": "To evaluate cardiovascular risk, metabolic profile, low urinary tract symptoms (LUTS), and sexual function in patients with nonfunctional pituitary macroadenoma (NFPMA) and hypogonadotropic hypogonadism with testosterone therapy (TTh). A retrospective clinical study at a tertiary care center was performed in 101 men with NFPMA, HH, and TTh; metabolic profile, cardiovascular risk, International Prostate Symptoms Score (IPSS), and International Index of Erectile Function 5 (IIEF-5) scores were evaluated before initiation of TTh and at the last checkup with TTh. Age was 49.3 ± 8.8 years; <iT</i before TTh was 195 ng/mL (101-259) vs. 574 (423-774) at the last checkup. The time of TTh administration was 34 months (12-72). An increase in triglyceride levels (200 (153-294) vs. 174 (134-233) mg/dL; <ip</i=0.03), dyslipidemia (40% vs. 52%; <ip</i=0.03), and MetS (25% vs. 34%; <ip</i=0.05) was corroborated. A statistical difference in the Globorisk score and cardiovascular (CV) risk stratification was not found. IIEF-5 score was 15.5 ± 6.5 vs. 17.8 ± 5.3 (<ip</i=0.11). An improvement in penetration quality (2.0 ± 1.5 vs. 2.6 ± 1.3; <ip</i=0.05), erection after penetration (1.8 ± 1.2 vs. 2.5 ± 1.6; <ip</i=0.02), completion of intercourse (1.8 ± 1.2 vs. 2.4 ± 1.3; <ip</i=0.03), and satisfaction of sexual intercourse (1.8 ± 1.3 vs. 2.5 ± 1.5; <ip</i=0.01) was evidenced. IPSS score was 6 (IQR 2-10) vs. 7 (IQR 4-12); <ip</i=0.30. A lower rate of intermittency (14% vs. 3%; <ip</i=0.02), urgency (39% vs. 16%; <ip</i=0.01), and episodes of nocturia (18% vs. 4%; <ip</i=0.02) was found. An increase of hematocrit (44.1 ± 4.4 vs. 47.3 ± 4.4%; <ip</i=0.001), hemoglobin (14.9 ± 1.4 vs. 15.9 ± 1.4 g/dL; <ip</i=0.001), and prostatic specific antigen (0.59 (0.43-1.19) vs. 0.82 (0.45-1.4) ng/mL; <ip</i=0.02) was evidenced during TTh. TTh in young men with NFPMA improves LUTS, sexual function, and some metabolic parameters, and it is relatively safe in the prostatic context." }, { "id": "pubmed23n0704_14925", "title": "[Brain tumor (germinoma) diagnosed after assessment for male late-onset hypogonadism syndrome: a case report].", "score": 0.01058068118369626, "content": "A 44-year-old man suffered from sleep disturbance, headache, lack of energy and appetite loss. His local doctor recommended he consult our clinic for further examination of late-onset hypogonadism. His aging males' symptoms (AMS) and international index of erectile function (IIEF-5) scores were 62 and 1, respectively. His biochemistry revealed 0.29 mIU/ml luteinizing hormone (LH), 1.36 mIU/ml follicular stimulating hormone (FSH), 0.16 ng/ml total testosterone (TT) and＜0.6 pg/ml free testosterone (FT). Male hypogonadotropic hypogonadism was suspected from these results, He was then referred to a neurosurgeon for discrimination of intracranial disease where magnetic resonance imaging (MRI) revealed multiple intracranial tumors. An open brain biopsy was performed, and germinoma was diagnosed. After 4 courses of anti-cancer chemotherapy, complete remission was achieved. He was followed up endocrinologically by administration of testosterone injections along with other endocrinology replacement treatments. However, MRI 3 months later revealed tumor recurrence in the left lateral ventricle, and he has been receiving radiation therapy." }, { "id": "InternalMed_Harrison_26469", "title": "InternalMed_Harrison", "score": 0.010091034008931639, "content": "Laboratory Investigation The presenting clinical features of functional pituitary adenomas (e.g., acromegaly, prolactinomas, or Cushing’s syndrome) should guide the laboratory studies (Table 403-2). However, for a sellar mass with no obvious clinical features of hormone excess, laboratory studies are geared toward determining the nature of the tumor and assessing the possible presence of hypopituitarism. When a pituitary adenoma is suspected based on MRI, initial hormonal evaluation usually includes (1) basal prolactin (PRL); (2) insulin-like growth factor (IGF) I; (3) 24-h urinary free cortisol (UFC) and/or overnight oral dexamethasone (1 mg) suppression test; (4) α subunit, follicle-stimulating hormone (FSH), and luteinizing hormone (LH); and (5) thyroid function tests. Additional hormonal evaluation may be indicated based on the results of these tests. Pending more detailed assessment of hypopituitarism, a menstrual history, measurement of testosterone and 8 A.M. cortisol levels," }, { "id": "pubmed23n0400_22076", "title": "Sarcoidosis within a pituitary adenoma.", "score": 0.009900990099009901, "content": "A 54 year old man presented with frontal headaches for one year. A CT scan of the head revealed a pituitary mass. He denied a change in vision or galactorrhea, but did have decreased frequency of erections and a recent episode of renal stones. On physical exam, the cranial nerves were normal. Visual field exam revealed mild bilateral temporal defects. The genitalia were normal and the testes were soft. Laboratory evaluation revealed: Na, 134 mM/l; K, 6.7 mM/l; Cl, 104 mM/l; HCO3, 22 mM/l; BUN, 47 mg/dl; Cr, 8.3 mg/dl; Ca, 12.5 mg/dl; Phos, 5.5 mg/dl; prolactin, 32.0 ng/ml; T4, 4.46 microg/dl; TSH, 2.07 microU/ml; LH, 18.1 mIU/ml; FSH 3.2 mIU/ml; alpha subunit 1.6 ng/ml; testosterone 255 ng/dl; cortisol, 20.3 microg/dl; cortisol after 250 microg cortrosyn, 38.5 microg/dl (time 60 minutes); growth hormone, 1.4 ng/ml; IGF-1, 47 ng/ml; PTH, &lt;1 pg/ml; 25-hydroxyvitamin D, 14 ng/ml; 1,25-dihydroxyvitamin D, 69 pg/ml. These results were felt to be consistent with a non-PTH-mediated hypercalcemia, such as humoral hypercalcemia of malignancy, or a vitamin D-mediated hypercalcemia, such as lymphoma, sarcoidosis or tuberculosis. Head MRI demonstrated a 3.5 x 3.5 x 2.5 cm heterogeneous mass enlarging the sella, deforming the clivus and compressing the cavernous sinus, basilar artery and left side of the optic chiasm. There was a small focus of high signal in the superior part of the mass on the T1-weighted image from either a proteinaceous cyst with early calcium deposition or sub-acute blood. These radiographic findings were felt to be consistent with a pituitary adenoma. The patient was treated with intravenous hydration and thyroxine 50 microg daily and underwent a transsphenoidal resection of the pituitary lesion. Pathologic examination revealed a pituitary adenoma with multiple granulomas and crystalline material; this was consistent with sarcoid within the adenoma. Post-operatively, the serum LH fell to 5.5 mIU/ml. A subsequent transbronchial biopsy revealed multiple non-caseating granulomas. A serum ACE level was elevated at 132.6 U/l. He received oral prednisone 60 mg daily with resolution of the hypercalcemia. Neurosarcoidosis occurs in 5 to 15% of patients with sarcoidosis and can involve the hypothalamus and pituitary gland. This is the first reported case of sarcoidosis occurring within a pituitary adenoma." }, { "id": "pubmed23n0750_17420", "title": "What causes a prolactinoma to be aggressive or to become a pituitary carcinoma?", "score": 0.00980392156862745, "content": "Malignant prolactinoma is an exceedingly rare endocrine tumor and cannot be diagnosed on histological grounds alone. Similarly to other neuroendocrine tumors such as pheochromocytoma, the mitoses index, Ki-67, p53, and others are utilized in helping understand whether a tumor is benign or malignant or to better predict tumor behavior. We here present the unusual case of an unfortunate young man with an aggressive prolactinoma, the complications of which led to his premature death. A 25-year-old white man developed severe headaches, low energy, and decreased libido. A brain magnetic resonance imaging (MRI) showed a 4 x 3 x 2 cm pituitary tumor invading the left cavernous sinus. Laboratory findings revealed elevated prolactin (470 ng/mL) and adrenocorticotropic hormone (ACTH, 82 pg/ml) and decreased total testosterone (176 ng/dl). Visual fields showed superior quadrantanopia in the left eye. Transsphenoidal pituitary resection was undertaken. Pathology revealed a prolactinoma with atypical cells, diffuse p53 nuclear labeling, and a Ki-67 index of 23% (high). Postoperatively, prolactin remained elevated (725-891 ng/ml) and cabergoline was increased to 1 mg three times weekly, with serum prolactin further increasing to 3507 ng/ml five months postoperatively. Repeat MRI revealed extension of the tumor with optic chiasm compression and left orbit invasion. Because of acute left vision loss with ophthalmoplegia, an urgent left frontotemporal craniotomy and tumor resection were conducted. The Ki-67 index of the tumor was 24.8%, the mitotic figure immunostain phosphohistone-H3 positive. Sixty percent (60%) of tumor cells were positive for p53. Cabergoline was increased to 1 mg daily but prolactin remained elevated (770 ng/ml). The patient then underwent proton beam radiation to the area of concern involving the sella. Prolactin thereafter improved to 44 ng/ml. He then developed acute vision loss of the right eye with an MRI showing tumor in the right cavernous sinus. A 15 mm dural-based right temporal mass believed to be a metastasis was also noted. Following this scan, he was considered too high risk for debulking surgery and instead underwent gamma knife irradiation to the sella area. This shrank the right cavernous sinus tumor mass, while the right temporal mass increased in size. The patient developed blindness and left-sided weakness and required enteral feeding and tracheostomy after prolonged intubation. A trial of chemotherapy with temozolomide (350 mg daily for 5 days) near the end of his life was unsuccessful. He died on home hospice 31 months after his first surgery. Headaches, vision changes, and symptoms of androgen deficiency syndrome can be manifestations of an aggressive prolactinoma that might require surgery and additional medical therapy including cabergoline and temozolomide with an unpredictable time of survival." }, { "id": "pubmed23n0036_7656", "title": "[Anterior pituitary regulation of testicular function in the elderly (author's transl)].", "score": 0.00980392156862745, "content": "Pituitary gonadotrophin regulation was examined with the LH-RH test in 15 men (aged between 55 and 90 years), five of them aged between 71 and 90 years. Compared to normal mature males, the plasma testosterone in these subjects was reduced or was in the lower range of normal, while basal LH levels were increased in half the cases. However, basal FSH values were increased in three only. In most of these subjects with increased basal values of LH, the LH-RH stimulation caused a paradoxical temporary reduction in LH release which did not occur with FSH. This paradoxical response also did not occur when basal LH values were normal." }, { "id": "pubmed23n1049_9771", "title": "Symptomatic Pituitary Metastasis as Initial Manifestation of Renal Cell Carcinoma: Case Report and Review of Literature.", "score": 0.009708737864077669, "content": "Metastasis to the pituitary gland is extremely rare (∼2% of sellar masses). Clinical, biochemical, and radiologic characteristics of pituitary metastasis are poorly defined and can be difficult to diagnose before surgery. We present an unusual case with pituitary metastasis as the first manifestation of renal cell carcinoma (RCC). A 70-year-old male presented with acute onset of weakness, dizziness, diplopia, and progressively worsening headache. The initial CT head revealed a heterogeneous sellar mass measuring 2.8 × 1.9 × 1.7 cm. A follow-up MRI showed the sellar mass invading the right cavernous sinus. The presumptive diagnosis was a pituitary macroadenoma. Physical examination revealed bilateral 6th cranial nerve palsy and episodes of intermittent binocular horizontal diplopia. Hormonal testing noted possible secondary adrenal insufficiency (AM serum cortisol: 3.3 mcg/dL, ACTH: 8 pg/mL), secondary hypothyroidism (TSH: &lt;0.01 mIU/L, FT4: 0.7 ng/dL), secondary hypogonadism (testosterone: 47 ng/dL, LH: 1.3 mIU/mL, and FSH: 2.3 mIU/mL), and elevated serum prolactin (prolactin: 56.8 ng/ml, normal: 4.0-15.2 ng/ml). IGF-1 level was normal at 110 ng/mL (47-192 ng/mL). The patient was discharged on levothyroxine and hydrocortisone therapy with plans for close surveillance. However, his condition worsened over the next three months, and he was subsequently readmitted with nausea, vomiting, and hypernatremia secondary to diabetes insipidus. Repeat MRI pituitary showed an interval increase in the size of the sellar mass with suprasellar extension and a new mass effect on the optic chiasm. The sellar mass was urgently resected via a trans-sphenoidal approach. The tumor was negative for neuroendocrine markers and pituitary hormone panel, ruling out the diagnosis of pituitary adenoma and triggered workup for metastatic renal cell carcinoma, clear cell type. The diagnosis of renal cell carcinoma was confirmed by the diffuse and strong staining for renal cell carcinoma markers (Pax-8, RCC-1, and CD10). A follow-up CT scan noted large right renal mass measuring 11 × 10 × 11 cm. The patient underwent a cytoreductive robotic right radical nephrectomy for WHO/ISUP histologic grade II clear cell RCC, stage pT2b pNX pM1. He subsequently received fractionated stereotactic radiotherapy to the pituitary gland. He is presently stable with no radiological evidence of progression or new intracranial disease on subsequent imaging. Pituitary metastasis most commonly occurs from breast, lung, or gastrointestinal tumors but also rarely from renal cell carcinoma. Biochemical findings such as panhypopituitarism, acute clinical signs such as headache, visual symptoms, and diabetes insipidus and interval increase in sellar mass in a short time interval should raise suspicion for sellar metastasis." }, { "id": "pubmed23n0083_18601", "title": "Effect of cranial irradiation on hypothalamus and pituitary functions.", "score": 0.009708737864077669, "content": "Hypopituitarism can occur after cranial irradiation for tumors distant from the pituitary gland. Recent studies have suggested that this is hypothalamic in origin. Hypothalamic and pituitary functions were studied in 11 patients, 4 men and 7 women, 4.5 years or more after radiotherapy for nasopharyngeal carcinomas. The estimated average total dose was 5000 cGys for the hypothalamus and pituitary gland. Except for 2 women with amenorrhea and 4 men with impotency, the patients did not have evident endocrine deficiency. Baseline hormone profiles revealed normal T4, T3 and cortisol levels, 6 with elevated prolactin, 3 with reduced testosterone and 3 with slightly elevated basal TSH. The four menopausal women had impaired gonadotropin response to LHRH (100 micrograms, i.v.). Four (1 menstruating, 1 amenorrheic, 2 menopausal) women did not reach peak FSH response 4 hours after LHRH injection. The other amenorrheic woman had minimal FSH and LH response to LHRH which persisted even after 8 days of pulsatile infusion of LHRH (1 microgram/90min). TSH response to TRH (400 micrograms, i.v.) was delayed in 7 patients. GH response to human GRH (1 microgram/kg, i.v.) was impaired in 6 patients (maximal GH less than 5 mU/l). ACTH response to ovine CRH (1 microgram/kg, i.v.) was impaired in 3 patients (less than 50% elevation from baseline). Three patients who had normal GRH tests had impaired GH response to insulin hypoglycemia. Six patients had an empty sella on CT scan. From this study the following conclusions are drawn: (1) Among the four axes, GH is the most vulnerable. (2) The insulin tolerance test is still the best single test for evaluation of hypothalamic function.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0634_22523", "title": "Incomplete deficiency of hypothalamic hormones in hypothalamic hypopituitarism associated with an old traumatic brain injury.", "score": 0.009615384615384616, "content": "A 62 year-old man was admitted to determine the pathogenesis of his hypoglycemia. He was unconscious and his plasma glucose level was 26 mg/dL. When he was 31 years old, he had a traffic accident and was unconscious for several days. Physical findings on admittance showed that the patient's BMI was 17.8 and blood pressure, 114/70 mmHg. He was alert. He had a hypogonadal face with a lack of beard, and he had an atrophic testis with a volume of 1 to 2 ml. Laboratory findings showed that his fasting plasma glucose was 73 mg/dL; serum sodium, 133 mmol/l; potassium, 4.1 mmol/l; serum insulin, less than 1.0 muU/ml.; plasma ACTH, 45.8 pg/ml; serum cortisol, 5.2 microg/dL; and free cortisol urinary excretion, less than 4.5 microg/day; serum LH, 0.8 mIU/ml; serum testosterone, less than 0.05 ng/ml; serum TSH, 2.0 uIU/ml; free T(4), 0.7 ng/dL; free T(3), 1.5 pg/ml; and serum prolactin, 29.0 ng/ml. The levels of all the pituitary hormones were elevated in response to a mixture of exogenous corticotrophin-releasing hormone (CRH), luteinizing hormone-releasing hormone (LH-RH), thyrotropin-releasing hormone (TRH), and growth hormone-releasing hormone (GRH). However, there was no increased secretion of adrenocorticotropic hormone (ACTH) in response to hypoglycemia (induced by the administration of insulin) and there was no increased secretion of luteinizing hormone (LH) and follicle stimulating hormone (FSH) in response to the administration of clomiphene. Magnetic resonance imaging revealed an atrophied pituitary gland with an empty sella, but there were no abnormal findings of the hypothalamus. Hydrocortisone replacement at a dosage of 20 mg/day increased the patient's plasma glucose from 73 to 100 mg/dL and his serum sodium from 133 to 138 mmol/l. These findings therefore indicate a partial impairment in hypothalamic hormone release, resulting from a traumatic brain injury that the patient had received 31 years ago." }, { "id": "pubmed23n0679_1892", "title": "Is it possible to avoid hypopituitarism after irradiation of pituitary adenomas by the Leksell gamma knife?", "score": 0.009615384615384616, "content": "Radiation therapy is one of the treatment options for pituitary adenomas. The most common side effect associated with Leksell gamma knife (LGK) irradiation is the development of hypopituitarism. The aim of this study was to verify that hypopituitarism does not develop if the maximum mean dose to pituitary is kept under 15 Gy and to evaluate the influence of maximum distal infundibulum dose on the development of hypopituitarism. We followed the incidence of hypopituitarism in 85 patients irradiated with LGK in 1993-2003. The patients were divided in two subgroups: the first subgroup followed prospectively (45 patients), irradiated with a mean dose to pituitary &lt;15 Gy; the second subgroup followed retrospectively 1993-2001 and prospectively 2001-2009 (40 patients), irradiated with a mean dose to pituitary &gt;15 Gy. Serum TSH, free thyroxine, testosterone or 17β-oestradiol, IGF1, prolactin and cortisol levels were evaluated before and every 6 months after LGK irradiation. Hypopituitarism after LGK irradiation developed only in 1 out of 45 (2.2%) patients irradiated with a mean dose to pituitary &lt;15 Gy, in contrast to 72.5% patients irradiated with a mean dose to pituitary &gt;15 Gy. The radiation dose to the distal infundibulum was found as an independent factor of hypopituitarism with calculated maximum safe dose of 17 Gy. Keeping the mean radiation dose to pituitary under 15 Gy and the dose to the distal infundibulum under 17 Gy prevents the development of hypopituitarism following LGK irradiation." }, { "id": "pubmed23n0922_6884", "title": "[Secondary male hypogonadism induced by sellar space-occupying lesion: Clinical analysis of 22 cases].", "score": 0.009523809523809525, "content": "To analyze the clinical characteristics of secondary male hypogonadism induced by sellar space-occupying lesion, explore its pathogenesis, and improve its diagnosis and treatment. We retrospectively analyzed the clinical data about 22 cases of secondary male hypogonadism induced by sellar space-occupying lesion, reviewed related literature, and investigated the clinical manifestation, etiological factors, and treatment methods of the disease. Hypogonadism developed in 10 of the patients before surgery and radiotherapy (group A) and in the other 12 after it (group B). The patients received endocrine therapy with Andriol (n=7) or hCG (n=15). The average diameter of the sellar space-occupying lesions was significantly longer in group A than in B (［2.35±0.71］ vs ［1.83±0.36］ cm, P&lt;0.05) and the incidence rate of prolactinomas was markedly higher in the former than in the latter group (60% vs 0, P&lt;0.01). The levels of lutein hormone (LH), follicle stimulating hormone (FSH) and testosterone (T) were remarkably decreased in group B after surgery and radiotherapy (P&lt;0.01). Compared with the parameters obtained before endocrine therapy, all the patients showed significant increases after intervention with Andriol or hCG in the T level (［0.78±0.40］ vs ［2.71±0.70］ ng/ml with Andriol; ［0.93±0.44］ vs ［3.07±0.67］ ng/ml with hCG) and IIEF-5 score (5.00±2.61 vs 14.50±3.62 with Andriol; 5.36±1.82 vs 15.07±3.27 with hCG) (all P&lt;0.01). The testis volume increased and pubic hair began to grow in those with hypoevolutism. The patients treated with hCG showed a significantly increased testis volume (P&lt;0.01) and sperm was detected in 7 of them, whose baseline testis volume was markedly larger than those that failed to produce sperm (［11.5±2.3］ vs ［7.5±2.3］ ml, P&lt;0.01). Those treated with Andriol exhibited no significant difference in the testis volume before and after intervention and produced no sperm, either. Hypothyroidism might be attributed to surgery- or radiotherapy-induced damage to the pituitary tissue, space-occupying effect of sellar lesion, and hyperprolactinemia. Both Andriol and hCG can improve the T level and erectile function, but the former does not help spermatogenesis." }, { "id": "pubmed23n0625_15177", "title": "An adolescent boy with thalassemia major presenting with bone pain, numbness, tetanic contractions and growth and pubertal delay: panhypopituitarism and combined vitamin D and parathyroid defects.", "score": 0.009433962264150943, "content": "A 16-year-old boy with transfusion-dependent thalassemia major presented with tetany, numbness, bone pain, short stature and pubertal delay. His height SDS score=-2.6, BMI=22.4, spleen was palpable 5 cm and liver 7 cm below the costal margins. The cardio-vascular examination was normal. Laboratory investigations showed a hemoglobin level (8 g/dL), hypocalcemia, hyperphosphatemia and elevated alkaline phosphatase (ALP) with serum 25-OH D below 3 ng/ml and a normal magnesium level. Serum parathyroid hormone (PTH) level was lower (21 pg/mL; normal 16-70 pg/mL) than expected for the degree of hypocalcemia. Serum ferritin concentration was 4442 ug/L, insulin-like growth factor I (IGF-I) was 31 microg/L (normal 122- 286 microg/L), free T4 was 13.1 microg/dL, TSH 1.2 mIU/ml. These results revealed a combined vitamin D-parathyroid defect. Peak growth hormone (GH) responses to clonidine and glucagon tests were 7.6 ng/ml and 6.2 ng/ml, respectively. Serum LH and FSH concentrations were below 0.5 U/L and testosterone was below 10 ng/dl. Radiographs revealed osteopenia of the phalanges and long bones and DXA scanning revealed low BMD Z-score of the femoral neck and 4th and 5th lumbar spines. MRI showed evidence of hemosiderin deposition in the pituitary. The patient was started on oral daily calcium carbonate (1500 mg elemental calcium) and vitamin D2 (calciferol) 25,000 IU/day and intensive iron chelation therapy. A low dose of IM testosterone enanthate (1 mg/kg/month) was injected for 6 months. Follow-up after 4, 8 and 12 months revealed normal Ca, PO4, ALP, and 25-OH D concentrations and disappearance of spasms and numbness and increased growth velocity. In conclusion, investigating calcium homeostasis at regular intervals and early management of any abnormality can preclude the occurrence of complications." }, { "id": "pubmed23n0422_22241", "title": "The value of pituitary magnetic resonance imaging in men with hypogonadism.", "score": 0.009433962264150943, "content": "We assessed the usefulness of magnetic resonance imaging (MRI) of the brain in the evaluation of hypogonadal men with a variety of endocrine patterns. A total of 51 men with low levels of total testosterone (TT) or free testosterone (FT) underwent MRI. Erectile dysfunction and/or decreased libido were present in 43 (84.3%) of cases and infertility in 8 (15.7%). Serum prolactin (PRL) was obtained in all cases. Low levels of TT and FT were defined as less than 300 and 1.5 ng/dl, respectively. Markedly low levels of TT were defined as less than 200 ng/dl. In 38 of 51 (74.5%) men the MRI was normal. A small pituitary gland (the partially empty sella syndrome) was noted in 9 (17.6%) cases and microadenoma was noted in 4 (7.8%). Prolactin levels were greater than twice the upper limit of normal in 3 of 4 (75%) cases of adenoma, and low FT was noted in all 4 cases. An additional case of adenoma was identified in a man with markedly decreased TT and normal PRL. All men with adenoma presented with the combination of erectile dysfunction and decreased libido. Among men without adenomas the highest PRL value was always less than twice the upper limit of normal. Overall, only 1 of 17 men with markedly decreased TT (less than 200 ng/dl) demonstrated adenoma. None of the 17 men with low luteinizing hormone with low TT or FT had an adenoma or pituitary/hypothalamic mass. The likelihood of identifying pituitary adenoma by MRI is high if PRL levels are more than twice the upper limit of normal. Medically significant abnormalities are identified in only a small percentage of hypogonadal men with low luteinizing hormone or if TT levels are markedly decreased. The decision to obtain MRI in these latter cases should be based on individual circumstances." }, { "id": "article-17652_9", "title": "Physiology, Anterior Pituitary -- Pathophysiology", "score": 0.00937558951141294, "content": "Both hypofunction and hyperfunction can result. Measurement of pituitary hormones and target hormones can help define the defects. In Cushing disease, there is an increase in both ACTH and Cortisol. In Prolactinomas, there are very high PRL levels, generally greater than 200 ng/mL. In Acromegaly IGF-1 levels are increased, and  GH fails to suppress during an oral GTT. In hypopituitarism, there is decreased GH, IGF-1, LH FSH, testosterone in males, ACTH, cortisol T4 and TSH levels and PRL in Sheehan Syndrome. [9] [10]" }, { "id": "pubmed23n0510_16449", "title": "[Primary hypothyroidism mimicking pituitary macroadenoma].", "score": 0.009345794392523364, "content": "A 21-year-old woman complaining of 8-month amenorrhea associated to weight gain, galactorrhea and frequent headaches, presented for clinical evaluation; her laboratory tests were: TSH: 1192 mUI/ml (0.27-4.2); TT4: 1.0 microg/dl (4.4-11.4 l); TT3: 0.41 ng/ml (0.7-2.1); prolactin: 69.2 ng/ml (3-20) and a diagnosis of myxedema associated to galactorrhea was made. A hypothalamic-pituitary magnetic resonance imaging (MRI) showed a suprasellar and intrasellar mass lesion of 1.9 x 1.4 x 1.9 cm, determining compression and deviation of the optic chiasm. Due to the possibility of hyperplasia of the TSH-producing cells, treatment of hypothyroidism was initiated with levothyroxine. Two months later, upon normalization of thyroid hormones and TSH levels, a second MRI showed an anatomically normal pituitary gland. Regression of the pituitary mass after treatment with levothyroxine confirmed the hypothesis of pituitary hyperplasia secondary to primary hypothyroidism. Our findings support the importance of determining thyroid function tests during the investigation of pituitary masses and thus avoiding an unnecessary surgery." }, { "id": "pubmed23n0226_734", "title": "[Selective venous sampling of pituitary hormones under provocative tests after retrograde cavernous sinus sinography (author's transl)].", "score": 0.009345794392523364, "content": "In 22 subjects, selective venous sampling from the inferior petrosal sinus was performed under provocative tests along with simultaneous sampling of pituitary blood from the antecubital vein, after retrograde cavernous sinography. The difference of hormonal levels between sinus blood (Bs) and peripheral blood (Bv) was measured by two antibody radioimmunoassay. Most extreme difference of hormonal levels was observed in acromegalic subjects, where Bs/Bv ratio of GH was 6.0 in the basal value and 4.9 in the peak value, and that of PRL 3.5 and 4.6, respectively. In subjects who reacted to provocative tests, the average ratio of Bs/Bv ranged from 6.9 to 1.1 in the order of GH, PRL, LH, TSH and FSH. Non-reactive subjects showed no significant difference in the hormonal levels between Bs and Bv. From the results obtained above, we assume a possible relationship between Bs/Bv ratio and metabolic clearance rate and between difference of Bs-Bv and basal production. The integral of Bs-Bv difference measured from time zero to the time returned to the basal value under provocative tests represents the sum of basal production and pituitary reserve according to compartment analysis." }, { "id": "pubmed23n0784_19690", "title": "Sixteen years post radiotherapy of nasopharyngeal carcinoma elicited multi-dysfunction along PTX and chronic kidney disease with microcytic anemia.", "score": 0.009259259259259259, "content": "The hypothalamic-pituitary (h-p) unit is a particularly radiosensitive region in the central nervous system. As a consequence, radiation-induced irreversible, progressively chronic onset hypopituitarism (RIH) commonly develops after radiation treatments and can result in variably impaired pituitary function, which is frequently associated with increased morbidity and mortality. A 38-year-old male subject, previously having received radiotherapy for treatment of nasopharygeal carcinoma (NPCA) 16 years ago, appeared at OPD complaining about his failure in penile erection, loss of pubic hair, atrophy of external genitalia: testicles reduced to 2×1.5 cm; penile size shrunk to only 4 cm long. Characteristically, he showed extremely lowered human growth hormone, (HGH, 0.115 ng/mL), testosterone (&lt;0.1 ng/mL), total thyroxine (tT4: 4.740 g/mL), free T4 (fT4, 0.410 ng/mL), cortisol (2.34 g/dL); lowered LH (1.37 mIU/mL) and estradiol (22 pg/mL); highly elevated TSH (7.12 IU/mL). As contrast, he had low end normal ACTH, FSH, total T3, free T3, and estriol; high end normal prolactin (11.71 ng/mL), distinctly implicating hypopituitarism-induced hypothyroidism and hypogonadism. serologically, he showed severely lowered Hb (10.6 g/dL), HCT (32.7%), MCV (77.6 fL), MCH (25.3 pg), MCHC (32.6 g/dL), and platelet count (139×103/L) with extraordinarily elevated RDW (18.2%), together with severely lowered ferritin (23.6 ng/mL) and serum iron levels; highly elevated total iron binding capacity (TIBC, 509 g/dL) and transferrin (363.4 mg/dL), suggesting microcytic anemia. Severely reduced estimated glomerular filtration rate (e-GFR) (89 mL/mim/1.73 m2) pointed to CKD2. Hypocortisolemia with hyponatremia indicated secondary adrenal insufficiency. Replacement therapy using androgen, cortisol, and Ringer's solution has shown beneficial in improving life quality. To our believe, we are the first group who report such complicate PTX dysfunction with adrenal cortisol insufficiency concomitantly occurring in a single patient." }, { "id": "pubmed23n0080_16886", "title": "Gonadotroph cell adenomas of the pituitary.", "score": 0.009259259259259259, "content": "Although the frequency of gonadotroph cell adenomas among all unselected pituitary adenomas is not yet known, it is probably much higher than previously suspected. The true incidence is probably somewhere between the 3-4% found in surgical and autopsy series, which is probably an underestimate because of its reliance on tissue content, and the 17% (24% when alpha-secreting adenomas are included) of 139 patients from this institution, which may be an overestimate of the incidence among all adenomas, because it is heavily weighted to very large adenomas in men only. Most patients who have been reported to have gonadotroph cell adenomas have similar clinical characteristics. Most are middle-aged men who have a history of normal pubertal development and a normal fertility history, and by examination are normally virilized and have testes of normal size. They are brought to medical attention because of visual impairment, which is the result of the enormous size of the adenoma. The most common hormonal characteristic of gonadotroph cell adenomas in vivo is hypersecretion of FSH, which is often accompanied by hypersecretion of FSH beta and alpha-subunit and less often by hypersecretion of LH beta or intact LH. Another common characteristic is secretion of FSH and/or LH in response to TRH. A few patients with gonadotroph cell adenomas hypersecrete intact LH and, therefore, have supranormal serum testosterone concentrations. A larger number have secondary hypogonadism because the adenomas are not secreting intact LH, but are compressing the normal gonadotroph cells and impairing LH secretion. These patients have concentrations of intact LH that are not elevated in spite of subnormal testosterone concentrations. Testosterone levels increase markedly in response to hCG. The hormonal characteristics of gonadotroph adenomas in dispersed cell culture are similar to their characteristics in vivo, including hypersecretion of FSH and LH subunits and responsiveness to TRH. Both the clinical and hormonal characteristics of gonadotroph cell adenomas usually make them readily distinguishable from pituitary enlargement due to long-standing primary hypogonadism. Pituitary adenomas that hypersecrete only alpha-subunit in vivo may also be adenomas of gonadotroph cells, because some of them secrete large amounts of FSH as well as alpha-subunit in culture. Most gonadotroph cell adenomas are now treated first by transsphenoidal surgery, to attempt to restore vision as quickly as possible, and then by supervoltage radiation to prevent regrowth of the remaining adenomatous tissue.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0339_16064", "title": "Unusual MRI finding of multiple adenomas in the pituitary gland: a case report and review of the literature.", "score": 0.009174311926605505, "content": "The simultaneous occurrence of multiple adenomas in the pituitary gland is a rare event. We report the coexistence of three non functioning pituitary microadenomas in a 37-year-old woman, referred to us for oligomenorrhea and headache. Biochemical evaluation revealed prolactin (131 U/liters), follicle-stimulating hormone (4.1 U/liters), luteinizing hormone (3.9 U/liters), 17beta-estradiol (74 pg/mL), free (2.0 pg/mL) and total testosterone (0.5 ng/mL), dehydroepiandrosterone-sulfate (3.5 microg/mL), 17OH-progesterone (0.8 ng/mL), cortisol (13.1 microg/dL), free triiodothyronine (4.8 pmol/L), free thyroxine (18.5 pmol/liters), thyrotropin (1.6 mU/L), and growth hormone (0.2 ng/mL) levels in the normal range, as for as the response to dynamic endocrine tests. MRI showed an enlarged sella turcica, occupied by three distinct hypointense areas that measured less than 5 mm in diameter in the left, medium and right side of the pituitary, respectively. This finding was confirmed 6 months later by a second MRI that revealed also a light increase in microadenomas dimensions. The patient, therefore, underwent neurosurgery by transfenoidal approach. Histologic examination showed no morphologic differences between the specimens obtained from the different microadenomas. Immunohistochemistry evaluation revealed a positive staining for the common alpha-subunit of glycoproteic hormones and negative for the other pituitary hormones tested, while electron microscopy showed cells with a poor secretory apparatus and a variable grade of cell differentiation. In conclusion, we report the fifth case described with multiple pituitary adenomas diagnosed in vivo and the first with three coexisting tumors revealed by MRI before neurosurgery. The occurrence of multiple pituitary tumors emphasizes the role of pituitary and extrahypophiseal factors in the clonal expansion of genetically altered cells." }, { "id": "pubmed23n0298_1013", "title": "[Gonadotropi adenoma linking labeled somatostatin analogs. Lack of relationship with therapeutic effect].", "score": 0.009174311926605505, "content": "Somatotropin- and thyrotropin-secreting adenomas are well known for positive uptake of radio-labeled octreotide in vivo, this fact is not so well assessed for gonadotropin-secreting adenomas (GSA). We report one case of positive somatostatin receptor scintigraphy in a woman suffering from histologically proven GSA. This 63 year old patient has been suffering for two years of akinetic syndrome when the outcome of diplopia led to the discovery of a large hypophyseal tumor spreading till V3 floor and in left cavernous sinus by resonance magnetic imaging (RMI). Clinical examination showed anterior hypopituitarism and bitemporal hemianopsia. Biologically, blood gonadotropins were decreased more on LH (0.6 UI/l, N &gt; 15) than on FSH (10 UI/l; N &gt; 20). A lack of response of gonadotropins to LHRH with low blood estradiol concentration (&lt; 10 pg/ml) was noticed. Basal blood measurement of alpha subunit was at 0.17 microgram/l (N = 0.10-1.6) and increased at 0.39 microgram/l after stimulation by LHRH. Although in low range of normal values, other hypophyseal hormones were normal except prolactinemia (45 mg/L; N &lt; 20), however stimulated by TRH and related to dopaminergic deconnection; Indium 111 labeled octreotide scintigraphy showed an over uptake of the tumor. Three month treatment by octreotide (100 micrograms x 3/day subcutaneously) did not allow to decrease significantly FSH concentration or to reduce the tumoral mass. Incomplete removal of the tumor was performed by transphenoidal route. Immunohistochemical analysis revealed positive immunostaining for alpha subunit and FSH beta on numerous cells while the labeling was slightly less strong for LH beta. These data evoked a GSA. This case record depicts the possibility of detection of GSA by somatostatin receptor imaging. However a positive result does not preclude of somatostatin analog therapeutic efficiency." }, { "id": "pubmed23n0626_10133", "title": "Recovery of persistent hypogonadism by clomiphene in males with prolactinomas under dopamine agonist treatment.", "score": 0.00909090909090909, "content": "Persistence of hypogonadism is common in male patients with prolactinomas under dopamine agonist (DA) treatment. Conventional therapy with testosterone causes undesirable fluctuations in serum testosterone levels and inhibition of spermatogenesis. To evaluate the use of clomiphene as a treatment for persistent hypogonadism in males with prolactinomas. Open label, single-arm, prospective trial. Fourteen adult hypogonadal males (testosterone &lt;300 ng/dl and low/normal LH) with prolactinomas on DA, including seven with high prolactin (range: 29-1255 microg/l; median: 101 microg/l) despite maximal doses of DA. Clomiphene (50 mg/day orally) for 12 weeks. Testosterone, estradiol, LH, FSH, and prolactin were measured before and 10 days, 4, 8, and 12 weeks after clomiphene. Erectile function, sperm analysis, body composition, and metabolic profiles were evaluated before and after clomiphene. Ten patients (71%), five hyperprolactinemic and two normoprolactinemic, responded to clomiphene (testosterone &gt;300 ng/dl). Testosterone levels increased from 201+/-22 to 457+/-37 ng/dl, 436+/-52, and 440+/-47 ng/dl at 4, 8, and 12 weeks respectively (0.001&lt;P&lt;0.01). Estradiol increased significantly and peaked at 12 weeks. LH increased from 1.7+/-0.4 to 6.2+/-2.0 IU/l, 4.5+/-0.7, and 4.6+/-0.7 IU/l at 4, 8, and 12 weeks respectively (0.001&lt;P&lt;0.05). FSH levels increased in a similar fashion. Prolactin levels remained unchanged. Erectile function improved (P&lt;0.05) and sperm motility increased (P&lt;0.05) in all six patients with asthenospermia before clomiphene. Clomiphene restores normal testosterone levels and improves sperm motility in most male patients with prolactinomas and persistent hypogonadism under DA therapy. Recovery of gonadal function by clomiphene is independent of prolactin levels." }, { "id": "pubmed23n0251_19097", "title": "[Initial experience of an endocrinologist with the treatment of hypophyseal adenomas with the Leksell gamma knife].", "score": 0.00909090909090909, "content": "Surgery of pituitary adenomas is not quite satisfactory so far and in some patients it is associated with a high risk. Conventional radiotherapy is only partly successful. Only few hospitals have experience with treatment of pituitary adenomas with Leksell's gamma knife. The objective of the presented paper is to give an account of the authors' own results of treatment of pituitary adenomas by irradiation with Leksell's gamma knife. The treated group comprised 13 patients (6 women, 7 men, 25-72 years old, median 44 years) with a pituitary adenoma. Hormonally active acromegaly was recorded in 9 patients, a prolactinoma in one female patient, afunctional adenoma in 3 patients. Twelve patients had been operated already previously, 3 of them twice. For visualization of the pituitary magnetic resonance (NMR) was used on a Magnetom apparatus 1.5 Tesla, Siemens Co. before surgery and one year after surgery. As hormonal indicators the following were examined: growth hormone (GH) profile in the course of the day and during the thyroliberin test (TRH), insulin-like growth factor I (IGF I), the prolactin level, the thyrotropin level (TSH) during the thyrotropin releasing hormone test (TRH) test the thyroxine level (T4) and the triiodothyronine level (T3), the plasma concentration of adrenocorticotropin (ACTH), the cortisol level, plasma testosterone level and 17-beta estradiol level. Complete recovery was achieved only in one female patient with acromegaly 18 months after irradiation, and in one patient with a prolactinoma a partial decline of hormone levels was recorded without detectable changes in the size of the adenoma. Only one female patient developed hypopituitarism. No other complications were recorded. Stereotactic irradiation with Leksell's gamma knife is valuable for treatment of pituitary adenomas and it is well tolerated therapy. Its effect is manifested only after several months. Complications in the sense of hypopituitarism may occur." }, { "id": "pubmed23n0549_16046", "title": "Multiple ovarian cysts and oligomenorrhea as the initial manifestations of a gonadotropin-secreting pituitary macroadenoma.", "score": 0.009009009009009009, "content": "To report a case of a follicle-stimulating hormone (FSH)-secreting pituitary adenoma, which manifested with oligomenorrhea, dysmenorrhea, and multiple bilateral ovarian cysts. We present a case report of a 29-year-old woman, including detailed laboratory, radiologic, and pathologic findings, who was diagnosed as having an FSH-secreting pituitary tumor. The pertinent literature is also reviewed. A 29-year-old woman, after experiencing oligomenorrhea and increasing abdominal girth for &gt;1 year, presented with an acute abdomen. Ultrasonography revealed multicystic ovaries &gt;15 cm in maximal diameter, causing bilateral adnexal torsion. After bilateral ovarian cystectomies, ultrasound study showed recurrence of the cysts. Relevant laboratory data were as follows: serum FSH 6.8 mIU/mL, luteinizing hormone 0.1 mIU/mL, prolactin 67 ng/mL, human chorionic gonadotropin &lt;2 mIU/mL, progesterone 3.5 ng/dL, estradiol 237 pg/mL, thyrotropin 1.8 microIU/mL, testosterone &lt;4 ng/dL, insulin 8.0 microIU/mL, and fasting plasma glucose 87 mg/dL. Magnetic resonance imaging (MRI) of the brain revealed a 2.5-cm pituitary mass, although the patient had no symptoms of pituitary dysfunction. Transsphenoidal removal of the mass was performed, and pathology studies were positive for FSH-secreting adenoma. Repeated MRI at 3 months showed an 0.8-cm residual tumor. The patient refused adjuvant radiotherapy. Regular menses resumed within 2 months postoperatively, and she later successfully became pregnant. Almost 3 years after treatment, the patient remained asymptomatic, results of pituitary function tests were normal, and follow-up MRI showed no signs of tumor regrowth. Although very uncommon, gonadotropin-secreting pituitary adenomas should be considered in the differential diagnosis of new-onset oligomenorrhea and dysmenorrhea, especially if associated with multicystic ovaries on ultrasound study, even in the absence of elevated levels of serum gonadotropins. Furthermore, we propose that it may be acceptable to withhold adjuvant radiotherapy in patients who are asymptomatic after transsphenoidal surgical excision of these tumors." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 688, 1093 ] ], "word_ranges": [ [ 116, 173 ] ], "text": "The diagnosis of lymph node tuberculosis is immediate when detecting \"isolated acid-fast bacilli and epithelioid granulomas\" in the puncture of one of the lymph nodes, however: considering the patient profile, this process will have been clinically unmasked during the immunological reconstitution and the infection is not the consequence of an incomplete immunological recovery (correct answer number 3)." }, "2": { "exist": true, "char_ranges": [ [ 300, 533 ] ], "word_ranges": [ [ 50, 93 ] ], "text": "answer 2 would not be correct, remember that it is desirable that it becomes negative 24 weeks after the start of treatment, although in patients with higher CV like ours, it could take longer - and the CD4+ count has begun to rise)." }, "3": { "exist": true, "char_ranges": [ [ 688, 1093 ] ], "word_ranges": [ [ 116, 173 ] ], "text": "The diagnosis of lymph node tuberculosis is immediate when detecting \"isolated acid-fast bacilli and epithelioid granulomas\" in the puncture of one of the lymph nodes, however: considering the patient profile, this process will have been clinically unmasked during the immunological reconstitution and the infection is not the consequence of an incomplete immunological recovery (correct answer number 3)." }, "4": { "exist": true, "char_ranges": [ [ 534, 687 ] ], "word_ranges": [ [ 93, 116 ] ], "text": "A negative Mantoux test does not rule out tuberculosis (incorrect answer 4), since in patients with severe immunosuppression it can give false negatives." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "It is a lymph node tuberculosis related to an incomplete immunologic recovery.", "2": "Treatment failure and it is an opportunistic infection.", "3": "This is an opportunistic infection unmasked within a picture of immune reconstitution.", "4": "A negative Mantoux test rules out tuberculosis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1081_9261", "title": "<i>Mycobacterium avium</i> complex and <i>Cryptococcus neoformans</i> co-infection in a patient with acquired immunodeficiency syndrome: a case report.", "score": 0.018137254901960782, "content": "Opportunistic infections (OI) are common in patients with acquired immunodeficiency syndrome (AIDS). Cryptococcus neoformans and Mycobacterium avium complex (MAC) are frequently responsible of such infections. However, concurrent infection with these two pathogens is uncommon and underreported in the literature. We describe the case of a 28-year-old Caucasian Belgian patient with no travel history, who presented with low-grade fever, headache and wasting syndrome. He was diagnosed with human immunodeficiency virus (HIV) infection at AIDS stage, with a HIV viral load of 506,000 viral copies/mL and a CD4 + T-cells count of 10 cells/µL. Diagnosis of disseminated Cryptococcus neoformans infection was made by positive serum cryptococcal antigen and positive culture for Cryptococcus neoformans in blood and in cerebrospinal fluid. Diagnosis of disseminated Mycobacterium avium complex infection was made by positive culture on a biopsy of a mediastinal lymph node. With adequate anti-retroviral therapy (ART) and treatment of these OIs, the patient recovered well and had a good clinical evolution. To our knowledge, this is the second case of coexistence of these two dangerous OIs reported in the post ART era. Clinicians should be aware that such co-infections still happen in high-income countries, in patients with severe immunodeficiency. Early detection and treatment of HIV is of paramount importance to prevent AIDS and its complications. We highlight the importance of thoroughly excluding all opportunistic infections in patients with newly diagnosed AIDS.<bAbbreviations:</b ABC: abacavir; AIDS: acquired immunodeficiency syndrome; AFB: acid-fast bacilli; ART: antiretroviral therapy; CM: cryptococcal meningitis; CrAg: cryptococcal antigen; CSF: cerebrospinal fluid; CT: computed tomography; EACS: European AIDS Clinical Society; FTC: emtricitabine; HIC: high-income countries; HIV: human immunodeficiency virus; HIV-VL: HIV-viral load; ICP: intracranial pressure; IRIS: immune reconstitution inflammatory syndrome; MAC: Mycobacterium avium complex; MRI: magnetic resonance imaging; MSM: man who has sex with men; NR: normal range; OD: omne in die = once daily; OI: opportunistic infection; RAL: raltegravir; TAF: tenofovir alafenamide fumarate." }, { "id": "pubmed23n0393_17776", "title": "[Skin manifestations of immune restoration syndrome in treated tuberculosis].", "score": 0.01692155196828094, "content": "Immune restoration syndrome was first described in 1998 and involved mycobacterium avium complex. We report the case of a patient with acquired immunodeficiency syndrome who had disseminated cutaneous lesions due to Mycobacterium tuberculosis, following initiation of highly active antiretroviral therapy. A 42 year-old HIV-infected man, was admitted for fever, cough, nocturnal sweat and impaired of general condition. He had a viral load of 127,200 copies/ml and 199/ml CD4 T-cells. He was treated with triple tuberculosis combination therapy according to tuberculous contagium, positivity of the tuberculin intradermoreaction (15 mm) and right upper lung nodule on thoracic scan. M. tuberculosis was not found. Fever improved at day 3. Highly active antiretroviral therapy with zidovudine, lamivudine, indinavir, was started at day 11 and 33 days after, fever and dermohypodermal nodules with necrotising evolution appeared. Skin biopsy specimen showed tuberculoid granuloma. The levels of viral load and CD4 T-cells were less than 200 copies/ml and 497/ml respectively. Fever and cutaneous lesions spontaneously resolved without changing therapy. Immune restoration syndrome appears after initiation of antiretroviral therapy, in patients with advanced HIV infection and without prophylactic treatment versus MAC. This case report probably involves mycobacterium tuberculosis. Bacterial lysis and immune restoration take part in cutaneous pathogenesis. Subclinical mycobacterial infection should be monitored during initiation of antiretroviral therapy in patients with advanced HIV infection." }, { "id": "pubmed23n0499_19952", "title": "Development of opportunistic infections after diagnosis of active tuberculosis in HIV-infected patients.", "score": 0.015460621912234816, "content": "Despite advances in highly active antiretroviral therapy (HAART), its use during tuberculosis (TB) treatment is fraught with challenges, often leading to delayed therapy. This report describes the course of HIV infection and outcomes of 26 consecutive TB/HIV coinfected patients who received TB treatment in Rhode Island. HIV infection was diagnosed in 26 (4%) of 598 TB cases in during a 10-year period. Of these patients, TB was the first indication of HIV infection in 15 patients (58%). Of the 21 patients who were not on antiretrovirals at the time of TB diagnosis, 17 (81%) met criteria for immediate initiation of HAART. The median CD4 cell counts and HIV-1 plasma viral load were 80 cells per microliter (range, 2-800 cells per microliter) and 255,631 copies per milliliter (range, 50,000 to &gt; 500,000 copies per milliliter), respectively, for the patients whose baseline measurements were available. CD4 lymphocyte count was less than 200 cells per microliter in 13 (76%) of the 17 patients whose measurements were available. Three (30%) of the 10 patients whose CD4 cell count was less than 100 cells per microliter developed subsequent AIDS-defining illness prior to the initiation of HAART and a fourth patient, within 30 days of starting HAART. None of the patients who had CD4 cell counts 100 cells per microliter or greater developed subsequent AIDS-defining illness during TB treatment. The median time to starting HAART after starting TB treatment was 12 weeks (range, 3-36 weeks). From our limited experience based on this case series, we recommend early initiation of HAART in coinfected patients with CD4 cell counts less than 100 cells per microliter." }, { "id": "pubmed23n0301_21145", "title": "[Clinical course of HIV-infected tuberculosis patients who admitted to the tuberculosis isolation ward: current problems of medical care].", "score": 0.0148380355276907, "content": "To clarify the problems of medical care of HIV-infected tuberculosis patients, we investigated clinical course of six cases admitted to our tuberculosis isolation ward. All cases were sputum smear positive for tubercle bacilli at the time of diagnosis of tuberculosis. HIV-positive was confirmed at the same time or soon after the diagnosis of tuberculosis in four cases. CD4+ cell count was on the average 21/mm3 on admission, and all cases were defined as acquired immunodeficiency syndrome (AIDS) by the criteria of AIDS surveillance committee in Japan. Two patients presented with miliary tuberculosis and five documented evidence for intrathoracic and/or cervical lymph node involvement. All cases but one responded well to antituberculosis drugs, and sputum smears and cultures became negative soon after the initiation of therapy. However, the patients were still needed to be hospitalized for the treatment and control of complications other than tuberculosis after sputum negative conversion, and they stayed in the isolation rooms of our tuberculosis ward for 110 +/- 49 days. During the treatment for tuberculosis, each patient developed 3 to 8 complications of HIV infection such as pneumocystis carinii pneumonia (PCP) (four cases), bacterial infection (four cases), neuropathy (four cases), and HIV encephalopathy (three cases). The last two complication worsened active daily life. White blood cell count was more likely to fall when sulfamethoxazole/trimethoprim mixture for the prevention of PCP and antituberculosis drugs were administered together. In three cases, ST mixture could not be continued, then two patients developed PCP after changing to an alternative pentamidine inhalation. Although three patients discharged from our tuberculosis ward, four died of AIDS related complications other than tuberculosis, one died of tuberculosis (multidrug-resistant M. tuberculosis strain was not documented initially but was detected five months later), one died of tuberculosis meningitis after the discharge, and one was lost because he returned to his own country. The survival time between the start of treatment and death ranged from 90 to 244 days in five cases. Integrated medical care system both for HIV and tuberculosis is warranted for the management of HIV-infected tuberculosis patients since they suffer many complication in addition to tuberculosis. A guideline of methods and duration of isolation for tuberculosis is needed for the most effective care of HIV-infected tuberculosis patients in Japan." }, { "id": "pubmed23n0678_1050", "title": "Unmasking tuberculosis-associated immune reconstitution inflammatory syndrome in HIV-1 infection after antiretroviral therapy.", "score": 0.014141414141414142, "content": "The exaggerated immune response to the subclinical opportunistic microorganisms or their antigens can be found in HIV-1 infected patients after receiving antiretroviral (ARV) therapy. We report a case of unmasking tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) in the HIV-1 infected patient who had no previous history of mycobacterial infection. She had tuberculosis of intestines, peritoneum and mesenteric glands within 2 months of ARV. However, her sputum acid-fast bacilli stain, sputum, blood and cervical lymph node aspiration cultures for mycobacterium were negative. Her CD4 cell count increased of from 46 cells/microL at baseline before receiving ARV to 155 cells/microL at month 6 of ARV. In addition, her plasma pro-inflammatory (IFN-gamma and TNF-alpha) and anti-inflammatory (IL-10) cytokine measurement was supported the occurrence of immune restoration reaction. Therefore, the changing in these cytokine profiles may be an important marker of developing unmasking TB-IRIS." }, { "id": "pubmed23n0054_1858", "title": "Clinical presentation and outcome of patients with HIV infection and tuberculosis caused by multiple-drug-resistant bacilli.", "score": 0.014030904672382962, "content": "To determine the clinical manifestations of patients with human immunodeficiency virus (HIV) infection and tuberculosis caused by multiple-drug-resistant bacilli compared with those with single-drug-resistant or susceptible bacilli. Descriptive, case-control, and cohort studies. A large urban teaching hospital. Sixty-two patients with tuberculosis caused by multiple-drug-resistant bacilli (cases) and 55 patients with tuberculosis caused by single-drug-resistant or susceptible bacilli (controls). Characteristics of clinical presentation, radiographs, pathologic abnormalities, antituberculosis treatment, and clinical course. Twenty cases (32%) had concomitant pulmonary and extrapulmonary disease at presentation compared with 9 controls (16%; odds ratio, 2.4; 95% CI, 1.0 to 5.9). More cases had alveolar infiltrates (76%; odds ratio, 3.6; CI, 1.2 to 11.4), interstitial infiltrates with a reticular pattern (67%; odds ratio, 7.8; CI, 1.0 to 83.5), and cavitations (18%; odds ratio, 6.6; CI, 0.8 to 315.3) on initial chest radiographs compared with controls (49%, 19%, and 3%, respectively). Pathologic specimens from cases showed extensive necrosis, poor granuloma formation, marked inflammatory changes with a predominance of neutrophils, and abundant acid-fast bacilli. Twenty-five cases received two or more effective antituberculosis drugs for more than 2 months. Only 2 cases had three consecutive negative cultures for Mycobacterium tuberculosis; one patient died within 1 day of the last negative culture, and the other had positive cultures 496 days later. The remaining 23 cases had persistently or intermittently positive cultures despite therapy. The clinical course of these cases suggested overwhelming miliary tuberculosis with involvement of the lungs (77%), pleura (15%), stool (34%), meninges (13%), bone marrow (16%), blood (10%), lymph nodes (10%), and skin (8%). The median survival time was 2.1 months for cases compared with 14.6 months for controls (P = 0.001, log-rank test). Tuberculosis caused by multiple-drug-resistant bacilli in patients with HIV infection is associated with widely disseminated disease, poor treatment response with an inability to eradicate the organism, and substantial mortality." }, { "id": "pubmed23n0479_4184", "title": "Medium-term survival, morbidity and immunovirological evolution in HIV-infected adults receiving antiretroviral therapy, Abidjan, Côte d'Ivoire.", "score": 0.013786937699981178, "content": "To evaluate survival, morbidity, and CD4 and viral load (VL) evolution in HIV-infected adults receiving antiretroviral therapy (ART) in Côte d'Ivoire. Since 1996, 723 HIV-infected adults have been followed up in the ANRS 1203 cohort study in Abidjan. For those patients who received ART, we describe data between ART initiation and August 2002. One-hundred-and-one adults (61% women) were followed up under ART for a median of 17 months. At ART initiation, median age, CD4 count and VL were 36 years, 135/mm3 and 5.3 log10 copies/ml, respectively. Initial ART regimens were two nucleoside reverse transcriptase inhibitors (NRTIs) plus one protease inhibitor in 74 patients, two NRTIs plus one non-nucleoside reverse transcriptase inhibitor in 16, and two NRTIs in 11. No patient was lost to follow-up. The most frequent causes of severe morbidity were bacterial infections [11.6/100 person-years (PY), 95% CI: 7.2-18.7], drug-related events (6.5/100 PY, 3.5-12.0), tuberculosis (3.1/100 PY, 1.3-7.4) and malaria (3.1/100 PY, 1.3-7.4). The incidence of death was 3.0/100 PY (1.1-8.0) in patients with baseline CD4 &gt; or = 50/mm3 and 16.1/100 PY (7.2-35.9) in patients with CD4 &lt; 50/mm3. Fifty percent of causes of death were active infections pre-existing ART initiation, mainly atypical mycobacteriosis. After 1 year, 51% of patients had undetectable VL, 28% had detectable VL reduced by more than 0.5 log10 copies/ml since ART initiation, and the median gain in CD4 was +115/mm3. Medium-term survival under ART may be as good in Africa as in industrialized countries, provided that patients benefit from access to care for opportunistic infections, including bacterial diseases, tuberculosis and malaria." }, { "id": "pubmed23n0698_24892", "title": "Clinical and laboratory profile of patients with TB/HIV coinfection: A case series of 50 patients.", "score": 0.013526785714285713, "content": "Tuberculosis (TB) is said to be one of the commonest opportunistic infection in patients with HIV/AIDS. To study the clinical and laboratory profile of patients with HIV/TB coinfection. Fifty adult TB patients having confirmed HIV seropositivity were included in randomized manner. A detailed history and thorough physical examination was done. Laboratory and radiological investigations were carried out as appropriately warranted. Most of the patients were farm workers (30%) followed by manual laborers (22%) and transport drivers (16%). Heterosexual route was found in 86% of patients. Cough was present in 94% while fever and weight loss in 86% and 78% of patients, respectively. Out of 50 patients, 40% had only pulmonary TB (PTB), 46% had pulmonary and extra-pulmonary TB (EPTB), 10% had only EPTB and 4% had multisystemic EPTB. Mediastinal lymphadenopathy was present in 34% while pleural effusion and extra-thoracic lymph nodes was present in 20% and 18% of patients, respectively. Positive smear for acid-fast bacilli (AFB) was found in 25.58% while positive Mantoux test was found in 32.14% of patients. HIV/TB coinfection is more common in sexually active age group and commonest mode of HIV infection is heterosexual transfer. Sputum smear AFB and Mantoux test positivity is low in TB patients having HIV. Disseminated TB is common in HIV. Mediastinal lymphadenopathy is common site among extra-pulmonary tuberculosis." }, { "id": "wiki20220301en099_37793", "title": "HIV/AIDS", "score": 0.013492063492063493, "content": "The World Health Organization first proposed a definition for AIDS in 1986. Since then, the WHO classification has been updated and expanded several times, with the most recent version being published in 2007. The WHO system uses the following categories: Primary HIV infection: May be either asymptomatic or associated with acute retroviral syndrome Stage I: HIV infection is asymptomatic with a CD4+ T cell count (also known as CD4 count) greater than 500 per microlitre (µl or cubic mm) of blood. May include generalized lymph node enlargement. Stage II: Mild symptoms, which may include minor mucocutaneous manifestations and recurrent upper respiratory tract infections. A CD4 count of less than 500/µl Stage III: Advanced symptoms, which may include unexplained chronic diarrhea for longer than a month, severe bacterial infections including tuberculosis of the lung, and a CD4 count of less than 350/µl" }, { "id": "pubmed23n1126_7219", "title": "A 34-Year-Old Man With a Neck Mass.", "score": 0.012674825174825176, "content": "A 34-year-old man presented to Queen Elizabeth Central Hospital in Blantyre, Malawi with multiple enlarged right cervical lymph nodes. He had no associated constitutional symptoms. Fine-needle aspirate (FNA) of one of the lymph nodes was negative for acid-fast bacilli (AFB) by smear microscopy. The FNA specimen was not sent for histological examination. Mycobacterial culture and Xpert MTB/RIF were not available at the time. He tested positive for HIV but CD4 T-cell count was not requested at the time of HIV diagnosis, and he did not start antiretroviral therapy (ART) pending confirmation of the cause of lymphadenopathy. Excision biopsy of the lymph nodes was planned; however, the patient was lost to follow-up before the procedure was performed." }, { "id": "wiki20220301en083_2534", "title": "Indinavir", "score": 0.012374524056767047, "content": "ACTG 320 This study took a look at clinical efficiency of the different treatments. Patients had to have CD4 cell counts less than 200 and at least 3 months of AZT therapy before the trials. 1156 patients with a mean of 87 CD4 cell counts and mean viral load of 100,000 copies/ml were randomized to one of the two groups: AZT plus lamivudine or AZT plus lamivudine plus indinavir. Just like Study 035, patients couldn't be in the study if they had prior protease inhibitor treatment or lamivudine for more than one week. The end point of the study was death or development of opportunistic infections. After 38 weeks, 6% of the people in the three-drug group died while 11% of the people died in the two-drug group. There were higher CD4 cell counts and less viral load in patients assigned to the three-drug group, proving that a three-drug treatment is more efficient than a two-drug one. Controversy" }, { "id": "pubmed23n0414_23497", "title": "[HIV infection and tuberculosis].", "score": 0.011497631879797486, "content": "The number of people infected with human immunodeficiency virus (HIV) is gradually increasing in Japan, and the morbidity rate from tuberculosis in the Japanese people is high. Accordingly, the number of cases with both infections is considered to increase in the future. Our hospital has already encountered 31 cases of HIV associated tuberculosis. HIV infects mainly CD4-positive cells. The extreme decrease in the cell count results in serious cellular immunological disorder. CD4-positive cell disorder induces disorders of B lymphocytes, cytotoxic T cells, natural killer cells, and macrophage functions. These destructive conditions show the state of immunodeficiency including macrophage that are most important for defense of acid-fast bacterial infection. Migration and activation of macrophages with cytokines derived from T cells are impaired to induce the following phenomena: hypoplasia of granuloma, failure of tubercule bacillus suppression, the spread to regional lymph nodes (hilar or mediastinal lymph nodes), and hematogenous dissemination. On this occasion, caseous necrosis and cavitation are unlikely to occur, and false-negative tuberculin reaction is often observed. The incidence of severe cases, which include miliary tuberculosis, tuberculous meningitis, etc., and extrapulmonary tuberculosis, are high among acquired immunodeficiency syndrome (AIDS)-associated tuberculosis cases. HIV-infected tuberculosis cases are generally regarded as endogenous exacerbation, but they include primary infection and reinfection as well. Even during the treatment for drug-sensitive strains particularly, some cases may have reinfection with multidrug-resistant bacteria, suggesting that caution should be taken against this point. Conversely, the association of tuberculosis is a factor for the poor prognosis of HIV infection, since it facilitates the development of HIV infection. If the bacteria belong to a drug-sensitive strain, the infection with them responds well to antituberculous drugs, the same as in tuberculosis cases without HIV infection, showing a favorable prognosis. However, the mortality rate of infection with multi-drug-resistant tuberculosis is extremely high. The combined use of a protease inhibitor, i.e., anti-HIV drug, with rifampicin is regarded as contraindication for the treatment because rifampicin strongly induces hepatic cytochrome P-450 and increases the metabolism of protease inhibitors and nonnucleoside reverse transcriptases to markedly decrease the blood concentrations. Accordingly, the treatment for tuberculosis should take priority over that for HIV infection in HIV-infected tuberculosis, and highly active antiretroviral therapy (HAART) may be administered after the treatment of tuberculosis. When HAART is necessary for the treatment during the tuberculosis treatment, rifampicin had better be exchanged to rifabutin because the effect of rifabutin to induce cytochrome P-450 is less potent than that of rifampicin. A report has recently shown that the exacerbation of pyrexia and chest X-ray findings was transiently observed approximately 2 weeks after potent anti-HIV therapy for HIV-infected tuberculosis, which included a protease inhibitor. The reason for the exacerbation has been believed to be that the impaired function of CD4-positive cells is improved by the administration of anti-HIV drugs to raise temporarily the reaction of the vital part to M. tuberculosis. A tuberculin skin test (TST) reaction size of &gt; or = 5 mm of induration is considered positive (i.e., indicative of M. tuberculosis infection) in persons who are infected with HIV. Persons with a TST reaction size &gt; or = 5 mm who have not previously received treatment for M. tuberculosis infection should receive tuberculosis preventive treatment. Prevention by BCG vaccination is regarded as contraindications for HIV-infected patients, because disseminated M. bovis infection may be associated with them. Many HIV-positive patients infected with tuberculosis show uneventful healing, when M. tuberculosis is the sensitive strain. However, since some patients show the rapid course of tuberculosis, clinical physicians keep the early detection of tuberculosis for HIV-infected patients and the association of HIV infection for tuberculosis patients in their mind, respectively." }, { "id": "wiki20220301en238_4683", "title": "Françoise Barré-Sinoussi", "score": 0.011254152823920265, "content": "transcriptase activity. If reverse transcriptase activity is present, it confirms that the virus is a retrovirus. In December 1982, heavy research began and clinical observations suggested that the disease attacked immune cells because of the significant CD4 cell depletion. However, the depletion of the CD4 lymphocytes made it very difficult to isolate the virus in patients with the disease later known as, AIDS. Because of the difficulty isolating an infected cell from a patient with late disease progression, Barré-Sinoussi and her colleagues decided to use a lymph node biopsy from a patient with generalized lymphadenopathy. Generalized lymphadenopathy was a common symptom of patients in the early stages of disease progression. In the second week of checking the biopsied cell cultures for reverse transcriptase activity, enzymatic activity was detected and increased for a short time until the reverse transcriptase activity decreased dramatically after the T-lymphocytes in the culture" }, { "id": "wiki20220301en078_25960", "title": "Immune reconstitution inflammatory syndrome", "score": 0.010421266448820984, "content": "Infections most commonly associated with IRIS include Mycobacterium tuberculosis and cryptococcal meningitis. Persons living with AIDS are more at risk for IRIS if they are starting for the first time, or if they have recently been treated for an opportunistic infection (OI). It is generally advised that when patients have low initial CD4 T cell count and opportunistic infection at the time of their HIV diagnosis, they receive treatment to control the opportunistic infections before HAART is initiated approximately two weeks later. This is true for most OIs, except for OIs involving the central nervous system. In cryptococcal meningitis IRIS is particularly problematic in cryptococcal meningitis as IRIS is fairly common and can be fatal." }, { "id": "wiki20220301en140_35318", "title": "HIV set point", "score": 0.010323847848998754, "content": "The asymptomatic or clinical latency phase is marked by slow replication of the HIV virus, followed by steady depletion of CD4 T cells with little to no symptoms. For individuals that are rapid progressors, this phase can be short lived, with an average of 2-3 years. Long-term progressors (LTNPS) can remain stable in this stage for over a decade. An uninfected person has 500-1500 CD4 T cells/µL of blood. When this count lowers to less than 500 CD4 T cells/µL, opportunistic infections can occur where the immune system is no longer able to fight pathogens it would have easily cleared in an unimpaired state. The infection progresses to AIDS when the count falls below 200 CD4 T cells/µL, at which point opportunistic infections can be lethal. At this stage, an infected person has 2-3 years of life expectancy. The use of antiretroviral therapy (ART) can greatly slow the progression of the virus to AIDS." }, { "id": "pubmed23n1149_14607", "title": "The Emergence of Resistance Under Firstline INSTI Regimens.", "score": 0.009900990099009901, "content": "We reported an HIV-naïve patient from a resource-limited area who was detected with multiple resistance sites associated with nucleoside reverse transcriptase inhibitors (NRTIs) and integrase strand transfer inhibitors (INSTIs) after the failure of the initial antiviral regimen dolutegravir/lamivudine (DTG/3TC) and subsequent Bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF). On May 8, 2021, a 53-year-old man was diagnosed with AIDS, Marneffei talaromycosis and fungal esophagitis, and was suspected of having tuberculosis (TB) in Guangxi, China. His baseline HIV RNA was 559,000 copies/mL and the CD4 count was 12 cells/µL, but resistance genotype testing was not performed. The patient remained immunosuppressed (CD4 count 3 cells/µL) after 12 weeks of initial antiviral treatment (ART) with DTG/3TC. After he was switched to BIC/FTC/TAF and started anti-TB treatment, the viral load (HIV RNA 163,200 copies/mL) was not effectively controlled, and there were multiple NRTIs drug-resistant mutations (D67N, K70R, M184V, T215V, K219Q) and INSTIs mutations (E138K, G140A, S147SG, Q148R). This suggested that in resource-limited areas, for HIV-naïve patients in advanced stages with active opportunistic infections, HIV RNA&gt;500,000 copies/mL, and low CD4 count, baseline resistance testing and increased HIV RNA testing frequency should be recommended, DTG/3TC was not recommended as initiation, and opportunistic infections should be treated promptly. In addition, switching to other INSTIs was not recommended in the absence of resistance testing and ineffective use of DTG." }, { "id": "pubmed23n0285_15382", "title": "[Problems in the diagnosis and therapy of lymph node tuberculosis in HIV-negative patients].", "score": 0.009900990099009901, "content": "Tuberculosis is the world's foremost cause of death from a single infectious agent in adults. During the past decade the nature and magnitude of the problem of tuberculosis have dramatically changed. Much of what physicians have learned about this disease is no longer true and tuberculosis has become a new entity. Migration from developing areas with a high prevalence of tuberculosis to industrialized countries, and the problem of HIV infection, have introduced new components to the epidemiology. We report three cases of young immigrants with lymph node tuberculosis. One patient was successfully treated with the usual 9-month-regimen. The other 2 patients, however, developed new lymph nodes or enlargement of existing nodes during treatment. They underwent further examinations, including surgical biopsies, because of diagnostic uncertainty (tuberculosis, superinfection or lymphoma). Finally the 2 patients were successfully treated with antituberculous agents for 12 and 15 months. These cases prompted a review of the literature and a reevaluation of the management of lymph node tuberculosis, including the value of surgical biopsy in the diagnosis of tuberculous lymphadenitis. We conclude that selective surgical biopsies should be recommended for differential diagnosis of tuberculous lymphadenitis. Histological examination (caseating epitheloid cell granulomas and giant cell formation) and microbiological examination (Ziehl-Neelsen staining and culture of native material) should be performed. Newer methods, such as amplification and detection of mycobacterial DNA, are rapid and sensitive tests helpful for diagnosis. Lymph nodes may increase in size and new nodes may appear both during and after chemotherapy, without indicating a failure of treatment or relapse. The usual treatment is a 9-month-regimen with rifamipicin, isoniazid, pyrazinamid and ethambutol. Prolonged or modified regimens are, however, necessary in some individuals." }, { "id": "pubmed23n1008_4194", "title": "Characteristics of residual lymph nodes after six months of antituberculous therapy in HIV-negative individuals with cervical tuberculous lymphadenitis.", "score": 0.00980392156862745, "content": "The therapeutic response of cervical tuberculous lymphadenitis (CTBL) may be delayed or paradoxical, with the frequent development of residual lymph nodes (LNs) during and after antituberculous treatment. We investigated the incidence of residual LNs and the clinical, radiological, microbiological, and pathologic responses of patients with CTBL after 6 months of antituberculous therapy. The medical records of HIV-negative adult patients with CTBL diagnosed between July 2009 and December 2017 were analyzed. After 6 months of first-line antituberculous treatment, computed tomography (CT) scans were conducted to evaluate for residual LNs. Fine-needle aspiration biopsy (FNAB) was carried out if a patient presented with residual LNs &gt; 10 mm in diameter with central necrosis, peripheral rim enhancement, or perinodal inflammation on CT scan. Residual LNs were detected in 35 of 157 patients who underwent follow-up CT scans and were more commonly observed in younger patients who completed the treatment (mean years ± standard deviation [SD]: 33 ± 13 vs. 44 ± 16, p &lt; 0.001). The recurrence rate was approximately 5%, which was not significantly different in both groups. Among the 15 patients who underwent FNAB, 3 (30%) presented with granuloma, and 2 of 15 and 10 of 14 patients had positive AFB and TB PCR results, respectively. The TB culture results of 15 patients were negative. Residual LNs may still be observed after 6 months of antituberculous treatment. Although the radiologic and pathologic findings after treatment are still indicative of TB, not all residual LNs indicate recurrence or treatment failure. A six-month therapy may be sufficient for cervical tuberculous lymphadenitis." }, { "id": "pubmed23n0331_2651", "title": "[Focal mycobacterial lymphadenitis after starting highly active antiretroviral therapy].", "score": 0.009708737864077669, "content": "A 30-year-old man with a known HIV infection for 7 years presented for treatment with antiretroviral drugs. He was known to have had herpes zoster, oral hairy leukoplakia and recurrent Candida stomatitis, but was otherwise without symptoms. The CD4 lymphocyte count was 19 cells/mm3 and there were 41,000 HIV-RNA copies/ml. The HIV infection was in CDC stage B3, indicating the need for combined antiretroviral treatment. A week after starting stavudine, saquinavir and ritonavir he had to be admitted because of nausea and vomiting, colicky abdominal pain, diarrhea, fever up to 39 degrees C and a rise of C-reactive protein to 207 mg/dl. Bacteriological examination of feces and biopsy of an enlarged retroperitoneal lymph node revealed atypical mycobacteria. Antituberculosis treatment was started. The CD4 cell count rose to 56/mm3 and the viral count fell to 11,000/ml. Each time after initiating a different antiviral regimen the symptoms recurred. This case illustrates an atypical manifestation of on opportunistic infection: during combined antiviral treatment the CD4 cell count rose and thus precipitated an heretofore subclinical mycobacterial infection with focal lymphadenitis. If, on starting antiretroviral treatment at a late HIV stage, new symptoms develop within 1-3 weeks, one should consider drug-induced side effects or the onset of an opportunistic infection that has become manifest as the result of an improved immunological state." }, { "id": "pubmed23n0523_11192", "title": "[Relapse of pulmonary tuberculosis in the context of tuberculosis-HIV co-infection in Abidjan (Côte d'Ivoire). Short note].", "score": 0.009708737864077669, "content": "A cohort study was carried out from October 2001 to March 2002, in order to analyze the main characteristics of 53 adults patients (38 HIV-positive and 15 HIV-negative), who had a relapse of pulmonary tuberculosis. The observance in the first period of the treatment of tuberculosis was regular in 79% of tuberculous patients infected by the HIV (30/38) and in 87% of tuberculous patients who where HIV-negative (13/15) (p = 0.7). The relapse occurred before one year after recovery in 74% among the HIV-positive (28/38) and in 33% among the HIV-negative patients (5/15) (p = 0.00). Most of the HIV-positive patients (74%) had CD4 counts under 200/mm3 and 80% of the HIV-negative patients had more than 500 CD4 counts/mm3 (p = 0.00). After two months of retreatment following the relapse diagnosis, the rate of improvement in patients was about 16% in HIV infected (6/38) and about 67% in HIV-negative patients (10/15) (p = 0.00)." }, { "id": "InternalMed_Harrison_13354", "title": "InternalMed_Harrison", "score": 0.00967024766405995, "content": "HIV-Associated TB (See also Chap. 226) TB is one of the most common diseases among HIV-infected persons worldwide and a major cause of death in this population; more specifically, it is responsible for an estimated 24% of all HIV-related mortality. In certain urban settings in some African countries, the rate of HIV infection among TB patients reaches 70–80%. A person with a positive TST who acquires HIV infection has a 3–13% annual risk of developing active TB. A new TB infection acquired by an HIV-infected individual may evolve to active disease in a matter of weeks rather than months or years. TB can appear at any stage of HIV infection, and its presentation varies with the stage. When CMI is only partially compromised, pulmonary TB presents in a typical manner (Figs. 202-6 and 202-7), with upper-lobe infiltrates and cavitation and without significant lymphadenopathy or pleural effusion. In late stages of HIV infection, when the CD4+ T cell count is <200/μL, a primary TB–like" }, { "id": "pubmed23n0879_10194", "title": "Immune reconstitution inflammatory syndrome associated with secondary syphilis.", "score": 0.009615384615384616, "content": "Immune reconstitution inflammatory syndrome (IRIS) is a condition associated with paradoxical worsening and/or new onset of an opportunistic infection in HIV patients following the initiation of anti-retroviral therapy or switching to more potent antiretroviral therapy (ART) regimen. Although IRIS associated with many opportunistic infections (OIs) has been well reported, syphilis has very rarely been mentioned in this regard. A 52-year-old male, diagnosed with AIDS six weeks ago, presented with the disseminated non-pruritic painless skin rash. He denied any fever, cough, shortness of breath, and joint pain or swelling. The patient had no similar symptoms, genital ulcers, or any medical illness in the past. CD4 cell count and viral load were 40 cells/mm<sup3</sup and 280,000 copies/ml, respectively, while screening tests for OIs including rapid plasma reagin test, quantiferon, cryptococcal antigen, and toxoplasma tests were negative at the time of HIV diagnosis. After three days of initiation of anti-retroviral therapy, he developed the above-mentioned skin rash. Repeat rapid plasma regain (RPR) test at this time was also negative. Punch biopsy of the skin lesion demonstrated findings suggestive of secondary syphilitic lesions, which was confirmed by immunostain. The repeat RPR, CD4 cell count, and viral load showed a titer of 1:256, 257 cells/mm<sup3</sup, and 5000 copies/ml, respectively. His skin rashes faded away, and RPR titer trended down on treatment with benzathine penicillin without discontinuation of ART. The presence of an IRIS response does not predict overall HIV or OI treatment responses, and discontinuation of ART is not generally recommended as the benefits of treating HIV infection outweighs the risk associated with IRIS." }, { "id": "pubmed23n0333_5739", "title": "Human immunodeficiency virus and the outcome of treatment for new and recurrent pulmonary tuberculosis in African patients.", "score": 0.009615384615384616, "content": "The purpose of this study was to evaluate the impact of human immunodeficiency virus (HIV) infection on treatment for tuberculosis (TB). The study population comprised 28,522 black Southern African gold miners. Patients with sputum culture-positive new or recurrent pulmonary TB diagnosed in 1995 were prospectively enrolled in the cohort. Directly observed therapy (DOT) was practiced and outcomes were assessed at 6 mo after treatment was begun. There were 376 cases of TB (incidence 1,318 per 100,000), of which 190 (50%) were HIV positive and 82 (22%) had recurrent TB. There was no association between HIV status and history of previous TB or drug resistance. Neither the treatment interruption rate (2%) nor the rate at which patients transferred out of the treatment program (1.6%) were associated with HIV status. Excluding deaths, cure rates were similar for HIV-positive and HIV-negative patients (89% versus 88%), but significantly lower in those with recurrent than in those with new TB (77% versus 92%). Mortality was 0.5% in HIV-negative patients versus 13.7% in HIV-positive patients, and in the latter group was associated with CD4(+) lymphocyte depletion. Autopsy examination showed that in HIV-positive patients, early mortality was due to TB whereas late deaths were most commonly due to cryptococcal pneumonia. The study showed that a well-run TB control program can result in acceptable cure rates even in a population with a very high incidence of TB and HIV infection. Particular vigilance is needed for concurrent infections, which may contribute significantly to mortality during treatment of TB in HIV-positive patients." }, { "id": "pubmed23n0315_4121", "title": "Clinical course of human immunodeficiency virus type 1 associated pulmonary tuberculosis during short-course antituberculosis therapy.", "score": 0.009523809523809525, "content": "To describe the clinical response to antituberculosis therapy in HIV-1 disease, 49 HIV-1 positive Ugandan adults (mean age 29.4 years; 68% men) with active pulmonary tuberculosis (PTB) were studied in a trial of rifampicin containing short-course antituberculosisis regimens. At presentation, 18 patients were PPD non-reactors (PPD skin test induration &lt; 2mm), ten patients (20%) had non-cavitary lung disease. The mean CD4 lymphocyte count at presentation was 339/microliters (+/- SD 275). Among patients with abnormal baseline clinical values, the median time to resolution of fever, weight gain of 10%, increase of haemoglobin to 10g/dl and of Karnofsky performance score (KPS) to 80 occurred before sputum smear and culture conversion. Short-term survival was associated with: baseline lymphocytes &lt; 1200/microliters, (Odds ratio (OR) 17.5), CD4+ lymphocytes &lt; 200/microliters (OR 9.8), cavitary lung disease, (OR 0.6), atypical chest radiograph, (OR 6.7), and PPD non-reactivity, (OR 13.5), PPD non-reactivity and non-cavitary disease were associated with significantly lower CD4 lymphocyte counts. Affordable serial measurements parallel the response to therapy and predict survival in HIV-associated PTB." }, { "id": "pubmed23n0925_7213", "title": "Tuberculous pyelonephritis in children: three case reports.", "score": 0.009433962264150943, "content": "Tuberculous pyelonephritis is rare in children; three case reports are presented. Case 1 was an 11-year-old girl with a previous history of pulmonary tuberculosis who presented with flank pain and fever for 10 days. An ultrasound suggested focal pyelonephritis, and a contrast-enhanced computed tomography (CECT) scan demonstrated acute focal pyelonephritis and a perinephric collection. Mycobacterium tuberculosis was cultured in the urine. She responded well to anti-tuberculous treatment (ATT). Case 2 was a 13-year-old boy who presented with fever, haematuria, burning micturition, proteinuria (3+) and cervical lymphadenopathy. The Mantoux test was strongly positive. Chest radiograph demonstrated right hilar lymphadenopathy and ultrasonography showed evidence of acute pyelonephritis. Tuberculous lymphadenitis was diagnosed by fine-needle aspiration cytology (FNAC) from cervical lymph nodes and he responded to ATT. Follow-up urinalysis and ultrasound were normal. Case 3 was a 6-year-old boy, a known case of pulmonary tuberculosis (from 2 years of age) and a previous defaulter from ATT. He presented with symptoms of lumbar pain and dysuria. Chest radiograph demonstrated mediastinal lymphadenopathy and a CECT of the head showed a tuberculous granuloma. CECT of the abdomen showed an enlarged left kidney with focal pyelonephritis, an abscess in the upper pole and parenchymal calcification. FNAC of the cervical lymph nodes supported a diagnosis of disseminated tuberculosis with tuberculous pyelonephritis. He was given 8 months of ATT. Fifteen months later he presented again with clinical and urinary findings of urinary tract infection. CECT now demonstrated gross hydronephrosis of the left kidney, and it was confirmed to be non-functioning by a DMSA scan and magnetic resonance urogram. Diethylenetriaminepentaacetic acid showed a GFR of 44.3 ml/min/1.73 m<sup2</sup. Nephrectomy was undertaken and the histology confirmed tuberculous pyelonephritis. Six months later he was well with an eGFR of 87.2 ml/min/m<sup2</sup. In patients with symptoms of urinary tract infection but sterile urine who do not respond to antibiotics or have evidence of tuberculous elsewhere in the body, careful consideration should be given to the possibility of tuberculous pyelonephritis." }, { "id": "pubmed23n0510_11378", "title": "[Clinical features of 23 cases of AIDS complicated by tuberculosis].", "score": 0.009433962264150943, "content": "To discuss the clinical features, treatment and prognosis of patients with AIDS complicated by tuberculosis(TB). The clinical features of 23 patients with AIDS complicated by tuberculosis admitted from 1997 to July 2004 were retrospectively analyzed. Of the 23 patients, most (94.3%) were young or middle-aged, and 11 (47.8%) died within half a year. The main HIV transmission was via sexual contact in 15 (65.2%) patients. Loss of body weight by 5 - 15 kg was present in all patients, cough for over 1 month in 15 (65.2%), and multiple opportunistic infections were complicated in most cases. Out of the 23 cases, 14 (60.9%) showed only pulmonary TB, and 8 (34.8%) showed lymph node TB. In 12 cases with infiltrated pulmonary TB, X-ray showed bilateral infiltration and no cavity formation was found. Slightly positive PPD test was found in 2 (8.7%) cases, and positive acid-fast bacilli was detected in sputum in 1 case (4.4%). The pre-treatment CD(4)(+) cell number in 23 patients was much lower than that in AIDS patients without complicated TB (P &lt; 0.05). The pre-treatment CD(4)(+) cell number in patients died shortly after diagnosis was much lower than that in survived patients (P &lt; 0.05). The HIV RNA level in the 23 patients was much higher than that in patients without complication of TB (P &lt; 0.05). The mortality in patients treated with therapy against both TB and HIV was much lower than that in patients untreated or treated only with anti-TB therapy (P &lt; 0.05). For patients with AIDS complicated by TB, the high negative rate in PPD test and the atypical chest X-ray manifestations are common. However, lymph node TB is quite common with high mortality. The pre-treatment CD(4)(+) level decreases significantly, and is associated with mortality. The TB bacilli may accelerate HIV virus duplication. It is suggested that the patients be treated with a combination of anti-TB and anti-HIV therapies." }, { "id": "pubmed23n0764_24542", "title": "[Severe oral mucositis in a patient with HIV infection].", "score": 0.009345794392523364, "content": "A 50-year-old man with HIV infection (first diagnosed &gt; 20 years ago) presented at our hospital with fulminant oral mucositis. Antiretroviral therapy (tenofovir, emtricitabine, raltegravir) had been started 2 months ago. Previously he had no opportunistic infections and no other pre-existing illnesses. He had not travelled outside Europe but stayed in Spain for several weeks during summer. Physical examination revealed swelling of the lips and severe ulcerative mucositis of the gums and pharynx. The patient complained of painful swallowing. The blood-chemistry showed no abnormalities. The microscopical analysis of a smear and a biopsy of the buccal mucosa revealed amastigotes of leishmania. By means of PCR technique, Leishmania donovani complex was specified. The patient was treated with liposomal amphotericin B (1 mg/kg) for 21 days. Because of the immunosuppression he was put on maintenance therapy afterwards (liposomal amphotericin B every 3 weeks). However, 4 months later there was a clinical relapse of the mucositis and a new cultural and PCR detection of leishmania in a buccal biopsy. After another course of 21 days with liposomal amphotericin B (3 mg/kg) and miltefosine (150 mg/d), the mucositis subsided. Therapy with liposomal amphotericin B (3 mg/kg single dose every 3 weeks) has since been maintained. The antiretroviral therapy was changed meanwhile to lamivudin, abacavir and raltegravir because of kidney failure with elevated urea and creatinine. The patient has been clinically stable ever since without any other HIV-related problems. The latest CD4 count was 456/µl and the HIV load 340 copies/ml. Leishmaniasis is a severe infection in HIV-positive patients. Clinical manifestations can be atypical in immunosuppressed patients and the treatment is complicated with HIV coinfection. This is also due to a lifelong persistence of the parasite with potential reactivation especially in patients with suppressed CD4 cells. Therefore maintenance therapy after standard therapy of leishmaniasis is mandatory at least for a CD4 count below 350/µl. Especially in HIV patients with a leishmaniasis relapse lifelong maintenance therapy should be considered." }, { "id": "pubmed23n0391_9526", "title": "Clinical and biological evolution of HIV-1 seroconverters in Abidjan, Côte d'Ivoire, 1997-2000.", "score": 0.009259259259259259, "content": "To describe the clinical and biologic evolution of HIV-1 infection in Africa. One hundred four HIV-1-infected individuals were identified prospectively from regular blood donors in Abidjan, Côte d'Ivoire. The date of seroconversion was estimated from results of sequential serologic tests. Biologic and clinical follow-up was performed every 6 months, starting as early as possible after seroconversion. Case management followed national guidelines. The median interval between estimated seroconversion and study inclusion was 9.7 months, and the median window of seroconversion was 2.8 months. At baseline, all but two patients were asymptomatic; the median CD4 + cell count was 527/mm 3 (interquartile range [IR], 395-684), and the median plasma HIV RNA level was 4.6 log 10 copies/ml (IR, 3.8-4.9). The median follow-up was 23.9 months, and 95% of the patients received primary prophylaxis with co-trimoxazole for opportunistic infections. Of the patients, 1 presented with wasting syndrome, 3 developed tuberculosis, and 17 had a Centers for Disease Control and Prevention category B-defining event. The 3-year AIDS-free and symptom-free probabilities were 96.7% (95% confidence interval [CI], 87.0-99.2] and 79.3% (95% CI, 67.5-87.2), respectively. During the first 3 years of follow-up, we observed that the median plasma viral load stabilized at &gt;4 log 10 copies/ml and that the median CD4 + cell count declined by 20 to 25/mm 3 per year. These African seroconverters were moderately immunosuppressed. The median HIV RNA level was high and varied very little during the first 3 years, and there were few clinical events." }, { "id": "pubmed23n0878_4390", "title": "[A pediatric case of HIV who diagnosed by virtue of disseminated cryptococcus infection].", "score": 0.009174311926605505, "content": "Cryptococcus neoformans is an important opportunistic pathogen that causes serious mortality and morbidity in AIDS patients. Although its incidence has decreased with proper antiretroviral treatment (ART), it is still a major concern in areas with low socioeconomic HIV endemic countries with poor sources of therapy. In our country, pediatric HIV infection and so, HIV-related opportunistic infections are very rare. In order to pay attention to this unusual collaboration; herein, we presented a pediatric case who was diagnosed with HIV and disseminated cryptococcus infection concomitantly. A 6.5-year-old previously healthy girl has admitted to our hospital with the complaints of prolonged fever, cough and hemoptysis. On her physical examination she had oral candidiasis, generalized lymphadenopathy and hepatosplenomegaly. Laboratory findings were as follows; white blood cell count: 3170 µL (neutrophil: 2720 µL, lymphocyte: 366 µL), hemoglobin level: 7.8 gr/dl, hematocrit: 25.5% platelets: 170.000 µL, CRP: 15.2 mg/L and serum IgG level: 1865 mg/dl. Her anti-HIV test yielde,d positive result and confirmed by Western blot assay, together with a high viral load (HIV-RNA: 3.442.000 copies/ml). She was started ART (lamivudine, zidovudine and lopinavir/ritonavir combination) with the diagnosis of stage 3 HIV infection (AIDS). Posteroanterior chest radiograph showed mediastinal extension and nodular parenchyma. Since the patient was suspected to have pulmonary tuberculosis based on the clinical and radiological findings, empirical antituberculosis therapy was started. Because of the insistance of fever, three different blood specimens, bone marrow and gastric aspirates were collected for culture, in which all of them yielded C.neoformans growth. She was then diagnosed as disseminated cryptococcosis and treated with liposomal amphotericin B and fluconazole successfully. Although pediatric HIV infection is usually diagnosed secondary to maternal disease, it can rarely be presented later in life with opportunistic infections. In the case of unusual infectious diseases, in addition to primary immune deficiency syndromes, HIV infection should also be kept in mind. Herein, we discussed a pediatric case with two rare infectious agents reported in our country and wanted to focus on secondary immune deficiency related with pediatric HIV infection. " }, { "id": "pubmed23n0406_11606", "title": "[Paradoxical aggravation of tuberculosis after antiretroviral therapy in HIV-infected patients].", "score": 0.009174311926605505, "content": "Restoration of immunocompetence in HIV-infected patients after antiretroviral treatment can have unexpected effects. An unusual course of treated tuberculosis was observed in four HIV-infected patients soon after initiation of antiretroviral therapy. These patients developed fever and enlarged necrotic adenopathies despite an efficacious antituberculous therapy. They were in the initial stage of their antituberculous therapy that had been initiated a mean 12 days prior to initiation of antiretroviral therapy. The antiretroviral therapy led to an undetectable HIV load within 2 months. These unusual features, which also occurred with an increase in CD4 cell counts, could be related to the immunological restoration and to the reappearance of delayed type hypersensitivity. The onset of antiretroviral therapy could thus be delayed by several weeks in HIV-infected patients treated for active tuberculosis and who have never received antiretroviral therapy." }, { "id": "pubmed23n0693_21371", "title": "Disseminated lupus vulgaris.", "score": 0.009009009009009009, "content": "A 28-year-old woman presented with reddish raised, shiny lesions over the face and ears present for the past 3 years. Four years ago, she developed in her left axilla a nodule that became fluctuant and tender, which ruptured to discharge seropurulent material. It subsided after the patient had received antibiotics for 6 months, leaving puckered scarring. There was no history of antituberculous treatment. After 1 year, she developed papulonodular lesions on her face, nose, and ears. There was now a history of malaise, fever, dry cough, and anorexia and weight loss for the past 2 months. The patient was fully vaccinated in childhood, including against varicella infection. The general physical examination revealed lymphadenopathy involving cervical, axillary, and inguinal lymph nodes 0.5 x 0.5 cm to 1 x 1.5 cm, firm in consistency, and nontender. They were discrete except in the left axilla where multiple matted lymph nodes were present with overlying scarring and a papule. Her systemic examination was normal. Cutaneous examination showed a shiny erythematous plaque 3x2 cm with central atrophy and scarring on the face (Figure). It was comprised of multiple shiny nontender soft papules arranged in annular configuration. Similar discrete papules and nodules with adherent fine scaling were seen bilaterally on the alar prominence of the nose, lower lip, and post-auricular area. On diascopy, apple jelly nodules were seen. The hemogram, liver function tests, and renal function tests were normal, except for an elevated erythrocyte sedimentation rate. The Mantoux test showed erythema and an induration of 20 x 20 cm. A posteroanterior view on the chest x-ray showed fibrotic changes suggestive of pulmonary tuberculosis. Ultrasonography of the abdomen and pelvis showed no tubercular foci. Human immunodeficiency virus serology by enzyme-linked immunosorbent assay with 3 different kits was nonreactive. Histopathology from a nodule showed a focally thinned-out epidermis with follicular plugging and multiple epithelioid cell granulomas, rimmed by lymphocytes in the deeper portion of the dermis, mainly peri-appendageal. Stain for acid-fast bacteria was negative. Cultures from the skin lesions were negative. The patient was diagnosed as having lupus vulgaris with multiple lesions of varying morphology at different sites with pulmonary tuberculosis and healed lymph node involvement." }, { "id": "pubmed23n0380_17117", "title": "[Recurrence of tuberculosis in patients infected with the human immunodeficiency virus].", "score": 0.008928571428571428, "content": "To determine the clinical manifestations of the relapse of the tuberculosis (TB) in the patients infected by the human immunodeficiency virus (HIV) and the degree of immunodeficiency shown. They are analyzed retrospectively 121 cases, all they HIV+, diagnosed of TB from November of 1985 until December of 1999. All they fulfilled correctly the specific treatment of the tuberculosis. Of 121 studied cases, a total of 13 (10.7%) presented relapse of tuberculosis finally of a mean of 31.8 months (range 1-95). In 7 cases the affectation was pulmonary (2 typical, 5 non typical), in 3 mixed (pulmonary and extrapulmonary) and in 3 extrapulmonary. The clinical sintomatology were present in 92% of the cases and, predominantly, was: fever (92%), cough (69%), sweating, weight loss (61%). Hepatomegaly results be the exploratory finding quite frequent (54%). The mean of CD4+ lymphocytes was 141.7 (range 3-406), in 8 (61%) the lymphocyte counts was inferior to 100 cells/mm3. PPD was positive in 1 case (14%) and with respect to delayed-type hypersensitivity reaction test, it was observed not normoergia in all the cases (100%). Relapse of the tuberculosis in patient infected by the VIH is presented with a manifested clinical expresivity in the course of a severe degree of immunodeficiency. In certain groups of risk as the intravenous drugs users, it must of be had a high level of suspicion of the relapse of the disease, above all in those patients that show low CD4+ lymphocyte counts." } ] } } }

{ "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, 244 ] ], "word_ranges": [ [ 0, 34 ] ], "text": "Typical case of acute mesenteric ischemia, which should be suspected in elderly patients with abdominal pain and distension of sudden onset, diarrhea or vomiting and who present cardiovascular risk factors, especially emboligenic heart disease." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Perforation of gastric or duodenal ulcus.", "2": "Biliary leak.", "3": "Obstructive neoplasia of the sigma with perforation.", "4": "Mesenteric ischemia.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0710_17980", "title": "Synchronous celiac axis and superior mesenteric artery embolism.", "score": 0.01538021726700972, "content": "We present a case of combined celiac axis and superior mesenteric artery embolism in a 70-year-old patient that was examined in emergency department for atrial fibrillation and diffuse abdominal pain. Standard abdominal x-ray showed air in the portal vein. CT scan with contrast showed air in the lumen of the stomach and small intestine, bowel distension with wall thickening, and a free gallstone in the abdominal cavity. Massive embolism of both celiac axis and superior mesenteric artery was seen after contrast administration. On laparotomy, complete necrosis of the liver, spleen, stomach and small intestine was found. Gallbladder was gangrenous and perforated, and the gallstone had migrated into the abdominal cavity. We found free air that crackled on palpation of the veins of the gastric surface. The patient,s condition was incurable and she died of multiple organ failure a few hours after surgery. Acute visceral thromboembolism should always be excluded first if a combination of atrial fibrillation and abdominal pain exists. Determining the serum levels of d-dimers and lactate, combined with CT scan with contrast administration can, in most cases, confirm the diagnosis and lead to faster surgical intervention. It is crucial to act early on clinical suspicion and not to wait for the development of hard evidence." }, { "id": "pubmed23n1094_17295", "title": "Portal pneumatosis in a patient with severe Salmonella colitis.", "score": 0.01490596238495398, "content": "A 65-year-old patient with a history of ischemic stroke, residual ophthalmoparesis, positive fecal occult blood screening and pending colonoscopy attended the Emergency Room due to three days with pain, abdominal distension and diarrhea. In the Emergency Room, he presented diffuse abdominal pain, hemodynamic instability with acute renal failure and metabolic acidosis, with severe elevation of acute phase reactants. Abdominal fluid resuscitation and computed tomography (CT) were performed, which reported a dilatation of the loops of the small intestine to the distal ileum with thickening of the wall of the right colon and gas, dissecting intrahepatic portal branches and splanchnic veins." }, { "id": "pubmed23n0743_9562", "title": "A rare case of digestive hemorrhage in an elderly patient: diagnosis and treatment difficulties.", "score": 0.013803941556235134, "content": "Abdominal pain represents one of the most common clinical conditions. However, there are some challenging cases in which an extensive work-up is mandatory for the diagnosis. We present the case report of a 65-year-old man admitted to our department for diffuse abdominal pain, nausea, vomiting, diarrhea, painful joints and rectal tenesmus. He initially had an urticarial rash, followed by palpable purpura involving the lower extremities. The diarrheic stools evolved towards melena. Endoscopic examination of the upper gastrointestinal tract showed hiatal hernia, superficial erosions in the stomach and multiple areas of deep and superficial ulcerations disseminated from the second to the third portion of the duodenum. Terminal ileum intubation at colonoscopy showed redness, edema, swelling, petechiae and ecchymosis, irregular erosions and ulcers. Endoscopic biopsy specimens showed non-specific inflammation. Computed tomography showed moderate ascites, small pleural effusion, mesenteric lymphadenopathy and small bowel wall thickening at the level of the second duodenum, proximal jejunum and segments of ileum. The urine analysis revealed microscopic hematuria with nephrotic range proteinuria, red cells and cellular casts. Therapy with corticosteroids and pulses of cyclophosphamide was started with significant clinical improvement. Three weeks after the first admission, the patient developed an acute peritonitis due to an intestinal perforation and acute mesenteric ischemia of the small bowel. We concluded that the patient had a Henoch-Schönlein type vasculitis with acute mesenteric ischemia and perforation of the small bowel." }, { "id": "InternalMed_Harrison_23152", "title": "InternalMed_Harrison", "score": 0.012337662337662338, "content": "Nonocclusive or vasospastic mesenteric ischemia presents with generalized abdominal pain, anorexia, bloody stools, and abdominal distention. Often these patients are obtunded, and physical findings may not assist in the diagnosis. The presence of a leukocytosis, metabolic acidosis, elevated amylase or creatinine phosphokinase levels, and/or lactic acidosis is useful in support of the diagnosis of advanced intestinal ischemia; however, these markers may not be indicative of either reversible ischemia or frank necrosis. Investigational markers for intestinal ischemia include D-dimer, glutathione S-transferase, platelet-activating factor (PAF), and mucosal pH monitoring. Regardless of the need for urgent surgery, emergent admission to a monitored bed or intensive care unit is recommended for resuscitation and further evaluation. Early manifestations of intestinal ischemia include fluid sequestration within the bowel wall leading to a loss of interstitial volume. Aggressive fluid" }, { "id": "wiki20220301en130_51797", "title": "Pylephlebitis", "score": 0.012111303883624715, "content": "Pylephlebitis is an uncommon thrombophlebitis of the portal vein or any of its branches (i.e. a portal vein thrombosis) that is caused by infection. It is usually a complication of intra-abdominal sepsis, most often following diverticulitis, perforated appendicitis, or peritonitis. Considered uniformly lethal in the pre-antibiotic era, it still carries a mortality of 10-30%. Presentation It typically presents with fever, rigors, and right upper quadrant abdominal pain, but sometimes abdominal pain may be absent. Liver function test abnormalities are usually present but frank jaundice is uncommon. Cause It is a cause of portal hypertension and can cause bowel ischemia sometimes leading to bowel infarction. Diagnosis In the modern era, it is usually diagnosed by CT scans of the abdomen and pelvis. Bacteriology is often polymicrobial and blood cultures are positive in some cases. A significant fraction of people presenting with this condition have an underlying hypercoagulable state." }, { "id": "wiki20220301en022_92250", "title": "Abdominal pain", "score": 0.01201515500387248, "content": "By location The location of abdominal pain can provide information about what may be causing the pain. The abdomen can be divided into four regions called quadrants. Locations and associated conditions include: Diffuse Peritonitis Vascular: mesenteric ischemia, ischemic colitis, Henoch-Schonlein purpura, sickle cell disease, systemic lupus erythematosus, polyarteritis nodosa Small bowel obstruction Irritable bowel syndrome Metabolic disorders: ketoacidosis, porphyria, familial Mediterranean fever, adrenal crisis Epigastric Heart: myocardial infarction, pericarditis Stomach: gastritis, stomach ulcer, stomach cancer Pancreas: pancreatitis, pancreatic cancer Intestinal: duodenal ulcer, diverticulitis, appendicitis Right upper quadrant Liver: hepatomegaly, fatty liver, hepatitis, liver cancer, abscess Gallbladder and biliary tract: inflammation, gallstones, worm infection, cholangitis" }, { "id": "wiki20220301en056_56030", "title": "Necrotizing enterocolitis", "score": 0.011909184726522188, "content": "Diagnosis is usually suspected clinically, but often requires the aid of diagnostic imaging, most commonly radiography, which can show the intestines and may show areas with death tissue or a bowel perforation. Specific radiographic signs of NEC are associated with specific Bell's stages of the disease: Bell's stage 1 (suspected disease): Mild systemic disease (apnea, lethargy, slowed heart rate, temperature instability) Mild intestinal signs (abdominal distention, increased gastric residuals, bloody stools) Nonspecific or normal radiological signs Bell's stage 2 (definite disease): Mild to moderate systemic signs Additional intestinal signs (absent bowel sounds, abdominal tenderness) Specific radiologic signs (pneumatosis intestinalis or portal venous gas) Laboratory changes (metabolic acidosis, too few platelets in the bloodstream) Bell's stage 3 (advanced disease): Severe systemic illness (low blood pressure)" }, { "id": "pubmed23n0312_16149", "title": "[Twenty-six consecutive patients with acute superior mesenteric infarction. Comparison of conventional radiology, ultrasonography, and computerized tomography].", "score": 0.011771222822323778, "content": "Ischemic bowel disease is a rare disorder whose incidence is increasing as the mean age of the population increases. Diagnosis by clinical, laboratory and radiologic means is often difficult, and delay in definitive therapy results in substantial morbidity and mortality. A series of 26 consecutive patients, with proved acute superior mesenteric ischemia, was retrospectively reviewed: the authors report the diagnostic methods performed preoperatively, the site and the cause of infarction and the time passed between the first radiograph ans surgery. Plain abdominal radiographs were performed in 25 of 26 patients, screening abdominal US in 23 cases and CT in 19 cases. All radiological examinations were retrospectively reviewed by three authors, independently, to recognize the different signs of infarction. On plain abdominal films, the findings warranting a presumptive diagnosis of bowel infarction were air-fluid levels (84% of cases), dilated bowel loops (48%), thickened and unchanging loops (20%), gastric distension and gasless abdomen (12%), small bowel pseudo-obstruction (8%). Screening abdominal US demonstrated intraperitoneal free fluid (26%) and dilated bowel loops (22%). Abdominal CT showed air-fluid levels (79%), dilated loops and free intraperitoneal fluid (47%), intramural gas and thickened bowel loops (36.8%), engorgement of the mesenteric vessels (31%), mesenteric-portal gas, mesenteric thrombus and marked reduction in the volume of gas in the small bowel (10.5%) and paper-thin bowel loops (5%). The authors conclude that air-fluid levels, dilated loops and intraperitoneal free fluid are the most frequent findings, even though they are not specific. While abdominal plain film and screening ultrasonography can be negative, CT detects at least one abnormal finding and at least three abnormal findings in 73% of cases." }, { "id": "pubmed23n1030_14249", "title": "Hepatic portal venous gas with pneumatosis intestinalis secondary to mesenteric ischemia in elderly patients: Two case reports.", "score": 0.011666082300066936, "content": "Hepatic portal venous gas (HPVG) is a rare imaging finding. When HPVG is accompanied with pneumatosis intestinalis (PI), the underlying cause is usually mesenteric ischemia with consequent intestinal necrosis. This combination of clinical conditions is associated with a poor prognosis. In this study, we present the cases of 2 elderly patients with HPVG and PI secondary to mesenteric ischemia. In case 1, a 89-year-old male patient was admitted to intensive care unit with respiratory failure, On the fifth day of admission, he developed a high fever (39.5°C) and abdominal distension. In case 2, a 92-year-old male patient admitted to our intensive care unit and received mechanical ventilation due to acute respiratory failure. During the treatment, the patient developed gastrointestinal bleeding. On physical examination, abdominal bulging and tense abdominal walls were detected. Both patients underwent abdominal contrast-enhanced computed tomography, showed abundant HPVG with PI. The patients were diagnosed as acute mesenteric ischemia, bowel necrosis, septic shock, multiple organ dysfunction syndrome based on computed tomography scan, abdominal signs, and laboratory tests. Fluid resuscitation, high-dose vasopressors, and intravenous antibiotic therapy were given. Despite prompt treatment, the condition of both patients rapidly deteriorated, and the patients died shortly thereafter. Mesenteric ischemia is a clinical emergency. In patients with risk factors and abdominal signs, the clinical suspicion for this condition should be high. Although rare, both HPVG and PI are important radiological clues that usually indicate the presence of mesenteric ischemia with consequent intestinal necrosis." }, { "id": "Surgery_Schwartz_6226", "title": "Surgery_Schwartz", "score": 0.011638598528842432, "content": "ensues. The classical symptoms include postprandial abdominal pain, food fear, and weight loss. Persistent nausea and occasionally diarrhea may coexist. Diagnosis remains challenging, and most of the patients will undergo an extensive and expensive gastro-intestinal tract workup for the above symptoms prior to referral to a vascular service.The typical patient who develops nonocclusive mesenteric ischemia is an elderly patient who has multiple comorbidities, such as congestive heart failure, acute myocardial infarction with cardiogenic shock, hypovolemic or hemorrhagic shock, sepsis, pancreatitis, and administration of digitalis or vasocon-strictor agents such as epinephrine. Abdominal pain is only present in approximately 70% of these patients. When present, the pain is usually severe but may vary in location, character, and intensity. In the absence of abdominal pain, progressive abdominal distention with acidosis may be an early sign of isch-emia and impending bowel" }, { "id": "wiki20220301en022_92244", "title": "Abdominal pain", "score": 0.010989224724783132, "content": "Given that a variety of diseases can cause some form of abdominal pain, a systematic approach to the examination of a person and the formulation of a differential diagnosis remains important. Differential diagnosis The most frequent reasons for abdominal pain are gastroenteritis (13%), irritable bowel syndrome (8%), urinary tract problems (5%), inflammation of the stomach (5%) and constipation (5%). In about 30% of cases, the cause is not determined. About 10% of cases have a more serious cause including gallbladder (gallstones or biliary dyskinesia) or pancreas problems (4%), diverticulitis (3%), appendicitis (2%) and cancer (1%). More common in those who are older, ischemic colitis, mesenteric ischemia, and abdominal aortic aneurysms are other serious causes." }, { "id": "wiki20220301en099_51689", "title": "Acute abdomen", "score": 0.010835156897320954, "content": "An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate surgical treatment. Differential diagnosis The differential diagnosis of acute abdomen includes: Acute appendicitis Acute peptic ulcer and its complications Acute cholecystitis Acute pancreatitis Acute intestinal ischemia (see section below) Acute diverticulitis Ectopic pregnancy with tubal rupture Ovarian torsion Acute peritonitis (including hollow viscus perforation) Acute ureteric colic Bowel volvulus Bowel obstruction Acute pyelonephritis Adrenal crisis Biliary colic Abdominal aortic aneurysm Familial Mediterranean fever Hemoperitoneum Ruptured spleen Kidney stone Sickle cell anaemia Carcinoid" }, { "id": "First_Aid_Step2_303", "title": "First_Aid_Step2", "score": 0.010698932521856736, "content": "Patients present with sudden onset of severe abdominal pain out of proportion to the exam. A history of prior episodes of similar abdominal pain after eating (“intestinal angina”) may be present. Other symptoms may include nausea, vomiting, diarrhea, and bloody stools. Early abdominal exam is often unremarkable; later findings may include peritoneal signs (suggest bowel infarction). Lab tests may show leukocytosis, metabolic acidosis with ↑ lactate, ↑ amylase, ↑ LDH, and ↑ CK. AXR and CT may reveal bowel wall edema (“thumbprinting”) and air within the bowel wall (pneumatosis intestinalis). Mesenteric angiography is the gold standard for arterial occlusive disease. Volume resuscitation, broad-spectrum antibiotics, optimization of hemodynamics, and avoidance of vasoconstrictors. Anticoagulation for arterial or venous thrombosis or embolism. The mortality rate for acute mesenteric ischemia is > 50%." }, { "id": "Surgery_Schwartz_6228", "title": "Surgery_Schwartz", "score": 0.010557635089739899, "content": "localized in the upper abdomen, which may be precipitated by meals.Diagnostic EvaluationThe differential diagnosis of acute mesenteric ischemia includes other causes of severe abdominal pain of acute onset, such as perforated viscus, intestinal obstruction, pancreatitis, cholecys-titis, and nephrolithiasis. Laboratory evaluation is neither sensitive nor specific in distinguishing these various diagnoses. Figure 23-39. A lateral projection of the magnetic resonance angi-ography of the aorta showing a chronic compression of the celiac artery by the median arcuate ligament (arrow).Brunicardi_Ch23_p0897-p0980.indd 93027/02/19 4:14 PM 931ARTERIAL DISEASECHAPTER 23In the setting of mesenteric ischemia, complete blood count may reveal hemoconcentration and leukocytosis. Metabolic acidosis develops as a result of anaerobic metabolism. Elevated serum amylase may indicate a diagnosis of pancreatitis but is also com-mon in the setting of intestinal infarction. Finally, increased lac-tate" }, { "id": "wiki20220301en158_20838", "title": "Abdominal guarding", "score": 0.010416666666666668, "content": "Diagnosis Differential diagnosis Abdominal aortic aneurysm Appendicitis Blunt force trauma to the abdomen Bowel obstruction Diverticulitis Dyspepsia Ectopic pregnancy GERD Ileus Inflammatory bowel disease Intussusception Mesenteric ischemia Nephrolithiasis Ovarian cyst Pancreatitis Pelvic inflammatory disease Perforated peptic ulcer disease Pneumonia Spontaneous bacterial peritonitis (SBP) Urinary tract infection/pyelonephritis Volvulus Zoster Skin lesions may not be visible until another day or two Abdominal migraine Abdominal wall strain/injury Abscess (e.g. iliopsoas) Hepatic or splenic contusion/laceration Incarcerated hernia Insect toxins (e.g. black widow spider) Malingering Pneumoperitoneum secondary to abdominal trauma Septic miscarriage (See Miscarriage)" }, { "id": "article-18478_12", "title": "Bowel Ischemia -- History and Physical", "score": 0.01015987852804573, "content": "A careful review of the patient's medical conditions and family history is essential for the evaluation of intestinal ischemia. The history of cardiac disease [34] , aortic surgery, peripheral artery disease, hemodialysis, vasoconstrictive medications, acquired or hereditary thrombotic conditions, hypovolemia, and inflammation or infections should increase suspicion of intestinal ischemia in a patient with abdominal pain. [35] Abdominal pain is the most common symptom in patients with intestinal ischemia. Some features of a patient can help to distinguish between the acute small bowel and colonic ischemia. Patient's characteristics, such as age over 60 years, not appearing severe ill, mild abdominal pain, tenderness, rectal bleeding, or bloody diarrhea, are the features that are more common in acute colonic ischemia. [9] The features of the pain, physical exam, and accompanying symptoms can help to distinguish the etiology of intestinal ischemia. In mesenteric artery embolism, usually, the pain is sudden onset, severe, periumbilical, and often accompanied by nausea and vomiting. [36] The pain in thrombotic mesentery ischemia commonly presented postprandial. [37] In mesenteric veins thrombosis, the pain usually described as wax and wane before the definite diagnosis. [38] The patients with nonocclusive mesenteric ischemia do not have classic severe pain and typically present in patients with a history of hypotension, hypovolemia, cardiac arrhythmia, and heart failure. [39] Patients with chronic mesenteric ischemia usually present with recurrent abdominal pain after eating and subsequently can cause patients losing weight. [26] Patients with acute colonic ischemia commonly are presented with sudden onset cramping abdominal pain, which usually involves the left side. The pain can be accompanied by an urgent desire for a bowel movement. Instead of periumbilical pain in small intestine ischemia, patients with colonic ischemia usually feel the pain laterally. [40] [41] Physical examination in patients with intestinal ischemia can vary from normal to peritoneal sign (rebound tenderness and guarding) based on the time course of the onset. [42]" }, { "id": "InternalMed_Harrison_24368", "title": "InternalMed_Harrison", "score": 0.010077519379844961, "content": "Any severe acute pain in the abdomen or back should suggest the possibility of acute pancreatitis. The diagnosis is established by two of the following three criteria: (1) typical abdominal pain in the epigastrium that may radiate to the back, (2) threefold or greater elevation in serum lipase and/or amylase, and (3) confirmatory findings of acute pancreatitis on cross-sectional abdominal imaging. Patients also have associated nausea, emesis, fever, tachycardia, and abnormal findings on abdominal examination. Laboratory studies may reveal leukocytosis, hypocalcemia, and hyperglycemia. Although not required for diagnosis, markers of severity may include hemoconcentration (hematocrit >44%), admission azotemia (BUN >22 mg/dL), SIRS, and signs of organ failure (Table 371-3)." }, { "id": "pubmed23n0598_8772", "title": "[Mesenteric ischemia in hemodialysis patients].", "score": 0.009900990099009901, "content": "Mesenteric ischaemia is an abdominal pathology with a high mortality rate. Among the population under dialysis treatment it presents some different traits such as non-occlusive mesenteric attacks in most of the cases. Its diagnosis is difficult and it is usually the result of an interdisciplinary collaboration. It is necessary to know better the symptoms of this illness among dialytic patients in order to improve its prognosis. Eleven haemodialytic patients in our hospital (0.87% per patient-year) have diagnosed with mesenteric ischaemia confirmed by a laparothomy. We will list the main risk factors of this pathology, its symptoms, its evolution, some radiological and laboratory data more pointed out, the surgical findings anf its treatment. Ten patients (91%) had suffer from cardiovascular pathologies, five of them (45%) had suffer an ischaemia cardiopathy. Seven patients (64%) had a spell of arterial hypotension during their haemodialysis session, which preceded mesenteric ischaemia. The reason for consulting a physician was abdominal pain, specially on the right hemiabdomen (64%). The analytical date most frequently observed was leucocytosis (54%). The usual radiological tests such as abdominal plain radiography and ecography didn't give any detailed formation. Ten out of eleven patients (91%) had necrosis on the intestinal wall. The ileum was the most affected intestinal section. Five of the patients presented only a limited damage of the ileum (45%). Two patients (18%) presented an extensive damage in the whole small intestine and part of the right colon. Intestinal resection was the most chosen way of treatment, which was practiced on eight patients (73%). Only three of them (27%) survived the mesenteric ischaemia and were sent to their homes. The key factor of their survival was that they were operated on in less than 8 hours from their arrival at emergency room. Mesenteric ischaemia must be expected among patients under haemodialysis who suffer from abdominal pain, especially if they have had some arterial hypotensive spells during their previous dialytic session. It s a matter of urgent surgery where not only its diagnosis but also its early surgical treatment can lessen its high morbi-mortality risk." }, { "id": "article-18478_13", "title": "Bowel Ischemia -- Evaluation", "score": 0.009793836526509794, "content": "Laboratory tests in intestinal ischemia are nonspecific. In the early stage of the disease, complete blood cell count can be normal, but with the progression of the ischemia, leukocytosis with the leftward shift, elevated amylase, and lactate dehydrogenase levels may be observed. [43] Based on underlying risk factors, laboratory studies can be abnormal. In MVT, patients need to evaluate for hypercoagulopathy states such as examined for protein C and S and antithrombin III deficiency, lupus anticoagulant, and platelet aggregation. [15] [44] In CMI, abnormal laboratory tests, including leukopenia, hypoalbuminemia, and electrolyte abnormalities, may be observed secondary to malnourishment. [45] The diagnostic approach in patients with intestinal ischemia depends on the severity of symptoms. In patients with peritonitis signs, the diagnosis will be made by abdominal exploration. Plain radiographs, computed tomography angiography (CTA) or magnetic resonance angiography (MRA), invasive angiography, and duplex ultrasound are common radiology studies in patients with suspicion of intestinal ischemia. [42] Plain abdominal radiography is nonspecific; however, the presence of ileus with bowel loops distention, bowel wall thickening, and pneumatosis intestinalis can be suggestive for mesenteric ischemia. Plain abdominal radiography commonly used in patients with signs of sepsis and unstable hemodynamics. [46] Generally, abdominal CT is used in hemodynamically stable patients who present with acute abdominal pain. In addition to, rule out other causes of abdominal pain, some findings including pneumatosis intestinalis, portal vein gas, mesenteric edema, streaking of the mesentery, focal edematous bowel wall, abdominal gas pattern, and solid organ infarction can be suggestive for acute mesenteric ischemia in abdominal CT scan. [10] [11] In patients with high suspicious for intestinal ischemia, CT angiography, and MR angiography are the initial tests. However, the CTA is preferred over MRA due to lower cost, white availability, and speed. [12] The CT scans should be done without oral contrast due to oral contrast that can obscure the bowel wall enhancement and the mesenteric vessels, which both lead to a delay of definitive diagnosis. [47] [48] [49] [50] Angiography usually reserved in patients with high suspicious of AMI with negative CTA or patients with NOMI. Diffuse stenosis in mesenteric vessels with the absence of occlusive lesions is the finding in NOMI patients by angiography. [51] The role of duplex ultrasound is just limited to the detection of clots in the proximal of the main vessels. In addition to that, peritoneal gas, previous abdominal surgical intervention, obesity can decrease the sensitivity of duplex ultrasound. [42] In hemodynamically stable patients with clinical features of acute colonic ischemia, including abdominal pain, urgent desire to defecation, diarrhea, and lower gastrointestinal bleeding in addition to common imaging studies (plain radiography, CTA) may require sigmoidoscopy or colonoscopy and biopsy for definitive diagnosis. [52] If colonic ischemia is suspected, colonoscopy preferred to be performed within 48 hours of initial symptoms rather than later. [53] [54]" }, { "id": "wiki20220301en164_18523", "title": "Abdominal x-ray", "score": 0.009708737864077669, "content": "An abdominal x-ray is an x-ray of the abdomen. It is sometimes abbreviated to AXR, or KUB (for kidneys, ureters, and urinary bladder). Indications In children, abdominal x-ray is indicated in the acute setting: Suspected bowel obstruction or gastrointestinal perforation; Abdominal x-ray will demonstrate most cases of bowel obstruction, by showing dilated bowel loops. Foreign body in the alimentary tract; can be identified if it is radiodense. Suspected abdominal mass In suspected intussusception, an abdominal x-ray does not exclude intussusception but is useful in the differential diagnosis to exclude perforation or obstruction. Yet, CT scan is the best alternative for diagnosing intra-abdominal injury. Computed tomography provides an overall better surgical strategy planning, and possibly less unnecessary laparotomies. Abdominal x-ray is therefore not recommended for adults with acute abdominal pain presenting in the emergency department. Projections" }, { "id": "pubmed23n0268_7530", "title": "[Clinical and prognostic factors of mortality in upper digestive hemorrhage].", "score": 0.009708737864077669, "content": "In order to investigate prognostic factors we prospectively followed 741 patients with upper gastrointestinal bleeding (UGIB). Eleven variables were identified with mortality predictive value. Hematemesis, age of 50 y/o, more than 120 heart beat/minute, 3 or more units of pack red blood cells, esophageal varices, cirrhotic liver and renal failure had independent predictive value. Our findings could help to identify high risk patients." }, { "id": "InternalMed_Harrison_24319", "title": "InternalMed_Harrison", "score": 0.009625519559294395, "content": "Elevation of ascitic fluid amylase occurs in acute pancreatitis as well as in (1) ascites due to disruption of the main pancreatic duct or a leaking pseudocyst and (2) other abdominal disorders that simulate pancreatitis (e.g., intestinal obstruction, intestinal infarction, or perforated peptic ulcer). Elevation of pleural fluid amylase can occur in acute pancreatitis, chronic pancreatitis, carcinoma of the lung, and esophageal perforation. Lipase is the single best enzyme to measure for the diagnosis of acute pancreatitis. No single blood test is reliable for the diagnosis of acute pancreatitis in patients with renal failure. Pancreatic enzyme elevations are usually less than three times the upper limit of normal. Determining whether a patient with renal failure and abdominal pain has pancreatitis remains a difficult clinical problem. One study found that serum amylase levels were elevated in patients with renal dysfunction only when creatinine clearance was <0.8 mL/s (<50 mL/min)." }, { "id": "wiki20220301en022_92251", "title": "Abdominal pain", "score": 0.009615384615384616, "content": "Right upper quadrant Liver: hepatomegaly, fatty liver, hepatitis, liver cancer, abscess Gallbladder and biliary tract: inflammation, gallstones, worm infection, cholangitis Colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer Other: pneumonia, Fitz-Hugh-Curtis syndrome Left upper quadrant Splenomegaly Colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer Peri-umbilical (the area around the umbilicus, aka the belly button) Appendicitis Pancreatitis Inferior myocardial infarction Peptic ulcer Diabetic ketoacidosis Vascular: aortic dissection, aortic rupture Bowel: mesenteric ischemia, Celiac disease, inflammation, intestinal spasm, functional disorders, small bowel obstruction Lower abdominal pain Diarrhea Colitis Crohn's Dysentery Hernia Right lower quadrant Colon: intussusception, bowel obstruction, appendicitis (McBurney's point)" }, { "id": "pubmed23n0505_3349", "title": "Unspecific clinical presentation of bowel ischemia in the very old. Digitalis treatment--a reason for higher mortality?", "score": 0.009615384615384616, "content": "Ischemic bowel disease predominantly affects the elderly (&gt;65 years). Early diagnosis and treatment are of vital importance for the outcome. The vague symptoms of ischemic bowel disease entail a risk of delayed diagnosis, with a subsequent risk of increased mortality. The aims of this retrospective study were to identify symptoms and prodromes, to study factors associated with mortality in ischemic bowel disease, and to describe the influence of age, by comparing patients &lt;80 and &gt; or = 80 years. The subjects of the study were 135 patients, mean age 77 years, admitted to Malmö University Hospital, Sweden, between 1987 and 1996, with a ICD-9 diagnosis of acute or chronic splanchnic ischemia. Patients aged 80 years or more presented with a significantly higher prevalence of confusion (29% vs 12%), hematemesis (57% vs 14%), vomiting (82% vs 65%) and dehydration (58% vs 36%) at admission compared with patients aged under 80 years, and presented a higher mortality (87% compared with 65%, p=0.003). The prevalence of digitalis treatment was 34%, which was high compared with other Swedish cohort studies. Digitalis, adjusted for age, congestive heart failure and atrial fibrillation, was associated with increased mortality (odds ratio 4.6, 95% CI 1.3-16.1). Prodromal signs predicted poor outcome, and were found in one out of 4 patients, without any age differences. Bowel ischemia in the very old is associated with a different clinical presentation and a higher mortality compared with younger patients. Digitalis treatment seems to be associated with increased mortality in ischemic bowel disease. Prodromal signs are prognostically unfavorable." }, { "id": "wiki20220301en556_34602", "title": "Biloma", "score": 0.009523809523809525, "content": "Biloma is collection of bile within the abdominal cavity. It happens when there is a bile leak, for example after surgery for removing the gallbladder (laparoscopic cholecystectomy), with an incidence of 0.3–2%. Other causes are biliary surgery, liver biopsy, abdominal trauma, and, rarely, spontaneous perforation. Symptoms are usually diffused or localized abdominal pain. Ascites and peritonitis are less common. Fever is often absent. Blood tests may show leukocytosis and nonspecific liver test abnormalities. Diagnosis is by abdominal ultrasound, MRCP, or HIDA scan. Treatment depends on the severity of the condition and ranges from ERCP with sphincterotomy or stent placement to surgical hepaticojejunostomy. See also Biliary injury References External links Bile Duct Leaks Biliary tract disorders" }, { "id": "pubmed23n1017_19051", "title": "Gangrenous Gastritis: Unusual Cause Of Upper Gi Bleeding.", "score": 0.009523809523809525, "content": "Chronic Mesenteric ischemia is an episodic hypoperfusion of small intestine due to atherosclerotic narrowing of mesenteric vessels. Typically, patients report postprandial epigastric pain. The association of abdominal pain with eating results in fear of eating and weight loss. Some patients present atypically with nausea, vomiting and/or GI bleeding likely from gut ischemia. We present here a case of 67-yearold male with history of COPD, Coronary artery disease and atrial fibrillation presented with hematemesis and black stools for one day. Patient reports no abdominal pain or weight loss. He was dizzy and nauseous. He was vitally stable and physical exam including abdominal exam was unremarkable except for the rectal exam which revealed black stools. Investigations revealed Haemoglobin of 16.1 and hematocrit of 45, WBCs of 34000 with 83% neutrophils and bicarbonate of 20. Patient underwent EGD for localizing the site of bleeding and showed stomach lumen completely filled with thrombus which prevented the accurate assessment if gastric mucosa. Repeat EGD was recommended and it revealed gangrenous appearing gastritis throughout with multiple clean ulcers which raised the suspicion of vascular compromise. CT angiography abdomen revealed complete proximal occlusion of Superior Mesenteric artery and near complete occlusion of celiac artery. He underwent successful SMA bypass from left iliac to mid SMA with PTFE graft. Symptoms of mesenteric ischemia can be non-specific and can mimic other aetiologies. Clinicians should consider this diagnosis in elderly patient with risk factors of atherosclerosis as early diagnosis reduces complication associated with serious life-threatening disease." }, { "id": "wiki20220301en003_145860", "title": "Defecation", "score": 0.009433962264150943, "content": "Bowel obstruction Bowel obstruction is a bowel condition which is a blockage that can be found in both the small intestines and large intestines. Increase of contractions can relieve blockages, however, continuous contractions with decreasing functionality may lead to terminated mobility of the small intestines, which then forms the obstruction. At the same time, the lack of contractility encourages liquid and gas accumulation. and \"electrolyte disturbances\". Small bowel obstruction can result in severe renal damage and hypovolemia. while evolving into \"mucosal ischemia and perforation\". Patients with small bowel obstruction were found to experience constipation, strangulation and abdominal pain and vomiting. Surgical intervention is primarily used to cure severe small bowel obstruction condition. Nonoperative therapy included nasogastric tube decompression, water-soluble-contrast medium process or symptomatic management can be applied to treat less severe symptoms" }, { "id": "pubmed23n0523_1906", "title": "Clinical factors and outcomes in patients with acute mesenteric ischemia in the emergency department.", "score": 0.009433962264150943, "content": "The purpose of this study was to determine the initial clinical characteristics of acute mesenteric ischemia and identify variables associated with adverse outcomes in the emergency department (ED). The charts of 124 consecutive patients with surgically and pathologically identified acute mesenteric ischemia from September 1990 to September 2000 were reviewed retrospectively to obtain data about demographics, initial clinical presentations, predisposing diseases, previous medications, laboratory tests, and common findings on computed tomography scans with contrast. Only patients admitted through the ED and treated on medical or surgical wards were enrolled. Mean patient age was 71.1 years (range, 25-100 years). The overall mortality rate was 50%. There were no significant differences in gender, underlying disease, previous medication, initial signs and symptoms, and causes of mesenteric infarction, between survivors and non-survivors. Univariate analysis demonstrated that older age, bandemia, hepatic and renal impairment, hyperamylasemia, metabolic acidosis, hypoxia, intramural pneumatosis, and septic syndrome, were more frequent in patients who died than in those who survived (p &lt; 0.05). Logistic regression identified the following variables as independent predictors of death: old age (odds ratio, OR, 1.077; 95% confidence interval, Cl, 1.013, 1.146; p = 0.02); bandemia (OR, 3.894; 95% Cl, 1.160, 13.074; p = 0.03); elevated serum aspartate aminotransferase (AST; OR, 4.532; 95% Cl, 1.274, 16.122; p = 0.02); increased blood urea nitrogen (BUN; OR, 7.219; 95% Cl, 1.166, 44.696; p = 0.03); and metabolic acidosis (OR, 6.604; 95% Cl, 1.804, 24.171; p &lt; 0.01). A high index of suspicion and aggressive diagnostic imaging can facilitate early diagnosis and improve outcomes for patients with acute mesenteric ischemia. Risk stratification showed that elderly patients with metabolic acidosis, bandemia, or elevated AST and BUN had a poor prognosis. Greater therapeutic intervention is advocated to reduce mortality in high-risk patients with acute mesenteric ischemia." }, { "id": "wiki20220301en158_23059", "title": "Intestinal ischemia", "score": 0.009345794392523364, "content": "Diagnostic heuristics In the absence of adequate quantitative studies to guide diagnosis, various heuristics help guide diagnosis: Intestinal ischemia\" should be suspected when individuals, especially those at high risk for acute intestinal ischemia, develop severe and persisting abdominal pain that is disproportionate to their abdominal findings\"., or simply, pain out of proportion to exam. Regarding intestinal arterial thrombosis or embolism: \"early symptoms are present and are relative mild in 50% of cases for three to four days before medical attention is sought\". Regarding intestinal arterial thrombosis or embolism: \"Any patient with an arrhythmia such as atrial fibrillation who complains of abdominal pain is highly suspected of having embolization to the superior mesenteric artery until proved otherwise.\"" }, { "id": "InternalMed_Harrison_23144", "title": "InternalMed_Harrison", "score": 0.009345794392523364, "content": "Acute mesenteric ischemia resulting from arterial embolus or thrombosis presents with severe acute, nonremitting abdominal pain strikingly out of proportion to the physical findings. Associated symptoms may include nausea and vomiting, transient diarrhea, anorexia, and bloody stools. With the exception of minimal abdominal distention and hypoactive bowel sounds, early abdominal examination is unimpressive. Later findings will demonstrate peritonitis and cardiovascular collapse. In the evaluation of acute intestinal ischemia, routine laboratory tests should be obtained, including complete blood count, serum chemistry, coagulation profile, arterial blood gas, amylase, lipase, lactic acid, blood type and cross match, and cardiac enzymes. Regardless of the need for urgent surgery, emergent admission to a monitored bed or intensive care unit is recommended for resuscitation and further evaluation. If the diagnosis of intestinal ischemia is being considered, consultation with a surgical" }, { "id": "wiki20220301en035_34631", "title": "Polyarteritis nodosa", "score": 0.009259259259259259, "content": "Renal system: Kidney involvement is common and often leads to death of parts of the kidney. Involvement of the renal artery, which supplies the kidneys with highly oxygenated blood, often leads to high blood pressure in about one-third of cases. deposition of protein or blood in the urine may also be seen. Almost all patients with PAN have renal insufficiency caused by renal artery narrowing, thrombosis, and infarctions. Cardiovascular system: Involvement of the arteries of the heart may cause a heart attack, heart failure, and inflammation of the sac around the heart (pericarditis). Gastrointestinal system: Damage to mesenteric arteries can cause abdominal pain, mesenteric ischemia, and bowel perforation. Abdominal pain may also be seen. Musculoskeletal system: Muscle and joint aches are common. Complications Stroke Heart failure resulting from cardiomyopathy and pericarditis Intestinal necrosis and perforation" }, { "id": "pubmed23n0226_7371", "title": "[Abdominal complications of heart surgery].", "score": 0.009259259259259259, "content": "Abdominal complications after cardiac surgery (excluding \"medical\" jaundice) are rare. Twenty six cases were observed out of a total of 7 847 operations (0.33%) performed between 1973 and 1980. The causes were very diverse; the most common being gastroduodenal ulceration, usually acute (9 cases). Other cases included intestinal (3 cases of postoperative ileus, 4 cases of mesenteric infarction, 2 cases of necrosing enterocolitis), biliary (2 cases of acute cholecystitis) and splenic pathology (2 cases of splenic infarction, one associated with necrosing enterocolitis). Anticoagulant therapy was implicated in 3 cases. Diagnosis is difficult in the immediate postoperative period, some complications only being recognised at autopsy. The clinical signs may be misleading and the interpretation of complementary investigations difficult. Therefore, the possibility of abdominal complications must be kept in mind, especially in patients with one or more predisposing factors. Excluding accidents due to anticoagulant therapy the following factors were associated with an increased risk of abdominal complications: previous history of gastro intestinal pathology (ulcer, gall stone, alcoholism) the nature of the underlying cardiac disease (coronary artery and aortic valve disease), cardiopulmonary bypass, and, above all, per- and postoperative incidents: hypovolaemia, low output syndrome (half the patients in this series) respiratory and infectious complications. The inappropriate use of vasoconstricting agents may also play a role. The majority of abdominal complications seemed to be related to ischaemia and anoxia in the splanchnic territory, which explains the important role of the preceding factors. The prognosis of abdominal complications after cardiac surgery was poor, mortality reaching 50 to 100% in some causes: in this series, 12 of the patients died. This justifies certain prophylactic measures: strict selection of patients, diagnosis and treatment of associated abdominal pathology before operation, prevention of low output states, respiratory and infectious complications ... and careful examination of the abdomen after operation to ensure the early diagnosis and treatment of complications, should they develop." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 1243, 1353 ] ], "word_ranges": [ [ 208, 227 ] ], "text": "An alteration of the III cranial nerve can produce ptosis, but the pupil, if affected, should be in mydriasis." }, "2": { "exist": true, "char_ranges": [ [ 1457, 1636 ] ], "word_ranges": [ [ 243, 272 ] ], "text": "An involvement of the optic chiasm would produce a bilateral loss of vision (probably a bitemporal hemianopsia). We are told in the statement that he maintains good visual acuity." }, "3": { "exist": true, "char_ranges": [ [ 852, 1186 ] ], "word_ranges": [ [ 140, 196 ] ], "text": "We should suspect an aneurysm. We should suspect a dissecting carotid aneurysm, which is one of the best known (and most serious) causes of an acquired Horner's syndrome. The superior cervical ganglion is a ganglion of the sympathetic nervous system located in the sheath of the carotid artery, and at this level it has been affected." }, "4": { "exist": true, "char_ranges": [ [ 1714, 1966 ] ], "word_ranges": [ [ 286, 325 ] ], "text": "an alteration of the medulla oblongata would produce different neurological symptoms not described, and there should be no ptosis or pupillary alterations, because the third pair is located in the midbrain and the sympathetic nuclei in the spinal cord." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "III cranial nerve.", "2": "Optic chiasm.", "3": "Upper cervical ganglion.", "4": "Spinal cord.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0078_12406", "title": "[Bilateral internuclear ophthalmoplegia in association with basilar artery occlusive disease].", "score": 0.018311036789297658, "content": "A 56 year-old man presented with vertigo and the right sided weakness. Neurological examination revealed a lethargic man with good orientation to three spheres. His neck was supple. He had anisocoria, the right pupil being larger than the left by 1.5 mm with sluggish light reaction bilaterally. He had exotropia of the right eye in primary gaze. The abduction of both eyes were full with terminal horizontal nystagmus. The adduction of both eyes were quite limited in each eye. He had a limited upward gaze with poor convergence. These were interpreted as the syndrome of the medial longitudinal fasciculus (MLF) bilaterally. He had a depressed gag reflex on the right side with tongue deviation to the right. He had a mild weakness of the right side limb and also had the right sided hemihyperesthesia including his face to pain and temperature. Twenty four hours after the onset, the left brachial angiography revealed a complete occlusion of the rostral portion of the basilar artery without visualization of the posterior cerebral and superior cerebellar arteries bilaterally. CT scans three days after the onset revealed a low density area in the mid pons with extension rostrally up to the mesencephalon. Four days later he became quadriplegic with bilateral horizontal gaze palsy. No more internuclear ophthalmoplegia is noted on both sides. The midline location of the MLF in the pons, and the separate blood supplies by different paramedian branches of the basilar artery, form the anatomical explanation for the frequent unilaterality of vascular and bilaterality of demyelinating lesions. Bilateral MLF syndrome has been considered almost pathognomonic of multiple sclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0298_11176", "title": "[A 56-year-old man with fever, backache and tetraparesis].", "score": 0.015791945520723258, "content": "We report a 56-year-old man who developed progressive paraparesis. He was apparently well, except for left Bell's palsy which developed on May 9 of 1994, for which he received stellate ganglion block on the left side more than ten times until July 2nd of 1994, when he noted pain in his left shoulder and in his lumbar region. On July 5th, he noted some difficulty in urination. On July 6th, he noted tingling sensation in his four extremities and difficulty in gait. He was admitted to another hospital where he was treated with intravenous infusion of glycerol. After this treatment, his gait and sensory disturbance showed some improvement, however, on July 7th, his shoulder and lumbar pain worsened, and he became unable to stand. His temperature went up to 39 degrees C on the next day. Lumbar CSF on that day contained 119 cells/microliters, 112 mg/dl of protein, and 53 mg/dl of sugar. He was transferred to our hospital on July 14th. His past medical history revealed that he had suffered from frequent bouts of osteomyelitis since the age of 13 years. He was operated on several times on osteomyelitis. He had been treated on his tooth ache until shortly before the onset of the present illness. He also received steroid hormone for his Bell's palsy. On admission, his consciousness varied from alert to stupor. His BP was 150/100 mmHg, HR 98/min and regular, BT 39.4 degrees C. The bulbar conjunctiva appeared somewhat icteric. Otherwise, general physical examination was unremarkable. On neurologic examination, there was no apparent dementia. Higher cerebral functions appeared intact. The optic discs were flat. Pupils were round and isocoric reacting to light and accommodation promptly. Ocular movements were full without nystagmus. Some exophthalmos was noted bilaterally. The sensation of the face and facial muscles were intact. The remaining cranial nerves also appeared intact. Nuchal rigidity was present. He was unable to stand or walk. Muscle strength was markedly diminished in all four limbs; manual muscle testing revealed 1 to 2/5 weakness in both upper and lower extremities bilaterally. Muscle stretch reflexes were decreased or lost in both upper and lower limbs, but the plantar response was extensor on the right. Sensation appeared to be diminished in legs, but detail was not clear because of disturbance of consciousness. Pertinent laboratory findings were as follows: WBC 12,800/microliter, GPT 58 IU/l, total bilirubin 2.65 mg/dl, and CRP 16.8 mg/dl. Cerebrospinal fluid contained 34 cells/microliter (approximately two thirds were neutrophils), RBC 1,110/microliter, 2,949 mg/dl of protein, and 119 mg/dl of glucose; stapylococcus aureus was cultured from the CSF. Myelogram showed a filling defect in the anterior epidural space between the low thoracic and the upper lumbar region. The patient was treated with cephotaxim, aminobenzyl penicillin, and chloramphenicol. On the second hospital day, his BT was still 39 degrees C and he was agitated His weakness was worse than the previous day. Spinal MRI was attempted; as he was agitated 5 mg of diazepam was given intravenously at 4 PM. His respiration was rapid and somewhat shallow. At 6 PM, gadolinium DTPA was injected intravenously; at that time, he was breathing and pupils were 3 mm on both sides. At 6:35 PM, an examiner noted that he stopped breathing; the left pupil was dilated to 5 mm. Cardiopulmonary resuscitation was initiated immediately, and intubation was performed. He was placed on a respirator. His blood pressure did not reach 100 mmHg; he was in deep coma. Cardiac arrest occurred at 8:53 AM on the next morning. The patient was discussed in a neurological CPC. Most of the participants thought that the patient had either spinal epidural empyema or spinal subdural abscess. The question was what might be the original focus of infection. Three possibilities were considered, i.e., stellate ganglion block, teeth infection, and osteomyelitis..." }, { "id": "pubmed23n1052_9242", "title": "An Interesting Case of Pupillary Changes During the Testing of Ocular Movements and its Influence on the Diagnosis?", "score": 0.014731907973406035, "content": "To describe an unusual case presentation of a decompensating exotropia with an incidental pupil anomaly highlighting the importance of observing pupils during the assessment of ocular movements. A case whose signs included an exotropia and an enlarged tonic pupil which were initially mistaken for an atypical case of Oculomotor nerve palsy, triggering immediate imaging investigations. We discuss how understandable it would be for experienced clinicians to arrive at this case's misdiagnosis and how it could have been avoided thereby helping to preserve where possible costly resources of neuro imaging and inpatient stays. A 71 year old man who was seen as a tertiary referral case by the Queen Elizabeth Hospital Birmingham's (QEHB's) neuro-ophthalmology service, where a second opinion for the patient was sought from a neurology team from another hospital. He was seen by the orthoptist and neuro-ophthalmologist consultant. On presentation at QEHB visual acuity measured 6/9 Snellens in each eye with varifocals, improving to 6/6 with pinhole testing, the fundi and optic discs were normal. Anisocoria was noted with the left pupil being larger than the right pupil. Orthoptic assessment revealed a small angle left exotropia on cover test, increasing in size on alternate cover test with a blink type recovery to its original angle. An orthoptic diagnosis of a decompensating left microexotropia with identity was given. In the left eye there was a slight mechanical restriction in adduction, underacting superior rectus and a larger underacting inferior rectus with an \"A\" type alphabet pattern with symptoms of horizontal diplopia on all right gaze positions. There was no evidence of ptosis, convergence was intact and saccades were fast and appeared of a normal velocity. The anisocoria appeared more obvious when the patient looked to right gaze where his left pupil seemed to enlarge further. Assessment of the pupillary function led to the patient being diagnosed as having bilateral asymmetrical Adies (tonic) pupils. This case highlights the importance of not only carrying out a detailed pupil reaction assessment but also the necessity of observing the pupils during the assessment of ocular movements. This case highlights how anisocoria can mislead a clinician's attention to believing that only one particular pupil is abnormal where as it could be both. Also it highlights that the classic combination of symptoms and observations of diplopia, exotropia, longstanding incomitance and anisocoria in terms of a dilated pupil may not necessarily be an Oculomotor cranial nerve palsy and requiring the patient to undergo imaging investigations on an urgent basis may be avoided." }, { "id": "pubmed23n0314_1466", "title": "[A 62-year-old man with an acute onset of consciousness disturbances].", "score": 0.014353824305132887, "content": "We report a 62-year-old man who developed coma and died in a fulminant course. The patient was well until May 1, 1996 when he noted chillness, tenderness in his shoulders, and he went to bed without having his lunch and dinner. In the early morning of May 2, his families found him unresponsive and snoring; he was brought into the ER of our hospital. He had histories of hypertension, gout, and hyperlipidemia since 42 years of the age. On admission, his blood pressure was 120/70, heart rate 102 and regular, and body temperature 36.3 degrees C. His respiration was regular and he was not cyanotic. Low pitch rhonchi was heard in his right lower lung field. Otherwise general physical examination was unremarkable. Neurologic examination revealed that he was somnolent and he was only able to respond to simple questions such as opening eyes and grasping the examiner's hand, but he was unable to respond verbally. The optic discs were flat; the right pupil was slightly larger than the left, but both reacted to light. He showed ptosis on the left side, conjugate deviation of eyes to the left, and right facial paresis. The oculocephalic response and the corneal reflex were present. His right extremities were paralyzed and did not respond to pain Deep tendon reflexes were exaggerated on the right side and the plantar response was extensor on the right. No meningeal signs were present. Laboratory examination revealed the following abnormalities; WBC 18,400/ml, GOT 131 IU/l GPT 50 IU/l, CK616 IU/l, BUN 30 mg/dl, Cr 2.1 mg/ dl, glucose 339 mg/dl, and CRP 27.4 mg/dl. ECG showed sinus tachycardia and ST elevation in II, III and a VF leads and abnormal q waves in I, V5, and V6 leads. Chest X-ray revealed cardiac enlargement but the lung fields were clear. Cranial CT scan revealed low density areas in the left middle cerebral and left posterior cerebral artery territories. The patient was treated with intravenous glycerol infusion and other supportive measures. At 2: 10 AM on May 3, he developed sudden hypotension and cardiopulmonary arrest. He was pronounced dead at 3:45 AM. The patient was discussed in a neurological CPC, and the chief discussant arrived at the conclusion that the patient had acute myocardial infarction involving the inferior and the true posterior walls and left internal carotid embolism from a mural thrombus. Post mortem examination revealed occlusion of the circumflex branch of the left coronary artery due to atherom plaque rupture and myocardial infarction involving the posterior and the lateral wall with a rupture in the postero-lateral wall. Marked atheromatous changes were seen in the left internal carotid, the middle cerebral and the basilar arteries; the left internal carotid and the middle cerebral arteries were almost occluded by thrombi and blood coagulate. The territories of the left middle cerebral and the occipital arteries were infarcted; but the left thalamic area was spared. The neuropathologist concluded that the infarction was thrombotic origin not an embolic one as the atherosclerotic changes were severe. Cardiac rupture appeared to be the cause of terminal sudden hypotension and cardiopulmonary arrest. It appears likely that a vegetation which had been attached to the aortic valve induced thromboembolic occlusion of the left internal carotid artery which had already been markedly sclerotic by atherosclerosis. It is also possible that the vegetations in the aortic valve came from mural thrombi at the site of acute myocardial infarction, as no bacteria were found in those vegetations." }, { "id": "pubmed23n0089_18943", "title": "[An adult case of congenital Horner's syndrome with heterochromia iridis--with special reference to alteration of Horner's sign associated with development].", "score": 0.013952413952413954, "content": "It is well known that when the Horner's syndrome is congenital, a defect in pigmentation of the iris is usual; all or part of the iris remains light brown. We reported an adult case of congenital Horner's syndrome with remission and relapse of unilateral ptosis. A 25-year-old man was admitted to our hospital for ophthalmologic surgical treatment of right ptosis. According to the patient's mother, the patient was delivered with the aid of forceps at birth, and the right ptosis was observed during the first few days of his life. At 2 to 3 years of age, his parents noted lighter color of the right eye. The right ptosis was gradually improved as he grew older. However, he developed right ptosis again with left meralgia paresthesia since eighteen age. At age 25 years, he was noted to have right ptosis, right miosis (the left pupil measured 4.5 mm in diameter and the right 3.0 mm), right heterochromia iridis with pigmented iris nevi, and left meralgia paresthesia . Laboratory data of urine, blood and CSF as well as radiological studies of chest X-ray, skull X-ray, spine X-ray, brain MRI and spinal cord MRI showed unremarkable. Sweating test was intact, pharmacologic test to Horner's syndrome with 5% cocaine and 1.25% 1-epinephrine indicated that the damage was pointed to the post ganglionic sympathetic neuron. Ten patients with congenital Horner's syndrome reported in Japan since 1953 were reviewed including our case. Ten of eleven were male and Horner's sign was recorded on the left eye in 8 cases.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0308_15735", "title": "[A 76-year-old man with loss of vision and dementia].", "score": 0.013951598338450423, "content": "We report a 76-year-old man who developed blurred vision and dementia. He was apparently well until April 4, 1990 (70-year-old at that time) when he had a sudden onset of bilateral loss of vision. Corrected vision was 0.1 (right) and 0.09 (left). He was admitted to the ophthalmology service of our hospital on April 9, 1990, and neurological consultation was asked on April 11. Neurologic examination revealed alert and oriented man without dementia. Higher cerebral functions were intact. He had bilateral large visual field defects with loss of vision; he was only able to count the digit number with his right eye and to recognize hand movement with his left eye. Otherwise neurologic examination was unremarkable. General physical examination was also unremarkable; he had no hypertension. Cranial CT scan was normal on April 11; lumber spinal fluid contained 1 cell/microliter, 63 mg/dl of sugar, and 97 mg/dl of protein; myelin basic protein was detected, however, oligoclonal bands were absent. He was treated with methylprednisolone pulse therapy and oral steroid, however, no improvement was noted in his vision. He started to show gaze paresis to left, ideomotor apraxia, agnosia of the body, and dementia. Cranial CT scan on June 11 revealed a low density area in the deep left parietal white matter facing the trigonal area of the lateral ventricle. He was discharged on July 2, 1990. Hasegawa dementia scale was 2/32.5 upon discharge. In the subsequent course, he showed improvement in his mental capacity and Hasegawa dementia scale was 22.5/32.5 in 1991, however, no improvement was noted in his vision. In 1994, he started to show mental decline in that he became disoriented, and showed delusional ideation of self persecution and depersonalization with occasional confusional state. He also showed unsteady gait. Cranial MRI on February 13, 1996 revealed a T2-high signal intensity lesion on each side of the parietal deep white matter more on the left and another T2-high signal intensity lesion in the left pons as well as in the right thalamus. He complained of right hypochondrial pain and was admitted to another hospital on April 22, 1996. He was markedly confused and demented. He continued to show bilateral loss of vision, but no motor palsy was noted. Cranial CT scan on April 23, 1996 revealed diffuse cortical atrophy and ventricular dilatation in addition to the low density areas in both parietal deep white matter. He developed jaundice in the middle of May. Abdominal CT scan revealed multiple low-to iso-density areas in the liver and marked iso-to high-density swelling of the right kidney. The patient expired on June 9th, 1996. The patient was discussed in a neurological CPC and the chief discussant arrived at the conclusion that the patient had had a carcinomatous limbic encephalitis with optic neuropathy and a choleduct carcinoma. Other opinions entertained included acute disseminated encephalomyelitis with optic neuritis, and granulomatous angiitis of the central nervous system. Some participants thought the primary site of the carcinoma was the right kidney with metastasis to the liver. Post mortem examination revealed a mixed type carcinoma in the right kidney with liver metastases. Neuropathologic examination revealed an incomplete softening in the optic chiasm and the left optic nerve, and in the left parieto-occipital areas. (The right hemisphere was frozen for future biochemical assay.) One of the adjacent cortical arteries had an organized thrombus. Other arteries and arterioles also showed sclerotic changes. Some of the leptomeningeal arteries were positive for Congored staining as well as for beta-amyloid immunostaining. Many senile plaques were seen diffusely in the cerebral cortex and neurofibrillary tangles were seen in the CA1 area and the parahippocampal gylus. No cellular infiltrations or demyelinated foci were seen. The neuropathologic features were consistent with circulatory disturbance based on the amyloid angiopa" }, { "id": "pubmed23n0724_3584", "title": "[Neuromyelitis optica with high aquaporin-4 expression and positive serum aquaporin-4 autoantibodies].", "score": 0.01390369580668088, "content": "Disease-specific aquaporin-4 antibodies (NMO-IgG) are the main effector of lesions in neuromyelitis optica (NMO) patients. Brain MRI lesions are detected in 60% of them, with 8% (almost infants) at sites of high aquaporin-4 expression. Patient 1: A fifty-year-old male with loss of vision in the right eye. Empiric treatment with metilprednisolone 1g/d for 3 days was indicated. After 30 days he complained of generalized pain, and a right hemiparesis was evident. The patient received bolus of metilprednisolone 1g/d for 5 days plus IgG 400 mg/kg/d IV for 5 days. He recovered ambulation but persisted with pain and paroxysmal phenomena (Lhermitte). Visual Evoked Potentials (VEP): P100 left eye 123 ms, right eye without response. Brain MRI (FLAIR) showed hyperintensity in the right optic nerve, hypothalamus and anterior white commissure. Cervical MRI showed extensive spinal cord lesion to an extension of 5 vertebral bodies. Patient 2: A fifty-three-year-old female who referred decreased visual acuity in both eyes and paresthesia in lower limbs which subsided spontaneously. One month later the patient evolved with cuadriparesis and sphincter incontinence. No improvement was observed with bolus of metilprednisolone 1g/d for 5 day. VEP: P100 left eye 124 ms, right eye 128 ms. Brain MRI (FLAIR) disclosed hypothalamic and periaqueductal hyperintensity. Cervical MRI showed extensive spinal cord lesion to an extension of 7 vertebral bodies. NMO-IgG antibodies were positive in both patients (indirect immunofluorescence assay). NMO brain lesions at sites of high aquaporin-4 expression, once considered atypical for their topography and infrequency in adults, should be borne in mind when considering differential diagnosis." }, { "id": "Neurology_Adams_2040", "title": "Neurology_Adams", "score": 0.010739991003148899, "content": "Normally, movement of the head at a rate of one to two cycles per second does not cause blurring of vision because of the rapidity with which the VOR accomplishes compensatory eye movements. Dynamic visual acuity is a term applied to testing by having the patient read an eye chart while the head is rotated back-and-forth. A substantial drop in acuity occurring with head movements at this speed is indicative of failure of the VOR. Zee has described yet another means of testing the VOR in which the examiner observes the optic nerve head while the patient rotates the head back and forth. With a normal VOR, the optic disc does not appear to move since the eye’s position in space has remained unchanged. However, if the VOR is impaired, the optic nerve head appears to oscillate. Visual Fixation Reflex (Suppression of the Vestibuloocular Reflex)" }, { "id": "pubmed23n0224_8413", "title": "[An acute syndrome of opsoclonus and body tremulousness. A case report of benign encephalitis].", "score": 0.009900990099009901, "content": "A 30-year-old woman was admitted to our hospital in May 1977, suffering from oscillation, body tremulousness and astasia-abasia. Two months prior to admission she had caught a common cold and felt paresthesia on the right arm. Three days before admission, she had photophobia, tremulousness of the trunk and head, and astasia-abasia. A neurological examination revealed difficulty in standing, and jerky movement of the body and right arm, her limbs were well coordinated. An ocular examination resulted in normal findings except for intermittent oscillation of the eyeballs. As the pupils and fundi were normal, so were the routine laboratory tests. The cerebrospinal fluid was clear and colorless under normal pressure, and showed no more than 6 mononuclear cells in any of the three examinations. CSF protein was registered 20 mg/dl, glucose 75 mg/dl, and no virus titers were elevated. Electroencephalogram was slightly abnormal due to a slowing of the Alpha wave in the background activity. Both computerized tomography and vertebral-angiography were normal. A slow and steady abatement of all symptoms started while she was taking steroid treatment in hospital. Electrooculogram showed irregular disconjugation of the eyes rotating or moving in horizontal and vertical direction. There movements conjugated or disconjugated in both eyes with 5-7 Hz of frequency and 10-20 degrees of amplitude. They decreased when the eyelids were closed or staying in a dark room. These ocular movements were regarded as opsoclonus. Then opsoclonus changed to flutter-like oscillation.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "Neurology_Adams_7259", "title": "Neurology_Adams", "score": 0.009880778797495497, "content": "As noted in Chap. 12, about half of patients with optic neuritis recover completely, and most of the remaining ones improve significantly, even those who present initially with profound visual loss (Slamovitis et al). Pain around the eye is short-lived and persistent pain should prompt an evaluation for local disease. In a cohort of 397 patients enrolled in the Optic Neuritis Treatment Trial and examined 5 years after the initial attack of optic neuritis, visual acuity had returned to 20/25 or better in 87 percent of patients and to 20/40 or better in 94 percent—even if there had been a recurrence of optic neuritis during the 5-year period. Moreover, the mode of treatment did not appear to influence the final visual outcome. Dyschromatopsia and impaired contrast sensitivity frequently persist, as does the Pulfrich effect, wherein an object such as a pendulum that is swinging perpendicular to the patient’s line of sight appears to move in a three-dimensional, circular path." }, { "id": "pubmed23n0324_1982", "title": "[A rare cause of peracute vision loss: pseudotumor cerebri. Case report of course with recurrence after decompression of the optic nerve].", "score": 0.00980392156862745, "content": "In primary pseudotumor cerebri (PTC) intracranial pressure is elevated by so far unknown mechanisms. There is a wide range of clinical courses. Therapy is controversial. We present a case of PTC with acute visual loss. After optic nerve sheath decompression a relapse occurred. A 30-year old female patient experienced visual loss within 48 h accompanied by headache and slight neck stiffness. Visual acuity was 1/50 in the right eye; in the left eye just hand movements and light were perceived. Fundoscopy revealed a 9 dptr. prominent optic disc bilaterally. After optic nerve sheath decompression (ONSD) she improved, but underwent a relapse after 3 months. Twenty-four-hour measurement of intracranial pressure revealed elevated values. As a consequence ventriculo-peritoneal shunting was performed, leading to prominent improvement. Primary PTC can cause acute visual loss. If conservative treatment fails, different surgical procedures should be considered." }, { "id": "pubmed23n0322_20086", "title": "Consultation section. Cataract surgical problem.", "score": 0.009708737864077669, "content": "A 68-year-old diabetic Pakistani presented with a 3 year history of progressive bilateral painless loss of vision. Although he was previously untreated for glaucoma, his examination revealed the following: visual acuity, finger counting in the right eye and 20/60 in the left; intraocular pressure (IOP), 41 and 31 mm Hg, respectively. Physical findings included bilateral shallow anterior chambers, minimal nuclear and cortical cataract formation, and extensive glaucomatous optic nerve cupping and atrophy worse in the right eye than in the left. Gonioscopy revealed angles narrowed to grade 1 for 360 degrees in both eyes. Visual field analysis was commensurate with the marked degree of optic nerve damage and reduced visual acuity. Bilateral laser iridotomies and a combination of topical antiglaucoma agents reduced IOP to the mid-20s in both eyes. Subsequently, the right eye had an uneventful trabeculectomy with application of intraoperative mitomycin. Postoperatively, the patient developed posterior aqueous entrapment and was managed with topical cycloplegics, aqueous suppressants, and corticosteroids. After a few weeks, a shallow anterior chamber was present centrally, a filtration bleb was noted, and IOP was 9 mm Hg. Unexpectedly, the patient returned to his native country, discontinued medications, and was lost to follow-up for 1 year. Upon his return, he presented with these findings: visual acuity, hand motion in the right eye and 20/60 in the left eye; IOP, 10 and 30 mm Hg, respectively. Physical findings in the right eye (Figure 1) included a superiorly oriented, thin-walled filtration bleb, a formed anterior chamber with multiple broad peripheral and midperipheral synechias, and a bound pupil covering a dense nuclear sclerotic cataract. The left eye had progressive glaucomatous optic nerve changes. Given the patient's history, now would you manage the glaucoma in the left eye, and what surgical methods would you plan for the right eye, assuming cataract surgery is indicated?" }, { "id": "article-18523_16", "title": "Brain Death Criteria -- Clinical Significance -- I. Physical Examination", "score": 0.009708737864077669, "content": "CN III, IV, VI: Loss of pupillary light reflex as mentioned above (CN III). For cranial nerves IV, VI, and VIII, the oculocephalic reflex can be tested by holding a patient's eyelids open and turning their head from side to side. A positive oculocephalic reflex is present when the eyes reflexively look in the position opposite to that of the direction the head is turning. When the oculocephalic reflex is absent, the eyes will turn in the same direction in which the head is turning (Doll's eyes). It is imperative to only perform this examination maneuver in patients with a stable cervical spine who are not in cervical spine precautions." }, { "id": "pubmed23n0513_18909", "title": "Upper cranial nerve palsy resulting from spontaneous carotid dissection.", "score": 0.009615384615384616, "content": "Upper cranial nerve palsy has a variety of causes such as cerebral and nerve ischemia, diabetes, infectious and non-infectious meningitis, subarachnoid hemorrhage and intracranial aneurysm. CASE 1 : A 45-year-old man suffered from holocephalic headaches and a right-sided neck pain for two weeks. He presented to our emergency department because of a sudden ptosis of the right eye. On admission neurological examination revealed a right sided Horner's syndrome and hypesthesia of the right side of the face. Magnetic resonance angiography identified a circumscribed dissection of the right extracranial internal carotid artery originating from the carotid bifurcation. Conventional angiography 2 weeks later showed a nearly recanalized artery. CASE 2 : A 55-year-old previously healthy man without cardiovascular risk factors developed right sided neck pain when loading a seeder with several sacks of crop. A few hours later he noticed a left-sided weakness. On admission a severe left sided hemiparesis and a mild neglect were present. Duplex sonography revealed a right-sided distal internal carotid artery (ICA) occlusion. The next morning the patient complained of double vision; he had a right-sided pupil-sparing oculomotor palsy. The diagnosis of ICA dissection was confirmed by conventional angiography, at that time showing a partially recanalized ICA without involvement of the cavernous region by the dissection. ICA dissection must be included in the differential diagnosis of upper cranial nerve palsy and should be assessed by duplex ultrasound and magnetic resonance imaging. A possible explanation is nerve ischemia due to a transient or permanent interruption of the blood supply by compression of the vasa nervorum originating from the intracranial carotid artery." }, { "id": "pubmed23n1081_21469", "title": "A cataract, 'a million cut' radial keratotomy, and Marfan syndrome February consultation #1.", "score": 0.009523809523809525, "content": "A 56-year-old man with an ocular history of 20+ cut radial keratotomy (RK) in both eyes and Marfan syndrome presented with blurred vision in both eyes 2 years previously. He was intolerant of contact lenses and was correctable with spectacles for the past 10 years. His presenting photographs and corneal topographies are shown in Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202102000-00022/figure1/v/2021-04-12T204757Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202102000-00022/figure2/v/2021-04-12T204757Z/r/image-tiff, respectively. His left eye had greater than 270 degrees of zonulopathy and a visually significant cataract. He underwent a planned pars plana lensectomy/vitrectomy and implantation of a scleral-fixated CZ70BD (Alcon Laboratories, Inc.) intraocular lens (IOL). He has enjoyed adequate vision in the left eye and now has a worsening cataract in his right eye. He is a practicing dentist and requested the fastest visual rehabilitation possible. His corrected distance visual acuity was 20/50 with a manifest refraction of +5.00-4.00 × 90 in the right eye and 20/25 with a manifest refraction of +1.75-2.50 × 180 in the left eye. Intraocular pressure (IOP) was measured at 16 mm Hg in both eyes, and extraocular motility, confrontational visual fields, and pupils were normal in both eyes. On slitlamp examination, he had mild ptosis in both eyes, the corneas had 20+ RK with multiple arcuate incisions at the 3- and 9-o'clock positions in both eyes, the anterior chamber (AC) was deep and quiet in both eyes, both irides had mild iridodonesis, the right lens had a 2 to 3+ nuclear sclerotic cataract with 6 clock hours of superotemporal zonulopathy that was only evident with dilation (Figure 3JOURNAL/jcrs/04.03/02158034-202102000-00022/figure3/v/2021-04-12T204757Z/r/image-tiff) and no phacodonesis. The left lens had a well-positioned CZ70BD IOL fixated at 6 and 12 o'clock without extrusion or exposure of the Gore-Tex suture. The posterior segment examination was unremarkable. What counseling would you provide for this patient in preparation for surgery? How would you plan the IOL calculations? What intraoperative techniques would you use to achieve the safest outcomes given his comorbidities?" }, { "id": "article-20650_1", "title": "Doll's Eyes -- Definition/Introduction", "score": 0.009523809523809525, "content": "The oculocephalic reflex is performed by holding a patient’s eyelids open and moving their head from side to side. The examination should only be performed on patients with a stable cervical spine without c-spine precautions. With the patient's eyelids open, the examiner briskly rotates the patient's head from side to side while the examiner observes the patient’s eyes. The examiner observes a positive oculocephalic reflex when the patient moves their eyes opposite of the rotation of their head, such that their eyes stay looking forward (like a doll’s eyes). The examiner observes a negative oculocephalic reflex when the patient’s eyes stay midline and do not move while the examiner rotates the head. A similar examination is performable for vertical eye movements. [6] Note that the designation of \"positive\" (eyes moving in the opposite direction of head movement indicating an intact brainstem function) or \"negative\" (eyes moving towards the same direction of head movement indicating severe brainstem dysfunction) doll's eyes reflex is an oversimplification and that some eye movement with nystagmus can occur in pathologic states. [7] The reflex is suppressed in a conscious adult with normal neurologic function but is active in a comatose patient with gross brainstem function, absent if there is damage to the reflex arc. [6]" }, { "id": "wiki20220301en019_111265", "title": "Human brain", "score": 0.009468599033816425, "content": "The cerebrum has a contralateral organisation with each hemisphere of the brain interacting primarily with one half of the body: the left side of the brain interacts with the right side of the body, and vice versa. The developmental cause for this is uncertain. Motor connections from the brain to the spinal cord, and sensory connections from the spinal cord to the brain, both cross sides in the brainstem. Visual input follows a more complex rule: the optic nerves from the two eyes come together at a point called the optic chiasm, and half of the fibres from each nerve split off to join the other. The result is that connections from the left half of the retina, in both eyes, go to the left side of the brain, whereas connections from the right half of the retina go to the right side of the brain. Because each half of the retina receives light coming from the opposite half of the visual field, the functional consequence is that visual input from the left side of the world goes to the" }, { "id": "Neurology_Adams_1840", "title": "Neurology_Adams", "score": 0.009460654288240495, "content": "Figure 12-2 illustrates the visual field defects caused by lesions of the retina, optic nerve and tract, lateral geniculate body, geniculocalcarine pathway, and striate cortex of the occipital lobe. In the alert, cooperative patient, the visual fields can be plotted fairly accurately at the bedside. With one of the patient’s eyes covered and the other fixed on the corresponding eye of the examiner (patient’s right with examiner’s left), a target—such as a moving finger, a cotton pledget, or a white disc mounted on a stick—is brought from the periphery toward the center of the visual field (confrontation testing). With the target at an equal distance between the eye of the examiner and that of the patient, the fields of the patient and examiner are then compared. Similarly, the patient’s blind spot can be aligned with the examiner’s, and its size determined by moving a small target outward from the blind spot until it is seen. For reasons not known, red-green test objects are more" }, { "id": "pubmed23n0387_1798", "title": "A case of Brown-Sequard syndrome with associated Horner's syndrome after blunt injury to the cervical spine.", "score": 0.009433962264150943, "content": "A 26 year old motorcyclist was received by the trauma team in our accident and emergency department after a head on collision with a motor vehicle. He had been correctly immobilised and his primary survey was essentially normal. He was alert and orientated with a Glasgow Coma score of 15 and had no symptoms or signs of spinal injury. His cervical spine radiography was also normal. Neurological examination however, revealed anisocoria, his left pupil being smaller than his right, and a Brown-Sequard syndrome, with a sensory level at C6. Immobilisation was maintained and he was transferred to the regional neurosurgical centre where magnetic resonance imaging revealed a contusion of the left half of the spinal cord adjacent to the 6th cervical vertebrae. Computed tomography revealed no bony injury but spinal column instability was demonstrated after flexion-extension spinal views and he underwent surgery to fuse his spine at the C5-C6 level. This report highlights the necessity to observe strict ATLS guidelines. This must include a thorough examination of the central and peripheral nervous system where spinal injury is suspected, even in the absence of radiographic abnormality and neck pain. This article also presents the unusual phenomena of Brown-Sequard syndrome and unilateral Horner's syndrome after blunt traumatic injury to the cervical spine." }, { "id": "InternalMed_Harrison_1791", "title": "InternalMed_Harrison", "score": 0.009433962264150943, "content": "The range of eye movements and whether they are equal in each eye should be observed. Peripheral eye movement disorders (e.g., cranial neuropathies, eye muscle weakness) are usually disconjugate (different in the two eyes). One should check pursuit (the ability to follow a smoothly moving target) and saccades (the ability to look back and forth accurately between two targets). Poor pursuit or inaccurate (dysmetric) saccades usually indicates central pathology, often involving the cerebellum. Finally, one should look for spon taneous nystagmus, an involuntary back-and-forth movement of the eyes. Nystagmus is most often of the jerk type, in which a slow drift (slow phase) in one direction alternates with a rapid saccadic movement (quick phase or fast phase) in the opposite direction that resets the position of the eyes in the orbits. Except in the case of acute vestibulopathy (e.g., vestibular neuritis), if primary position nystagmus is easily seen in the light, it is probably due to a" }, { "id": "pubmed23n0968_15434", "title": "Isolated Horner syndrome as a rare initial presentation of nasopharyngeal carcinoma: a case report.", "score": 0.009345794392523364, "content": "Horner syndrome refers to a set of clinical presentations resulting from disruption of sympathetic innervation to the eye and adnexa. Classically, the clinical triad consists of ipsilateral blepharoptosis, pupillary miosis, and facial anhidrosis. Ocular sympathetic denervation may signify life-threatening causes. Timely investigation and accurate diagnosis are essential in patients with oculosympathetic denervation. A 33-year-old Asian man with a heavy smoking habit presented with a 3-week history of left ptosis and no other complaints. His visual acuity was 20/20 bilaterally. An ophthalmic examination was significant for mild ptosis of his left eyelid and anisocoria (smaller left pupil), which was greater in the dark. Both pupils reacted to light briskly without an afferent pupillary defect. Anhidrosis was found on the medial side of the left forehead. A 10% cocaine test was positive. At his first visit, neurologic examination was unremarkable. Comprehensive radiological investigations were scheduled for a left-sided isolated Horner syndrome. Two weeks after his first visit, he experienced a left-sided headache along with ipsilateral Horner syndrome. Neurologic examination revealed hypoesthesia in the left cranial nerve V<sub1-3</sub territories. Emergent computed tomography angiography was suspected for petrous part of the left internal carotid artery (ICA) dissection. Magnetic resonance imaging demonstrated an enhancing infiltrative lesion with its epicenter at the left sphenoid bone. The lesion encased the left ICA and invaded the left Meckel cave. Rhinoscopy with incisional biopsy revealed squamous cell nasopharyngeal carcinoma. This case involved an unusual initial presentation of nasopharyngeal carcinoma: isolated Horner syndrome with clinical progression to adjacent structures. Infiltration involving the Meckel cave and ICA at the foramen lacerum can present as postganglionic Horner syndrome associated with trigeminal pain and hypoesthesia. These clinical findings may mimic carotid artery dissection on computed tomography angiography. Detailed magnetic resonance imaging with careful attention to the skull base should be performed." }, { "id": "pubmed23n0549_8892", "title": "Visual loss in one eye after spinal surgery.", "score": 0.009345794392523364, "content": "To report a patient who developed an unusual combination of central retinal artery occlusion with ophthalmoplegia following spinal surgery in the prone position. A 60-year-old man underwent a cervical spinal surgery in the prone position. Soon after recovery he could not open his right eye and had ocular pain due to the general anesthesia. Upon examination, we determined that he had a central retinal artery occlusion with total ophthalmoplegia. Despite medical treatment, optic atrophy was still present at the following examination. Ptosis and the afferent pupillary defect disappeared and ocular motility was recovered, but visual loss persisted until the last follow-up. A prolonged prone position during spinal surgery can cause external compression of the eye, causing serious and irreversible injury to the orbital structures. Therefore, if the patient shows postoperative signs of orbital swelling after spinal surgery the condition should be immediately evaluated and treated." }, { "id": "pubmed23n0667_22897", "title": "Anti-aquaporin-4 antibody-positive optic neuritis treated with double-filtration plasmapheresis.", "score": 0.009259259259259259, "content": "The anti-aquaporin-4 (AQP4) antibody was recently reported to be associated with neuromyelitis optica (NMO). Optic nerve involvements in many NMO cases are bilateral and the prognosis is poor. However, it has been suggested that plasma exchange is effective for those patients when steroid pulse therapy is ineffective. Herein, we report successful treatment of a patient with NMO using double-filtration plasmapheresis (DFPP). A 22-year-old woman consulted a neurologist for neck pain in March 2008. High-intensity lesions were shown in the cervical spinal cord by T2-weighted magnetic resonance imaging. On July 15, the patient was referred to our department for a headache and pain and blurred vision in the left eye. The best-corrected visual acuity was 20/50 and 20/500 in the right and left eyes, respectively, with visual field defects observed in both. After 3 courses of steroid pulse therapy, anti-AQP4 antibodies were positive. In November, the patient again noticed visual acuity loss in the left eye and was treated by additional steroid pulse therapy, which was not effective. Next, she underwent plasma exchange therapy, though it was stopped due to hypotension and dyspnea. The next day, the patient underwent DFPP treatment and visual function gradually recovered. It is important to consider NMO when steroid pulse therapy is not effective. We successfully and safely treated NMO in a young adult patient using DFPP." }, { "id": "pubmed23n0901_9946", "title": "Syringomyelia presenting with unilateral optic neuropathy: a case report.", "score": 0.009259259259259259, "content": "In this case report, we present two cases of syringomyelia with optic neuropathy. In Case 1, a 36-year-old Malay lady presented to our clinic with acute onset of blurring of vision in her left eye that she experienced since past 1 month. She was diagnosed with syringomyelia 12 years ago and was on conservative management. Her visual acuity was 6/6 in the right eye and counting fingers at 1 m in the left. There was a positive relative afferent pupillary defect in her left eye. Optic nerve functions of her left eye were reduced. Visual field showed a left inferior field defect. Her extraocular muscle movements were full. Magnetic resonance imaging of the brain and spine showed syringomyelia at the level of C2-C6 and T2-T9. Both of her optic nerves were normal. Her condition improved with intravenous and oral corticosteroids. In Case 2, a 44-year-old Malay lady presented to our clinic with a progressive central scotoma in her right eye that she experienced since past 1 month. She had previous history of recurrent episodes of weakness in both of her lower limbs from past 8 months. Visual acuity in her right and left eye was 6/9 and 6/6, respectively. The relative afferent pupillary defect in her right eye was positive. Optic nerve functions of her right eye were affected. Visual field showed a central scotoma in her right eye. Her extraocular muscle movements were full. Fundoscopy of her right eye showed a pale optic disc. Her left eye fundus was normal. Magnetic resonance imaging of the brain and spine showed syringomyelia at T3-T6. Both of her optic nerves were normal. A diagnosis of syringomyelia with right optic atrophy was performed. Her condition improved with intravenous and oral corticosteroids. Optic neuropathy is a rare neuro-ophthalmic manifestation in patients with syringomyelia. Prompt diagnosis and timely management are essential to avoid a poor visual outcome. Intravenous corticosteroids are beneficial in the treatment of early optic neuropathy in syringomyelia." }, { "id": "pubmed23n0304_19072", "title": "[A 29-year-old man with diabetes insipidus and cerebellar ataxia and development of spinal cord swelling 15 years after the onset].", "score": 0.009174311926605505, "content": "We report a 29-year-old man with diabetes insipidus and cerebellar ataxia who developed spinal cord swelling 15 years after the onset. He was well until 14 years of the age when he noted dizziness. Two years after there was an onset of gait disturbance and slurred speech. He also noted polydipsia and polyuria. He was evaluated at the neurosurgery service of our hospital when he was 17 years of the age. Neurologic examination at that time revealed memory loss, horizontal nystagmus, cerebellar ataxic gait, dysmetria and decomposition more on the left. Cranial CT scan revealed a mass lesion involving the left subthalamic region and the head of the caudate area. Spinal fluid was unremarkable, however, human chorionic gonadotropin was increased to 27 mIU/ml. He was treated by radiation therapy (3,000 rads for total brain area and 5,460 rads for focal region). His CT scan and memory loss improved, however, cerebellar ataxia was unchanged. Three years after the radiation, he started to show choreic movement in his neck and left upper extremity. He was admitted to our service in August 14, 1995 when he was 29 years of the age. On admission, he was alert but disoriented to time; calculation was also poor. Higher cerebral functions were intact. The optic fundi were normal without papilledema. Visual field appeared intact. Gaze nystagmus was observed in all the directions, but more prominent in the horizontal direction. Speech was slurred. Otherwise, cranial nerves were unremarkable. Motor wise, he showed marked truncal and gait ataxia; he was unable to walk because of ataxia. Muscle atrophy and marked weakness was noted in both upper extremities more on the left side. Deep tendon reflexes were diminished in the upper extremities but active in the lower extremities. He was polyuric; urinary specific gravity was low. Spinal fluid contained 6 cells/cmm and 113 mg/ dl of protein; Queckenstedt was positive. MRI revealed swelling of the cervical cord; in addition, the entire cervical region and the medullar oblongata appeared as high signal intensity areas. No mass lesion was noted in the supratentorial structures but the third ventricle was markedly enlarged. Surgical biopsy was performed on the cervical lesion. The patient was discussed in neurologic CPC, and the chief discussant arrived at the conclusion that the patient had germinoma with syncytiotrophoblastic giant cells in the diencephalic region which appeared to have been cured by radiation therapy; he thought that the cervical lesion was the seeding of germinoma. Cerebellar ataxia was ascribed to the remote effect of germinoma. Most of the participants thought that the original tumor was germinoma and the cervical lesion was its spread. Some participants thought that his ataxia was caused by germinoma cells involving the medulla and the inferior cerebellar peduncles. Histologic observation of the biopsied tissue from the spinal cord revealed the typical two cell patterned germinoma. Most of the tumor cells were not stained for an antibody against HCG, but some tumor cells were positively stained. Germinoma is very radio-sensitive; this patient showed T2 high signal lesion involving the medulla oblongata and cervical cord continuously. Probably, tumor cells in the lower brain stem escaped radiation, and gradually spread to the spinal cord over many years. At the time of operation, the surface of the spinal cord was free from tumor cells. Therefore, tumor cells invaded the spinal cord continuously from the medulla oblongata. He was treated with cervical radiation, and his neurologic as well as radiologic findings showed marked improvement." }, { "id": "pubmed23n0273_1475", "title": "[A 50-year-old man with metamorphopsia and optic nerve swelling].", "score": 0.009174311926605505, "content": "We report a 50-year-old male having metamorphopsia associated with retinal edema. He was well until one month prior to the present admission when he developed occipital headache and backache. Three weeks later, he noted a sudden onset of twisting of visual images. On admission, he was in no acute distress with well preserved general conditions. Only neurological abnormalities were bilateral papilledema, retinal edema and horizontal nystagmus with a rotatory component. Routine blood chemistries were unremarkable. The CSF contained 28 cells/cmm with 60% consisting of large atypical cells. Cranial CT scans revealed no mass, however, the magnified orbital CT showed bilateral swelling of the optic nerve. He was treated with ventriculoperitoneal shunt and Ommaya tube placement through which methotrexate, cytarabine and prednisolone were administered. He was also treated with systemic cisplatin, mitomycin-C and 5-fluorouracil. With these therapy, his headache, metamorphopsia and papilledema improved. He was discharged for out-patient follow-up, however, he had to admitted again because of progressive difficulty of gait and loss of appetite. On admission, he complained of severe backache, and his gait disturbance appeared to be in part due to his backache. A slight weakness was noted in all four limbs with loss of deep reflexes. Mentally he was alert and cranial nerves appeared intact without papilledema. But nuchal rigidity was noted. Cranial CT scan revealed attenuation of all the cortical sulci and marked diffuse low density changes in the cerebral white matter, and his chest film revealed a ring-shape shadow in his left lung field. He deteriorated progressively with terminal gastrointestinal hemorrhage. He expired three weeks after his second admission.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n1081_21454", "title": "Management of hypotony-related maculopathy after combined phacoemulsification and trabeculectomy: January consultation #1.", "score": 0.00909090909090909, "content": "A 59-year-old man with mild to moderate pigmentary glaucoma was referred for management of hypotony-related maculopathy 3 years after combined phacoemulsification and trabeculectomy in his right eye. His ocular history is significant for retinal detachment in the right eye that was surgically treated with a pars plana vitrectomy and scleral buckle 5 years prior to the current presentation and 1 year prior to his combined phacoemulsification-trabeculectomy procedure. After trabeculectomy, he reportedly had a wound leak with hypotony and choroidal effusion. The patient was referred to a second surgeon who performed a bleb revision with a pericardial patch graft, but the patient had a severe intraocular pressure (IOP) spike in the immediate postoperative period requiring suture removal. This resulted in recurrent hypotony with maculopathy. A second bleb revision with pericardial patch graft was performed but was not successful in raising the IOP out of the single digits or in resolving the maculopathy. Accordingly, the patient was referred for further assessment. At presentation, the patient's corrected distance visual acuity was 20/100 in the right eye and 20/20 in the left eye. Applanation tonometry IOP was 4 mm Hg and 16 mm Hg for the right and left eyes, respectively. Central corneal thickness was 609 μm in the right eye and 574 μm in the left eye. The right pupil was noted to be slightly irregular with a relative afferent pupillary defect. Slitlamp examination of the right eye was notable for a moderately elevated, Seidel test-negative bleb, and deep anterior chamber. The left eye had a Krukenberg spindle and mild nuclear sclerotic cataract but was otherwise unremarkable. Fundus examination of the right eye was notable for significant macular folds with edematous nerve fiber layer (NFL) and optic nerve. The left optic nerve and fundus examination were unremarkable. Gonioscopy revealed open angles with dense trabecular meshwork pigment in both eyes. There was a nicely patent superior sclerostomy in the right eye. There was no cyclodialysis cleft. Optical coherence tomography (OCT) of the macula showed chorioretinal folds and NFL edema in the right eye and was normal in the left eye (Figure 1JOURNAL/jcrs/04.03/02158034-202101000-00022/figure1/v/2021-01-04T143903Z/r/image-tiff). The OCT of the optic nerve in the right eye was distorted secondary to the chorioretinal folds, whereas the left eye was notable for mild superior thinning of the NFL (Figure 2JOURNAL/jcrs/04.03/02158034-202101000-00022/figure2/v/2021-01-04T143903Z/r/image-tiff). Humphrey visual field revealed a superior nasal step in the right eye (Figure 3JOURNAL/jcrs/04.03/02158034-202101000-00022/figure3/v/2021-01-04T143903Z/r/image-tiff). Axial lengths were 25.33 mm and 26.53 mm in the right and left eye, respectively; it is notable that the right eye had a shorter axial length despite the scleral buckle, which demonstrates the degree of axial shortening from hypotony (Figure 4JOURNAL/jcrs/04.03/02158034-202101000-00022/figure4/v/2021-01-04T143903Z/r/image-tiff). What would be your approach for managing this patient's hypotony? Does the fact that the referring surgeon had performed 2 failed bleb revision procedures prior to referral influence your approach? Given that a previous attempt at revision resulted in an extreme IOP spike would you also recommend a glaucoma procedure? If so, what procedure would you perform? Would you do it coincident with the revision or in a staged procedure later on an as-needed basis?" }, { "id": "pubmed23n0063_728", "title": "Human ocular torsional position before and after unilateral vestibular neurectomy.", "score": 0.00909090909090909, "content": "The static ocular torsional position of both eyes of 23 patients was measured by means of fundus photographs one day before and one week after unilateral vestibular neurectomy for the treatment of acoustic neuroma, Ménière's disease or paroxysmal vertigo. The results showed that in all patients the vestibular neurectomy caused both eyes to tort (i.e. to roll around the visual axis) toward the side of the neurectomy when measured one week after operation. The extent of this torsion was an average of 9.5 degrees one week after operation and there was no statistically significant difference in the average magnitude of the torsion in the two eyes. In 8 of these patients, additional measurements were made at intervals up to one year after operation and it was found that in these patients there is a significant reduction in torsion over time from an average of 10.2 degrees one week after operation to an average of 2.8 degrees by 16 weeks after operation. The change in torsional eye position following the neurectomy was accompanied by a change in the perceived visual orientation of a small (9.5 degrees visual angle) illuminated horizontal line at a straight ahead eye level position in an otherwise completely darkened room. One week after operation when asked to adjust the line to the perceived gravitational horizontal by rotating it in roll (i.e. around an X axis), patients who had had a right vestibular neurectomy consistently set the line so that the right side of the line (from the patient's point of view) was below the true gravitational horizontal. Similarly patients after a left neurectomy consistently set the line so that the left side of the line was below the true gravitational horizontal. There is a high correlation (r = 0.95) between the direction and magnitude of the change in torsional eye position and the direction and magnitude of the change in the perceived visual horizontal one week after operation.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n1028_14773", "title": "Unilateral progressive epitheliopathy after LASIK.", "score": 0.009009009009009009, "content": "A 36-year-old man was referred back to our clinic after an uneventful laser in situ keratomileusis (LASIK) surgery 6 months previously, with a chief complaint of declining vision in the left eye for the last several months. His pertinent ocular history prior to the LASIK surgery was significant for episodic left eye irritation and inflammation of the superior part of the left cornea secondary to contact lens-induced keratopathy, according to his optometrist.This was a femtosecond-assisted LASIK surgery using the WaveLight FS200 femtosecond laser (Alcon) with the Allegretto EX500 excimer laser (Alcon) for attempted correction of -4.50 diopter (D) of myopia in both eyes under an 8.8 mm flap with a thickness of 100 μm. The uncorrected distance visual acuity (UDVA) was 20/15 in both eyes for the first 2 weeks; at the 1-month follow-up visit, a well-demarcated, wavelike plaque of coarse, thickened corneal epithelium along the superior aspect of the cornea was noted. The UDVA had declined to 20/30 in the left eye. The right eye remained clear with a UDVA of 20/15. The patient was treated for presumed interface inflammation with 1% topical prednisolone acetate for 3 weeks on a tapering regimen and it was noted that there was some improvement in the vision subjectively although the epithelial ridge involving the superior one third of the LASIK flap was present without any change.Over the course of the next 2 months, a progressive decline in vision was noted in the left eye. At no point did his right eye experience symptoms or visual decline. Four months postoperatively the UDVA had declined to 20/60 in the left eye. A linear epithelial ridge extending from limbus at 11 to 2 o'clock position was noted superiorly; staining showed the ridge involved the superior aspect of the flap. The patient was again given corticosteroid treatment, which would improve the symptom of irritation without any change in the visual acuity. Over the course of the next few months, a new wave of abnormal epithelium involving the inferior aspect of the limbus and the flap, encompassing the 2 o'clock position of the flap from the 4 to 6 o'clock positions, was also noted ().(Figure is included in full-text article.)Conjunctival staining using lissamine green and fluorescein dye showed staining of the well-demarcated epithelial ridge superiorly and inferiorly involving the flap encroaching the visual axis. On examination, the patient's corrected distance visual acuity was now 20/80 in the left eye. , , and show the tomographic, topographic, and optical coherence tomography (OCT) results at the 6-month follow-up post-LASIK surgery.(Figure is included in full-text article.)(Figure is included in full-text article.)(Figure is included in full-text article.)Preoperatively the patient denied any ocular history but on further questioning at the 6-month follow-up visit, he provided information about the use of systemic isotretinoin (Accutane) for juvenile acne for 1 year at age 17 and potential exposure to chemicals during military service although he denied any specific ocular exposure. He is a barbeque enthusiast and brews his own alcohol but denies any thermal or direct injury to either eye. His mother had recently told him that he might have had battery acid exposure when he was very young, before age 10, but never required medical attention.What is the most likely diagnosis? What medical or surgical interventions would you recommend for this patient? What is the prognosis for this patient?" }, { "id": "pubmed23n0087_15017", "title": "[Superior oblique myokymia--a case report and pathogenetic consideration].", "score": 0.009009009009009009, "content": "A 30-year-old male visited us with complaints of dizziness and diplopia of abrupt onset in September, 1988. Neurological studies demonstrated paroxysmal rotatory to-and-fro oscillations of the left eye. There has been the same clinical episode at 25 years of age, lasting approximately 6 months. The characteristics of his ocular involuntary movement with the mild IVth cranial nerve paresis were as follows: quick, nonrhythmic, initially counterclockwise-rolling, more prominent in moving the left eye to the lower medial side, persisting for 1-10 seconds and rapidly repeated oscillations. When oscillations were prominent, he complained of faintness in addition to double vision. Except for the ocular signs, other neurological and laboratory examinations including cerebrospinal fluid, brain MRI and brain stem auditory evoked response, failed to disclose the precise location and nature of the lesion. Abnormal ocular movement was fluctuating for 4 months and gradually disappeared without any medication. In conclusion, the faintness could be considered to result from a lesion of reticular activating system adjacent to the IVth cranial nerve nucleus and its rostral (excitatory or inhibitory) supranuclei, and it suggests that a responsible lesion of the abnormal ocular movement is located at a region of the dorsomedial midbrain." }, { "id": "pubmed23n0494_1430", "title": "Rapid, painless unilateral vision loss in a 37-year-old healthy woman.", "score": 0.008928571428571428, "content": "A 37-year-old woman experienced painless, progressive vision loss to no light perception in the left eye over the course of 3 days. The right eye was unaffected. On examination, the only other abnormal finding was a +4 left afferent pupillary defect. She was initially diagnosed with retrobulbar optic neuritis and admitted for treatment with intravenous methylprednisolone. Neuro-imaging revealed a large right anterior cerebral artery aneurysm that crossed the midline to compress the left optic nerve. The aneurysm was treated with coil embolization, which was technically successful but which did not lead to significant improvement in vision." }, { "id": "pubmed23n0085_11973", "title": "[Subacute sensory neuropathy manifestated by tonic pupils associated with small cell carcinoma of the lung].", "score": 0.008849557522123894, "content": "Only a few cases of carcinomatous neuropathy with tonic pupils have been reported. In the present paper we described a 53-year-old woman with subacute sensory neuropathy who had presented with bilateral tonic pupils. She noticed numbness over the medial aspect of the left thigh in March, 1988, and then developed dysesthesia over the left forearm and hand, mild weakness of left upper and lower extremities and urinary disturbance. Neurological symptoms were subacutely progressive and she was bed-ridden in May. She was admitted to our hospital in June, 1988. On examination, she had body-weight loss of 6 kg during the last six months and general status was otherwise unremarkable. She had anisocoria; the left pupil was larger in daylight than the right, while smaller in dim light. The left pupil scarcely reacted to light, but promptly constricted to near vision. The right pupil constricted normally to light and near vision. An instillation of 0.0625% pilocarpine solution showed supersensitive response of both pupils. An instillation of 1.25% epinephrine solution demonstrated mild dilation of both pupils. Thus, it was conceivable that she had postganglionic ciliary nerve damage characteristic of tonic pupil as well as the lesion of sympathetic nerve innervating pupillary dilator. She had severe sensory ataxia and pseudoathetosis of the hands. Weakness was mild to moderate in extremities. Almost all deep tendon reflexes were absent. All modalities of sensation, particularly on deep sense, were severely involved with sea-level-type distribution below Th7, and over C2 to C3 regions on the left side.(ABSTRACT TRUNCATED AT 250 WORDS)" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 25, 244 ] ], "word_ranges": [ [ 5, 41 ] ], "text": "A common bile duct cyst is a congenital pathology that usually presents clinically beyond the neonatal period. It is appropriate to have a quality image that delimits the lesion in order to decide the surgical approach." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "A percutaneous puncture for peritoneal lavage will be performed to verify that the cyst contains bile in order to leave a drainage to improve the abdominal pain.", "2": "An exploratory laparotomy will be indicated and a radical resection of the entire biliary tract will be performed to replace it with a loop of intestine.", "3": "A laparotomy will be indicated to drain the cyst and when the dilatation remits the drainage will be removed.", "4": "A cholangio-resonance will be performed to delimit the cyst and a laparotomy will be indicated for cyst resection and anastomosis of the biliary tract.", "5": "A HIDA gammagraphic study is necessary to delimit the cyst and to be able to perform percutaneous drainage safely." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1071_21741", "title": "Comparison and Selection of Three Methods of Minimally Invasive External Drainage for Children with Congenital Choledochal Cysts.", "score": 0.015924741760944418, "content": "<b<iAim:</i</b Emergent biliary drainage is necessary due to acute symptoms of choledochal cysts. Percutaneous biliary drainage (PBD), laparoscopic bile duct drainage (LBD), and laparoscopic cholecystostomy (LC) are the three most common drainage treatments. So far, there is no comparative study on these three approaches, which all have been applied in our hospital. This article compares the drainage effects of these three approaches and illustrates their respective merits and demerits, with the aim of providing a reference for clinical application. <b<iMaterials and Methods:</i</b We conducted a retrospective study of 20 children who underwent biliary drainage before their definitive surgery due to acute symptoms of choledochal cysts between June 2008 and May 2015. Among them, 6 underwent PBD, 8 underwent LBD, and 6 underwent LC. <b<iResults:</i</b Preoperative abdominal pain, fever, and jaundice symptoms were effectively relieved by the three approaches. There were no significant differences in terms of the recovery of liver functions. The average interval and duration of procedures of three groups were PBD (25.00 ± 4.47 minutes and 262.50 ± 35.74 minutes), LBD (84.37 ± 24.99 minutes and 283.75 ± 39.62 minutes), and LC (50.83 ± 13.57 minutes and 218.33 ± 28.58 minutes), respectively. <b<iConclusions:</i</b LC has advantages of a comparatively simple operation and no foreign body sensation (external drain) in the hepatic duct, which is beneficial for relieving inflammation of the common bile duct, and thus is suitable for majority of patients needing external bile drainage. Meanwhile, PBD and LBD also have their respective applicable patients." }, { "id": "pubmed23n0860_10625", "title": "Endoscopic biliary drainage as a bridging procedure to single-stage surgery for perforated choledochal cyst: a case report and review of the literature.", "score": 0.01589323627540188, "content": "Choledochal cyst (CC)-a congenital anomaly of the bile duct-is rare. We report a 28-year-old woman complaining of epigastralgia who was transferred to our hospital. Physical examination revealed severe tenderness to abdominal palpation without symptoms of diffuse peritonitis. Urgent contrast-enhanced abdominal computed tomography indicated the dilated common bile duct (CBD) was perforated, with a presumed diagnosis of perforated CC. Endoscopic external biliary drainage was performed immediately as a bridging procedure to the definitive surgery. Additional evaluations confirmed a type IVa CC, according to Todani's classification, but no signs of malignancy. Twenty-two days after biliary drainage, laparotomy was performed. A large cystic mass was found in the CBD with a perforated scar on the right-side wall. Because inflammation around the pancreas head was too severe to perform cyst excision safely, the patient underwent subtotal stomach-preserving pancreatoduodenectomy. The postoperative course was uneventful, and the patient was discharged on the 29th postoperative day. Pathologic examination of a specimen showed no malignancy, and the patient has remained well during the 3-year follow-up. Our experience with this case suggests that definitive single-stage surgery for perforated CC in an adult can be performed safely owing to external biliary drainage as a bridging procedure, if manifestation of diffuse peritonitis is not evident. " }, { "id": "pubmed23n0821_22785", "title": "Ruptured choledochal cyst: a rare presentation and unique approach to management.", "score": 0.015229885057471264, "content": "We present the rare case of a ruptured choledochal cyst (CC) in a young woman presenting with a two-day history of worsening upper abdominal pain. Imaging revealed a contracted gallbladder, dilated common bile duct (CBD), and a large amount of peritoneal fluid. Percutaneous paracentesis was performed, obtaining bilious fluid. Further imaging revealed cystic dilatation of the CBD and the diagnosis of rupture CC type I was made. The patient was initially managed conservatively with percutaneous drains, IV antibiotic therapy, and sphincterotomy through an ERCP. Elective cyst resection and Roux-en-Y hepatojejunostomy was performed 8 weeks later. It is important to differentiate a ruptured CC from other surgical emergencies without exploratory laparotomy. Initial conservative management could be considered, followed by elective resection once inflammation, infection, and other complications have resolved, avoiding the increased risk associated with an emergency operation or two-stage laparotomy. " }, { "id": "pubmed23n0354_21039", "title": "[Obstructive jaundice caused by hydatid cyst rupture in main bile duct].", "score": 0.0147932131495228, "content": "Hydatid hepatic cyst rupture into bile duct is a complication of hydatid disease. The rupture is more frequent in right or left epatic duct and occasionally in common bile duct (7-9%). A 50-year old man came to emergency room owing to jaundice, fever and abdominal pain. TC show an hydatid cyst with daughter's cyst of left liver and dilatation of biliary tree. Laboratory data of significance included an increased of liver function tests (Bilirubin, Alkaline ph., SGOT, SGPT), VES and leukocytosis. The patients was surgically treated, by total pericystectomy, colecystectomy and coledocotomy with lavage o common bile duct; finally we placed one Kehr drainage and two abdominal drainage. After 15 days of postoperative hospitalization patient was discharged. The best treatment of hydatid cyst is total pericystectomy (when possible). An alternative surgical treatment is possible for the presence of communication with biliary tree. ERCP is very important for a correct diagnosis and for a complete surgical treatment." }, { "id": "pubmed23n0500_12670", "title": "Cholecystectomy alone is inadequate for treating forme fruste choledochal cyst: evidence from a rare but important case report.", "score": 0.01384895533831704, "content": "Treatment of \"forme fruste\" choledochal cyst (FFCC) where pancreaticobiliary malunion (PBMU) is associated with minimal dilatation of the common bile duct (CBD) remains controversial. PBMU allows pancreaticobiliary reflux to occur, which causes complications such as recurrent pancreatitis and gallbladder cancer. Therefore, some surgeons opt to treat FFCC by cholecystectomy alone in order to prevent gallbladder cancer, with the result that pancreaticobiliary reflux could still occur. Our treatment of choice-excision of both the CBD and the gallbladder, followed by Roux-en-Y hepatico-jejunostomy-can eliminate pancreaticobiliary reflux and prevent complications. Our case, a 2-year-old boy, initially presented to a hospital abroad with recurrent abdominal pain. Endoscopic retrograde cholangiopancreatography showed massive protein plugs impacted in the papilla of Vater and mild CBD dilatation, but PBMU was not identified. Intraoperative cholangiography performed during laparotomy 5 days later suggested PBMU with minimal CBD dilatation. Despite these findings, cholecystectomy with T-tube drainage was performed rather than CBD excision with biliary reconstruction. Postoperative T-tube cholangiography clearly showed PBMU. The T-tube was removed after 2 weeks, and 3 months later the boy was referred to us because of recurrent pancreatitis. We performed CBD excision and Roux-en-Y hepatico-jejunostomy. His postoperative course was uneventful, and he is well after 10 years of follow-up. This case provides strong evidence that CBD excision with biliary reconstruction is mandatory for treating FFCC and, conversely, that cholecystectomy alone is inadequate for treating children with FFCC." }, { "id": "wiki20220301en071_6934", "title": "ICD-9-CM Volume 3", "score": 0.013453458306399484, "content": "() Repair of liver () Other operations on liver () Operations on gallbladder and biliary tract () Cholecystotomy and cholecystostomy () Diagnostic procedures on biliary tract () Endoscopic retrograde cholangiopancreatography (ERCP) () Cholecystectomy () Anastomosis of gallbladder or bile duct () Incision of bile duct for relief of obstruction () Other incision of bile duct () Local excision or destruction of lesion or tissue of biliary ducts and sphincter of Oddi () Repair of bile ducts () Other operations on biliary ducts and sphincter of Oddi () Other operations on biliary tract () Operations on pancreas () Pancreatotomy () Diagnostic procedures on pancreas () Local excision or destruction of pancreas and pancreatic duct () Marsupialization of pancreatic cyst () Internal drainage of pancreatic cyst () Partial pancreatectomy () Total pancreatectomy () Radical pancreaticoduodenectomy () Transplant of pancreas () Other operations on pancreas" }, { "id": "pubmed23n1072_10395", "title": "Biliary Peritonitis Caused by Spontaneous Bile Duct Rupture in the Left Triangular Ligament of the Liver after Endoscopic Sphincterotomy for Choledocholithiasis.", "score": 0.012861869313482217, "content": "Spontaneous bile duct rupture is a rare condition in adults, with only 70 cases reported. Increased bile duct wall pressure may lead to rupture and biliary peritonitis. In this patient, the bile duct ruptured in the hepatic left triangular ligament. A 91-year-old man underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and endoscopic retrograde biliary drainage (ERBD) placement. One week later, removal of the ERBD and common bile duct stones and an endoscopic sphincterotomy (EST) were performed. Four days later, the patient had abdominal pain, increased inflammatory reaction, and jaundice. Abdominal computed tomography showed ascites, bile duct dilatation and fluid collection under the liver (10 cm in diameter). Emergency surgery was performed to drain the fluid. On laparotomy, encapsulated biliary ascites was seen. To search for the site of the leak, after cholecystectomy, a tube (C-tube) was inserted into the common bile duct via cystic duct stump. Because of uncontrollable bleeding, after packing with surgical gauze, the operation was temporarily stopped. The next day, reoperation was performed. Intraoperative cholangiography with contrast dye revealed the perforation site in the left triangular ligament and a partial resection was performed. Bile excretion from the C-tube was subsequently observed, but the patient's jaundice did not improve. Although endoscopic retrograde cholangiopancreatography revealed that the EST site was normal, ERBD was placed again, and the jaundice gradually improved. Although EST was performed in this case, biliary peritonitis resulting from spontaneous bile duct rupture occurred. This case was very informative because biliary perforation may occur even after EST." }, { "id": "wiki20220301en144_7134", "title": "Percutaneous transhepatic cholangiography", "score": 0.01256635250785397, "content": "Cholangiography during a biliary drainage intervention is called perioperative or primary choloangiography, and when performed later in the same drain it is called secondary cholangiography. Indications Cholestatic jaundice, to exclude extra hepatic bile duct obstruction, prior to biliary drainage procedure. If endoscopic retrograde cholangiopancreatography has failed and/or there is an obstruction in the proximal biliary tree. Contraindications Bleeding tendency Biliary tract sepsis Being unfit for surgery Hydatid cysts Ascites CLD (Chronic liver disease)" }, { "id": "wiki20220301en144_7135", "title": "Percutaneous transhepatic cholangiography", "score": 0.012149432669663883, "content": "Contraindications Bleeding tendency Biliary tract sepsis Being unfit for surgery Hydatid cysts Ascites CLD (Chronic liver disease) Complications Percutaneous transhepatic cholangiography may increase the incidence of metastasis, tube dislocation, and bleeding when compared to endoscopic biliary drainage. However, it has lower rate of cholangitis, pancreatitis when compared to endoscopic biliary drainage, probably because the latter has higher chance of incomplete drainage of infected bile, or accidental resection of papilla that causes the backflow of infected bile from the duodenum into the biliary system. References External links Medline page Projectional radiography Digestive system imaging" }, { "id": "Surgery_Schwartz_9335", "title": "Surgery_Schwartz", "score": 0.010994034919667349, "content": "in the distal common bile duct behind the duodenum.Brunicardi_Ch32_p1393-p1428.indd 140811/02/19 2:43 PM 1409GALLBLADDER AND THE EXTRAHEPATIC BILIARY SYSTEMCHAPTER 32decompression. This is most often accomplished through ERCP and sphincterotomy. ERCP will show the level and the reason for the obstruction, allow for culture of the bile, permit the removal of stones if present, and accomplish drainage of the bile ducts. Placement of drainage catheters or stents can also be performed if needed. In cases in which ERCP is not available, PTC, EUS, or surgical drainage can be utilized. The selection of the appropriate approach will depend on the type and location of the suspected obstruction as well as the avail-ability of local resources and expertise. Cholecystostomy tubes are not indicated in the acute management of cholangitis as the primary source of the infection is extrinsic to the gallbladder.Patients with cholangitis can deteriorate rapidly and may require intensive care unit" }, { "id": "pubmed23n0592_9438", "title": "[A case of choledochal cyst complicated by biliary peritonitis].", "score": 0.009900990099009901, "content": "Choledochal cyst is a rare congenital malformation of the extrahepatic bile ducts. Its incidence varies among different populations, but it is highest in North East Asia. It is most frequent in childhood, and very rare in adults. A 7-year-old boy was admitted to the hospital with severe abdominal pain under the right rib margin. He presented with constant nausea, occasional jaundice and high coloured urine. The following day the boy underwent ultrasound examination and computer tomography (CT). A choledochal cyst was found, and a CT-controlled puncture of the cyst was performed. An Xray was taken by injecting contrast medium through the drain. A small leakage into the abdominal cavity was observed with subsequent peritonitis. The general condition of the child deteriorated and a decision was made to operate immediately. An upper medial laparotomy was performed. A cystic formation was noted in the hepatoduodenal ligament of 90 x 70 mm in dimension. The cyst was completely removed and a hepaticojejunal anastomosis was performed The child tolerated the surgery well and recovered quickly. Cystic dilation of the common bile duct, known as choledochal cyst, is related to a rare malformation of this region. The exact mechanism of cyst formation remains unknown. Choledochal cysts usually present in the early childhood, with higher frequency in females. The diagnosis is easily made, especially with the use of ultrasound and computed tomography. The treatment is usually surgical, and complete resection of the cyst with hepatico-jejunal anastomosis is the therapy of choice. One year later, ultrasound examination and specific dynamic tests (HIDA) showed normal liver function, and good anastomosis." }, { "id": "pubmed23n0703_13798", "title": "EUS-Guided Biliary Drainage.", "score": 0.009900990099009901, "content": "The echoendoscopic biliary drainage is an option to treat obstructive jaundices when ERCP drainage fails. These procedures compose alternative methods to the side of surgery and percutaneous transhepatic biliary drainage, and it was only possible by the continuous development and improvement of echoendoscopes and accessories. The development of linear setorial array echoendoscopes in early 1990 brought a new approach to diagnostic and therapeutic dimenion on echoendoscopy capabilities, opening the possibility to perform punction over direct ultrasonographic view. Despite of the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty could be found at the presence of stent tumor ingrown, tumor gut compression, periampulary diverticula, and anatomic variation. The echoendoscopic technique starts performing punction and contrast of the left biliary tree. When performed from gastric wall, the access is made through hepatic segment III. From duodenum, direct common bile duct punction. Dilatation is required before stent introduction, and a plastic or metallic stent is introduced. This phrase should be replaced by: diathermic dilatation of the puncturing tract is required using a 6F cystostome. The technical success of hepaticogastrostomy is near 98%, and complications are present in 36%: pneumoperitoneum, choleperitoneum, infection, and stent disfunction. To prevent bile leakage, we have used the 2 stent techniques, the first stent introduced was a long uncovered metallic stent (8 or 10 cm), and inside this first stent a second fully covered stent of 6 cm was delivered to bridge the bile duct and the stomach. Choledochoduodenostomy overall success rate is 92% and described complications include, in frequency order, pneumoperitoneum and focal bile peritonitis, present in 19%. By the last 10 years, the technique was especially performed in reference centers, by ERCP experienced groups, and this seems to be a general guideline to safer procedure execution." }, { "id": "InternalMed_Harrison_24277", "title": "InternalMed_Harrison", "score": 0.00987627043747238, "content": "Choledochal Cysts Cystic dilatation may involve the free portion of the 2083 CBD, i.e., choledochal cyst, or may present as diverticulum formation in the intraduodenal segment. In the latter situation, chronic reflux of pancreatic juice into the biliary tree can produce inflammation and stenosis of the extrahepatic bile ducts leading to cholangitis or biliary obstruction. Because the process may be gradual, ∼50% of patients present with onset of symptoms after age 10. The diagnosis may be made by ultrasound, abdominal CT, MRC, or cholangiography. Only one-third of patients show the classic triad of abdominal pain, jaundice, and an abdominal mass. Ultrasonographic detection of a cyst separate from the gallbladder should suggest the diagnosis of choledochal cyst, which can be confirmed by demonstrating the entrance of extrahepatic bile ducts into the cyst. Surgical treatment involves excision of the “cyst” and biliary-enteric anastomosis. Patients with choledochal cysts are at increased" }, { "id": "Surgery_Schwartz_9428", "title": "Surgery_Schwartz", "score": 0.00980392156862745, "content": "to dilatation of the extraand intrahepatic bile ducts as well as the gallbladder. Initial imaging is important to determine the level of obstruction and to rule out the presence of bile duct stones as the cause of the obstructive jaundice (Fig. 32-32). It is usually difficult to visualize the tumor itself on ultrasound, CT, or even MRCP, but any of these modalities can provide an outline of biliary anatomy, an estimate of the level of obstruc-tion, evaluation of portal vein patency, and screening for nearby lymphadenopathy. Detailed evaluation of the biliary anatomy and tumor itself is best completed through cholangiography. ERCP is generally adequate, but in cases where the proximal extent of the tumor remains in question, PTC may be required to determine resectability.Tissue diagnosis may be difficult to obtain. Current diag-nostic techniques including fine-needle aspiration (percutaneous or endoscopic), and biliary brushings have been shown to have a low sensitivity in detecting" }, { "id": "wiki20220301en105_10328", "title": "Ascending cholangitis", "score": 0.00971058644325971, "content": "Percutaneous biliary drainage In cases where a person is too ill to tolerate endoscopy or when a retrograde endoscopic approach fails to access the obstruction, a percutaneous transhepatic cholangiogram (PTC) may be performed to evaluate the biliary system for placement of a percutaneous biliary drain (PBD). This is often necessary in the case of a proximal stricture or a bilioenteric anastomosis (a surgical connection between the bile duct and small bowel, such as the duodenum or jejunum). Once access across the stricture is obtained, balloon dilation can be performed and stones can be swept forward into the duodenum. Due to potential complications of percutaneous biliary drain placement and the necessity of regular drain maintenance, a retrograde approach via ERCP remains first-line therapy." }, { "id": "pubmed23n0060_11482", "title": "Controversy in the management of cholangitis secondary to hydatid daughter cysts.", "score": 0.009708737864077669, "content": "A 36 year old Cypriot woman, resident in the U.K. since the age of three years, presented with pyrexia, jaundice and upper abdominal pain. On ultrasound examination the biliary tree was dilated, contained sludge and a cystic lesion was present in the liver. An endoscopic cholangiogram showed multiple filling defects in the bile duct which were not felt to be removable endoscopically and a nasobiliary drain was therefore inserted. On resolution of the cholangitis with drainage and antibiotics a laparotomy was performed. The right lobe of the liver was largely replaced by a multiloculated cyst and the bile duct contained multiple hydatid daughter cysts. A right hepatectomy was performed with t-tube drainage of the evacuated bile duct. She made an uneventful recovery and has had no problems on subsequent follow up. Histology confirmed an intrabiliary rupture of a hydatid liver cyst. Cholangitis secondary to daughter cysts is a rare but recognised complication of hydatid liver cysts. Management of hydatid liver cysts by formal resection is controversial but may be preferable in this situation." }, { "id": "pubmed23n0257_16883", "title": "[Argument for choledochostomy, intraoperative endoscopy and external biliary drainage in the treatment of lithiasis of the common bile duct. A 15-year experience].", "score": 0.009708737864077669, "content": "The treatment of common bile duct stones is controversial. The objective of our study was to report the results of choledochotomy, rigid choledochoscopy and systematic external biliary drainage in the treatment of stones of the common bile duct. Over a 15-year period, 555 patients were operated in our department according to a precise surgical protocol. 14% of these patients were operated as an emergency and 11.8% were operated immediately after endoscopic sphincterotomy. One third of patients suffered from cholangitis. The endoscopic investigation of the common bile duct was positive in 81.5% of patients. The investigation was negative in 18.5% and negative choledochotomy was significantly more frequent in patients operated for acute pancreatitis (p &lt; 0.05). External biliary drainage was performed in 95.7% of patients. When necessary, a bilioenteric anastomosis (3%) or a surgical sphincterotomy (1.9%) was also performed. The postoperative mortality rate was 4.8% significantly higher in patients over the age of 70, in patients operated as an emergency and in patients operated immediately after endoscopic sphincterotomy (p &lt; 0.05). The morbidity rate was 8.4%. Residual stones were diagnosed in 4.4% of the patients. The presence of residual stones was significantly more frequent in patients with multiple stones of the common bile duct (p &lt; 0.05). Long-term follow-up was available for 89% of patients, 95% of whom were asymptomatic. These results, based on a homogeneous therapeutic protocol, can be used as a reference for the evaluation of other techniques, especially endoscopic and laparoscopic techniques." }, { "id": "wiki20220301en071_6935", "title": "ICD-9-CM Volume 3", "score": 0.009615384615384616, "content": "() Internal drainage of pancreatic cyst () Partial pancreatectomy () Total pancreatectomy () Radical pancreaticoduodenectomy () Transplant of pancreas () Other operations on pancreas () Anastomosis of pancreas () Repair of hernia hernia repair () Other operations on abdominal region () Laparotomy () Other operations of abdominal region () Percutaneous abdominal drainage Paracentesis" }, { "id": "pubmed23n0037_245", "title": "[Ways of mortality reduction after operations on the extrahepatic bile ducts].", "score": 0.009615384615384616, "content": "Based on the analysis of the immediate results of 231 operations on extrahepatic bile ducts, 174 primary interventions and 57 reoperations, it is concluded that the operation at the height of the attack of acute cholecystitis or in total obturation of bile passages yields considerable mortality (1/3 and 1/5 of observations, accordingly). The best results of surgery were obtained in attenuation of acute inflammatory phenomena in the gallbladder under conditions of liquidation of obturation of extrahepatic bile ducts (1/7 of observations). However, bile peritonitis and progression of destructive acute cholecystitis would necessitate an urgent operation. According to the authors' data well-grounded indications to surgery, a selection of optimum terms and extent of its accomplishment could contribute to favourable immediate results of surgical therapy for diseases of extrahepatic ducts." }, { "id": "pubmed23n0723_15086", "title": "Indirect biliary drainage as an alternative solution for biloma due to complicated biliary drainage.", "score": 0.009523809523809525, "content": "Pancreas cancer has increased morbidity and mortality. It generally result in biliary obstruction which life threatening importance. Main biliary drainage method is endoscopic retrograde cholangiopancreatography. When endoscopic retrograde cholangiopancreatography is not successful, second preferred method is percutaneous biliary drainage. Percutaneous biliary drainage has some complications which is an invasive procedure. A complication of percutaneous biliary drainage due to patient iatrogenity which was not ever reported in the literature biliary drainage according to our literature research. In these circumstances an alternative solution is indirect biliary drainage." }, { "id": "pubmed23n0510_13946", "title": "[Congenital dilatation of the common bile duct (congenital choledochal cyst)].", "score": 0.009433962264150943, "content": "Choledochal cyst, although a rare disease, is the most frequent malformation of the extrahepatic biliary ducts. The review of the world medical literature gives the overall number of 2500 cases of choledochal cyst. The incidence of this disease is about 1 in 2000000, but it is about four times more frequent in the Yellow race, and 3 times more frequent in females. Congenital choledochal cyst is a disease of paediatric population, as 60% of all patients are younger than 10 years. The basic anomaly of the disease is the embryological arrest of the normal migration of the pancreaticobiliary junction towards the duodenal wall. The result of the disturbance is the extraduodenal location of the pancreaticobiliary junction and the abnormally long common biliopancreatic channel. The flow of bile and pancreatic juice in the duodenal luminary space is insufficient, so the accumulation of bile and pancreatic juice in the common channel and the reflux of this activated mixture towards biliary ducts occur. Choledochal cyst is formed with all its complications: cholangitis, liver abscess, biliary stone formation, biliary cirrhosis, acute and chronic relapsing pancreatitis, and after many years, biliary cancer. Our results in the treatment of this disease are given. We operated on 31 paediatric patients for choledochal cyst over the period 1978-1998. The study is both retrospective and prospective. There were 24 girls and 7 boys, from neonates to teenagers. In 83 percent of patients the complaints started during the first 3 years of life. Unfortunately, only in 22% of patients the complaints were lasting less than 3 months untill the time of operation. The basic complaints were: abdominal pain and jaundice in 95% of patients, vomiting in 74%, high temperature and fever in 56% and palpabile tumour in 48%. About 30% of children had a relapsing cholangitis and 35% of patients an acute or chronic relapsing pancreatitis. Biliary stones were found in 18% of patients. High level of bilirubins was found in 52% of patients, serum transaminase (SGOT and SGPT) in 69%, amylase level was elevated in blood and urine in about half of the patients, and in choledochal cyst in 91%. Ultrasonography was carried out in 78% of patients and has proved to be a very good screening diagnostic tool. Endoscopic retrograde cholangiopancreaticography (ERCP) was performed in most of the patients. The only treatment of choledochal cyst is surgical. The conservative treatment is reserved only for complications (pancreatitis, cholangitis). The only adequate surgical treatment is the radical treatment, which consists of the resection of the whole anomalous choledochus and definitive separation of bile ducts from the pancreatic duct. This is achieved by the technique of Roux-en-Y hepaticojejunostomy. The paliative method of internal drainage of choledochal cyst consists of cystoduodeno or cystojejunostomy, but is now abandoned, as the disease continues with all its manifestations and complications. The internal drainage was performed in 6 our patients, but one of them died (a neonate with sepsis at admitance). Three patients were excluded from the study, and 2 girls were later radically reoperated on. In all other 25 patients resection of the whole choledohus and Roux-Y hepaticojejunostomy were carried out. There were neither operative, nor postoperative deaths. Except the temporary bile leaking, spontaneously healed, there were no significant intraoperative complications. All patients were regularly followed-up, they had no complaints, and all their laboratory and ultrasonographic findings were normal. Congenital dilatation of biliary ducts is a rare disease, but it must be considered in differential diagnosis of unclear upper abdominal pains, jaundice and pancreatitis in children. In the diagnosis of this disease the ultrasound imaging is of utmost importance as a screening method, and endoscopic retrograde cholangio-pancreaticography as a method of complete visualization. Resection of the diseased common bile duct and Roux-Y hepatico-jejunostomy are the method of choice in the treatment of children with choledochal cyst." }, { "id": "pubmed23n0344_10148", "title": "[Diagnosis and treatment of congenital choledochal cyst].", "score": 0.009433962264150943, "content": "From January 1980 to June 1996, 82 patients with congenital choledochal cysts were treated and 76 of them were operated on B-ultrasonic diagnosis was made with a correct diaginostic rate of 93.9%. The total effective rate was was 78.4% after follow-up for 84 months. Resection of the cyst with Roux-Y hepaticojejunostomy was successful in 96.2% of the patients. Outer drainage was used as the first-aid measure. Cystoduodenostomy and cystojejunostoy which may lead to complications should be abandoned." }, { "id": "pubmed23n1122_16333", "title": "Diagnostic challenges and management of choledochal cyst in an 11-year-old child: a delayed diagnosis (a case report).", "score": 0.009345794392523364, "content": "Choledochal cyst are rare congenital disease of the biliary tree. It presenting as cystic dilatations of the biliary tree can involve the extrahepatic biliary radicles, the intrahepatic biliary radicles or both. They are typically a surgical problem of infancy and childhood, but less than a quarter of the patients the diagnosis is delayed until adulthood as it presenting with vague and nonspecific signs and symptoms. In a case with biliary symptoms, abdominal ultrasound scan is the initial imaging modality of choice. Precise and accurate delineation of the biliary system mandates cholangiography with the advantage of non-invasive magnetic resonance cholangiopancreatography (MRCP) over endoscopic retrograde cholangiopancreatography. A case report of 11-year-old Tanzania girl with abdominal swelling and jaundice presented to a health facility for evaluation. She complained of abdominal swelling that her mother noticed when she was 3 years old, located above the umbilicus and since then it was not changed its size until 8 years later when it rapidly increased in size associated with non-specific dull pain. Abdominal computed tomography (CT) scan was done showed A well-defined hypo-attenuated non-enhancing retro-gastric cyst. Percutaneous transhepatic cholangiopancreatography (PTC) was performed due to inconclusive findings from CT-scan showed extrahepatic huge cystic dilatation, dilated central right hepatic ducts, left intrahepatic ducts failed to be visualize. Diagnosis of choledochal cyst type isovaleric acidaemia (IVA) was made. Explorative laparotomy was done, huge cystic mass occupying common bile duct was seen below the liver with distended gallbladder covered with visceral peritoneum. Second part of duodenum, pancreases and transverse colon was adhered to the inferior surface of the mass that further make difficult for cyst excision and reconstruction. Cyst was decongested and cholangioenterostomy with Roue-en-Y reconstruction was made. Cholecystectomy was done, hemostasis archived abdomen closed and patient sent to Intensive care units (ICU). Despite of advanced diagnostic modalities, delayed diagnosis of choledochal cyst can be a challenge due to its vague and nonspecific signs and symptoms. Excision of the cyst and reconstruction by hepatojejunostomy as the standard therapy could be difficult due to its biliary complications such as adhesion and infection and hence cyst-enterostomy drainage procedure can be done as option for relief of patient discomfort and prevent further complications." }, { "id": "pubmed23n0494_2383", "title": "[Common bile duct stones: the surgical treatment is always valid].", "score": 0.009259259259259259, "content": "The treatment of common bile duct stones has changed with the new therapeutic techniques, that have replaced the conventional therapy, represented by surgery. Anyway, they could cause some problems, that must be regarded. Therefore, we wish to confirm the importance of the conventional surgery in the management of patients with common bile duct stones. A total of 147 patients were operated for common bile duct stones (73 in emergency and 74 in election). The intraoperative cholangiography was carried out in 141 patients and a choledocoscopy in 130 patients. A drain of Kehr was positioned in 120 patients, a bilio-digestive anastomosis in 26 cases and in 1 case there was a direct suture of the common bile duct without drain. All patients were treated with a short-term antibioticotherapy, protracted to 5 days in the emergency cases. In the patients with the drain of Kehr there was a control cholangiography after 7 days from operation and it was removed after 25 days. The analysis of the results was done dividing the patients according to the age: &lt;75 years old and &gt;75 years old. Nobody died during the operation. Complications were 17.4% in the patients &gt;75 years old and 2,6% in the patients &lt;75 years old. There were 2 death, in the postoperative period, for the group &gt;75 years old. Cases operated in emergency were 68.1% of \"old\" patients and 37.2% of \"young\" patients. The postoperative period was 14.9+/-9.2 days for the \"old\" group and 10.9+/-5.2 days for the \"young\" group. The treatment of common bile duct stones is still a surgical treatment, particularly for \"old\" patients." }, { "id": "pubmed23n0309_15438", "title": "[Bile duct cysts in adults].", "score": 0.009174311926605505, "content": "Bile duct cysts are rare, congenital dilations of the intrahepatic and/or extrahepatic biliary tract. Most of them present during childhood. The classical triad right upper quadrant pain, jaundice and abdominal mass is present only in a few instances. We report here the bile duct cysts which were diagnosed at our institution from 1989 to 1996. 3245 consecutive endoscopic retrograde cholangiopancreatograms (ERCP) were evaluated retrospectively. Diagnosis was made when localized cystic dilations of the intrahepatic and/or extrahepatic biliary tract were present. Diffuse dilations of the intrahepatic and extrahepatic biliary tract were excluded. Bile duct cysts were found in 20 patients (17 females, 3 males) among 3245 ERCPs. Their mean age was 56 +/- 20 (median 64, range 10 to 83) years. The cyst types (according to the Alonso-Lej classification with the Todani modification) were type I in 11 (55%), type II, III and IV in two instances each (10%), and type V (or Caroli's disease) in 3 patients (15%). Leading symptoms were cholestasis in 14 patients, 10 of whom had abdominal pain, jaundice in 4 patients, and single cases of pancreatitis, cholangitis, and abdominal mass. In 2 patients the diagnosis was made incidentally. 10 patients had bile duct stones. We performed endoscopic sphincterotomy in 15 patients with concretions or persistent symptoms, 3 patients had cyst resection. One of these, with a type I cyst, already had a disseminated cholangiocarcinoma. 10 of 17 patients without cyst resection are currently symptom-free after complete removal of all gallstones. One male patient with cholecystolithiasis, who is not operable due to advanced liver disease, has recurrent cholangitis, 4 patients have died from causes unrelated to the bile duct cysts, and 2 patients are lost to follow up. Bile duct cysts in adults are rare. There is a preponderance in the female gender, and the most common type is the extrahepatic (choledochal) cyst. The leading symptoms are cholestasis and right upper quadrant pain. There is an increased risk of cholangiocarcinoma. In young patients the cysts should be entirely removed to prevent malignancy. Older persons are usually symptomless after complete removal of gallstones." }, { "id": "pubmed23n0057_1278", "title": "[Diagnosis and surgical treatment of cancer of the gallbladder and extrahepatic bile ducts].", "score": 0.009174311926605505, "content": "Data on 148 cases of cancer of the gallbladder and extrahepatic bile ducts were studied. Jaundice proved the cardinal symptom. No clear-cut clinical picture of the disease was identified. Diagnostic procedure should start with ultrasonography. Cholangiectasia and the enlarged pancreatic head make the case for fiber bronchoscopy and hypotonic duodenography. Cancer-negative patients should further undergo transcutaneous transhepatic cholangiography and, if proving still negative, retrograde cholangiopancreatography. Resection of bile ducts with simultaneous lymphadenectomy is considered radical. The authors suggest a surgical procedure for cancer of the gallbladder which includes resection of the liver, hepatico-choledoctomy and cholecystectomy with formation of cholangio-jejuno-anastomosis using disposable transhepatic drains. Recanalization of bile ducts by transhepatic drain is considered optimal for palliation. Survival depends upon extent of surgery and level of bile duct obstruction." }, { "id": "pubmed23n0946_16353", "title": "Obliterative cholangiopathy in acquired cystic biliary atresia type III after cyst perforation: a case report.", "score": 0.00909090909090909, "content": "In biliary atresia, the disease process of obliterative cholangiopathy may begin in the perinatal period; however, no chronological evidence exists on how the cholangiopathy progresses to biliary obliteration. This is the first acquired case with the final diagnosis of type III cystic biliary atresia with an extrahepatic biliary cyst which showed the progression of obliterative cholangiopathy in chronological order after birth. An 81-day-old girl presented with acute abdominal distress due to bilious peritonitis caused by biliary cyst perforation, for which she underwent emergency biliary drainage. Postoperative images showed a dilated common bile duct and hepatic ducts bilaterally, with flow of the contrast medium to the duodenum through the dilated common bile duct. Biochemistry of the bile collected during and after the operation revealed elevated levels of pancreatic enzymes in the bile from the gallbladder. The patient was diagnosed as having a congenital choledochal cyst and underwent laparotomy at 120 days of age which revealed that she had pancreaticobiliary maljunction. The biliary cyst was resected at the narrow portion just above the junction with the main pancreatic duct. During dissection up to the hepatic hilum, we found that the hilar hepatic ducts were bilaterally replaced by fibrous tissue and were obstructed, leading to a diagnosis of type III a1, μ biliary atresia. The fibrous tissue was excised, and hepatic portoenterostomy was performed according to the Kasai procedure. The patient's postoperative course was uneventful and the jaundice resolved within 1 month. She has had normal liver function tests with no episode of cholangitis for 3 years after discharge. We demonstrated the process of acquired type III biliary atresia in a patient with cystic biliary atresia and biliary cyst perforation. To the best of our knowledge, this is the first case of acquired cystic biliary atresia showing chronological progression of the course of obliterative cholangiopathy, providing a better understanding of the development of type III biliary atresia as an acquired disease." }, { "id": "pubmed23n0004_1493", "title": "[Drainage in biliopancreatic surgery].", "score": 0.00909090909090909, "content": "Among the various drains used in biliary tract surgery the T-tube drain proves to be most useful as a routine drainage procedure after any intervention for common duct stones. This drain allows an undisturbed healing of the common duct incision, an intra- and postoperative control cholangiography and, if necessary, a non-operative extraction of a residual stone. For high strictures of the hepatic duct we recommend the straight transhepatic drain and for palliative procedures in cases of centrally located tumors the Y-T-drain may restore bile flow from both the left and the right liver into the duodenum. If a drain in the pancreatic duct is necessary at all, one best uses a straight catheter that is brought out through the jejunum by means of a Witzel canal. The abdominal cavity is being drained routinely also for simple biliopancreatic surgery with a Penrose drain." }, { "id": "wiki20220301en159_4951", "title": "Choledochal cysts", "score": 0.009009009009009009, "content": "Choledochal cysts (a.k.a. bile duct cyst) are congenital conditions involving cystic dilatation of bile ducts. They are uncommon in western countries but not as rare in East Asian nations like Japan and China. Signs and symptoms Most patients have symptoms in the first year of life. It is rare for symptoms to be undetected until adulthood, and usually adults have associated complications. The classic triad of intermittent abdominal pain, jaundice, and a right upper quadrant abdominal mass is found only in minority of patients. In infants, choledochal cysts usually lead to obstruction of the bile ducts and retention of bile. This leads to jaundice and an enlarged liver. If the obstruction is not relieved, permanent damage may occur to the liver - scarring and cirrhosis - with the signs of portal hypertension (obstruction to the flow of blood through the liver) and ascites (fluid accumulation in the abdomen). There is an increased risk of cancer in the wall of the cyst." }, { "id": "pubmed23n0383_20793", "title": "Laparoscopic surgery and the common bile duct.", "score": 0.009009009009009009, "content": "Many biliary tract surgeons have now reached a level of sophistication with laparoscopic cholecystectomy that they are now able to deal with the common bile duct at the same time. Preoperative endoscopic cholangiography can be reserved for cases where choledocholithiasis has a high degree of probability. This has served to decrease the number of negative studies. The surgeon has five choices regarding stones confirmed by operative cholangiography during laparoscopic cholecystectomy: (1) do nothing, hoping the stones will pass spontaneously or that a postoperative sphincterotomy with stone extraction will be successful; (2) perform a transcystic laparoscopic common bile duct exploration (best for stones less than 1 cm and distal to the cystic duct); (3) perform a laparoscopic common bile duct exploration by choledochotomy (best for large stones in patients with common bile ducts greater than 1 cm. It is also the preferred approach with stones proximal to the insertion of the cystic duct.); (4) perform an intraoperative sphincterotomy with stone extraction, either retrograde or antegrade (this approach has some proponents but has not gained popularity among the majority of surgeons); and (5) place a double lumen catheter through the cystic duct with a proximal lumen in the common bile duct and the distal lumen in the duodenum. This can be used for serial postoperative cholangiography to confirm spontaneous stone passage or falsely positive operative cholangiograms. It is useful in situations when laparoscopic common bile duct exploration equipment or surgeon expertise is not available. If stones persist, a guidewire can be introduced through the distal lumen of the catheter for a guidewire-assisted sphincterotomy. Other CBD interventions that have been reported include laparoscopic biliary bypass and resection of choledochal cysts. Malignant lesions should not be approached by a laparoscopic method except in unusual circumstances." }, { "id": "wiki20220301en064_5512", "title": "Pseudocyst", "score": 0.008976833976833977, "content": "Percutaneous drainage involves the guidance of a CT scan or ultrasound. A drainage catheter is placed into the fluid cavity to drain the fluid, which is then collected over several weeks into an external collection system. The catheter is removed when the drainage becomes minimal. Once the catheter is removed, contrast is injected into the cyst cavity to determine the remaining size and to monitor progress. The success rate is around 50%, and the unsuccessful drainages are mostly caused by large ductal leaks or blockage of the main pancreatic duct. This method is not recommended when patients cannot manage a catheter at home or with patients whose cysts contain bloody or solid material. Surgical drainage of a pseudocyst involves creating a pathway between the pseudocyst cavity and the stomach or small bowel. This method is generally only used if the patient cannot tolerate or failed percutaneous or endoscopic drainage. This method is more risky than the others." }, { "id": "pubmed23n0117_16417", "title": "[Common channel for bile and pancreatic ducts. Presentation of 12 cases and discussion].", "score": 0.008928571428571428, "content": "Between 1978 and 1985, 11 girls and one boy underwent an elective operation for a congenital choledochal dilatation associated with an anomalous biliopancreatic junction. In 10 out of these 12 cases the children suffered several episodes of abdominal pain, and the diagnosis was missed since a jaundice appeared. The ultrasonographic examination demonstrated in all cases a dilatation of both extra- and intrahepatic bile ducts. The preoperative diagnosis was always established by the mean of a transhepatic cholangiography (8 cases) or a percutaneous cholecystography (4 cases), which showed in every case a dilated choledochus, and a common biliopancreatic channel, 15 to 35 mm long. A high amylase level was found in the bile in 10/10 cases when it was measured. A cholecystokinin test was performed in 4 cases, resulting in each case in a considerable increase of amylase and lipase levels in bile. All children were treated by excision of the dilated choledochus and gallbladder, followed by an hepaticojejunostomy with a Roux en Y loop. The follow-up is 6 months to 5 years for 9 children: 8 are cured, and on girl, who had a major dilatation of the left intrahepatic bile ducts, suffered from episodic abdominal pain and an episode od cholangitis 6 years after the operation. The role of such a common channel in the pathogeny of congenital choledochal cysts, acute pancreatitis in children, and biliary carcinomas in young adults is discussed according to the literatures of the last 10 years." } ] } } }

{ "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, 189 ] ], "word_ranges": [ [ 0, 27 ] ], "text": "According to the SEGO, in perimenopausal women with heavy and/or prolonged menstrual bleeding who require contraception, the levonorgestrel IUD (also called MIRENA IUD) is the first option." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Total hysterectomy preserving appendages.", "2": "Combined oral contraceptives.", "3": "Endometrial ablation.", "4": "Levonorgestrel IUD.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0667_14440", "title": "Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause.", "score": 0.01951637471439452, "content": "Normal menstrual periods last 3-6 days and involve blood loss of up to 80ml. Menorrhagia is defined as menstrual periods lasting more than 7 days and/or involving blood loss greater than 80ml. The prevalence of abnormal uterine bleeding (AUB) is estimated at 11-13% in the general population and increases with age, reaching 24% in those aged 36-40 years. A blood count for red cells+platelets to test for anemia is recommended on a first-line basis for women consulting for AUB whose history and/or bleeding score justify it. A pregnancy test by an hCG assay should be ordered. A speculum examination and Pap smear, according to the French High Health Authority guidelines should be performed early on to rule out any cervical disease. Pelvic ultrasound, both abdominal (suprapubic) and transvaginal, is recommended as a first-line procedure for the etiological diagnosis of AUB. Hysteroscopy or hysterosonography can be suggested as a second-line procedure. MRI is not recommended as a first-line procedure. In idiopathic AUB, the first-line treatment is medical, with efficacy ranked as follows: levonorgestrel IUD, tranexamic acid, oral contraceptives, either estrogens and progestins or synthetic progestins only, 21 days a month, or NSAIDs. When hormone treatment is contraindicated or immediate pregnancy is desired, tranexamic acid is indicated. Iron must be included for patients with iron-deficiency anemia. For women who do not wish to become pregnant in the future and who have idiopathic AUB, the long-term efficacy of conservative surgical treatment is greater than that of oral medical treatment. Placement of a levonorgestrel IUD (or administration of tranexamic acid by default) is recommended for women with idiopathic AUB. If this fails, a conservative surgical technique must be proposed; the choices include second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency), or, if necessary, first-generation techniques (endometrectomy, roller-ball). A first-line hysterectomy is not recommended in this context. Should a hysterectomy be selected for functional bleeding, it should be performed by the vaginal or laparoscopic routes." }, { "id": "pubmed23n0568_20004", "title": "Diagnosis and treatment of menorrhagia.", "score": 0.01596617442887795, "content": "One-third of all women experience heavy menstrual bleeding at some point in their life. In western countries, about 5% of women of reproductive age will seek help for menorrhagia annually. Half of all women who consult for hypermenorrhea have some uterine abnormality, most often fibroids (among patients under 40 years of age) and endometrial polyps (above 40 years of age). Appropriate treatment considerably improves the quality of life of these patients, and it is important to make a rigorous assessment of the patient to provide the best treatment options. This guideline provides instructions on how to examine and treat women of fertile age who have menorrhagia. The subject's own assessment of the amount of menstrual blood loss does not generally reflect the true amount. All patients should undergo a pelvic examination and, if the menstrual pattern has changed substantially or if anaemia is present, a vaginal sonography should be carried out as the most important supplemental examination. Vaginal sonography combined with an endometrial biopsy is a reliable method for diagnosing endometrial hyperplasia or carcinoma, but it is insufficient for diagnosing endometrial polyps and fibroids; these can be diagnosed more reliably by sonohysterography or hysteroscopy. Non-steroidal anti-inflammatory drugs and tranexamic acid reduce menstrual blood loss by 20-60%, and the effectiveness of a hormonal intrauterine system (IUS) is comparable with that of endometrial ablation or hysterectomy. Cyclic progestogens do not significantly reduce menstrual bleeding of women who ovulate. Treatment should be started with one of the drug therapies, i.e. the IUS, tranexamic acid, anti-inflammatory drugs, or oral contraceptive. Drug treatment should be used and evaluated before surgical interventions are considered. With an effective training and feedback system, it is possible to organise the diagnostics, medical treatment and follow-up of heavy menstrual bleeding in the primary health care setting or in outpatient clinics, which reduces the burden on specialist health care." }, { "id": "pubmed23n0686_1279", "title": "One patient, two uteri, two endometrial ablations: case report of thermal balloon ablation in uterine didelphys.", "score": 0.015489084684886918, "content": "To describe the clinical application and outcomes after endometrial ablation with ThermachoiceIII (Ethicon, Somerville, NJ) in a patient with uterine didelphys with heavy menstrual bleeding. Case report. Inner-city community obstetrics and gynecology clinic. A 44-year-old Hispanic woman, gravida 3, para 0, with three spontaneous abortions. The patient underwent diagnostic hysteroscopy, gynecologic dilation and curettage, and endometrial ablation with ThermachoiceIII. Menstrual pattern at 3 months postoperatively, as either amenorrhea (complete lack of menstrual flow), hypomenorrhea (scant or minimal flow lasting &lt;5 days, requiring only light pads), or failure (flow similar to pretreatment state or requiring any other therapy), as well as dysmenorrhea reduction from baseline. Hemoglobin value at 3 months was compared with baseline. At 3 months, hypomenorrhea was maintained. Bleeding days were 10 per month at baseline and 2 per month after therapy. Visual analogue scale score for dysmenorrhea was 8 at baseline and 2 (mean) at study end. Hemoglobin was 8.9 g/dL at baseline (preoperatively) and 11.1 g/dL at 3 months postoperatively. Successful conservative therapy of menorrhagia seems possible with thermal balloon ablation in a uterine didelphic patient." }, { "id": "pubmed23n1163_1705", "title": "Medical treatment for heavy menstrual bleeding in primary care: 10-year data from the ECLIPSE trial.", "score": 0.015324325905129556, "content": "Heavy menstrual bleeding (HMB) is a common problem that can significantly affect women's lives. There is a lack of evidence on long-term outcomes after seeking treatment. To assess continuation rates of medical treatments and rates of surgery in women 10 years after initial management for HMB in primary care. This was a prospective observational cohort study. Women with HMB who participated in the ECLIPSE primary care trial (ISRCTN86566246) completed questionnaires 10 years after randomisation to the levonorgestrel-releasing intrauterine system (LNG-IUS) or other usual medical treatments (oral tranexamic acid, mefenamic acid, combined oestrogen-progestogen; or progesterone alone). Outcomes were rates of surgery, medical treatments, and quality of life using the 36-item Short-Form Health Survey (SF-36) and EuroQoL EQ-5D. The responding cohort of 206 women was demographically and clinically representative of the original trial population. Mean age at baseline was 41.9 years (SD 4.9) and 53.7 years (SD 5.1) at follow-up. Over the 10-year follow-up, 60 of 206 (29.1%) women had surgery (hysterectomy <in</i = 34, 16.5%; endometrial ablation <in</i = 26, 12.6%). Between 5 and 10 years, 89 women (43.2%) ceased all medical treatments and 88 (42.7%) used LNG-IUS alone or in combination with other treatments. Fifty-six women (27.2%) were using LNG-IUS at 10 years. There were improvements over time in quality-of-life scores, with no evidence of differences in these or other outcomes between the two groups. Medical treatments for women with HMB can be successfully initiated in primary care, with low rates of surgery and improvement in quality of life observed a decade later." }, { "id": "pubmed23n0985_3760", "title": "Abnormal Uterine Bleeding in Premenopausal Women.", "score": 0.014829047196768155, "content": "Abnormal uterine bleeding is a common symptom in women. The acronym PALM-COEIN facilitates classification, with PALM referring to structural etiologies (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia), and COEIN referring to nonstructural etiologies (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). Evaluation involves a detailed history and pelvic examination, as well as laboratory testing that includes a pregnancy test and complete blood count. Endometrial sampling should be performed in patients 45 years and older, and in younger patients with a significant history of unopposed estrogen exposure. Transvaginal ultrasonography is the preferred imaging modality and is indicated if a structural etiology is suspected or if symptoms persist despite appropriate initial treatment. Medical and surgical treatment options are available. Emergency interventions for severe bleeding that causes hemodynamic instability include uterine tamponade, intravenous estrogen, dilation and curettage, and uterine artery embolization. To avoid surgical risks and preserve fertility, medical management is the preferred initial approach for hemodynamically stable patients. Patients with severe bleeding can be treated initially with oral estrogen, high-dose estrogen-progestin oral contraceptives, oral progestins, or intravenous tranexamic acid. The most effective long-term medical treatment for heavy menstrual bleeding is the levonorgestrel-releasing intrauterine system. Other long-term medical treatment options include estrogen-progestin oral contraceptives, oral progestins, oral tranexamic acid, nonsteroidal anti-inflammatory drugs, and depot medroxyprogesterone. Hysterectomy is the definitive treatment. A lower-risk surgical option is endometrial ablation, which performs as well as the levonorgestrel-releasing intrauterine system. Select patients with chronic uterine bleeding can be treated with myomectomy, polypectomy, or uterine artery embolization." }, { "id": "wiki20220301en024_103789", "title": "Heavy menstrual bleeding", "score": 0.014708682406702209, "content": "NICE guidelines says that for women (with HMB and no identified pathology or fibroids less than 3 cm in diameter) who do not wish to have pharmacological treatment and who do not want to conserve their fertility, surgical options could be considered as a first-line treatment option. And options are hysterectomy and second generation endometrial ablation. With hysterectomy more effective than second generation endometrial ablation. Tranexamic acid treatments, which reduce bleeding by inhibiting the clot-dissolving enzymes, appear to be more effective than anti-inflammatory treatment like NSAIDs, but are less effective than LNG-IUS. Tranexamic acid tablets may reduce loss by up to 50%. This may be combined with hormonal medication previously mentioned. NSAIDs are also used to reduce heavy menstrual bleeding by an average of 20-46%. For this purpose, NSAIDs are ingested for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia." }, { "id": "pubmed23n0552_5137", "title": "[Levonorgestrel-releasing intrauterine system in the treatment of dysfunctional uterine bleeding: A French multicenter study].", "score": 0.014272256241168159, "content": "To evaluate the levonorgestrel-releasing intra-uterine system as an alternative to surgical treatment in patients presenting with menorrhagia. In the set of a prospective multicenter study, 49 patients with menorrhagia resistant to medical treatment and/or referred for hysterectomy or endometrial ablation were included. Medical visits were organized 3, 6, 12, 24 and 36 months after insertion of the levonorgestrel-releasing intra-uterine system. Visual score of menstrual bleeding and satisfaction index were noted on each visit. Transvaginal ultrasound, pap smear, endometrial biopsy, and clinical data were retrieved one month before and 12 months after inclusion for tolerance evaluation. Renouncement rate was 90.0% (95% CI = 80.7-96.6%). After a twelve months follow-up, 86.1% of patients were satisfied or very satisfied with their clinical state. We found a significant increase of hemoglobin rates from baseline (14,0 versus 12,9 g/dl; P &lt; 10(-4)). Similar increases were also found in serum iron and ferritin. This study confirms the efficacy of the levonorgestrel-releasing intra-uterine system in the control and reduction of menstrual blood loss in patients with dysfunctional uterine bleeding. The high rate of surgery cancellation is a proof of the potential role of the levonorgestrel-releasing intra-uterine system as an alternative treatment in these patients." }, { "id": "pubmed23n0633_8", "title": "The levonorgestrel intrauterine system is an effective treatment in women with abnormal uterine bleeding and anticoagulant therapy.", "score": 0.014264112903225806, "content": "To evaluate the efficacy of levonorgestrel intrauterine systems (LNG-IUS) in obese women with AUB on anticoagulant therapy. Prospective observational case series (Canadian Task Force Classification II-3). University affiliated teaching hospital. Premenopausal women on Warfarin therapy. From January 2002 through January 2007, 10 women were identified from the senior author's clinical practice (G.A.V.). After clinical assessment, including Papanicolaou smear, endometrial biopsy, and pelvic sonography, the LNG-IUS was placed to treat their AUB. The median and range of age, parity, and body mass index were 45 years (34-49), 1 (0-4), and 38 kg/m(2) (26-52), respectively. All women were receiving warfarin therapy (4-12.5 mg/d) for previous venous thromboembolism. Some patients had additional comorbid conditions and were at high risk for traditional medical or surgical therapies. After placement of the LNG-IUS, all women reported menstrual reduction at 3 and 6 months. By 12 months, 1 woman with large fibroids expelled the LNG-IUS and was treated with transfemoral uterine artery embolization. Two women had amenorrhea, and 7 had hypomenorrhea. At 2 to 5 years, 1 woman expelled the LNG-IUS and hysterectomy indicated extensive adenomyosis in a 195-g uterus, and 1 woman had hysteroscopic endometrial ablation, 4 were menopausal, 2 had amenorrhea, and 1 had hypomenorrhea. In the 5 women with uterine fibroids measuring 4.2 to 147 cm(3), the fibroids were reduced in volume by approximately 75% in 2, were no longer detectable in 1, were subsequently shown to be adenomyoma in 1, and required uterine artery embolization in 1. In properly assessed and selected obese, premenopausal women with AUB receiving warfarin therapy and at high risk for traditional therapies, the LNG-IUS was an effective treatment in 70% of patients." }, { "id": "pubmed23n0323_19413", "title": "Hysteroscopic endometrial ablation without endometrial preparation.", "score": 0.014160133048229984, "content": "To study the effectiveness of endometrial ablation by hysteroscopic resection without prior medical preparation for the treatment of women with persistent menorrhagia. From January 1996 to January 1997, a total of 170 women with persistent menorrhagia and/or dysmenorrhea and who underwent hysteroscopic endometrial resection were included in the study. A thorough suction curettage was done before the procedure. The operation was conducted through a continuous flow hysteroscopic resectoscope with electrosurgery while the patient was under intravenous general anesthesia. The distention fluid used was 5% dextrose with a gravity feed infusion system consisting of a 2-1 bag between 1 and 1.5 m above the uterine cavity. After the procedure, the patients' conditions were followed for at least 6-18 months by telephone interview or at our clinic. A total of 127 women were available for a follow-up period of at least 6 months. Operative complications were 3%; three women had fever and received oral antibiotics; no uterine perforation occurred; one case of post-operative bleeding was controlled by intrauterine balloon inflation; the average operation time was 21 min; The mean fluid deficit was 435 ml. Ninety-nine out of 127 women (78%) had adequately controlled menorrhagia (18.1% had amenorrhea, 42.5% hypomenorrhea and 17.3% had normal menstrual flow), while 27 women (21.2%) were failed due to unchanged or heavier menstrual flow after surgery. Eleven (40%) out of the 27 failed cases had myoma with menorrhagia, whereas only five women (5%) out of the 99 adequately treated women had myomas (P &lt; 0.05). Thirty-eight (54%) out of the 70 women with severe dysmenorrhea reported either lessening dysmenorrhea or no dysmenorrhea after the surgery. A total of 76 women (60%) were satisfied with the procedure. A second surgical procedure, either a resection or hysterectomy, was necessary in 13 women (10%) after ablation (seven received repeated ablations and six underwent hysterectomy). Endometrial ablation without endometrial suppression is a cheap, effective and acceptable procedure for treatment in women with persisted persistent menorrhagia." }, { "id": "pubmed23n0834_20966", "title": "Combined Endometrial Ablation and Levonorgestrel Intrauterine System Use in Women With Dysmenorrhea and Heavy Menstrual Bleeding: Novel Approach for Challenging Cases.", "score": 0.014145551533625452, "content": "To evaluate the feasibility and impact of levonorgestrel intrauterine system (LNG-IUS) on treatment failure after endometrial ablation (EA) in women with heavy menstrual bleeding (HMB) and dysmenorrhea at 4 years. Cohort study (Canadian Task Force II-2). An academic institution in the upper Midwest. All women with HMB and dysmenorrhea who underwent EA with combined placement of LNG-IUS (EA/LNG-IUS cohort, 23 women) after 2005 and an historic reference group from women who had EA alone (EA cohort, 65 women) from 1998 through the end of 2005. Radiofrequency EA, thermal balloon ablation, and LNG-IUS. The primary outcome was treatment failure defined as persistent pain, bleeding, and hysterectomy after EA at 4 years. The combined treatment failure outcome was documented in 2 patients (8.7%) in the EA/LNG-IUS group and 19 patients (29.2%) in the EA group with an unadjusted OR of .23 (95% CI, .05-1.08). After adjusting for known risk factors of failure, the adjusted OR was .19 (95% CI, .26-.88). None of the women who underwent EA/LNG-IUS had hysterectomy for treatment failure compared with 16 (24%) in the EA group (p = .009); postablation pelvic pain was documented in 1 woman (4.3%) in the EA/LNG-IUS group compared with 8 women (12.3%) in the EA group (p = .24). One woman in the EA/LNG-IUS group (4.3%) presented with persistent bleeding compared with 15 (23.1%) in the EA group (p = .059). Office removal of the intrauterine device was performed in 4 women with no complications. LNG-IUS insertion at the time of EA is feasible and can provide added benefit after EA in women with dysmenorrhea and HMB." }, { "id": "pubmed23n0780_19077", "title": "Use of a levonorgestrel-releasing intrauterine device in the treatment of adenomyosis associated heavy menstrual bleeding.", "score": 0.014140562813129184, "content": "To evaluate the effects of a levonorgestrel-releasing intrauterine device in the treatment of adenomyosis associated with heavy menstrual bleeding. The retrospective study was conducted at a tertiary referral hospital in Izmir, Turkey, and comprised data on adenomyosis patients who were implanted with a levonorgestrel-releasing intrauterine device for heavy menstrual bleeding between December 2004 and January 2008. After the insertion of the device, all patients were followed up by transvaginal ultrasonography and serum haemoglobin levels and menstrual patterns were determined at the 6th and 12th month. Data was analysed using SPSS 10. The mean age of the 42 women in the study was 43.2 +/- 0.8 years. At the sixth month, amenorrhoea, oligomenorrhoea, spotting and regular menstrual flow were 9.5% (n = 4), 7% (n = 3), 19% (n = 8), and 64% (n = 27), respectively. At the 12th month, the same parametres were 9.5% (n = 4), 7% (n = 3), 12% (n = 5), and 71% (n = 30), respectively. Haemoglobin levels had increased and endometrial thickness had decreased, and these differences were statistically significant (p &lt; 0.001). The easy-to-use levonorgestrel-releasing intrauterine device can be added to the treatment options as a well-tolerated alternative in cases where a woman who has completed her fertility and does not request a hysterectomy has anaemia associated with adenomyosis." }, { "id": "wiki20220301en024_103788", "title": "Heavy menstrual bleeding", "score": 0.01397624039133473, "content": "Usually, oral combined contraceptive or progesterone only pills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Provera or the more recent progesterone releasing IntraUterine System (IUS) may be used. In particular, an oral contraceptive containing estradiol valerate and dienogest may be more effective than tranexamic acid, NSAIDs and IUDs. Fibroids may respond to hormonal treatment, and if they do not, then surgical removal may be required. Concerning hormonal treatment, the NICE guidelines states that: \"No evidence was found on MRI-guided transcutaneous focused ultrasound for uterine fibroids nor for the progestogen-only pill, injectable progestogens, or progestogen implants.\" Progestogen pills, independently if taken in a short or long course, are not as effective at reducing menstrual blood loss as LNG-IUS or tranexamic acid." }, { "id": "wiki20220301en084_38803", "title": "Menstrual disorder", "score": 0.01365861685934093, "content": "Amenorrhea associated with structural anomalies can be addressed with surgical treatment such as gonadectomy. Menorrhagia Acute management of menstrual bleeding includes hormonal therapy with estrogen or oral contraceptives until bleeding has stopped followed by a oral contraceptive tapering regimen. Adjunctive therapy may include iron supplements and nonsteroidal anti-inflammatory drugs. Patients who do not respond to hormonal therapy may use antifibrinolytics. Procedural therapy such as a suction curettage and intrauterine balloon tamponade are reserved for patients who do not respond to medication therapy and do not put fertility at risk. Life-threatening situations may consider more invasive procedures such as endometrial ablation, uterine artery embolization, and hysterectomy. Long-term management include estrogen-containing therapy and progestin therapy." }, { "id": "pubmed23n0398_15139", "title": "[The role of copper-releasing intrauterine device or levonorgestrel-releasing intrauterine system on uterine bleeding and iron status (prospective study of 8 years)].", "score": 0.013629215446444173, "content": "The aims of this study were the effects of copper intrauterine device (Cu-IUD) compared to progesterone (PRG-IUS) or levonorgestrel releasing intrauterine system (LNg-IUS) on menstrual bleeding, menorrhagia and dysfunctional uterine bleeding. The authors evaluated the effect of copper surface area on uterine bleeding. Between March 1992 and November 1999, 223 women, referred to I Institute of Obstetrics and Gynaecology University of Rome, were recruited in a prospective study with follow up at 3, 6 and 12 months to evaluate the incidence of endometrial pathology. The study includes 38 fertile women with regular menstruations and without intrauterine devices, as control group, and 185 patients with intrauterine devices, divides as follows: - 117 copper-releasing intrauterine devices: 30 with a copper (Cu) surface area =200 mm2, releasing 45 microgram Cu/24h (Nova T (R)); 27 with a copper surface area =250 mm2, releasing 50 microgram Cu/24h (Multiload 250 (R)); 25 with a copper surface area =375 mm2, releasing 65 microgram Cu/24h (Multiload 375 (R)); 20 with a copper surface area =384 mm2, releasing 100 microgram Cu/24h (No Gravid M (R)); 15 with a copper surface area =440 mm2, releasing 120 microgram Cu/24h (No Gravid 0,5 (R)). - 68 progesterone/levonorgestrel-releasing intrauterine devices: 40 progesterone-releasing intrauterine systems (Progestasert(R)); 28 levonorgestrel-releasing intrauterine systems 20 mg/24h (Mirena (R)). A total of 211 subjects had data that were valid for analysis: 12 women out of 223 (5,4%) were excluded from the prospective study lost to follow-up. A venous blood sample for serum ferritin (mg/l), iron (mg/dl), hemoglobin (g/dl), hematocrit (%), blood cell count, MCHC and MCV was taken during follow-up. PRG or LNg-IUSs determined a significant reduction in menstrual blood loss and in irregular bleeding by gradually reducing endometrial fitness and vascularisation. Serum ferritin significantly increased in women inserted with LNg- IUSs already after 6 months (26+/-22 e 28+/-14 microgram/l versus 32.5+/-19 e 34.5+/-25 microgram/l). Hemoglobin significantly increased (p&gt;0.05) 6 months after insertion. On the contrary this did not occur with the insertion of Cu-IUDs. We observed that the increased amount of copper, released by IUD, causes increasing of bleeding. The LNg-IUS is a new contraceptive method combining the advantages of both hormonal and intrauterine contraception. In addition, it can be considered an alternative method in the treatment of menorrhagia and dysfunctional uterine bleeding. On the contrary, in women inserted with Cu-IUDs, the main reason of menorrhagia probably is due both to the shape of device and to copper surface area." }, { "id": "pubmed23n0739_20964", "title": "Thermal balloon endometrial ablation for dysfunctional uterine bleeding: an evidence-based analysis.", "score": 0.0134446198962328, "content": "The objective of this review was to evaluate the effectiveness and cost-effectiveness of thermal balloon endometrial ablation (TBEA) for dysfunctional uterine bleeding (DUB). CONDITION AND TARGET POPULATION Abnormal uterine bleeding is defined as an increase in the frequency of menstruation, duration of flow or amount of blood loss. (1) DUB is a diagnosis of exclusion when there is no pelvic pathology or underlying medical cause for the increased bleeding. (1) It is characterized by heavy prolonged flow with or without breakthrough bleeding. It may occur as frequent, irregular, or unpredictable bleeding; lengthy menstrual periods; bleeding between periods; or a heavy flow during periods. Menorrhagia, cyclical HMB over several consecutive cycles during the reproductive years, is the most frequent form of DUB. The incidence of DUB has not been reported in the literature. For Ontario, an expert estimated that about 15% to 20% of women over 30 years have DUB. The prevalence increases with age and peaks just before menopause. (1) Using 2001 Ontario census-based population estimates, there are about 2 million women between the ages of 30 and 49 years; therefore, of these, about 290,965 to 387,953 may have DUB. THERMAL BALLOON ENDOMETRIAL ABLATION Since the 1990s, second-generation endometrial ablation (EA) techniques developed, the aim to provide simpler, quicker, and more effective treatment options for menorrhagia compared with first-generation EA techniques and hysterectomy. (2) Compared with first-generation techniques these depend less on the people operating them and more on the actual devices to ensure safety and efficacy. TBEA relies on the transfer of heat from heated liquid within a balloon that is inserted into the uterus. (2) It does not require a hysteroscope for direct visualization of the uterus and can be performed under local anesthesia. In order to use TBEA, patients with DUB cannot have a long (&gt;10-12 cm) or irregularly shaped uterine cavity, because the balloon must be in direct contact with the uterine wall to cause ablation. For Ontario, an expert estimated that about 70% of patients with DUB considered for EA would have a uterus suitable for TBEA based on these criteria. If 70% of Ontario women between 30 and 49 years of age with DUB have a uterus suitable for TBEA, then about 203,675 to 271,567 women may be eligible. However, some of these women will be successfully treated by drugs or will want amenorrhea (the cessation of their periods) and therefore choose to have a hysterectomy. The standard Medical Advisory Secretariat search strategy was used to locate international health technology assessments and English-language journal articles published from January 1996 to June 2004. A Cochrane systematic review from 2004 was identified that examined the effectiveness and cost-effectiveness of TBEA for heavy menstrual bleeding. (2) Another literature search was done to update information from the systematic review. A 2004 systematic review of the literature by Garside et al. (2) in the United Kingdom, found that overall, there were few significant differences between outcomes for first-generation techniques and TBEA. The outcomes were bleeding, postoperative complications, patient satisfaction, quality of life, and repeat surgery rates. Significant differences were reported most often by one study by Pellicano et al., (3) but this was a level 2 study with methodological weaknesses. Furthermore, according to Garside et al., there was considerable clinical and methodological heterogeneity among the studies in the systematic review. Therefore, a quantitative synthesis using meta-analysis was not done. In Garfield and colleagues' review: TBEA had significantly shorter operating and theatre times (P &lt; .05, &lt; .01, and .0001).TBEA had fewer intraoperative adverse effects (e.g., reported rates of uterine perforation with RB ablation: from 1% to 5%; TBEA: 0%; rates of cervical laceration with RB: 2% to 5%; TBEA 0%).They found no studies have directly compared second-generation techniques and hysterectomy; therefore, the comparison can only be indirectly inferred from studies of first-generation techniques and hysterectomy.Compared with hysterectomy, TCRE and RB are quicker to perform and result in shorter hospitalization stays and a faster return to work.Hysterectomy results in more adverse effects.Satisfaction with hysterectomy is initially higher, but there is no difference after 2 years.Studies (level 2 evidence) published after Garside's systematic review support these conclusions.A study with level 2 evidence reported a significantly higher risk overall of intraoperative complications for RB compared with TBEA (P &lt; .001). This included uterine perforation (RB, 5%; TBEA, 0%) and suspicion of perforation (RB, 2%; TBEA, 0%).A multicentre long-term case series (level 4 evidence) that examined avoidance of hysterectomy after TBEA for menorrhagia reported that 86% of women who had TBEA did not require a hysterectomy, and 75% did not have any further surgery during a follow-up period of 4 to 6 years. (4)Several TBEA studies did not provide justification for using general anesthesia over local anesthesia.Patient preferences for different treatments will depend on a woman's desire for amenorrhea as an outcome and/or avoidance of major surgery. Hysterectomy is the only procedure that can guarantee amenorrhea. TBEA will not totally replace hysterectomy in the treatment of DUB, because some women may want cessation of menstruation.Ensuring that patient expectations are consistent with the outcomes achievable with TBEA is important to obtain high levels of satisfaction. Vilos et al. (5) noted that up to one-half of patients who underwent a second attempt at TBEA might have avoided the second procedure with proper preoperative counselling. Meyer et al. (6) noted that one consideration for patients with menorrhagia (and no structural lesions) is to return to normal or less blood loss rather than amenorrhea. Patients may have distinct concepts of menstrual bleeding depending on cultural background, and maintaining an acceptable menstrual flow instead of amenorrhea may represent a healthier status. (7)A budget impact analysis suggests that the net annual budget outlay for TBEA would be between $1.4 million in savings and $2.8 million in additional outlays. (Note: Not all savings would be realized directly by the Ministry of Health and Long-Term Care, because much of the savings would accrue to the global budgets of hospitals). TBEA is effective, safe, and cost-effective for patients with DUB.For women who are not worried about amenorrhea, first-generation techniques offer advantages over hysterectomy.TBEA is a better alternative to first-generation techniques for DUB, because it is associated with fewer intraoperative adverse effects." }, { "id": "pubmed23n0615_1402", "title": "The impact of alternative treatment for abnormal uterine bleeding on hysterectomy rates in a tertiary referral center.", "score": 0.013315696649029981, "content": "The purpose of this study was to estimate the influence of alternatives to hysterectomy for abnormal uterine bleeding (AUB) on hysterectomy rates. Retrospective cohort study. Canadian Task Force II-2. University hospital. Premenopausal patients with AUB. Medical records of all premenopausal patients treated for AUB in our university clinic between January 1, 1995, and December 31, 2004, were reviewed. Patients were identified based on (specific) diagnostic and therapy codes used in the registry system of the hospital. The total number of placements of levonorgestrel-releasing intrauterine device (LNG-IUD), hysteroscopic surgery, and hysterectomies performed/year was estimated. In addition, the course of treatment of each patient was assessed. A total of 640 patients received surgery and 246 LNG-IUDs were placed. The proportion of endometrial ablations decreased significantly over time (p &lt;.001), whereas hysteroscopic polyp or myoma removal (p =.030) and insertion of LNG-IUD (p &lt;.001) both increased. The proportion of patients receiving hysterectomy for AUB as their first therapy decreased significantly (p =.005) from 40.6% to 31.4%, although the total number of patients receiving hysterectomy remained similar (p =.449). The 5-year intervention-free percentage for LNG-IUD was 70.6% (SD = 3.3%), for hysteroscopic polyp or myoma removal 75.5% (SD = 3.3%), and for endometrial ablation 78.0% (SD = 4.3%; p =.067). Despite the introduction of alternative therapies, the total hysterectomy rate in the management of AUB did not decrease in our clinic." }, { "id": "pubmed23n0914_8139", "title": "Cost-effectiveness of treatments for heavy menstrual bleeding.", "score": 0.012865061636468934, "content": "Heavy menstrual bleeding affects up to one third of women in the United States, resulting in a reduced quality of life and significant cost to the health care system. Multiple treatment options exist, offering different potential for symptom control at highly variable initial costs, but the relative value of these treatment options is unknown. The objective of the study was to evaluate the relative cost-effectiveness of 4 treatment options for heavy menstrual bleeding: hysterectomy, resectoscopic endometrial ablation, nonresectoscopic endometrial ablation, and the levonorgestrel-releasing intrauterine system. We formulated a decision tree evaluating private payer costs and quality-adjusted life years over a 5 year time horizon for premenopausal women with heavy menstrual bleeding and no suspected malignancy. For each treatment option, we used probabilities derived from literature review to estimate frequencies of minor complications, major complications, and treatment failure resulting in the need for additional treatments. Treatments were compared in terms of total average costs, quality-adjusted life years, and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was conducted to understand the range of possible outcomes if model inputs were varied. The levonorgestrel-releasing intrauterine system had superior quality-of-life outcomes to hysterectomy with lower costs. In a probabilistic sensitivity analysis, levonorgestrel-releasing intrauterine system was cost-effective compared with hysterectomy in the majority of scenarios (90%). Both resectoscopic and nonresectoscopic endometrial ablation were associated with reduced costs compared with hysterectomy but resulted in a lower average quality of life. According to standard willingness-to-pay thresholds, resectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 44% of scenarios, and nonresectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 53% of scenarios. Comparing all trade-offs associated with 4 possible treatments of heavy menstrual bleeding, the levonorgestrel-releasing intrauterine system was superior to both hysterectomy and endometrial ablation in terms of cost and quality of life. Hysterectomy is associated with a superior quality of life and fewer complications than either type of ablation but at a higher cost. For women who are unwilling or unable to choose the levonorgestrel-releasing intrauterine system as a first-course treatment for heavy menstrual bleeding, consideration of cost, procedure-specific complications, and patient preferences can guide the decision between hysterectomy and ablation." }, { "id": "wiki20220301en043_2454", "title": "Adenomyosis", "score": 0.012789575289575288, "content": "Levonorgestrel-releasing intrauterine devices or hormonal IUDs, such as the Mirena, are an effective treatment for adenomyosis. They reduce symptoms by causing decidualization of the endometrium, reducing or eliminating menstrual flow. Additionally, by helping downregulate estrogen receptors, hormonal IUDs shrink the clusters of endometrial tissue within the myometrium. This leads to reduced menstrual blood flow, helps the uterus contract more properly, and helps to reduce the menstrual pain. The use of hormonal IUDs in patients with adenomyosis have been proven to reduce menstrual bleeding, improve anemia and iron levels, reduce pain, and even result in an improvement of adenomyosis with a smaller uterus on medical imaging. At least in the short term, patients who can tolerate hormonal IUDs for the treatment of adenomyosis result in equivalent improvement of symptoms and better quality-of-life and social well-being as compared to women who undergo a hysterectomy. Hormonal IUDs are" }, { "id": "pubmed23n0356_16740", "title": "[Hysteroscopic resection of submucosal myomas in abnormal uterine bleeding: results of a 4-year prospective study].", "score": 0.012774016763378465, "content": "The evaluation of the effect of transcervical resection of submucous myoma/s in patients with abnormal uterine bleeding. Prospective clinical study. Department of Obstetrics and Gynaecology, 1st Medical Faculty, Charles University and General Faculty Hospital in Prague, Czech Republic. 45 patients with resected submucous myoma/s within the period 1995-1998 were selected. Patients in whom resection of myoma was combined with endometrial ablation were excluded. The average age of the cohort was 43 years (29-53). In 37 patients (82%) therapeutical curettage was performed for severe bleeding in the past (3 procedures on average, interval 1-7). In 16 patients (36%) transfusion was administered in the treatment of anaemia secondary to abnormal uterine bleeding in the past. Hysteroscopy, ultrasound scan or both techniques were used to diagnose and classify myomas. In 39 patients 1 myoma was resected, in 6 patients 2 myomas. In 12 (27%) patients myoma of 0., in 29 (64%) of I. and in 4 (9%) of II. has been diagnosed according to the ESH classification. In case of several myomas, the classification was based on the one of the highest degree. Surgery was performed in the early proliferative phase of the menstrual cycle. Purisol (sorbitol and mannitol) was used as a distension medium. Myomas were resected using loop high frequency electroendoresection technique. In 3 (7%) patients myomas of ESH II. were resected in more steps--in 2 cases (5%) in 2 steps and in 1 case (2%) in 3 steps. In patients with myomas classified as a 0. and I., only the character of menstrual cycle has been monitored after surgery. Ultrasound investigation was performed in patients with myomas of II. 3 months after surgery. The bleeding was controlled in terms of eumenorrhoea or hypomenorrhoea in all 45 patients (100%). Ultrasound investigation showed no residual myoma in any of 4 patients after resection of II. myoma. One case fluid overload syndrome of minor degree was documented as the only complication. Hysteroscopic high frequency endorsection is a safe and effective method and method of choice in the treatment of submucous myomas in patients with abnormal uterine bleeding. The high success rate in our cohort is certainly influenced by the number of patients included and by the length of follow-up." }, { "id": "wiki20220301en081_13710", "title": "Endometrial ablation", "score": 0.012718697702723263, "content": "Endometrial ablation is most often employed in women who suffer from excessive menstrual bleeding, who have failed medical therapy and do not wish to undergo a hysterectomy. Heavy menstrual bleeding is most commonly due to dysfunctional uterine bleeding or adenomyosis. The procedure is almost always performed as an outpatient treatment, either at the hospital, ambulatory surgery center, or physician office. The Endometrial Ablation procedure is primarily performed while patients are under local and/or light sedative anesthesia, or if necessary, general or spinal anesthesia. Patients normally leave the treatment facility within one hour following the procedure and generally spend one day resting at home, before returning to the activities of daily living." }, { "id": "pubmed23n0397_19230", "title": "The effect on menstrual blood loss in women with uterine fibroids of a novel \"frameless\" intrauterine levonorgestrel-releasing drug delivery system: a pilot study.", "score": 0.012509534706331045, "content": "To evaluate the effect on menstrual blood loss, in women with uterine fibroids, of a novel \"frameless\" intrauterine drug delivery system (IUS), FibroPlant-levonorgestrel (LNG), releasing 14 microg of LNG per day. An open label, non-comparative ongoing pilot study. Fourteen insertions were performed in premenopausal women between 39 and 48 years of age for the treatment of menorrhagia. The effect on menstrual blood loss was evaluated using a simple visual assessment technique. Women were followed-up for at least 12 months (range 12-30 months). At the time of study analysis the total number of women-months was 283. All women, except one reported greatly reduced bleeding. In two women, the treatment failed although both reported reduced bleeding. One failure (patient no. 4) was due to the presence of a large endometrial polyp. This patient underwent hysterectomy. The other women (patient no. 1) had submucosal fibroids. She refused hysterectomy and is continuing treatment. In the other 12 patients, reduction of bleeding was appreciable after one month of treatment and tended to decrease further over the next months to stabilize afterwards. The mean bleeding score before treatment was 465 (185-960) and dropped to a mean score of 100 (range 5-300) after a minimum of 12 months of treatment which is highly statistically significant (P&lt;0.001). In eight women, the bleeding reduced to very low scores. An effect on the size of the uterine fibroids could not be demonstrated. Significant spotting was rare after the first 3 months following insertion. Neither complications (e.g. infection, expulsion or perforation) nor pregnancies occurred. The FibroPlant-LNG IUS was well tolerated by all women involved in the study and no systemic hormonal side effects were reported. This study suggests that FibroPlant-LNG IUS is effective to significantly reduce the amount of menstrual blood loss in women with menorrhagia in the presence of intramural and subserosal fibroids and can avoid surgery. The strong endometrial suppression is the principal mechanism explaining the effect on menstrual blood loss of the IUS. The two failures probably explain that a successful treatment in women with endometrial abnormalities (e.g. polyps, submucous fibroids) is unlikely with the IUS. The low daily release rate of LNG from the FibroPlant-LNG IUS results in a low incidence of hormonal side effects. The simple design characteristics and revolutionary anchoring system account for minimizing the occurrence of complaints of pain and expulsion. The flexible fibrous delivery system adapts to cavities of every size even when severely distorted." }, { "id": "wiki20220301en081_13713", "title": "Endometrial ablation", "score": 0.012454212454212455, "content": "Sterilization Women who wish to become pregnant should not undergo endometrial ablation; pregnancy is rare (less than 2 percent) and can have mortal risks for the mother and child. Effectiveness The U.S. Food and Drug Administration approves and audits clinical studies to test and evaluate the effectiveness of all endometrial ablation treatments. Two patient effectiveness outcomes are measured at one year following treatment: 1.) Success Rate = the % of women who have their bleeding reduced to a normal period level or less, and 2.) Amenorrhea Rate = the % of women that have their bleeding completely eliminated. According to the results of the Randomized Controlled Trials performed for the FDA approval of the different treatment options, effectiveness Success Rates range from a high of 93% to a low of 67%, and the Amenorrhea Rates range from a high of 72% to a low of 22%." }, { "id": "pubmed23n0976_12734", "title": "Endometrial resection and ablation techniques for heavy menstrual bleeding.", "score": 0.012393523137134526, "content": "Heavy menstrual bleeding (HMB) is a significant health problem in premenopausal women; it can reduce their quality of life and can cause social disruption and physical problems such as iron deficiency anaemia. First-line treatment has traditionally consisted of medical therapy (hormonal and non-hormonal), but this is not always successful in reducing menstrual bleeding to acceptable levels. Hysterectomy is a definitive treatment, but it is more costly and carries some risk. Endometrial ablation may be an alternative to hysterectomy that preserves the uterus. Many techniques have been developed to 'ablate' (remove) the lining of the endometrium. First-generation techniques require visualisation of the uterus with a hysteroscope during the procedure; although it is safe, this procedure requires specific technical skills. Newer techniques for endometrial ablation (second- and third-generation techniques) have been developed that are quicker than previous approaches because they do not require hysteroscopic visualisation during the procedure. To compare the efficacy, safety, and acceptability of endometrial destruction techniques to reduce heavy menstrual bleeding (HMB) in premenopausal women. We searched the Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase, CINAHL, and PsycInfo (from inception to May 2018). We also searched trials registers, other sources of unpublished or grey literature, and reference lists of retrieved studies, and we made contact with experts in the field and with pharmaceutical companies that manufacture ablation devices. Randomised controlled trials (RCTs) comparing different endometrial ablation or resection techniques for women reporting HMB without known uterine pathology, other than fibroids outside the uterine cavity and smaller than 3 centimetres, were eligible. Outcomes included improvement in HMB and in quality of life, patient satisfaction, operative outcomes, complications, and the need for further surgery, including hysterectomy. Two review authors independently selected trials for inclusion, assessed trials for risk of bias, and extracted data. We contacted study authors for clarification of methods or for additional data. We assessed adverse events only if they were separately measured in the included trials. We undertook comparisons with individual techniques as well as an overall comparison of first- and second-generation ablation methods. We included in this update 28 studies (4287 women) with sample sizes ranging from 20 to 372. Most studies had low risk of bias for randomisation, attrition, and selective reporting. Less than half of these studies had adequate allocation concealment, and most were unblinded. Using GRADE, we determined that the quality of evidence ranged from moderate to very low. We downgraded evidence for risk of bias, imprecision, and inconsistency.Overall comparison of second-generation versus first-generation (i.e. gold standard hysteroscopic ablative) techniques revealed no evidence of differences in amenorrhoea at 1 year and 2 to 5 years' follow-up (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.78 to 1.27; 12 studies; 2145 women; I² = 77%; and RR 1.16, 95% CI 0.78 to 1.72; 672 women; 4 studies; I² = 80%; very low-quality evidence) and showed subjective improvement at 1 year follow-up based on a Pictorial Blood Assessment Chart (PBAC) (&lt; 75 or acceptable improvement) (RR 1.03, 95% CI 0.98 to 1.09; 5 studies; 1282 women; I² = 0%; and RR 1.12, 95% CI 0.97 to 1.28; 236 women; 1 study; low-quality evidence). Study results showed no difference in patient satisfaction between second- and first-generation techniques at 1 year follow-up (RR 1.01, 95% CI 0.98 to 1.04; 11 studies; 1750 women; I² = 36%; low-quality evidence) nor at 2 to 5 years' follow-up (RR 1.02, 95% CI 0.93 to 1.13; 672 women; 4 studies; I² = 81%).Compared with first-generation techniques, second-generation endometrial ablation techniques were associated with shorter operating times (mean difference (MD) -13.52 minutes, 95% CI -16.90 to -10.13; 9 studies; 1822 women; low-quality evidence) and more often were performed under local rather than general anaesthesia (RR 2.8, 95% CI 1.8 to 4.4; 6 studies; 1434 women; low-quality evidence).We are uncertain whether perforation rates differed between second- and first-generation techniques (RR 0.32, 95% CI 0.10 to 1.01; 1885 women; 8 studies; I² = 0%).Trials reported little or no difference between second- and first-generation techniques in requirement for additional surgery (ablation or hysterectomy) at 1 year follow-up (RR 0.72, 95% CI 0.41 to 1.26; 6 studies: 935 women; low-quality evidence). At 5 years, results showed probably little or no difference between groups in the requirement for hysterectomy (RR 0.85, 95% CI 0.59 to 1.22; 4 studies; 758 women; moderate-quality evidence). Approaches to endometrial ablation have evolved from first-generation techniques to newer second- and third-generation approaches. Current evidence suggests that compared to first-generation techniques (endometrial laser ablation, transcervical resection of the endometrium, rollerball endometrial ablation), second-generation approaches (thermal balloon endometrial ablation, microwave endometrial ablation, hydrothermal ablation, bipolar radiofrequency endometrial ablation, endometrial cryotherapy) are of equivalent efficacy for heavy menstrual bleeding, with comparable rates of amenorrhoea and improvement on the PBAC. Second-generation techniques are associated with shorter operating times and are performed more often under local rather than general anaesthesia. It is uncertain whether perforation rates differed between second- and first-generation techniques. Evidence was insufficient to show which second-generation approaches were superior to others and to reveal the efficacy and safety of third-generation approaches versus first- and second-generation techniques." }, { "id": "pubmed23n0390_2110", "title": "Endometrial ablation in the year 2000--do we have more methods than indications?", "score": 0.01205519244734931, "content": "Approximately 20-25% of hysterectomies are done for the relief of menorrhagia, excessive menstrual bleeding without gynecologic pathology. Menorrhagia represents a widespread clinical problem, and it is one of the leading causes of elective hysterectomy in women with a normal uterus in the US as well as in Europe. The current management of dysfunctional bleeding includes medical or different types of surgical therapies. When patients wish a nonsurgical therapy for menorrhagia we can offer them different medical treatments, a IUD releasing levonorgestrel or a therapeutic dilatation and curettage (D&amp;C). Until recently, women who did not respond to medication were limited to either hysterectomy or continued cycles of heavy menstrual bleeding. Methods for hysteroscopic endometrial ablation were introduced in the 1980s including Nd:YAG laser ablation, transcervical resection of the endometrium (TCRE) and 'rollerball' electrocoagulation (RBE). These first-generation procedures are nowadays the gold standard for the hysteroscopic treatment of menorrhagia. In the 1990s different types of therapeutic alternatives were introduced. The second generation of hysteroscopic ablation techniques include: balloon heating methods, methods with intrauterine instillation of heated saline, the endometrial laser intrauterine thermal therapy procedure ELITT using a diode laser, global 3-D bipolar ablation method, punctual vaporizing methods, photodynamic endometrial ablation method, microwave endometrial ablation method, the radiofrequency method menostat and a cryotherapy method." }, { "id": "pubmed23n0820_13974", "title": "Medical management of heavy menstrual bleeding: a comprehensive review of the literature.", "score": 0.011992748570631711, "content": "Heavy menstrual bleeding (HMB) is a common complaint among reproductive-aged women, which negatively affects their health as well as their social, professional, and family lives. Modern medical management usually provides effective control of HMB irrespective of the underlying cause. Surgical interventions should be reserved for women with significant pelvic pathology and those unresponsive to medical therapy. The aim of this review was to provide a comprehensive summary of the efficacy and safety of available medical treatments of HMB. A comprehensive MEDLINE and EMBASE literature search was undertaken using selected terms associated with HMB to identify clinical studies published before March 20, 2013, that reported changes in menstrual blood loss in women receiving medical intervention. The effectiveness of treatments to reduce HMB due to endometrial dysfunction in descending order was as follows: (1) the levonorgestrel-releasing intrauterine system (LNG-IUS) (initial release rate of 20 μg of LNG per 24 hours), (2) combined hormonal contraceptives (oral or transvaginal), (3) tranexamic acid, and (4) long-course oral progestogens (≥3 weeks per cycle). The LNG-IUS was found to reduce HMB due to some structural causes (leiomyomas and adenomyosis). The reduction in menstrual blood loss achieved with nonsteroidal anti-inflammatory drugs and short-course oral progestogens (≤14 days per cycle) is less impressive but may be sufficient for women who have marginally increased blood loss. For women not seeking pregnancy, the LNG-IUS is the first-line medical therapy for HMB, with combined hormonal contraceptives as second choice. For other women, fewer effective options exist." }, { "id": "pubmed23n1110_22164", "title": "Heavy menstrual bleeding due to primary myelofibrosis in a woman: a case report.", "score": 0.011942959001782532, "content": "Heavy menstrual bleeding (HMB) due to primary myelofibrosis (PMF) is secondary to progressive pancytopenia, which is a rare and difficult to treat condition. We report this case with the aim of sharing our experiences and exploring a safe and effective way to treat patients with HMB due to PMF. A 40-year-old woman who had been taking combined oral contraceptives (COCs) for eight years was admitted to our hospital with HMB. A bone marrow biopsy report and genetic testing confirmed the diagnosis of PMF. Norethisterone tablets had an unsatisfactory hemostatic effect. The patient underwent a hysteroscopy and the insertion of a levonorgestrel intrauterine system (LNG-IUS). At the 5-month follow-up, the patient had a lower menstruation bleeding volume. COCs are unsuitable for managing the menstruation of patients with PMF in the long run. Endometrial ablation is the long-term method. However, the patient's fertility requirements should be taken into account. The insertion of an LNG-IUS after hysteroscopic curettage to exclude endometrial malignant lesions is recommended." }, { "id": "wiki20220301en015_82896", "title": "Hysterectomy", "score": 0.01188947979705361, "content": "Alternatives Depending on the indication there are alternatives to hysterectomy: Heavy bleeding Levonorgestrel intrauterine devices are highly effective at controlling dysfunctional uterine bleeding (DUB) or menorrhagia and should be considered before any surgery. Menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less invasive endometrial ablation which is an outpatient procedure in which the lining of the uterus is destroyed with heat, mechanically or by radio frequency ablation. Endometrial ablation greatly reduces or entirely eliminates monthly bleeding in ninety percent of patients with DUB. It is not effective for patients with very thick uterine lining or uterine fibroids. Uterine fibroids" }, { "id": "wiki20220301en024_103790", "title": "Heavy menstrual bleeding", "score": 0.01143273460924146, "content": "A definitive treatment for heavy menstrual bleeding is to perform hysterectomy (removal of the uterus). The risks of the procedure have been reduced with measures to reduce the risk of deep vein thrombosis after surgery, and the switch from the front abdominal to vaginal approach greatly minimizing the discomfort and recuperation time for the patient; however extensive fibroids may make the womb too large for removal by the vaginal approach. Small fibroids may be dealt with by local removal (myomectomy). A further surgical technique is endometrial ablation (destruction) by the use of applied heat (thermoablation). The effectiveness of endometrial ablation is probably similar to that of LNG‐IUS but the evidence is uncertain if hysterectomy is better or worse than LNG-IUS for improving HMB." }, { "id": "wiki20220301en024_103792", "title": "Heavy menstrual bleeding", "score": 0.011144669284204168, "content": "Surgery Dilation and curettage (D&C) is not recommended for cases of simple heavy menstrual bleeding, having a reserved role if a spontaneous abortion is incomplete Endometrial ablation is not recommended for women with active or recent genital or pelvic infection, known or suspected endometrial hyperplasia or malignancy. Uterine artery embolization (UAE): The rate of serious complications is comparable to that of myomectomy or hysterectomy; however, UAE presents an increased risk of minor complications and requiring surgery within two to five years. Hysteroscopic myomectomy to remove fibroids over 3 cm in diameter Hysterectomy" }, { "id": "pubmed23n0639_23957", "title": "von Willebrand disease and other disorders of hemostasis in the patient with menorrhagia.", "score": 0.011029300366633337, "content": "Separately, von Willebrand disease and menorrhagia are two relatively common conditions; in combination they occur at a prevalence of approximately 11-16%. Such patients exhibit a reduced quality of life and can incur a relatively high rate of gynecologic interventions; for example dilatation and curettage, endometrial ablation and hysterectomy. Initial evaluation involves a focused history for the following bleeding symptoms: menorrhagia since menarche, easy bruising of greater than 5 cm 1-2 times/month, frequent gum bleeding when flossing or brushing teeth or epistaxis 1-2 times/month. In addition, for those who have already undergone invasive interventions with the subsequent risk for hemorrhage, inquiry should be made regarding excessive bleeding with childbirth, dental tooth extraction and/or surgery. Step-wise testing includes a complete blood cell count and an assessment of the prothrombin time, activated partial thromboplastin time, iron profile, serum creatinine and thyroid-stimulating hormone level, followed by Factor VIII level, von Willebrand factor antigen and ristocetin cofactor, followed by consideration of platelet aggregation studies. Additional hemostatic studies may include obtaining a Factor XI level and euglobulin clot lysis time. Intuitively, failure to diagnose an underlying hemostatic disorder may lead to continued menorrhagia and diminished quality of life, as well as unnecessary surgical interventions that may in turn be fraught with an increased risk of bleeding. The management of von Willebrand disease-related menorrhagia involves consideration of the patient's age, childbearing status and preference. In the adolescent, surgical intervention is not an option, whereas an older patient beyond her childbearing years may choose a hysterectomy as a definitive treatment in lieu of continued medical therapy with intranasal/subcutaneous 1-deamino-8-D-arginine vasopressin (DDAVP), oral antifibrinolytic agents or oral contraceptive. The sexually active patient may initially choose a trial of oral contraceptive or the levonorgestrel intrauterine device, Mirena((R)). Pending ongoing comparative trials in von Willebrand disease-related menorrhagia of intranasal DDAVP, tranexamic acid and the levonorgestrel intrauterine device, specific recommendations cannot be made at present regarding the superiority of one intervention compared with another. It should also be noted that the dose and schedule of intranasal DDAVP, tranexamic acid and epsilon-amino caproic acid have not been well established and warrant further study in combination and at various doses and schedules." }, { "id": "wiki20220301en055_63841", "title": "Hormonal IUDs", "score": 0.010959190063667676, "content": "The IUD with levonorgestrel was first approved for medical use in 1990 in Finland and in the United States in 2000. It is on the World Health Organization's List of Essential Medicines. Medical uses The hormonal IUD is an extremely effective method of birth control, and a 2021 study demonstrated that it may be used for emergency contraception. In addition to birth control, the hormonal IUD is used for prevention and treatment of: Heavy menstrual periods Endometriosis and chronic pelvic pain Adenomyosis and dysmenorrhea Anemia Endometrial hyperplasia (especially in pre-menopausal women who wish to maintain fertility in the treatment of endometrial hyperplasia) In some cases, use of a hormonal IUD may prevent a need for a hysterectomy." }, { "id": "pubmed23n0934_8176", "title": "HEALTH: laparoscopic supracervical hysterectomy versus second-generation endometrial ablation for the treatment of heavy menstrual bleeding: study protocol for a randomised controlled trial.", "score": 0.010901162790697675, "content": "Heavy menstrual bleeding (HMB) is a common problem affecting approximately 1.5 million women in England and Wales with a major impact on their physical, emotional, social and material quality of life. It is the fourth most common reason why women attend gynaecology outpatient clinics and accounts for one-fifth of all gynaecology outpatient referrals. Initial treatment in primary care is medical - either by means of oral or injected medication or the levonorgestrel-intrauterine system (Mirena®). If medical treatment fails then surgical treatment can be offered, either endometrial ablation (EA), which destroys the lining of the cavity of the uterus (endometrium), or hysterectomy, i.e. surgical removal of the uterus. While effective, conventional hysterectomy is invasive and carries a risk of complications due to injury to other pelvic structures. The procedure can be simplified and complications minimised by undertaking a 'supracervical' hysterectomy where the cervix is left in situ and only the body of the uterus removed. Recent advances in endoscopic technologies have facilitated increased use of laparoscopic supracervical hysterectomy (LASH) which can be performed as a day-case procedure and is relatively easy for the surgeon to learn. HEALTH (Hysterectomy or Endometrial AbLation Trial for Heavy menstrual bleeding) aims to address the question 'Is LASH superior to second generation EA for the treatment of HMB in terms of clinical and cost effectiveness?' Women aged &lt; 50 years, with HMB, in whom medical treatment has failed and who are eligible for EA will be considered for trial entry. We aim to recruit women from approximately 30 active secondary care centres in the UK NHS who carry out both surgical procedures. All women who consent will complete a diary of pain symptoms from day 1 to day 14 after surgery, postal questionnaires at six weeks and six months after surgery and 15 months post randomisation. Healthcare utilisation questions will also be completed at the six-week, six-month and 15-month time-points. Measuring the comparative effectiveness of LASH vs EA will provide the robust evidence required to determine whether the new technique should be adopted widely in the NHS. International Standard Randomised Controlled Trials, ISRCTN49013893 . Registered on 28 January 2014." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 243, 377 ] ], "word_ranges": [ [ 29, 47 ] ], "text": "the patient presents findings compatible with collagenous colitis (band of collagen underlying the epithelium greater than 10 microns)" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 548, 756 ] ], "word_ranges": [ [ 68, 94 ] ], "text": "Olmesartan enteropathy produces a picture similar to celiac disease and is characterized by duodenal biopsy with villous atrophy, mucosal inflammation with increased intraepithelial lymphocytes and cryptitis." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Microscopic colitis.", "2": "Enteropathy due to NSAIDs.", "3": "Olmesartan-associated enteropathy.", "4": "Irritable bowel syndrome.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0302_11357", "title": "[Are lymphocytic and collagenous colitis two forms of a single disease? Arguments taken from a biopsy quantitative study].", "score": 0.01951265943270512, "content": "Collagenous colitis and lymphocytic colitis are defined by a clinicopathologic syndrome with chronic watery diarrhea, microscopic lesions of colonic biopsies, and normal barium enema and colonoscopy. A histopathological study was performed on multiple colorectal biopsies to compare 12 cases of collagenous colitis (defined by a subepithelial collagen thicker than 10 microns) and 7 cases of lymphocytic colitis (defined by a number of intraepithelial lymphocytes more than 20 per 100 epithelial cells at least in one biopsied site). The study included a semiquantitative analysis of inflammatory infiltrate in the lamina propria, crypts distortion and epithelial detachment. The number of intraepithelial lymphocytes per 100 epithelial cells was determined in surface epithelium and crypts. The subepithelial collagen thickening was studied by computerised morphometry. The intraepithelial lymphocytes, villous atrophy and thickness of the subepithelial collagen were also determined in gastric and duodenal biopsies. In collagenous colitis, the subepithelial collagenous thickness ranged from 10 to 40 microns in the colon (median 20.99 microns). In 4 cases of collagenous colitis, no thickening of the collagen plate was seen in the rectum. We found constant epithelial detachment and mucosal distortion. In lymphocytic colitis, the thickness of the subepithelial collagen ranged from 6 to 10 microns in 4 cases and was less than 6 microns in 3 cases (median 6.24 microns). The median number of intraepithelial lymphocytes in surface epithelium was 22.35 (range 18.2 to 40) in lymphocytic colitis versus 12.22 (range 4.6 to 24.4) in collagenous colitis. In conclusion, we observed an overlap of both the collagenous plate thickness and the number of intraepithelial lymphocytes in collagenous colitis and lymphocytic colitis. This result favours a unified histogenesis for these two entities." }, { "id": "pubmed23n0382_12641", "title": "Chronic use of non-steroidal anti-inflammatory drugs does not alter colonic mucosa of patients without diarrhoea.", "score": 0.018543956043956044, "content": "Several types of colitis can be NSAID-induced, but whether chronic use of NSAIDs alters colonic mucosa in patients without diarrhoea is not known. Biopsy specimens of rectal mucosa were taken in six patients with rheumatoid arthritis without diarrhoea receiving NSAIDs (group 1, n=6). Patients with rheumatoid arthritis without diarrhoea not receiving NSAIDs (group 2, n=9), and patients undergoing surveillance colonoscopy (group 3, n=23) served as controls. In all patients from the three study groups, intraepithelial lymphocyte count and apoptotic cell count were assessed, and sub-epithelial collagen band thickness was measured. Leucocyte population of lamina propria was evaluated semi-quantitatively. HLA-DR and CD25 expression of mucosal cells was appreciated by immunohistochemistry. Intraepithelial lymphocyte count was in the normal range in all three group patients, and not statistically different between groups. Apoptotic epithelial cell count was not different between groups. Sub-epithelial collagen band thickness was normal in all the patients. No patient had a marked infiltration of lamina propria by leucocytes, and HLA-DR and CD25 were normally expressed in all patients. These results from a small sample of patients suggest that patients without diarrhoea receiving NSAIDs on a long-term basis do not develop microscopic or inflammatory colitis." }, { "id": "pubmed23n0604_19194", "title": "Prevalence of microscopic colitis in patients with diarrhea of unknown etiology in Turkey.", "score": 0.01778093883357041, "content": "To investigate the prevalence and demography of microscopic colitis in patients with diarrhea of unknown etiology and normal colonoscopy in Turkey. Between March, 1998 to July, 2005, 129 patients with chronic non-bloody diarrhea of unexplained etiology who had undergone full colonoscopy with no obvious abnormalities were included in the study. Two biopsies were obtained from all colonic segments and terminal ileum for diagnosis of microscopic colitis. On histopathologic examination, criteria for lymphocytic colitis (intraepithelial lymphocyte &gt;or= 20 per 100 intercryptal epithelial cells, change in surface epithelium, mononuclear infiltration of the lamina propria) and collagenous colitis (subepithelial collagen band thickness &gt;or= 10 microm) were explored. Lymphocytic colitis was diagnosed in 12 (9%) patients (Female/Male: 7/5, mean age: 45 year, range: 27-63) and collagenous colitis was diagnosed in only 3 (2.5%) patients (all female, mean age: 60 years, range: 54-65). Biopsy of Turkish patients with the diagnosis of chronic non-bloody diarrhea of unexplained etiology and normal colonoscopic findings will reveal microscopic colitis in approximately 10% of the patients. Lymphocytic colitis is 4 times more frequent than collagenous colitis in these patients." }, { "id": "pubmed23n0299_9915", "title": "[Functional diarrheas are not, in most cases, minor clinical forms of lymphocytic or collagenous colitis].", "score": 0.017733835530445698, "content": "The aim of the study was to test the hypothesis that some patients with functional diarrhea could actually suffer from a mild clinical pattern of collagenous or lymphocytic colitis. Twenty consecutive patients with chronic diarrhea were included in the study if the colonic mucosa appeared normal during colonoscopy. From multiple colonic biopsies were established a conventional histological diagnosis and a quantitative histological diagnosis. This latter diagnosis was based on the semiquantitative evaluation of epithelial morphological alterations and lamina propria monocellular infiltration, and on the determination of both intraepithelial lymphocyte count and subepithelial collagen layer thickness. Multiple colonic biopsies from 12 control patients without diarrhea were analyzed according to the same protocol. Among the 20 patients with diarrhea, the quantitative diagnosis of collagenous colitis was made in 3 patients (thickness of the collagen band between 11 and 26 microns) and the diagnosis of lymphocytic colitis in one (21% of intraepithelial lymphocytes). The percentage of intraepithelial lymphocytes did not differ between the 16 remaining patients and the controls (12 +/- 5% and 9 +/- 4%, respectively). Similarly, the score of surface epithelial damage and the score of lamina propria infiltration in patients with diarrhea (1.2 +/- 1.0 et 1.7 +/- 1.5) were not different from the values in the control group (1.3 +/- 1.3 et 1.5 +/- 1.2). The mean fecal weight in patients with diarrhea but without colitis was 161 +/- 130 g/d. All the values of fecal weight were below 300 g/d, except in one patient with a past history of truncular vagotomy. These results suggest that most of the patients with functional diarrhea do not suffer from mild clinical patterns of collagenous or lymphocytic colitis." }, { "id": "wiki20220301en070_39278", "title": "Microscopic colitis", "score": 0.017322718561108653, "content": "Diagnosis Colonoscopic appearances are normal or near normal. As the changes are often patchy, an examination limited to the rectum may miss cases of microscopic colitis, and so a full colonoscopy is necessary. Multiple colonic biopsies are taken in order to make the diagnosis. Histological features of colonic biopsies indicating microscopic colitis are: greater than 20 intraepithelial lymphocytes per 100 epithelial cells and, additionally, 10-20 μm of a thickened subepithelial collagen band in collagenous colitis. Inflammation of the lamina propria, with mainly mononuclear cells, may be observed in collagenous colitis." }, { "id": "pubmed23n0601_8065", "title": "[Microscopic colitis: collagenous colitis and lymphocytic colitis].", "score": 0.01622784150156413, "content": "Microscopic colitis is currently classified as a chronic inflammatory bowel disorder and encompasses two entities: lymphocytic colitis and collagenous colitis. Patients with microscopic colitis present with a well-tolerated chronic watery diarrhea, sometimes with abdominal pain. Colonoscopy is normal. Diagnosis of microscopic colitis is established by histologic examination of colonic biopsies, showing a thickened subsurface collagen band higher than 10 microm in collagenous colitis, and an increased number of surface intra-epithelial lymphocytes higher than 20 lymphocytes per 100 epithelial cells in lymphocytic colitis. Causes of microscopic colitis are still unknown, although a drug-induced etiology is found in some cases. Patients are usually treated with budesonide but recurrences are frequent." }, { "id": "pubmed23n0970_15369", "title": "Microscopic colitis: a narrative review with clinical approach.", "score": 0.016036949130797357, "content": "Microscopic colitis (MC) is diagnosed in presence of microscopic alterations of colonic mucosa, in patients without macroscopic lesions who referred for chronic diarrhea. The two types of MC are lymphocytic colitis (LC) and collagenous colitis (CC), but it is unclear whether these are the different expression of one unique disease or if they are distinct conditions. Today, although MC represents a consistent health problem, being responsible for a large part of gastroenterological consultations for diarrhea, it remains often underestimated. The detailed pathogenesis of MC has not been determined yet. Probably, it is the result of an interaction between individual, environmental and genetic factors. The most relevant risk factor for the development of MC is the use of certain drugs (such as non-steroidal anti-inflammatory drugs [NSAIDs], proton pump inhibitors [PPIs], selective serotonin reuptake inhibitors, beta-blockers, statins). Smoking is another relevant factor reported as associated with the development of MC. Diagnosis needs the execution of a colonoscopy in patients complaining about chronic diarrhea and abdominal pain. The crucial role is played by histology: MC is characterized by the presence of colonic mucosal lymphocytic infiltrate, with intraepithelial lymphocytes ≥20 per 100 enteric surface cells, in CC there is a typical subepithelial collagen layer, whose thickness is ≥10 μm. We carried out a review of the current literature to rule out what is new on epidemiology, diagnosis and therapy of MC." }, { "id": "wiki20220301en126_13995", "title": "Lymphocytic colitis", "score": 0.015696649029982364, "content": "Lymphocytic colitis is a subtype of microscopic colitis, a condition characterized by chronic non-bloody watery diarrhea. Causes No definite cause has been determined. The peak incidence of lymphocytic colitis is in persons over age 50; the disease affects women and men equally. Some reports have implicated long-term usage of NSAIDs, proton pump inhibitors, and selective serotonin reuptake inhibitors, and other drugs. Associations with other autoimmune disorders suggests that overactive immune responses occur. Diagnosis The colonoscopy is normal but histology of the mucosal biopsy reveals an accumulation of lymphocytes in the colonic epithelium and connective tissue (lamina propria). Collagenous colitis shares this feature but additionally shows a distinctive thickening of the subepithelial collagen table." }, { "id": "pubmed23n0833_949", "title": "[Enteropathy due to olmesartan].", "score": 0.015639481000926783, "content": "The olmesartan is a selective antagonist of angiotensin II indicated for the treatment of essential hypertension. We report the case of a gastrointestinal involvement with duodenal villous atrophy and lymphocytic infiltrate duodenal epithelial and colonic secondary to the olmesartan taking with test of positive reintroduction. The patient had chronic diarrhea with weight loss of 10kg occurred 1 month after the passage of 20 to 40mg/day olmesartan took 3 years. A rectosigmoidoscopy highlighted some puncture slightly erythematous areas. The responsibility of olmesartan was suspected and the drug was stopped. The evolution was rapidly favorable with disappearance of diarrhea 4 8hours later. Two days after the patient took the drug on its own initiative. Sigmoid biopsies showed an inflammatory infiltrate rich in lymphocytes. Gastroscopy showed erosive esophagitis and duodenal biopsies showed chronic duodenitis with epithelial lymphocytosis and subtotal villous atrophy. The reintroduction has led to the immediate resumption of diarrhea. olmetec was finalized. Diarrhea has not returned since. A colonoscopy performed 6 weeks after discharge was normal. Knowledge of the bowel olmesartan is recent and based almost solely on the description of 22 cases observed at the Mayo Clinic with patients, as in our case, have similar symptoms and lesions. We stress about a publication an isolated case the possibility of less severe cases with histological abnormalities without clinical translation." }, { "id": "pubmed23n0866_7979", "title": "[Enteropathy due to olmesartan].", "score": 0.015351122027464553, "content": "The olmesartan is a selective antagonist of angiotensin II indicated for the treatment of essential hypertension. We report the case of a gastrointestinal involvement with duodenal villous atrophy and lymphocytic infiltrate duodenal epithelial and colonic secondary to the olmesartan taking with test of positive reintroduction. The patient had chronic diarrhea with weight loss of 10kg occurring one month after the passage of 20 to 40mg/day olmesartan took three years. A rectosigmoidoscopy highlighted some puncture slightly erythematous areas. The responsibility of olmesartan was suspected and the drug was stopped. The evolution was rapidly favorable with disappearance of diarrhea 48hours later. Two days after the patient took the drug on its own initiative. Sigmoid biopsies showed an inflammatory infiltrate rich in lymphocytes. Gastroscopy showed erosive esophagitis and duodenal biopsies showed chronic duodenitis with epithelial lymphocytosis and subtotal villous atrophy. The reintroduction has led to the immediate resumption of diarrhea. Olmesartan was finalized. Diarrhea has not returned since. A colonoscopy performed six weeks after discharge was normal. Knowledge of the bowel olmesartan is recent and based almost solely on the description of 22 cases observed at the Mayo Clinic with patients, as in our case, have similar symptoms and lesions. We stress, about a publication of an isolated case, the possibility of less severe cases with histological abnormalities without clinical translation. " }, { "id": "wiki20220301en070_39279", "title": "Microscopic colitis", "score": 0.015164147993746744, "content": "Pathology Microscopic colitis is characterized by an increase in inflammatory cells, particularly lymphocytes, in colonic biopsies with an otherwise normal appearance and architecture of the colon. Inflammatory cells are increased both in the surface epithelium (\"intraepithelial lymphocytes\") and in the lamina propria. The key feature is more than 20 intra-epithelial lymphocytes per 100 epithelial cells. These are the principal features of lymphocytic colitis. An additional distinguishing feature of collagenous colitis is a thickened subepithelial collagen layer, which may be up to 30 micrometres thick, that occurs in addition to the features found in lymphocytic colitis. The fact that the two types of microscopic colitis share many features including epidemiology, risk factors and, response to therapy has led to the suggestion that they are actually subtypes of the same disease." }, { "id": "pubmed23n0888_20960", "title": "Microscopic colitis in patients with mild duodenal damage: A new clinical and pathological entity (\"lymphocytic enterocolitis\")?", "score": 0.014810306350172449, "content": "To evaluate the potential association between mild duodenal damage and microscopic colitis (MC). We retrospectively included 105 consecutive patients with type I Marsh-Oberhuber duodenal damage and negativity for immunoglobulin A anti-endomysium and anti-tissue transglutaminase. The following parameters were analyzed: Sex, age at execution of esophagogastroduodenoscopy, duodenal damage, and number of intraepithelial lymphocytes at biopsies, prevalence of <iHelicobacter pylori</i infection, age at execution of colonoscopy, macroscopic and microscopic features of colonoscopy, family history of gastrointestinal and autoimmune diseases, smoking habits, biochemical parameters of inflammation and autoimmunity, use of proton pump inhibitors or nonsteroidal anti-inflammatory drugs, adverse reactions to drugs or foods, pathologies known to be associated with celiac disease or MC, living on a gluten-free diet or on a gluten-low diet for at least 1 mo. Colonoscopy was performed in 59 patients, but only in 48 of them biopsies were taken in the entire colon. Considering the latter cohort, the diagnosis of MC was met in 25 (52.1%) patients while in 18 patients other pathologic findings were reported: 13 (27%) cases of nonspecific inflammatory bowel disease, 2 (4.2%) cases of Crohn's disease, 2 (4.2%) cases of eosinophilic gastroenteritis, and 1 (2.1%) case of autoimmune enteritis. Five (10.4%) patients had a normal colonoscopic result. Matching the groups by age, and considering only patients who underwent colonoscopy (42.7 ± 15.5 years) <ivs</i those who did not undergo colonoscopy (36.9 ± 10.6 years), a statistical difference was found (<iP</i = 0.039). Focusing on symptoms, diarrhea was statistically more prevalent in MC group than in patients who did not undergo colonoscopy (<iP</i = 0.03). Mild duodenal damage is associated with MC in more than half of the cases. This association supports the hypothesis of a link between these two entities." }, { "id": "pubmed23n0716_5777", "title": "Endoscopic and histopathological evaluation of collagenous colitis.", "score": 0.014433942880624615, "content": "Collagenous colitis (CC) is a well-known cause of chronic non-bloody diarrhea, especially in elderly women. CC is characterized histopathologically by an increase in the thickness of the subepithelial collagen layer to at least 10 μm, epithelial damage, and chronic inflammation of the lamina propria. Generally, the colonic mucosa in CC is macroscopically normal, although minor, non-specific abnormalities may be found. Due to the recent advancement of endoscopic and diagnostic technologies, however, microscopic mucosal abnormalities and specific longitudinal linear lacerations of the mucosa characteristic of CC have been identified. The association of CC with non-steroidal anti-inflammatory drugs and proton pump inhibitors has also been reported. Since definitive diagnosis of CC has to rely on pathologically documented collagen bands and mononuclear infiltration, the efficiency and precision of colonic biopsy need to be improved. Of the 29 CC patients that we have encountered at our institution, it was in 15 of 29 cases that the endoscopic finding that we performed a biopsy on was apparent. Our comparison of the endoscopic and histopathological findings of CC in the 15 patients showed that the mucosa frequently appeared coarse and nodular on the surface of the mucosa, which was also significantly thicker in collagen bands, demonstrating a strong correlation between collagen band formation and CC. Also, the coarse and nodular surface of the mucosa was most frequently seen affecting the proximal colon. The results suggest that endoscopic observation and biopsy of the proximal colon, where a coarse and nodular surface of the mucosa is often found, may be useful for confirmation of the diagnosis in patients with suspected CC." }, { "id": "pubmed23n0739_4498", "title": "[Histopathology of microscopic colitis].", "score": 0.014415348716619134, "content": "Microscopic colitis (MC) is recognized to be a common cause of chronic, non-bloody diarrhea with rising incidence in the last decade. The diagnosis can only be made by histology and the specific histological findings define two subtypes of MC: lymphocytic (LC) or collagenous colitis (CC). The key histological feature of LC is an increased number of surface intraepithelial lymphocytes (IEL). In the literature, &gt;20 IELs/100 epithelial cells are required to warrant the diagnosis of LC. IELs are mostly cytotoxic CD8+ T-lymphocytes. The key histological criterion for CC is a continuous subepithelial fibrous band underneath the surface epithelium (&gt;10 µm). Other hallmarks of CC are chronic mucosal inflammation, and the collagen band can contain entrapped capillaries, red blood cells, and inflammatory cells. Damaged epithelial cells appear flattened, mucin depleted, and irregularly oriented. Focally, small strips of surface epithelium may lift off from their basement membrane. In both subtypes of MC, the lamina propria shows increased numbers of plasma cells and lymphocytes with loss of the normal gradient, even eosinophilic and neutrophilic granulocytes may be present. But these histological features alone do not warrant the diagnosis of MC even though they may be responsible for the clinical symptoms. The term MCi (MC incomplete) is suggested for the subgroup of patients with diarrhea and an increase in cellular infiltrate in the colonic lamina propria and either an abnormal collagenous layer and/or intraepithelial lymphocytes coming but not fulfilling the criteria for CC or LC." }, { "id": "pubmed23n0550_19839", "title": "Collagenous and lymphocytic colitis.", "score": 0.014395194697597348, "content": "Collagenous and lymphocytic colitis have been recognized as chronic intestinal inflammatory disorders causing watery diarrhea, which have been recognized in the past three to two decades, respectively. Collagenous colitis is primarily a disorder of middle-aged women and is characterized on biopsy by increased subepithelial collagen as well as increased inflammatory cells in the lamina propria and increased intraepithelial lymphocytes. Key to the correct diagnosis in this condition is recognizing that there are two words in this diagnostic entity, and colitis is, by definition, present. Focusing solely on the collagen band can result in both over- and underdiagnosis. Newer therapeutic options are available in this condition, and patients are now frequently being treated either with budesonide or with high dose bismuth preparations. Whereas collagenous colitis is a tightly coherent clinical pathologic entity, lymphocytic colitis has a more varied clinical picture. Lymphocytic colitis is also seen in middle-aged patients but has a more equal female-to-male ratio. Lymphocytic colitis is defined by increased intraepithelial lymphocytes, with the median being 30 lymphocytes per 100 epithelial cells. There are also an increase in inflammatory cells in the lamina propria, but the increase may be milder than in collagenous colitis and there are usually minimal eosinophils. Although numerous studies have described lymphocytic colitis causing a chronic diarrhea, more recent studies suggest that patients may have a single attack in approximately 60% of cases. Although most cases of lymphocytic colitis are idiopathic, there is a clear association with multiple drugs, celiac disease, and there may be an infectious trigger. Approximately 10% of lymphocytic colitis patients have a positive family history of some type of inflammatory intestinal disease, including ulcerative colitis, Crohn's disease, collagenous colitis, and celiac disease. Therapy in lymphocytic colitis is less well studied, but the same medications are used with success, including budesonide and high dose bismuth." }, { "id": "pubmed23n1085_15535", "title": "Histological disease activity in patients with microscopic colitis is not related to clinical disease activity or long-term prognosis.", "score": 0.013942307692307693, "content": "Microscopic colitis (MC) is a common cause of chronic watery diarrhea. Biopsies with characteristic histological features are crucial for establishing the diagnosis. The two main subtypes are collagenous colitis (CC) and lymphocytic colitis (LC) but incomplete forms exist. The disease course remains unpredictable varying from spontaneous remission to a relapsing course. To identify possible histological predictors of course of disease. Sixty patients from the European prospective MC registry (PRO-MC Collaboration) were included. Digitised histological slides stained with CD3 and Van Gieson were available for all patients. Total cell density and proportion of CD3 positive lymphocytes in lamina propria and surface epithelium were estimated by automated image analysis, and measurement of the subepithelial collagenous band was performed. Histopathological features were correlated to the number of daily stools and daily watery stools at time of endoscopy and at baseline as well as the clinical disease course (quiescent, achieved remission after treatment, relapsing or chronic active) at 1-year follow-up. Neither total cell density in lamina propria, proportion of CD3 positive lymphocytes in lamina propria or surface epithelium, or thickness of collagenous band showed significant correlation to the number of daily stools or daily watery stools at any point of time. None of the assessed histological parameters at initial diagnosis were able to predict clinical disease course at 1-year follow-up. Our data indicate that the evaluated histological parameters were neither markers of disease activity at the time of diagnosis nor predictors of disease course." }, { "id": "pubmed23n0648_22118", "title": "Microscopic colitis in patients presenting with chronic diarrhea.", "score": 0.013752276867030965, "content": "To investigate the prevalence of microscopic colitis among patients presenting with chronic watery diarrhea. Colonic biopsies from 400 patients presenting with chronic watery diarrhea and other symptoms pertaining to lower gastrointestinal tract were studied. After a detailed clinical history and thorough physical examination full length colonoscopy was done using flexible colonoscope. Colonic biopsies were taken from abnormal and normal areas. Three to five micron thick sections were cut and stained with hematoxylin and eosin and Masson's trichrome stain to highlight sub epithelial collagen. Fifteen out of 400 (3.7%) colonic biopsies from patients presenting with chronic diarrhea had evidence of microscopic colitis. Five out of fifteen biopsies (33%) were diagnosed as collagenous colitis, 10 biopsies (67%) had evidence of lymphocytic colitis; 14/400(3.5%) histologically normal biopsies were taken as controls to compare various demographic and risk factors. Ten out of 15 patients (67%) were clinically diagnosed as irritable bowel syndrome. In the remaining five an infective etiology was suspected. On colonoscopy12/15 (80%) had no abnormality and 3/15 (20%) had mild hyperemia. A possibility of microscopic colitis should be considered while examining colonoscopic biopsy of a patient with chronic watery diarrhea and normal colonoscopy to avoid the misdiagnosis that may affect the treatment of patients." }, { "id": "pubmed23n1033_10464", "title": "Undiagnosed microscopic colitis: a hidden cause of chronic diarrhoea and a frequently missed treatment opportunity.", "score": 0.013638963438778653, "content": "Microscopic colitis (MC) is a treatable cause of chronic, non-bloody, watery diarrhoea, but physicians (particularly in primary care) are less familiar with MC than with other causes of chronic diarrhoea. The colon in patients with MC is usually macroscopically normal. MC can only be diagnosed by histological examination of colonic biopsies (subepithelial collagen band &gt;10 µm (collagenous colitis) or &gt;20 intraepithelial lymphocytes per 100 epithelial cells (lymphocytic colitis), both with lamina propria inflammation). The UK National Health Service exerts downward pressure to minimise colonoscopy referrals. Furthermore, biopsies are often not taken according to guidelines. These factors work against MC diagnosis. In this review, we note the high incidence of MC (comparable to ulcerative colitis and Crohn's disease) and its symptomatic overlap with irritable bowel syndrome. We also highlight problems with the recommendation by National Health Service/National Institute for Health and Care Excellence guidelines for inflammatory bowel diseases that colonoscopy referrals should be based on a faecal calprotectin level of ≥100 µg/g. Faecal calprotectin is &lt;100 µg/g in over half of individuals with active MC, building into the system a propensity to misdiagnose MC as irritable bowel syndrome. This raises important questions-how many patients with MC have already been misdiagnosed, and how do we address this silent burden? Clarity is needed around pathways for MC management; MC is poorly acknowledged by the UK healthcare system and it is unlikely that best practices are being followed adequately. There is an opportunity to identify and treat patients with MC more effectively." }, { "id": "wiki20220301en070_39276", "title": "Microscopic colitis", "score": 0.013276640055536273, "content": "Microscopic colitis refers to two related medical conditions which cause diarrhea: collagenous colitis and lymphocytic colitis. Both conditions are characterized by the presence of chronic non-bloody watery diarrhea, normal appearances on colonoscopy and characteristic histopathology findings of inflammatory cells. Signs and symptoms The main symptom is persistent non-bloody watery diarrhea, which may be profuse. People may also experience abdominal pain, fecal incontinence, and unintentional weight loss. Microscopic colitis is the diagnosis in around 10% of cases investigated for chronic non-bloody diarrhea." }, { "id": "pubmed23n0339_15415", "title": "[Chronic diarrhea due to lymphocytic colitis treated with piroxicam beta cyclodextrin].", "score": 0.01284096020938126, "content": "Lymphocytic colitis is a chronic diarrhea syndrome with no endoscopically detectable anomaly and histological colonic lesions. A 52-year-old woman was hospitalized for chronic diarrhea. She experienced 10 to 30 liquid bowel movements per day. Symptoms had begun 8 days after taking piroxicam fl-cyclodextrin. Intraepithelial cell counts on rectum and colon endoscopic biopsies showed more than 20% lymphocytes, giving the diagnosis of lymphocytic colitis. The patient was given 5ASA 3 g/24 h. Symptoms regressed in less than one week. Lymphocytic colitis is uncommon. The cause remains unknown but a secondary autoimmune mechanism triggered by drugs has been suggested. This case would implicate nonsteroidal antiinflammatory drugs. Certain authors have demonstrated that they can be involved in the development of collagen colitis." }, { "id": "pubmed23n0754_14583", "title": "Microscopic colitis in children with chronic diarrhea.", "score": 0.012833696680514994, "content": "The aim of the present study was to study microscopic colitis (MC) in children with special reference to its role in chronic diarrhea and changes in mucosal biopsies. A total of 100 consecutive children ages 3 to 12 years, with nonbloody diarrhea (passage of ≥3 loose stools per day) of &gt;12 weeks' duration were screened and 26 were enrolled in the study in which no specific etiology could be found and colonoscopy did not reveal any mucosal abnormality. Colonic biopsies were evaluated for the presence of lymphocytic colitis or collagenous colitis and those with the characteristic changes were defined to have MC (group A). Colonic biopsies from patients with MC were compared with biopsies from patients with chronic diarrhea but no evidence of MC (group B). One hundred children ages 3 to 12 years with bleeding per rectum were screened and colonic biopsies from 45 patients (group C) who had colonic mucosal changes but no vascular or polyp lesion were compared with patients with MC. Of the 26 patients with chronic diarrhea, MC was found in 5 (3 lymphocytic colitis and 2 collagenous colitis). Significantly higher polymorphonuclear infiltration was seen in group A as compared with group B (13.8 [5.4-20.6] vs 7.2 [0-19.6]; P = 0.03) or group C (13.8 [5.4-20.6] vs 4 [0-13.4]; P = 0.007). Intraepithelial lymphocytes (12 [4-32] vs 4 [0-24]; P = 0.008) and basement membrane thickening (3.5 [2.9-10.6] vs 2.5 [1.6-5.86]; P = 0.008) were also significantly higher in group A as compared with group C. MC was found to be present in children with nonbloody chronic diarrhea in children. Further multicentric studies may provide adequate data on its prevalence." }, { "id": "pubmed23n0416_3952", "title": "Suspicion of microscopic colitis raised by sonographic examination.", "score": 0.01251339354048676, "content": "This report describes the case of a 57-year-old woman who was incidentally identified as having lymphocytic colitis after she underwent routine transabdominal sonographic examination. She initially reported having no irregularities in her bowel movements. Sonography revealed the following nonspecific findings: watery stool in the entire colon, slight thickening of the hypoechoic mucosal layer and moderate thickening of the hyperechoic submucosal layer of the colon, and no pathologic findings in the small intestine. On additional questioning, the patient said that she had had watery diarrhea for the last 10 years, with as many as 10 bowel movements daily. Endoscopic examination and biopsy were performed. Histopathologic examination of biopsy specimens showed lymphocytic infiltration of the mucosa and some collagen deposits, consistent with a diagnosis of lymphocytic colitis. Treatment was begun with loperamide, sulfasalazine, and budesonide. Within 3 weeks of the start of treatment, the number of bowel movements decreased to 1-2 daily. Follow-up sonography at that time revealed normalization of the bowel contents and disappearance of the thickened submucosal layer of the colon. Nonspecific sonographic findings like those in this case lead to the need to rule out various diseases through further appropriate evaluations to identify the correct diagnosis." }, { "id": "pubmed23n1123_9186", "title": "Intraepithelial and Lamina Propria Lymphocytes Do Not Correlate With Symptoms or Exposures in Microscopic Colitis.", "score": 0.01208699743060833, "content": "Microscopic colitis, a common cause of diarrhea, is characterized by a largely normal appearance of the mucosa but increased numbers of lymphocytes in the epithelium and lamina propria on microscopy. We sought to determine whether T-cell percentage was associated with exposures or symptoms. We conducted a case-control study that enrolled patients referred for colonoscopy for diarrhea. Patients were classified as microscopic colitis cases or controls by an experienced pathologist. Participants provided information on symptoms and exposures during a telephone or internet survey. Research biopsies from the ascending colon and descending colon were examined using immunofluorescence stains for CD3, CD8, and FOXP3 to determine percent T cells per total epithelial or lamina propria cells. Digital images were analyzed by regions of interest using Tissue Studio. There were 97 microscopic colitis cases and 165 diarrhea controls. There was no association between demographic factors and percentage of intraepithelial or lamina propria T cells. In cases, the mean percent T cells were similar in the right colon and left colon. There was no association between mean percent T cells and stool frequency or consistency. There was no association with irritable bowel syndrome, abdominal pain, or medications purported to cause microscopic colitis. The lack of association between the density of T cells and medications raises further doubts about their role in disease etiology. Loose and frequent stools in patients with microscopic colitis are not correlated with T-cell density." }, { "id": "pubmed23n0699_1769", "title": "Collagenous ileitis: a study of 13 cases.", "score": 0.012030662218752219, "content": "Collagenous ileitis (CI), characterized by subepithelial collagen deposition in the terminal ileum, is an uncommon condition. The few cases reported to date have been associated with collagenous colitis (CC) or lymphocytic colitis. Thirteen cases of CI retrieved over a 9-year period were retrospectively studied. There were 7 female and 6 male patients, with an age range of 39 to 72 years (mean, 64 y). Two groups were identified: (1) CI associated with collagenous or lymphocytic disease elsewhere in the gastrointestinal tract and (2) CI as an isolated process. Diarrhea was the presenting symptom in 11 cases. Most patients had no regular medication use. Subepithelial collagen thickness ranged from 15 to 100 μm (mean, 32 μm) and involved 5% to 80% of the subepithelial region of the submitted biopsies. Six cases had &gt;25 intraepithelial lymphocytes (IELs)/100 epithelial cells, and villous blunting was observed in 11 cases. Chronic inflammation of the lamina propria was present in 9 cases, and focal neutrophil infiltration was identified in 3 cases. In biopsies taken from other sites, 7 of 13 colonic biopsies showed CC, 4 of 9 gastric biopsies showed collagenous gastritis, and 2 of 10 duodenal biopsies were abnormal with collagenous sprue (n=1) and partial villous atrophy and increased IELs (n=1) (both celiac disease related). Resolution of the subepithelial collagen deposition was found in the 1 case in which follow-up of terminal ileal biopsies were taken. There was partial or complete resolution of symptoms in 6 of 9 patients for whom follow-up information was available." }, { "id": "pubmed23n0516_4491", "title": "[Microscopic colitis].", "score": 0.011684782608695652, "content": "A 38-year old woman is admitted in the gastroenterology unit for a disabling episode of watery diarrhoea, not bloody and refractory to anti-diarrheic drugs. Different diagnostic exams remain negatives, with the exception of colic biopsies who disclose a lymphocytic colitis, one of the forms of the microscopic colitis entity. Microscopic colitis is an anatomo-clinic syndrome characterized by the presence of histological abnormalities on colic biopsies amongst patients suffering from chronic watery diarrhoea without endoscopic anomalies. Two clinical entities are today well known: collagenous colitis is characterized by a thickening of the sub-epithelial collagen band of the colon; lymphocytic colitis is defined as an increased level of lymphocytic cells, more than 20%, in the epithelial surface of colorectal mucosa. Inflammatory lesions of the chorion and alterations of the epithelial surface are seen in the two types of colitis. Their etiology remains unknown. It could be due to inflammatory lesions from autoimmune origin, activated by various exogenous agents such as bacteria and drugs. Clinical (feminine prevalence, frequent association with auto-immune diseases) and morphological similarities lead to argue and to hypothesis that both entities could represent different stages of the same disease, the lymphocytic colitis being the early stage. Various treatments have been proposed, for instance 5-aminosalicylates, but today mainly synthetic corticoids are used, especially budesonide. Others entities are recently been described: the chronic pericrypt eosinophilic enterocolitis and the colonic epithelial lymphocytosis (\"epidemic\")." }, { "id": "pubmed23n0652_9156", "title": "Collagenous and lymphocytic colitis: systematic review and update of the literature.", "score": 0.011252200150867489, "content": "Collagenous and lymphocytic colitis are well-described conditions causing chronic watery diarrhoea. A peak incidence from 60 to 70 years of age with a female predominance mainly in collagenous colitis is observed. Both conditions are characterised by a (near) normal colonoscopy, but with specific histologic findings on colonic biopsies. Histopathologically, both conditions are characterised by distinct epithelial abnormalities and a dense lymphoplasmocytic infiltrate. Distinct features consist of a characteristic collagen band deposition in the subepithelial layer in collagenous colitis and a markedly increased number of intra-epithelial lymphocytes in lymphocytic colitis. Although most cases are idiopathic, certain drugs can induce microscopic colitis. In addition, either condition can be associated with coeliac disease. For a long time patients with microscopic colitis were treated with non-specific anti-diarrhoeal agents, anti-inflammatory agents such as mesalazine, or systemic steroids, but with disappointing results. Bismuth subsalicylate was reported to be effective in a small controlled series of patients with collagenous colitis. Now, randomised controlled trials have shown the effectiveness of budesonide over placebo in collagenous colitis and more recently in lymphocytic colitis. The histologic response is variable, but a decrease in the subepithelial collagen layer and a decrease in the lymphoplasmocytic infiltrate in the lamina propria is observed in about half of the patients. In general, patients respond within 2 weeks with no major side effects. However, relapse is common (63-80% of patients) when budesonide is stopped. Longer-term treatment is effective but does not seem to reduce relapse rates upon discontinuation." }, { "id": "pubmed23n0697_7483", "title": "[Microscopic colitis: histopathological review with a clinicopathological correlation].", "score": 0.010882387637135778, "content": "Microscopic colitis is a clinicopathological entity which, in addition to typical symptoms such as watery diarrhea, is characterized by its specific histopathology. Since colonoscopy yields normal findings, microscopic colitis belongs in a histological domain. The term encompasses two forms: lymphocytic and collagenous colitis. Histologically, lymphocytic colitis shows an increase in intraepithelial lymphocytes of more than 20 lymphocytes per 100 surface colonocytes, while collagenous colitis is characterized by a thickened subepithelial collagen layer of more than 10 µm. Specific stains help in the quantification of both. Since microscopic colitis does not always affect the entire colon and the number of intraepithelial lymphocytes varies physiologically, obtaining stepwise biopsies of the colon (with information on location where possible) is recommended. A thickened collagen layer is relatively specific for collagenous colitis, whereas intraepithelial lymphocytosis is also found in other diseases. Therefore, to make a correct diagnosis, it is important to correlate histological findings with clinical symptoms, including the main symptom of watery diarrhea." }, { "id": "pubmed23n0313_9157", "title": "[Collagen colitis and lymphocytic (microscopic) colitis: different or common origin?].", "score": 0.0106951871657754, "content": "Collagenous and lymphocytic colitis are two chronic inflammatory colonic diseases characterized by chronic watery diarrhea. They can only be diagnosed by histological examination of colonic biopsies. The pathogenesis is unknown, but may be of an inflammatory possibly autoimmune nature. Others hypothesize that a bacterial toxin or another noxious luminal factor is responsible for the development of the microscopic colitis syndrome. Some studies suggest that NSAIDs may be an etiologic factor in collagenous colitis in a subgroup of patients with this disease. These disorders may be different entities, although some data support the possibility that they are only different manifestations of the same disease. Therapy with 5-aminosalicylate and in severe cases corticosteroids, is successful in most patients. The course of these chronic diseases is commonly benign and is characterized by periods of spontaneous remissions and relapses, but clinical and histopathological resolutions are occasionally seen. On the basis of our own two cases and the literature, these two diseases will be discussed. These patients were admitted to our hospital within a month of each other due to therapy-refractive chronic watery diarrhea. A 70-year-old woman had been suffering from diarrhea for more than ten years. The histological examination produced a diagnosis of collagenous colitis. Lymphocytic colitis was diagnosed from a histological examination in a 30-year-old man who had been suffering from diarrhea for six months. Both received a therapy of mesalazine and the symptoms disappeared within three weeks." }, { "id": "pubmed23n0768_14690", "title": "Chronic low-dose aspirin use does not alter colonic mucosa in asymptomatic individuals: a prospective cross-sectional study (STROBE 1a).", "score": 0.010481663929939792, "content": "Aspirin may be involved in microscopic colitis (MC) development, but there are no data on colon histology in asymptomatic aspirin users. We prospectively assessed colonic and rectal mucosa from aspirin users, searching for MC features. From colonoscopy screenees, two biopsy samples were taken from each of three locations: ascending colon, transverse colon and rectum. A pathologist measured chronicity of inflammation and activity indicators, epithelial cell height and subepithelial collagen layer width. Intraepithelial lymphocytes (IELs), intralaminal eosinophils and apoptotic cells/100 crypts were counted. Panel data models were used to analyse associations between aspirin use, biopsy location and microscopic parameters. Of 100 screenees (age: 40-65 years), 42 were current aspirin users. Median duration of aspirin usage was 48 months (range: 36-60) with dosage ranging from 75-325 mg/day. We observed reduced epithelium polymorphs in subjects who used aspirin for &lt;48 months versus non-users (p=0.008). Paneth cell metaplasia was significantly less frequent in aspirin users versus non-users (p=0.006). Inflammatory cells in lamina propria (eosinophils) and epithelium (IELs) were most abundant in the ascending colon and decreased distally (ascending colon vs transverse colon and transverse colon vs rectum). Cryptitis was more frequent in the ascending colon vs the rectum. We observed no specific MC features in asymptomatic chronic low-dose aspirin users. We found subtle physiological and histopathological differences between the bowel segments." }, { "id": "wiki20220301en084_292", "title": "Collagenous colitis", "score": 0.010025208454527826, "content": "Collagenous colitis is an inflammatory bowel disease affecting the colon specifically with peak incidence in the 5th decade of life, affecting women more than men. Its clinical presentation involves watery diarrhea in the absence of rectal bleeding. It is often classified under the umbrella entity microscopic colitis, that it shares with a related condition, lymphocytic colitis. Signs and symptoms Microscopic colitis causes chronic watery diarrhea with greater than 10 bowel movements per day. Some patients report nocturnal diarrhea, abdominal pain, urgency, fecal incontinence, fatigue, dehydration and weight loss. Patients report a significantly diminished quality of life. Causes The cause of collagenous colitis is unknown." }, { "id": "pubmed23n0833_17920", "title": "[Evolution of ideas on microscopic colitis].", "score": 0.009900990099009901, "content": "The literature review gives the present-day views of the definition, etiology, pathogenesis, diagnosis, and treatment of microscopic colitis (MC). In the present view, MC is an inflammatory bowel disease of unknown etiology, which is characterized by chronic watery diarrhea, no macroscopic signs of large bowel involvement in the presence of specific pathomorphological changes. There are two major forms of MC, which are similar in its clinical picture, yet, heterogeneous in histological criteria: collagenous colitis (CC) and lymphocytic colitis (LC). As of now, the prevalence of MC is about 100 cases per 100,000 population, which is similar with that in other inflammatory bowel diseases, such as ulcerative colitis and Crohn's disease. MC generally prevails in women aged over 50 years. The etiology and pathogenesis of MC have not fully investigated. Watery diarrhea is as a predominant pathognomonic symptom in all the patients with MC. The major histological criterion for the diagnosis of CC is subepithelial collagen lining thickening (more than 10 pm) and that for LC is higher intraepithelial lymphocyte counts (more than 20 intraepithelial lymphocytes/100 epitheliocytes). The topical glucocorticosteroid budesonide is currently the only agent, the efficacy of which has been proven in both inducing and maintaining remission in patients with MC in many clinical trials." }, { "id": "pubmed23n0598_13529", "title": "[Microscopic colitis - review].", "score": 0.009708737864077669, "content": "Microscopic colitis (MC) is an encompassing term for two diseases; collagenous colitis and lymphocytic colitis. The colon appears normal by colonoscopy and a diagnosis is only obtained with a biopsy. The histopathology of collagenous colitis is mainly characterized by a thickening of the subepithelial basement membrane of the colonic mucosa with a band of collagen. Lymphocytic colitis is mainly characterized by an intraepithelial lymphocytosis without the collagen thickening. Even though the two diseases have a distinctive pathology their clinical symptoms are characterized by chronic watery diarrhea without bleeding. Microscopic colitis is thought to cause about 4-13% of all chronic diarrhea but their relative frequency is much higher among older people. The mean annual incidence for collagenous and lymphocytic colitis has been increasing. Steroids are the most effective treatment for microscopic colitis and budesonide is the most studied and effective therapy for MC. The aim of this paper is to give a review of two relatively new diseases which are among the most common cause of chronic diarrhea, especially among older people." } ] } } }

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{ "1": "Reassure the nurse and family that the patient is a habitual snorer and is peacefully asleep. The patient should be placed in lateral decubitus.", "2": "Notify intensive care for suspected acute respiratory failure, to assess possible orotracheal intubation and assisted ventilation.", "3": "Perform polysomnographic study to rule out sleep apnea.", "4": "Decrease steroid dose; if he has a steroid myopathy he will improve.", "5": "Order a thoracic CT scan to rule out compressive thymoma over the trachea associated with myasthenia." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1140_26279", "title": "A Case of COVID-19 With Myasthenic Crisis.", "score": 0.019327731092436976, "content": "Coronavirus disease 2019 (COVID-19) infection can increase the risk of myasthenic crisis. Dexamethasone has been widely used to manage severe COVID-19 infection. Paradoxically, steroids are effective for treating myasthenia gravis; however, when they are started in high doses, there is an associated risk of steroid-induced exacerbation. This case report describes an 86-year-old male with seropositive generalised myasthenia gravis, whose course had been stable for years. At the time of his COVID-19 diagnosis, he was on pyridostigmine and prednisolone 10 mg daily. He was treated with IV dexamethasone 6 mg daily, remdesivir, and antibiotics. On day 10 of admission, he had a sudden deterioration with a Glasgow Coma Scale (GCS) score of 3. Arterial blood gas (ABG) showed a new type 2 respiratory failure suggesting myasthenic crisis. Although his ABG improved after commencing bilevel positive airway pressure (BiPAP), his condition continued to deteriorate and he died the next day. A decision not to intubate and ventilate had been made given his poor clinical state and low chance of recovery. His myasthenic crisis was likely precipitated by the COVID-19 infection, although steroids, azithromycin, and doxycycline also have the potential to cause the worsening of myasthenia gravis. Further studies are needed to evaluate the efficacy and risk of steroid use in this patient population. Ventilatory failure may occur insidiously and is often difficult to detect, especially in elderly and delirious patients in whom performing a neurological examination can be difficult. Regular ABG and bedside measures of forced vital capacity may be considered to monitor the development of type 2 respiratory failure." }, { "id": "pubmed23n0939_1829", "title": "Thymectomy during Myasthenic Crisis under Artificial Respiration.", "score": 0.017966484047695776, "content": "A 34-year-old man was diagnosed with thymoma, which was evaluated preoperatively as stage II or III, with myasthenia gravis (MG). The size of the tumor was 70 × 44 × 80 mm. No invasion to neighboring organs was observed. Prednisolone was prescribed for stabilization of MG. However, a myasthenic crisis (MC) occurred, and intensive care, including emergent endobronchial intubation followed by artificial ventilation, pulse steroid therapy, high-dose intravenous immunoglobulin, and tacrolimus hydrate, was initiated. A chest computed tomography on day 6 revealed tumor reduction to 50 × 30 × 60 mm. An extended total thymectomy by median sternotomy was performed, and artificial ventilation was continued after that. Scheduled artificial ventilation and steroid therapy together can, therefore, enable complete resection of thymoma in patients undergoing treatment for MC. While ventilation helps avert a respiratory failure, the steroid therapy temporarily reduces the tumor size, making resection easier." }, { "id": "pubmed23n1063_106", "title": "SOP myasthenic crisis.", "score": 0.01610062893081761, "content": "The overall prevalence of myasthenic crisis is quite low at 30/1 million inhabitants because myasthenia gravis is a rare disease per se. But it should be noted that 15-20% of patients with myasthenia gravis experience at least one crisis in their lives. Most often, the crisis occurs within the first 2 years of the disease or is even the first manifestation of a yet undiagnosed myasthenia gravis in up to 20%.Median duration of MC is about 2 weeks (median 12-14 days of ventilation) under sufficient treatment, but prolonged courses are not uncommon and often due to comorbidities and complications, so that about 20% are still mechanically ventilated after 1 month.The lifetime risk of recurrence of a crisis is approx. 30%. Data on mortality differ between about 2-5% to even more than 16%. Lethal outcomes are almost never caused by the crisis itself, but because comorbidities or complications eventually become limiting. Myasthenic crisis (MC) is the life-threatening maximal manifestation of myasthenia gravis (MG) necessitating mechanical ventilation, supportive feeding and (neuro-)intensive care. Weakness may develop within minutes to days and encompass flaccid tetraparesis with immobility, severe dyspnea, respiratory insufficiency and aspiration. Globus events may be life threatening due to rapidly exhausting coughing and swallowing. ● Check and secure vital functions. ● not applicable. The main symptom of (imminent) myasthenic crisis is the rapidly progressive weakness of the respiratory and bulbar muscles, which lead to a decompensation with aspiration and respiratory insufficiency. Clinical examination and clinical history should lead early to the diagnosis of MG with (impending) crisis. The detection of red flags and the dynamic deterioration of symptoms entail admission to the intensive care unit. Due to bulbar symptoms with aspiration and/or respiratory insufficency, early intubation to secure the airway is essential. Therapy includes symptomatic treatment with pyridostigmine or neostigmine and acute causal treatment by immunoadsorption/plasmapheresis or alternatively with immunoglobulins. If used early, intubation may still be prevented and clinical improvement can be achieved within a few days. At the same time, immunosuppression with corticosteroids and azathioprine should be initiated or optimized. For escalation rituximab is an option. The early diagnosis and consequent treatment of infections and other complications such as delirium influence the further course." }, { "id": "pubmed23n0308_10009", "title": "[Acute iatrogenic myopathy during treatment of status asthmaticus. Our experience and review of the literature].", "score": 0.01597911892029539, "content": "A young man was admitted to the ICU for acute asthmatic respiratory failure. He was sedated with propofol, curarized with pancuronium and put on mechanical ventilation for 15 day because of the persistent asthmatics crisis. Drug therapy for asthma included high-dose corticosteroids. When sedation and paralysis were stopped, the patient, that was fully conscious, showed flaccid quadriplegia. A muscular biopsy showed elective loss of the myosin thick filaments. Electrophysiologic evaluation was compatible with both neurologic or muscular pathology. The evolution of the disease was good; a drop-out performed 5 months later showed a complete motor recovery. This case report confirms that in some patients, intensive treatment of status asthmaticus may cause myopathy. Only recently this myopathy has been correlated to an interaction between steroids and neuromuscular blockers. Many experimental and clinical observations suggest a negative interaction between steroids and non-depolarizing curare derivatives. In the case reported here, diagnosis was based on electrophysiologic examination and above all on muscular biopsy. The occurrence of an acute toxic myopathy should always be taken into account, considering the high number of patients admitted with respiratory failure requiring steroid treatment and curare administrative for mechanical ventilation. It therefore seems reasonable to reduce steroid therapy as soon as possible with a periodic suspension of curare administration. Curare usage should be critically evaluated. Some basic examination such as serum CPK monitoring should allow early detection of muscular damage." }, { "id": "InternalMed_Harrison_31344", "title": "InternalMed_Harrison", "score": 0.012810272794298354, "content": "Myasthenic crisis is defined as an exacerbation of weakness sufficient to endanger life; it usually consists of respiratory failure caused by diaphragmatic and intercostal muscle weakness. Crisis rarely occurs in properly managed patients. Treatment should be carried out in intensive care units staffed with teams experienced in the management of MG, respiratory insufficiency, infectious disease, and fluid and electrolyte therapy. The possibility that deterioration could be due to excessive anticholinesterase medication (“cholinergic crisis”) is best excluded by temporarily stopping anticholinesterase drugs. The most common cause of crisis is intercurrent infection. This should be treated immediately, because the mechanical and immunologic defenses of the patient can be assumed to be compromised. The myasthenic patient with fever and early infection should be treated like other immunocompromised patients. Early and effective antibiotic therapy, respiratory assistance (preferably" }, { "id": "pubmed23n0360_23354", "title": "[A senile case of acute necrotizing myopathy presenting prolonged severe muscle paralysis due to high dose glucocorticoid and muscle relaxant].", "score": 0.01227682486232418, "content": "An 82-year old man was admitted with dyspnea, productive cough and wheezing. In addition to antibiotics (meropenem trihydrate 0.5 g/day), glucocorticoids (hydrocortisone 1.250 mg, methylpredonisolone 4.250 mg) were administered for the severe bronchospasms. Since his respiratory condition deteriorated, he underwent mechanical ventilation using a muscle relaxant (vecuronium bromide, total dose 776 mg) in combination with high dose glucocorticoid. As his pneumonia improved on the 10th hospital day, we started weaning him from the ventilator. However, we were unable to complete weaning from the ventilator because of prolonged quadriplegia and paralysis of the respiratory muscles. A few days later, myoglobinuria appeared. Electrophysiological examinations suggested the involvement of both neuromuscular junctions and muscles. Muscle biopsy showed rhabdomyolysis. Acute necrotizing myopathy was diagnosed due to high doses of glucocorticoid, muscle relaxant, or both. He required about 3 months to be weaned from the mechanical ventilation, and another 3 months to leave the hospital. Based on our experience, we should consider acute myopathy as an adverse effect of glucocorticoids, muscle relaxants or both in elderly patients who require mechanical ventilation." }, { "id": "Neurology_Adams_10447", "title": "Neurology_Adams", "score": 0.012060379707438531, "content": "General medical care In severe cases, respiratory assistance and assiduous nursing are paramount, because the disease remits naturally and the outlook for recovery is favorable in the majority of patients. About one-quarter of our patients have required mechanical ventilation. Because a patient’s condition may deteriorate unpredictably and rapidly in the first days of illness, virtually all but the mildest cases should be admitted to the hospital for observation of respiratory, autonomic, and motor function. The comments that follow are applicable to most other forms of acute and subacute neuromuscular respiratory failure, including myasthenia gravis and high spinal cord injury." }, { "id": "Neurology_Adams_11753", "title": "Neurology_Adams", "score": 0.011033834586466165, "content": "Patients with myasthenic crisis generally respond to plasma exchange or to immunoglobulin infusions in 1 or 2 days, but more often a week or more is required for recovery after a full course of 4 to 5 exchanges or 3 to 5 g/kg IVIg given in divided daily doses. Whether the previously mentioned studies (e.g., Gajdos et al) comparing the 2 treatments and comparing doses of IVIg in myasthenic exacerbations are pertinent to crisis is unknown but we almost always institute one or the other soon after it as it is apparent that respiratory failure is imminent or worsening." }, { "id": "wiki20220301en071_62228", "title": "Ocular myasthenia", "score": 0.009900990099009901, "content": "Patients with mild-to-moderate ocular myasthenia are usually treated initially with oral anticholinesterase agents, Mestinon (pyridostigmine) being the most commonly employed. There have not been any randomized clinical trials conducted with these agents, and this treatment is often unsuccessful, particularly in resolving diplopia. Immunosuppressive therapy is then started and the agent of choice is usually prednisone. In a small controlled study this drug demonstrated greater efficacy than pyridostigmine. Steroid therapy is controversial, but in another study the results suggested that prednisone does decrease progression to generalized MG. There is no single recommended dosing regimen in light of the side effects commonly associated with chronic corticosteroid therapy, and the difficulty in weaning patients from steroids without exacerbation of symptoms. Response to prednisone therapy is variable." }, { "id": "Neurology_Adams_11754", "title": "Neurology_Adams", "score": 0.009900990099009901, "content": "It is generally best to wait 2 or 3 weeks before committing a patient to tracheostomy. When weaning from the ventilator is anticipated, anticholinesterase agents are reintroduced slowly, and treatment with corticosteroids can be instituted if necessary. Oral doses of 60 mg pyridostigmine or 15 mg neostigmine are roughly equivalent to 0.5 to 1 mg neostigmine intravenously and 1.5 to 2 mg intramuscularly, as noted in Table 46-1. The management of the critically ill patient with myasthenia is reviewed in the monograph by Ropper and colleagues." }, { "id": "InternalMed_Harrison_31331", "title": "InternalMed_Harrison", "score": 0.009881756756756756, "content": "Glucocorticoid Therapy Glucocorticoids, when used properly, produce improvement in myasthenic weakness in the great majority of patients. To minimize adverse side effects, prednisone should be given in a single dose rather than in divided doses throughout the day. The initial dose should be relatively low (15–25 mg/d) to avoid the early weakening that occurs in up to one-third of patients treated initially with a high-dose regimen. The dose is increased stepwise, as tolerated by the patient (usually by 5 mg/d at 2to 3-day intervals), until there is marked clinical improvement or a dose of 50–60 mg/d is reached. This dose is maintained for 1–3 months and then is gradually modified to an alternate-day regimen over the course of an additional 1–3 months; the goal is to reduce the dose on the “off day” to zero or to a minimal level. Generally, patients begin to improve within a few weeks after reaching the maximum dose, and improvement continues to progress for months or years. The" }, { "id": "pubmed23n0328_12082", "title": "[Myasthenia gravis presenting as isolated respiratory failure].", "score": 0.00980392156862745, "content": "A 61-year-old woman in excellent health and taking no medications presented with progressive dyspnea on exertion. She did not exhibit diplopia, dysphagia, dysarthria or muscle weakness. Her condition deteriorated, and respiratory distress developed. The patient was intubated and placed on mechanical ventilation. A computed tomogram of her chest revealed a moderately enlarged thymus gland unsuspected on a plain x-ray film. Myasthenia gravis was diagnosed on the basis of a high acetylcholine receptor antibody titer. Treatment started with prednisolone, anticholinesterase agent, and plasma exchange. The patient underwent a thymectomy 3 weeks after her diagnosis. Her symptoms were brought under control by anticholinesterase agent and prednisolone. This case illustrates the need to consider myasthenia gravis as well as other motor-neuron disorders when evaluating individuals presenting acute respiratory failure of unknown origin." }, { "id": "pubmed23n0978_5162", "title": "Clinical Management of Pneumonitis in Patients Receiving Anti-PD-1/PD-L1 Therapy.", "score": 0.009708737864077669, "content": "<bCASE STUDY</b A 48-year-old gentleman with metastatic melanoma currently receiving the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) inhibitor, ipilimumab (Yervoy), and the programmed cell death protein 1 (PD-1) inhibitor, nivolumab (Opdivo), returned for evaluation prior to receiving cycle 2. The patient presented with new onset dyspnea and a non-productive cough over the past week, with a temperature of 100.6°F at home on one occasion. He was placed on observation for fever, cough, and shortness of breath. The patient had no previous history of lung disease and was a nonsmoker. Diminished breath sounds were noted on auscultation. However, the patient was without fever or chills, with a heart rate of 101 beats per minute and a blood pressure of 110/75 mm Hg. We obtained a computed tomography (CT) of his chest. The CT demonstrated diffuse ground-glass opacities in his bilateral lower lobes and some minor interstitial thickening of his right middle lobe, possibly suggestive of inflammation or cryptogenic organizing pneumonia. Based on his presentation and CT findings, the patient was initially treated empirically with antibiotics for suspected pneumonia vs. pneumonitis. During the first 12 hours in observation, the patient experienced increasing dyspnea and cough and was admitted to the hospital. Nebulizer treatments were administered with no improvement, so the patient was started on high-dose corticosteroids at 1 mg/kg, and pulmonary and infectious disease consults were ordered. After the administration of steroids, the patient's cough and breathing improved and he remained afebrile, eliciting a high suspicion for immune-related pneumonitis. The patient then underwent bronchoscopy to rule out other etiologies. Bronchoalveolar lavage was performed, which yielded no pathogenic organisms. The patient was placed on a 3-week course of a high-dose steroid taper, following which immunotherapy was reinstated. Within 4 days he again presented with similar symptoms, was restarted on high-dose steroids, and immunotherapy was permanently discontinued." }, { "id": "pubmed23n0291_16741", "title": "[Intensive care in myasthenic and cholinergic crises].", "score": 0.009708737864077669, "content": "Presents the epidemiology, possible etiology, and pathogenesis of myasthenia, methods of diagnosis of the disease, and clinical picture of critical states. Describes the present-day methods of treating myasthenic and cholinergic crises: programmed plasmapheresis combined with hormone therapy, pulsed therapy with superhigh doses of corticosteroids, and the most novel method for the treatment of autoimmune diseases, intravenous infusions of immunoglobulins. Draws attention to indications for artificial ventilation of the lungs and tracheostomy. Enumerates the drugs which are not recommended for patients with myasthenia. Emphasizes that the use of the whole complex of modern therapeutic methods for the treatment of grave myasthenia helps reduce the mortality to virtually null." }, { "id": "wiki20220301en097_51559", "title": "Allergic bronchopulmonary aspergillosis", "score": 0.009615384615384616, "content": "In order to mitigate these risks, corticosteroid doses are decreased biweekly assuming no further progression of disease after each reduction. When no exacerbations from the disease are seen within three months after discontinuing corticosteroids, the patient is considered to be in complete remission. The exception to this rule is patients who are diagnosed with advanced ABPA; in this case, removing corticosteroids almost always results in exacerbation and these patients are continued on low-dose corticosteroids (preferably on an alternate-day schedule). Serum IgE can be used to guide treatment, and levels are checked every 6–8 weeks after steroid treatment commences, followed by every 8 weeks for one year. This allows for a determination of baseline IgE levels, though it's important to note that most patients do not entirely reduce IgE levels to baseline. Chest X-ray or CT scans are performed after 1–2 months of treatment to ensure infiltrates are resolving." }, { "id": "pubmed23n0636_8972", "title": "Myasthenia gravis complicated with primary aldosteronism and hypokalemic myopathy.", "score": 0.009523809523809525, "content": "A 34-year-old Japanese man was admitted to an outside hospital with an elevated creatinine kinase level and suspected myositis. He was treated with high dose methylprednisolone, which caused severe aggravation of muscle weakness. He was transferred to our hospital at that time. On admission, chest computed tomography (CT) and the presence of anti-acetylcholine receptor antibodies supported a diagnosis of myasthenia gravis and thymoma. Laboratory findings showed hypokalemia, low plasma renin activity and high serum aldosterone. Further studies, including abdominal CT and adrenal venous sampling suggested primary aldosteronism. At first, thymectomy was performed, and one month later, he was treated with laparoscopic adrenalectomy. Immediately after this procedure, he suffered from myasthenic crisis, which was successfully managed with mechanical ventilation and steroid pulse therapy followed by oral prednisolone. This case presented a serious difficulty in differentiating from various myopathies and giving proper treatment because of a rare combination of independent diseases and their masquerading clinical features." }, { "id": "InternalMed_Harrison_31332", "title": "InternalMed_Harrison", "score": 0.009476083427001373, "content": "on the “off day” to zero or to a minimal level. Generally, patients begin to improve within a few weeks after reaching the maximum dose, and improvement continues to progress for months or years. The prednisone dosage may gradually be reduced, but usually months or years may be needed to determine the minimum effective dose, and close monitoring is required. Few patients are able to do without immunosuppressive agents entirely. Patients on longterm glucocorticoid therapy must be followed carefully to prevent or treat adverse side effects. The most common errors in glucocorticoid treatment of myasthenic patients include (1) insufficient persistence—improvement may be delayed and gradual; (2) tapering the dosage too early, too rapidly, or excessively; and (3) lack of attention to prevention and treatment of side effects." }, { "id": "pubmed23n0500_22593", "title": "Myasthenia in a patient with sarcoidosis and schizophrenia.", "score": 0.009433962264150943, "content": "A 44-year-old male patient was hospitalised with paranoid schizophrenia in 1985. Depot neuroleptic treatment was started which successfully prevented further psychotic relapses for the next ten years. His myasthenia gravis started with bulbar signs in 1997 and the symptoms soon became generalized. The diagnosis of myasthenia gravis was confirmed by electromyography, by positive anticholinesterase test and by the detection of anti-acetylcholine receptor antibodies in the serum. Mediastinal CT examination showed enlarged hilar lymph nodes on the left but no thymic pathology was observed. Mediastinoscopy was performed and biopsies were obtained from the affected nodes. Histology revealed sarcoidosis. The patient suffered respiratory crisis following the thoracic intervention (in September 1998). Combined oral corticosteroid (64 mg methylprednisolone/e.o.d.) and azathioprine (150 mg/day) treatment regimen was initiated and complete remission took place in both the myasthenic symptoms and the sarcoidosis. The follow-up CT scans showed no mediastinal pathology (January 2000). During steroid treatment a transient psychotic relapse occurred which was successfully managed by supplemental haloperidol medication added to his regular depot neuroleptics. The patient currently takes 150 mg/day azathioprine and receives 40 mg/month flupentixol depot i.m. His physical and mental status are stable and he has been completely symptom free in the last 24 months. The association of myasthenia gravis and sarcoidosis is very rare. To our best knowledge no case has been reported of a patient suffering from myasthenia gravis, sarcoidosis, and schizophrenia at the same time." }, { "id": "pubmed23n0380_17773", "title": "Myasthenia gravis in conjunction with Graves' disease: a diagnostic challenge.", "score": 0.009345794392523364, "content": "To describe an association between Graves' disease and myasthenia gravis and discuss the clinical features and laboratory tests that may help distinguish these two diseases. The clinical, laboratory, and electrophysiologic findings in a patient with Graves' disease and myasthenia gravis are presented. A 28-year-old African American man was admitted to the University of Louisville Hospital with generalized muscle weakness, exophthalmos, diplopia, weight loss, and mild dysphagia. The diagnosis of Graves' disease with ophthalmologic involvement was suspected clinically and confirmed by an undetectable thyrotropin level (&lt;0.03 mIU/mL), high total thyroxine (20.5 mg/dL), and increased homogeneous 123I thyroid uptake. Because of the generalized muscle weakness and mild dysphagia, assessment was done by a neurology team, and severe thyrotoxic myopathy was diagnosed. He was treated with 131I and b-adrenergic blocking agents and scheduled for follow-up as an outpatient. Two weeks later, the patient presented in acute respiratory failure. The neurology team was reconsulted because of suspected myasthenic crisis. Anti-acetylcholine receptor antibodies were undetectable in the serum, and computed tomography of the chest showed no thymic enlargement. Repetitive nerve stimulation testing, however, showed findings consistent with an abnormality of the neuromuscular junction. The patient responded dramatically to an anticholinesterase agent and corticosteroids. The overlapping clinical features may cause diagnostic confusion when myasthenia gravis and Graves' disease coexist, and numerous tests may be needed to distinguish these two conditions, which have differing treatments and prognoses." }, { "id": "pubmed23n1145_2669", "title": "An Unusual Case of Dilated Cardiomyopathy in Wegner's Granulomatosis.", "score": 0.009259259259259259, "content": "A 33-year-old male presented to the emergency with cough, hemoptysis, and shortness of breath. He was on steroids for suspected Still's disease due to arthralgias and fever prior to presentation to the emergency. He developed sudden hypoxic respiratory failure and required mechanical ventilation. The initial imaging studies of the chest including computed tomography (CT) of the chest showed marked diffuse central and basilar predominant opacities with associated smooth septal thickening. Furthermore, the patient's creatinine, troponin, B-type natriuretic peptide (BNP), rheumatoid factor, and D-dimer were elevated. Vasculitis workup, bronchoscopy, and echocardiogram were performed. The echocardiogram revealed severely decreased left ventricular systolic function with an ejection fraction of 24% with dilated left ventricle. The electrocardiogram did not show any findings of acute ischemia. He was started on pulse dose steroid and dobutamine drip along with intermittent diuresis. The patient was successfully extubated after two days of mechanical ventilation. He was started on cyclophosphamide in the hospital. Dobutamine was discontinued. He was moved to the general medical floor as his oxygenation improved, but later at night, he developed respiratory failure and required a bumetanide drip. The cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) (anti-PR-3 antibody) came back positive with titer &gt;1:40, so Wegner's granulomatosis was diagnosed. He received three sessions of plasmapheresis. The patient's kidney function improved significantly, and the bumetanide drip was transitioned to intravenous pushes. His oxygenation improved significantly with saturations of 92% on room air. The patient was discharged on steroid, Bactrim, and systolic heart failure medications to follow up with rheumatology, nephrology, pulmonology, and cardiology in the office. Due to insurance issues, his outpatient care was delayed significantly. The patient followed up with rheumatology after two months and has been planned for rituximab induction and to continue steroid along with Bactrim. This case is worth reporting because it describes dilated cardiomyopathy (DCM) as a cardiac manifestation of Wegner's granulomatosis. Early cardiac evaluation should be incorporated into the management of the patient suspected of Wegner's granulomatosis." }, { "id": "pubmed23n0732_20672", "title": "Effective treatment of a 13-year-old boy with steroid-dependent ocular myasthenia gravis using tacrolimus.", "score": 0.009174311926605505, "content": "Over the past several years, tacrolimus has attracted attention as a new therapeutic drug for myasthenia gravis (MG), but few reports have considered its use for MG in pediatric patients, and most of these have focused on severe systemic MG. In this case report, we used tacrolimus to successfully treat a 13-year-old boy with ocular MG who had suffered from severe steroid complications, including a failure of thrive and osteoporosis. He first showed symptoms of ocular MG at age 2 years 3 months. At age 13 years, he was receiving PSL (3.75 mg/day), but the symptoms of ocular MG recurred. We increased the dosage of oral PSL up to 30 mg/day, and three courses of mPSL pulse therapy were applied, but these therapies had only limited effect, and his symptoms worsened. Tacrolimus was started at 0.4 mg/day (0.011 mg/kg/day), and every 2 weeks the dose was gradually increased by 0.2 mg/day. His symptoms of MG began to improve 3 weeks after the initial administration of tacrolimus. Approximately 3 months after the start of tacrolimus administration, PSL was discontinued. Currently, at 1 year and 4 months after the start of tacrolimus administration, while slight ptosis is observed in the evening, it does not influence his daily life, and his condition remains comparable to that when he stopped taking PSL. No adverse effects of tacrolimus have been recognized. In pediatric patients with steroid-dependent ocular MG without thymectomy, tacrolimus may be a safe and effective alternative to steroid and thymectomy." }, { "id": "Neurology_Adams_11749", "title": "Neurology_Adams", "score": 0.009174311926605505, "content": "A rapid and severe deterioration of the myasthenia, termed myasthenic crisis, can bring the patient to the brink of respiratory failure in a matter of hours. A respiratory infection or excessive use of sedative medications or drugs with a potential for blocking neuromuscular transmission may precede the myasthenic crisis. We have encountered numerous cases in which oropharyngeal weakness has led to aspiration pneumonia, which, in turn, precipitated a crisis. Just as often, a precipitating event is not evident. Rarely, a respiratory arrest is the first manifestation of crisis. Such events may occur at any time after the diagnosis of myasthenia, but half are evident within 12 to 18 months. In an early but still salient experience with 53 patients in myasthenic crisis at the Columbia-Presbyterian Medical Center, pneumonia was the most frequent precipitating event, but no cause could be determined in almost one-third of cases (Thomas et al)." }, { "id": "wiki20220301en042_27997", "title": "Polysomnography", "score": 0.00909090909090909, "content": "Pulse oximetry determines changes in blood oxygen levels that often occur with sleep apnea and other respiratory problems. The pulse oximeter fits over a fingertip or an earlobe. Snoring may be recorded with a sound probe over the neck, though more commonly the sleep technician will just note snoring as \"mild\", \"moderate\" or \"loud\" or give a numerical estimate on a scale of 1 to 10. Also, snoring indicates airflow and can be used during hypopneas to determine whether the hypopnea may be an obstructive apnea. Procedure For the standard test, the patient comes to a sleep lab in the early evening and over the next 1–2 hours is introduced to the setting and \"wired up\" so that multiple channels of data can be recorded when he/she falls asleep. The sleep lab may be in a hospital, a free-standing medical office, or in a hotel. A sleep technician should always be in attendance and is responsible for attaching the electrodes to the patient and monitoring the patient during the study." }, { "id": "pubmed23n0949_393", "title": "[Myasthenic Crisis].", "score": 0.00909090909090909, "content": "Myasthenic crisis is the life threatening maximal manifestation of myasthenia gravis. Severe dysphagia and respiratory insufficiency demand admission to an intensive care unit (ICU). At variance, the timely recognition and treatment of myasthenic exacerbation may prevent a manifesting crisis. This reviews deals with red flags that pronounce exacerbation and crisis. Myasthenic crisis is an important differential diagnosis of bulbar symptoms and dysphagia. We elaborate on a structured and comprehensive approach to myasthenic crisis on the ICU. Hallmarks of therapy are symptomatic treatment with acetylcholine esterase inhibitors, plasmapheresis or immunoadsorption, polyvalent immunoglobulins, an early start of steroids and immunosuppressants, namely azathioprine, and a consequent escalation to monoclonal antibody therapy, with rituximab being the first choice. Special demands in ICU treatments are a structured weaning concept, consequent treatment of comorbidities and complications, first and foremost infections, dysphagia management, and comprehensive prevention and treatments of delirium." }, { "id": "pubmed23n1046_13213", "title": "The Pulmonary Complications of Paraneoplastic Autoimmune Vasculitis in a Patient With Myelodysplastic Syndrome.", "score": 0.009009009009009009, "content": "Paraneoplastic autoimmune phenomena may occur in up to 30% of patients with myelodysplastic syndrome (MDS). We present the case of a patient with MDS who developed diffuse alveolar hemorrhage due to paraneoplastic autoimmune vasculitis. The patient was a 55-year-old male who had been referred for outpatient hematology/oncology evaluation by his primary care physician for incidentally discovered thrombocytopenia. When he presented to the clinic, he reported new-onset chills, weakness, and night sweats. He endorsed a 20-pound weight loss over two months as well as two weeks of fatigue, exertional dyspnea, and epistaxis. He was noted to be ill-appearing and had bilateral pitting edema to the knees. Vital signs revealed a temperature of 102.3 °F, oxygen saturation of 84% on room air, and tachycardia to the 90s. Labs showed hemoglobin of 5.7 g/dL, hematocrit of 17.2 g/dL, and platelet count of 27 kµL. He was admitted to the hospital for blood and platelet transfusions, empiric antibiotics, and further diagnostic studies. The peripheral blood smear showed 4% blasts and frequent dyspoietic granulocytes. Bone marrow biopsy (BMB) was performed to differentiate between acute leukemia and myelodysplasia. BMB revealed myelodysplasia with excess blasts and erythroid predominance.During hospitalization, the patient developed acute hypoxemic respiratory failure due to bronchoscopy-confirmed diffuse alveolar hemorrhage from thrombocytopenia. His platelet count was 12 kµL. High-dose corticosteroids (2 mg/kg prednisone) were initiated for suspected paraneoplastic autoimmune vasculitis, pending BMB results. The patient steadily improved, was extubated, and had reduced oxygen and transfusion requirements.High-dose steroids were stopped, and the patient was started on decitabine chemotherapy with the ultimate goal of bone marrow transplantation. On day five of decitabine, the patient developed acute hypoxic respiratory failure requiring intubation as well as hypotension requiring vasopressors. Given that recurrent diffuse alveolar hemorrhage was again suspected, high-dose steroids were resumed upon transfer to the ICU. He continued to decompensate and ultimately experienced ventricular tachycardia requiring three separate episodes of cardiopulmonary resuscitation. Per the family's wishes, he was palliatively extubated, and he expired an hour later. Diffuse alveolar hemorrhage is a rare but potentially deadly pulmonary complication of MDS, stemming from a paraneoplastic autoimmune vasculitis. Patients who initially present with atypical autoimmune phenomena should raise suspicion for an underlying MDS, the presence of which can guide the promptness, extent, and duration of immunosuppressive therapy. Failure to expeditiously treat these patients with corticosteroids can lead to serious complications and death." }, { "id": "pubmed23n0600_15317", "title": "[Emergencies in neuromuscular pathology].", "score": 0.009009009009009009, "content": "Acute muscle weakness (AMW) is the predominant symptom of neuromuscular emergencies, especially if it affects the respiratory or oropharyngeal musculature . AMW is a multi-etiological syndrome, with different lesion levels in the motor unit. Within the broad group of neuromuscular diseases, those that most frequently provoke AMW and respiratory failure are Guillain-Barré syndrome (GBS) and myasthenia gravis (MG). GBS is the most frequent cause of acute flaccid paralysis; it can cause respiratory failure in a third of cases, making mechanical ventilation necessary. Accurate diagnosis of this syndrome enables immunomodulatory treatment to be started, which has been shown to modify the course of the disease. Besides, clinical evaluation of the patients and knowledge of the simple tests of neurophysiology and respiratory function will guide the decision on mechanical ventilation, avoiding emergency intubation. The most frequent emergency caused by MG is myasthenic crisis, defined by the deterioration in the bulbar function with acute respiratory insufficiency and risk of respiratory stoppage. This occurs in 15-20% of myasthenic patients and can be triggered by numerous factors. Besides early identification of the crisis, it is important to suppress the triggering factors and to provide measure of ventilatory support. Amongst the pharmacological measures, the most useful instruments at present are plasmapheresis and intravenous immunoglobulins; these treatments do not cancel the need for intensive vigilance and of checking for imminent signs of respiratory failure that will involve invasive or non-invasive ventilatory support." }, { "id": "InternalMed_Harrison_31323", "title": "InternalMed_Harrison", "score": 0.008950617283950617, "content": "Anticholinesterase medication produces at least partial improvement in most myasthenic patients, although improvement is complete in only a few. Patients with anti-MuSK MG generally obtain less benefit from anticholinesterase agents than those with AChR antibodies. Pyridostigmine is the most widely used anticholinesterase drug. The beneficial action of oral pyridostigmine begins within 15–30 min and lasts for 3–4 h, but individual responses vary. Treatment is begun with a moderate dose, e.g., 30–60 mg three to four times daily. The frequency and amount of the dose should be tailored to the patient’s individual requirements throughout the day. For example, patients with weakness in chewing and swallowing may benefit by taking the medication before meals so that peak strength coincides with mealtimes. Long-acting pyridostigmine may occasionally be useful to get the patient through the night but should not be used for daytime medication because of variable absorption. The maximum useful" }, { "id": "wiki20220301en472_1121", "title": "Pre-Descemet's Endothelial Keratoplasty", "score": 0.008928571428571428, "content": "Postoperative Care Post operatively these patients are given topical steroids and antibiotics for 1 month. Low dose steroids are kept in maintenance for one year. Topical lubricants are prescribed according to the ocular surface changes. Preservative free lubricants are initiated in patients with immediate epithelial changes. Intraocular pressure is monitoring on regular basis to assess the steroid induce glaucoma. Follow up visits are preferred as day 1, day 3, day 7, 2 weeks, 1 month, 3 months and then 6 monthly. Post operative anterior segment optical coherence tomography may be performed for assessing the anatomical success of the technique. Advantages" }, { "id": "pubmed23n1164_6614", "title": "Case Report of Multisystem Inflammatory Syndrome in Adults (MIS-A): A 31-Year-Old Man with Fever, Rash, and Cardiac Symptoms 6 Weeks Following SARS-CoV-2 Infection, Successfully Resuscitated Following Cardiac Arrest.", "score": 0.008849557522123894, "content": "BACKGROUND Multisystem inflammatory syndrome in adults (MIS-A) is an uncommon condition after a confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, manifesting as multiorgan failure despite apparent resolution of initial symptoms. While this syndrome shares similar characteristics with a syndrome found in children, fewer cases are reported in adults. This report details a 31-year-old man fulfilling the diagnostic criteria of MIS-A, who was successfully resuscitated following cardiac arrest. CASE REPORT A 31-year-old man was admitted to the intensive care unit for 3 days of progressively worsening fever, chills, diaphoresis, exanthematous rash, headache, and neck stiffness. The patient had a history of mild, resolved SARS-CoV-2 infection 6 weeks prior to his presentation, diagnosed by rapid antigen and reverse transcription polymerase chain reaction (RT-PCR) testing. Meningitis and autoimmune pathologies were initially suspected but were ruled out. Given the patient's symptoms, prior SARS-CoV-2 infection, and positive inflammatory markers, findings correlated with the Centers for Disease Control and Prevention's diagnostic criteria for multisystem inflammatory syndrome in adults. On hospital day 1, the patient decompensated into severe respiratory distress requiring intubation. Shortly after, the patient developed cardiac arrest and was successfully resuscitated. He was transferred from our rural hospital to an intensive care unit at a facility with additional resources. He remained critically ill for several weeks while receiving high-dose steroids, intravenous immunoglobulin (IVIG), and hemodialysis until his recovery. CONCLUSIONS Early diagnosis and treatment of MIS-A would significantly improve outcomes in this subset of patients, especially in clinical settings with limited resources." }, { "id": "Neurology_Adams_11689", "title": "Neurology_Adams", "score": 0.008849557522123894, "content": "In Simpson’s opinion, and this coincides with our observations, the danger of death from generalized myasthenia gravis is greatest in the first year after onset of the disease. A second period of danger in progressive cases is from 4 to 7 years after onset. After this time, the disease tends to stabilize and the risk of severe relapse diminishes. Fatalities relate mainly to the respiratory complications of pneumonia and aspiration. The mortality rate in the first years of illness, formerly in excess of 30 percent, is now less than 5 percent and with appropriate therapy virtually all patients lead normal lives." }, { "id": "pubmed23n1028_24521", "title": "Myasthenic crisis and late deep vein thrombosis following thymectomy in a patient with myasthenia gravis: A case report.", "score": 0.008771929824561403, "content": "Surgical stress and pain are potential provoking factors for postoperative myasthenic crisis (POMC). We report the occurrence of early POMC and late deep vein thrombosis (DVT) in a man with myasthenia gravis (MG) undergoing thymectomy, addressing possible link between reversal of opioid overdose with naloxone and the triggering of POMC. A 71-year-old man with impaired renal function (ie, estimated glomerular filtration rate [egfr]: 49.1 mL/min/1.73 m) with diagnosis of MG made 2 months ago was scheduled for thymectomy. After uncomplicated surgery, he experienced opioid overdose that was treated with naloxone. Hyperlactatemia then developed with a concomitant episode of hypertension. Three hours after reversal, he suffered from myasthenic crisis presenting with respiratory failure and difficult weaning from mechanical ventilation. Stress-induced hyperlactatemia and subsequent myasthenic crisis INTERVENTIONS:: Pyridostigmine and immunosuppressive therapy with prednisolone were initiated. Hyperlactatemia subsided on postoperative day (POD) 5. Tracheal extubation was performed successfully on POD 6. During the course of hospitalization, his eGFR (ie, 88.9 mL/min/1.73 m) was found to improve postoperatively. After discharge from hospital, he developed DVT in the left femoral and popliteal veins on POD 24 when he was readmitted for immediate treatment with low-molecular-weight heparin. He was discharged without sequelae on POD 31. There was no recurrence of myasthenic crisis or DVT at 3-month follow-up. Following naloxone administration, hyperlactatemia may be an indicator of pain-related stress response, which is a potential provoking factor for myasthenic crisis. Additionally, patients with MG may have an increased risk of DVT possibly attributable to immune-mediated inflammation. These findings highlight the importance of perioperative avoidance of provoking factors including monitoring of stress-induced elevations in serum lactate concentration, close postoperative surveying for myasthenic crisis, and early recognition of possible thromboembolic complications in this patient population." }, { "id": "pubmed23n0533_5044", "title": "Myasthenic crisis.", "score": 0.008771929824561403, "content": "Myasthenic crisis is a serious occurrence, affecting up to 27% of patients with myasthenia gravis. In the approach to the patient with myasthenic crisis, (1) the diagnosis of myasthenia gravis is confirmed; (2) respiratory failure is evaluated and treated in the intensive care unit, while potential precipitating factors are identified and managed; (3) immunomodulatory treatment is initiated; and (4) complications are avoided or managed promptly. The mortality rate should be 5% or less, with the elderly being most vulnerable." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 307 ] ], "word_ranges": [ [ 0, 52 ] ], "text": "Dementia with visual hallucinations at the beginning of the course (in the first 2 years) is very suggestive of Lewy bodies, and is the guiding symptom in these questions. If we add to this the falls and motor slowing suggestive of parkinsonism, it makes the question easier. Therefore, number 3 is correct." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Multi-infarct vascular dementia.", "2": "Alzheimer's type dementia.", "3": "Dementia with diffuse Lewy bodies.", "4": "Frontotemporal dementia.", "5": "Normal pressure hydrocephalus." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0414_12508", "title": "Familial dementia with Lewy bodies with an atypical clinical presentation.", "score": 0.017284495439835245, "content": "The authors report a case of a 64-year-old male with Alzheimer's disease (AD) and dementia with Lewy bodies (DLB) pathology at autopsy who did not manifest the core symptoms of DLB until very late in his clinical course. His initial presentation of early executive and language dysfunction suggested a cortical dementia similar to frontotemporal lobar degeneration (FTLD). Core symptoms of DLB including dementia, hallucination, and parkinsonian symptoms were not apparent until late in the course of his illness. Autopsy revealed both brainstem and cortical Lewy bodies and AD pathology. Family history revealed 7 relatives with a history of dementia including 4 with possible or probable DLB. This case is unique because of the FTLD-like presentation, positive family history of dementia, and autopsy confirmation of DLB." }, { "id": "pubmed23n0533_20724", "title": "[Cognitive disorders appearing before the age of 65 in patients of the Alzheimer Centre of the VU Medical Centre: diagnoses and clinical characteristics].", "score": 0.016864591385004568, "content": "To obtain a profile of the causes and clinical characteristics of cognitive disorders in patients referred to a memory clinic before the age of 65 years. Retrospective case-note study. Data were collected from 127 subjects with objective cognitive disorders who visited the Alzheimer Centre of the VU Medical Centre in Amsterdam, the Netherlands, in the period from 1 January 2001 to 31 December 2003 with an onset of complaints before the age of 65. Besides the diagnoses, we investigated the clinical presentations, the occurrence of cardiovascular risk factors, the family history, and the presence of noncognitive neurological signs. The most common causes of cognitive decline under the age of 65 were Alzheimer's disease (46%) and frontotemporal dementia (23%). Vascular dementia was seen in 5% and dementia with Lewy bodies in 2%; 9% had mild cognitive impairment but no dementia. Hypertension and a positive family history for dementia were each present in 40% of the patients. Non-cognitive neurological abnormalities were found only in cases of non-Alzheimer dementia. During the period under investigation, the number of patients with objective cognitive disorders increased more than did the number without a cognitive disorder. Within the population of a memory clinic, Alzheimer's disease was the most frequent cause of cognitive decline under the age of 65, followed by frontotemporal dementia. The distribution differed from causes of dementia at an older age, where vascular dementia had the second place." }, { "id": "wiki20220301en011_99603", "title": "Dementia with Lewy bodies", "score": 0.01620224435758416, "content": "Frontotemporal dementias Corticobasal syndrome, corticobasal degeneration and progressive supranuclear palsy are frontotemporal dementias with features of parkinsonism and impaired cognition. Similar to DLB, imaging may show reduced dopamine transporter uptake. Corticobasal syndrome and degeneration, and progressive supranuclear palsy, are usually distinguished from DLB by history and examination. Motor movements in corticobasal syndrome are asymmetrical. There are differences in posture, gaze and facial expressions in the most common variants of progressive supranuclear palsy, and falling backwards is more common relative to DLB. Visual hallucinations and fluctuating cognition are unusual in corticobasal degeneration and progressive supranuclear palsy. Management" }, { "id": "pubmed23n0403_5554", "title": "[Dementias with Lewy bodies].", "score": 0.0156315255653004, "content": "Dementias with Lewy bodies are no rare cause of cognitive and motor impairments in old age. Neuropathologically, they must be distinguished into diffuse Lewy body disease resp. dementia with Lewy bodies, Parkinson's disease with concomitant Alzheimer's pathology, and the Lewy body variant of Alzheimer's disease according to extent and concomitant pathology. The most reliable diagnostic features of dementia with Lewy bodies are fluctuating disturbances of cognition and consciousness, visual disorders (hallucinations, visuoperceptive and visuoconstructive impairments), and early extrapyramidal signs of the hypokinetic-rigid type with a propensity to frequent falls. The pertinent diagnostic criteria are the consensus criteria according to McKeith et al. Additional contributions are to be expected by functional neuroimaging (SPECT, PET) and CSF examination (homovanillic acid). However, even assuming the most favorable conditions a diagnostic accuracy of 85 % is presently hard to achieve. Particularly, as is demonstrated using a case example, reliable antemortem diagnosis of Lewy body variant of Alzheimer's disease is hardly possible. Clinically, this group of diseases is important, since increased neuroleptic sensitivity must be taken into account and modern central cholinergic agents seem to be a promising therapeutic option." }, { "id": "pubmed23n1155_24737", "title": "Frontotemporal Dementia: Dilemma in Discrimination From Similarly Presenting Neurological and Psychiatric Conditions.", "score": 0.015575757575757576, "content": "Frontotemporal dementia (FTD) is the most common cause of neurocognitive decline, second to Alzheimer's disease (AD) and Lewy body dementia. Its presence offers a unique challenge to physicians trying to detect cognitive deficits, as it not only arises in middle age but also can be misdiagnosed as a primary psychiatric disorder. The following case describes the clinical course of a 50-year-old male with a recent history of sporadic visual and auditory hallucinations, followed by a gradual decline in cognitive function including declining memory, apathy and behavioral disinhibition, and social functioning, which are suggestive of FTD-type. Apart from the gradual decline of his cognitive function, the patient had multiple clinical encounters, during which he was misdiagnosed with schizophrenia. Furthermore, the report showcases the handful of conditions that FTD can be misdiagnosed and discusses the thorough clinical/psychological examination and investigations to be done to arrive at FTD." }, { "id": "pubmed23n0495_8859", "title": "[Familial non-Alzheimer dementia].", "score": 0.015073212747631352, "content": "This is an abstract of my lecture on familial non-Alzheimer dementia. 1. Vascular dementia 1) Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is characterized by autosomal dominant inheritance, smooth muscle cell degeneration and granular osmiophilic material (GOM) in arterioles, and Notch 3 mutations. 2) CARASIL This is an autosomal recessive vascular dementia with unknown etiology. 3) Familial amyloid angiopathy Familial cerebral hemorrhage and dementia is caused by mutations in amyloid precursor protein, cystatin c, and Bri genes. 2. Familial non-Alzheimer degenerative dementia 1) Dementia with Lewy bodies This is characterized by Alzheimer like dementia, visual hallucination and diffuse Lewy bodies which are formed by ubiquitinated alpha-synuclein. Occasionally, familial forms are reported, but gene mutations are unknown. 2) Frontotemporal dementia (FTD) FTDP-17 is characterized by tau mutations, character and personal changes, and disinhibition. The gene mutations were also found in familial forms of Pick's disease, corticobasal degeneration, and other tauopathies. 3) Familial British dementia (FBD), familial Danish dementia (FDD) FBD and FDD are characterized by Abri amyloid deposits, amyloid angiopathy and dementia. Mutations in Bri gene are reported. 4) Familial encephalopathy with neuroserpin inclusion bodies (FENIB) FENIB is characterized by dementia, Collins body and neuroserpin gene mutation." }, { "id": "pubmed23n0419_19676", "title": "Dementia with Lewy bodies and the neurobehavioral decline of Mervyn Peake.", "score": 0.014459195224863643, "content": "Mervyn Peake (1911-1968) was an accomplished British artist, poet, novelist, and playwright. He was a prolific and talented illustrator and wrote hundreds of poems, 4 novels, and several plays. His exceptional career was prematurely ended by a neurodegenerative illness variously ascribed to Alzheimer disease, Parkinson disease, or postencephalitic parkinsonism. However, a detailed review of biographical accounts produces substantial evidence in support of a probable diagnosis of dementia with Lewy bodies, a clinical entity remaining undiagnosed outside specialty dementia clinics. Peake developed signs of parkinsonism and insidious cognitive decline during his fifth decade. A breakdown in his writing style has frequently been cited as reflecting his encroaching dementia. Visual hallucinations are portrayed in sketches, and together with paranoid delusions are apparent in poetry composed during his illness. His deterioration was progressive and punctuated by well-described episodes of confusion and psychosis. His occasional preservation of insight is poignantly captured in drawings of figures with dunce caps or pointed heads, often with expressions of fear and apprehension etched with an economy of strokes. Peake spent his final years in various psychiatric institutions but continued to exhibit lucid intervals even late into his illness. His tragic deterioration remained undiagnosed at the time, but in retrospect, his progressive dementia with parkinsonism, visual hallucinations, and marked cognitive fluctuations likely represents one of the earliest recognized historical cases of dementia with Lewy bodies." }, { "id": "pubmed23n0476_23968", "title": "[Frontal dementia or dementia praecox? A case report of a psychotic disorder with a severe decline].", "score": 0.013342821561999644, "content": "Many authors have described these last years the difficulty to establish a differential diagnosis between schizophrenia and frontotemporal dementia. However treatment and prognosis of these two separate diseases are not the same. Schizophrenia is a chronic syndrome with an early onset during teenage or young adulthood period and the major features consist of delirious ideas, hallucinations and psychic dissociation. However a large variety of different symptoms describes the disease and creates a heterogeneous entity. The diagnosis, exclusively defined by clinical signs, is then difficult and has led to the research of specific symptoms. These involve multiple psychological processes, such as perception (hallucinations), reality testing (delusions), thought processes (loose associations), feeling (flatness, inappropriate affect), behaviour (catatonia, disorganization), attention, concentration, motivation (avolition), and judgement. The characteristic symptoms of schizophrenia have often been conceptualised as falling into three broad categories including positive (hallucination, delision), negative (affective flattening, alogia, avolition) and disorganised (poor attention, disorganised speech and behaviour) symptoms. No single symptom is pathogonomonic of schizophrenia. These psychological and behavioural characteristics are associated with a variety of impairments in occupational or social functioning. Cognition impairments are also associated with schizophrenia. Since the original clinical description by Kraepelin and Bleuler, abnormalities in attentional, associative and volitional cognitive processes have been considered central features of schizophrenia. Long term memory deficits, attentional and executive dysfunctions are described in the neurocognitive profile of schizophrenic patients, with a large degree of severity. The pathophysiology of schizophrenia is not well known but may be better understood by neuronal dysfunctions rather than by a specific anatomical abnormality. Frontotemporal lobar degeneration (FTLD) is one of the most common causes of cortical dementia. FTLD is associated with an anatomical atrophy that can be generalised, with a frontotemporal or focal lobar predominance. Histologically there is severe neuronal loss, gliosis and a state of spongiosis. In a minority of case Pick cells and Pick bodies are also found. The usual clinical features of FTLD are divided in three prototypic syndromes: frontotemporal dementia (FTD), progressive non-fluent aphasia (PA) and semantic dementia (SD). FTD is the most common clinical manifestation of FTLD. FTD is first characterised by profound alteration in personality and social conduct, characterised by inertia and loss of volition or social disinhibition and distractibility. There is emotional blunting and loss of insight. Speech output is typically economical, leading ultimately to mutism, although a press of speech may be present in some overactive, disinhibited patients. Memory is relatively preserved in the early stage of the disease. Cognitive deficits occur in the domains of attention, planning and problems solving, whereas primary tools of language, perception and spatial functions are well preserved. PA is an initial disorder of expressive language, characterised by effortful speech production, phonologic and grammatical errors. Difficulties in reading and writing also occur but understanding of word meaning is relatively well preserved. In SD a severe naming and word comprehension impairment occur on the beginning in the context of fluent, effortless, and grammatical speech output. There is also an inability to recognise the meaning of visual percepts. The clinical syndromes of FTLD are associated with the brain topography of the degeneration. So considerable clinical overlap can exist between schizophrenia and FTLD and the object of the following case report is to remind the difficulty to make a differential diagnosis between these two pathologies. A 34 year old non-married man is admitted in mental health district of a general hospital for behavioural disturbances that include repeated aggressions towards his family. At initial interview visual and auditives hallucinations are described. The patient doesn't care about these abnormalities and a poverty of speech is observed. The affects, globally blunted, show some degree of sadness however. The patient's birth and early development were unremarkable. At the age of 26, the patient dismissed from his job because of poor performance and absenteeism. He spent a lot of time watching TV, showed poverty of speech and become sometimes angry and violent without an explanation. He was hospitalised for several months and a schizophrenia including predominant negative features, hallucinations and delusion was diagnosed. He was treated with bromperidol, could go back to home and was followed by a general practitioner for 8 years. The patient had a stereotyped way of life during these years with a poor communication and little activity. During the months preceding the current hospitalisation, these characteristics and avolition emphasised, urinary incontinence appeared. The patient receives risperidone 8 mg/day associated with citalopram 40 mg/day during several months of hospitalisation. No significant evolution is observed regarding apathic and stereotyped way of live. The capacity of communication remains very poor. Neurocognitive assessments reveal multiple and severe dysfunctions. Memory, executive and attentional tasks are extremely disturbed. Physical and neurological examinations reveal an isolated bilateral Babinski sign. Cerebral scanner and magnetic resonance show bifrontal atrophy and PET scan is normal. There are no significant abnormalities found on blood and urine samples and on lumbar puncture. The patient is sent to a chronic neuropsychiatric hospital and the treatment is stopped. One year later, a comparative evaluation is realised. The general clinical state shows no evolution. Neurocognitive assessments are repeated and severe dysfunctions are observed with more perseverations. A diagnosis of FTLD for this patient can be discussed regarding clinical features, neurocognitive testings and neuroradiological findings. Schizophrenia is a major differential diagnosis. Psychotic symptoms like hallucinations and age of onset are essential observations for the diagnosis of schizophrenia but can not exclude FTLD. Memory, intellectual functions, executive and attentional abilities may all be disturbed in schizophrenia and FTLD. Cerebral abnormalities well established in schizophrenia are lateral ventricles enlargements. Frontal lobar atrophy is a major argument for FTLD and is only a sporadic finding in schizophrenic populations. Schizophrenia and FTLD could be comorbid diseases by several ways. A differential diagnosis between schizophrenia and FTLD is difficult to establish. Schizophrenia is a heterogeneous disease with a large variety of cognitive dysfunctions. Neurocognitive tools may improve our knowledge of schizophrenia." }, { "id": "wiki20220301en001_276387", "title": "Dementia", "score": 0.013325048329190832, "content": "The most common type of dementia is Alzheimer's disease. Other common types include vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. Less common causes include normal pressure hydrocephalus, Parkinson's disease dementia, syphilis, HIV, and Creutzfeldt–Jakob disease." }, { "id": "pubmed23n0564_2055", "title": "Differentiating dementias in long-term care patients.", "score": 0.013317384370015948, "content": "Many long-term care residents are diagnosed with dementia, but dementia appears in many forms. Alzheimer's disease, the most common, is typified by a slow onset and relentless progression to complete incapacitation. Vascular dementia usually appears somewhat abruptly, is associated with vascular comorbidities, and has an unpredictable progression pattern. Lewy body dementia shares features of both Alzheimer's and Parkinson's disease; its hallmarks include fluctuating cognitive performance, visual hallucinations, and extrapyramidal motor symptoms. Frontotemporal dementias are associated less with memory disorders and more with behavioral and language aberrations. Mixed dementia covers those patients who do not have an apparent singular cause of dementia. Pseudodementia is a dementia resulting from underlying causes and is reversible, unlike the aforementioned dementias." }, { "id": "wiki20220301en491_26173", "title": "Early onset dementia", "score": 0.012931190175185119, "content": "Early onset dementia is dementia in which symptoms first appear before the age of 65. The term favored until about 2000 was presenile dementia; young onset dementia is also used. Early onset dementia may be caused by degenerative or vascular disease, or it may be due to other causes, such as alcohol-related dementia and other inflammatory or infectious processes. Early-onset Alzheimer's disease, vascular dementia and frontotemporal lobar degeneration are the most common forms of early onset dementia, with Alzheimer's accounting for between 30 and 40%. Early onset dementia may also occur, less frequently, in the Lewy body dementias (dementia with Lewy bodies and Parkinson's disease dementia), multiple sclerosis, Huntington's disease and other conditions. References Further reading Cognitive disorders Dementia" }, { "id": "pubmed23n0743_4547", "title": "Pathology and temporal onset of visual hallucinations, misperceptions and family misidentification distinguishes dementia with Lewy bodies from Alzheimer's disease.", "score": 0.012919020715630884, "content": "To determine whether the temporal onset of visual phenomena distinguishes Lewy body disease (LBD) from Alzheimer's disease (AD), and to characterize the extent Lewy bodies and neurofibrillary tangles are associated with these clinical features. Consecutive cases of autopsy-confirmed LBD (n = 41), AD (n = 70), and AD with amygdala-predominant Lewy bodies (AD-ALB) (n = 14) with a documented clinical history of dementia were included. We mailed questionnaires to next-of-kin asking about symptoms during life. Lewy pathology and neurofibrillary tangle pathology were assessed. The occurrence of visual hallucinations, misperceptions and family misidentification did not distinguish LBD from AD or AD-ALB, but the onset was earlier in LBD compared to AD and AD-ALB. When visual hallucinations developed within the first 5 years of dementia, the odds were 4-5 times greater for autopsy-confirmed LBD (or intermediate/high likelihood dementia with Lewy bodies) and not AD or AD-ALB. In LBD, limbic but not cortical Lewy body pathology was related to an earlier onset of visual hallucinations, while limbic and cortical Lewy body pathology were associated with visual misperceptions and misidentification. Cortical neurofibrillary tangle burden was associated with an earlier onset of misidentification and misperceptions in LBD and AD, but only with earlier visual hallucinations in AD/AD-ALB. When visual hallucinations occur within the first 5 years of the dementia, a diagnosis of LBD was more likely than AD. Visual hallucinations in LBD were associated with limbic Lewy body pathology. Visual misperceptions and misidentification delusions were related to cortical Lewy body and neurofibrillary tangle burden in LBD and AD/AD-ALB." }, { "id": "pubmed23n0584_1019", "title": "Cognitive-behavioral profiles of neurodegenerative dementias: beyond Alzheimer's disease.", "score": 0.01273741332529394, "content": "The neurocognitive and behavioral profiles of vascular dementia and vascular cognitive impairment, dementia with Lewy bodies and Parkinson's disease with dementia, and dementia syndromes associated with frontotemporal lobar degenerations are compared and contrasted with Alzheimer's dementia (AD). Vascular dementia/vascular cognitive impairment is characterized by better verbal memory performance, worse quantitative executive functioning, and prominent depressed mood. Dementia with Lewy bodies and Parkinson's disease with dementia are equally contrasted with AD by defective processing of visual information, better performance on executively supported verbal learning tasks, greater attentional variability, poorer qualitative executive functioning, and the presence of mood-congruent visual hallucinations. The frontal variant of frontotemporal lobar degeneration (frontotemporal dementia) differs from AD by better multimodal retention on learning tasks, different patterns of generative word fluency, defective qualitative executive functioning, and by markedly impairment of comportment. For temporal variants of frontotemporal lobar degenerations, progressive aphasia and semantic dementia, worse language performance relative to AD is typically characteristic." }, { "id": "pubmed23n0409_19055", "title": "Dementia with Lewy bodies showing advanced Lewy pathology but minimal Alzheimer pathology--Lewy pathology causes neuronal loss inducing progressive dementia.", "score": 0.012042693631065235, "content": "The present study concerns an autopsied case of dementia with Lewy bodies (DLB) showing advanced Lewy pathology but minimal Alzheimer pathology. The patient was a 50-year-old Japanese male without inheritance. His initial symptoms at the age of 43 suggested the diagnosis ofjuvenile idiopathic Parkinson's disease (PD), but were followed by memory disturbance 1 year later. He showed parkinsonism, dementia, personality change, fluctuating cognition and visual hallucinations 3 years later. Neuroradiological examination revealed moderate brain atrophy, predominantly in the frontal and temporal lobes. Neuropathological examination demonstrated a widespread occurrence of Lewy bodies (LB) with LB-related neurites not only in the brainstem but also in the cerebrum. The present case showed Lewy pathology which corresponded to stage IV by our staging and was parallel to neuronal loss. There was marked neuronal loss with many LB-related neurites in the CA2 of the hippocampus. Neurofibrillary tangles (NFT) were almost restricted to the entorhinal cortex, while senile plaques were absent. Consequently, the present case was pathologically diagnosed as having DLB of the neocortical type, pure form. In the present study, we suggest that Lewy pathology in the cerebral cortex could be responsible for progressive dementia." }, { "id": "article-143125_18", "title": "Parkinson-Plus Syndrome -- History and Physical -- Lewy Body Dementia", "score": 0.01194240542066629, "content": "LBD consists of dementia characterized by deficits in attention, cognition, and visuospatial function. Other notable features include visual hallucinations, rapid eye movement sleep behavior disorder (RBD), repeated falls, autonomic dysfunction, antipsychotic drug sensitivity, delusions, and depression. LBD consists of two clinical entities: dementia with Lewy bodies and PD dementia. Dementia with Lewy bodies is classified as dementia occurring first or within one year of the movement disorder. PD dementia occurs in a patient first receiving the diagnosis of PD and then developing dementia symptoms after one year or more of the diagnosis. [20]" }, { "id": "pubmed23n0732_1407", "title": "Visual signs and symptoms of dementia with Lewy bodies.", "score": 0.011871676102247384, "content": "Dementia with Lewy bodies ('Lewy body dementia' or 'diffuse Lewy body disease') (DLB) is the second most common form of dementia to affect elderly people, after Alzheimer's disease. A combination of the clinical symptoms of Alzheimer's disease and Parkinson's disease is present in DLB and the disorder is classified as a 'parkinsonian syndrome', a group of diseases which also includes Parkinson's disease, progressive supranuclear palsy, corticobasal degeneration and multiple system atrophy. Characteristics of DLB are fluctuating cognitive ability with pronounced variations in attention and alertness, recurrent visual hallucinations and spontaneous motor features, including akinesia, rigidity and tremor. In addition, DLB patients may exhibit visual signs and symptoms, including defects in eye movement, pupillary function and complex visual functions. Visual symptoms may aid the differential diagnoses of parkinsonian syndromes. Hence, the presence of visual hallucinations supports a diagnosis of Parkinson's disease or DLB rather than progressive supranuclear palsy. DLB and Parkinson's disease may exhibit similar impairments on a variety of saccadic and visual perception tasks (visual discrimination, space-motion and object-form recognition). Nevertheless, deficits in orientation, trail-making and reading the names of colours are often significantly greater in DLB than in Parkinson's disease. As primary eye-care practitioners, optometrists should be able to work with patients with DLB and their carers to manage their visual welfare." }, { "id": "wiki20220301en011_101511", "title": "Lewy body dementias", "score": 0.011720169594185342, "content": "Classification The synucleinopathies (dementia with Lewy bodies, Parkinson's disease dementia, and Parkinson's disease) are characterized by shared features of parkinsonism motor symptoms, neuropsychiatric symptoms, impaired cognition, sleep disorders, and visual hallucinations. The Lewy body dementias—dementia with Lewy bodies (DLB), and Parkinson's disease dementia (PDD)—are distinguished by the timing when cognitive and motor symptoms appear. The two Lewy body dementias are often considered to belong on a spectrum of Lewy body disease that includes Parkinson's disease. MeSH lists Lewy body disease in several categories: as a nervous system disease in two listings one as a basal ganglia Parkinsonian movement disorder and the other under brain disease as a dementia; as a neurodegenerative disorder listed as a synucleinopathy; and as a neurocognitive disorder listed with dementia. Cause and mechanisms" }, { "id": "wiki20220301en011_99562", "title": "Dementia with Lewy bodies", "score": 0.011681945505474918, "content": "Essential feature A dementia diagnosis is made after cognitive decline progresses to a point of interfering with normal daily activities, or social or occupational function. While dementia is an essential feature of DLB, it does not always appear early on, and is more likely to present as the condition progresses. Core features While specific symptoms may vary, the core features of DLB are fluctuating cognition, alertness or attention; REM sleep behavior disorder; one or more of the cardinal features of parkinsonism, not due to medication or stroke; and repeated visual hallucinations. The 2017 Fourth Consensus Report of the DLB Consortium determined these to be core features based on the availability of high-quality evidence indicating they are highly specific to the condition." }, { "id": "pubmed23n0253_16671", "title": "[Neuropsychological tests of simple application for diagnosing dementia].", "score": 0.01160826032540676, "content": "Thirty patients with dementia defined by DSM-III-R criteria (Alzheimer's disease (22), vascular dementia (3), Parkinson's disease, frontal lobe dementia, possible diffuse Lewy body dementia, normal pressure hydrocephalus and uncertain diagnosis), with scores below 24 points in the Mini-Mental Status Examination and more than 4 years of education were submitted to a neuropsychological evaluation. The scores in the neuropsychological tests were compared to those obtained by thirty normal volunteers paired for age, sex and education. Sensitivity, specificity and accuracy of the tests in the distinction of demented and normal volunteers were determined. The accuracies were calculated using ROC curves. Blessed's information-memory-concentration test showed greatest accuracy, followed by copy of simple figures, delayed memory of 10 figures (after 5 minutes), recognition of 10 figures and verbal fluency test (animals). A linear discriminant function, composed by 6 tests: visual perception, incidental memory, delayed memory (after 5 minutes), drawing of a clock, verbal fluency (animals) and calculation tests, was able to discriminate all controls from patients and only one patient was wrongly classified as normal control. These tests were chosen because they can be applied in less than 10 minutes and are very easy to interpret. This discriminant function must be applied in another group of patients and controls in order to demonstrate its value. When associated to the MMSE it may be useful to discriminate patients with dementia from normal people in epidemiological studies." }, { "id": "pubmed23n0522_21558", "title": "The evolution and pathology of frontotemporal dementia.", "score": 0.011584229390681003, "content": "This is a clinicopathologic study of a prospective, clinic-based cohort of patients with frontotemporal dementia (FTD)/Pick complex, who were followed to autopsy. A total of 60 patients with the clinical syndromes of the behavioural variant of FTD (FTD-bv) (n = 32), primary progressive aphasia (PPA) (n = 22), corticobasal degeneration syndrome (CBDS) (n = 4) and progressive supranuclear palsy (PSP) (n = 2) at onset, referred to a cognitive neurology clinic who had subsequent post-mortem examination were included. The most common histological variety was motor neurone disease type inclusion (MNDI) (n = 18), followed by corticobasal degeneration (CBD) (n = 12), then Pick's disease (n = 6), dementia lacking distinctive histology (DLDH) (n = 6) and PSP (n = 3). Others fulfilled the histological criteria for Alzheimer's disease combined with glial pathology (n = 6), Alzheimer's disease only (n = 4), Lewy body variant (n = 2), prion disease (n = 1), vascular dementia (n = 1) and undetermined (n = 1). The most common first syndrome among the MNDI and DLDH (tau negative) pathologies was FTD-bv, but subsequently progressive aphasia (PA), occasionally CBDS and semantic dementia also developed. Tau positive histologies of CBD, PSP and Pick bodies were most frequently associated with PPA onset or CBDS/PSP, but behavioural symptoms were also common. Age of onset was earlier in tau negative cases, but the duration of illness and gender distribution were about the same in all histological variants. Although the tau negative and positive histologies are predicted to some extent by the clinical onset, the extent of the overlap and the convergence of the syndromes in the course of the disease argue in favour of maintaining the clinical and pathological varieties under a single umbrella." }, { "id": "wiki20220301en001_276341", "title": "Dementia", "score": 0.011511269563115597, "content": "Many other medical and neurological conditions include dementia only late in the illness. For example, a proportion of patients with Parkinson's disease develop dementia, though widely varying figures are quoted for this proportion. When dementia occurs in Parkinson's disease, the underlying cause may be dementia with Lewy bodies or Alzheimer's disease, or both. Cognitive impairment also occurs in the Parkinson-plus syndromes of progressive supranuclear palsy and corticobasal degeneration (and the same underlying pathology may cause the clinical syndromes of frontotemporal lobar degeneration). Although the acute porphyrias may cause episodes of confusion and psychiatric disturbance, dementia is a rare feature of these rare diseases. Limbic-predominant age-related TDP-43 encephalopathy (LATE) is a type of dementia that primarily affects people in their 80s or 90s and in which TDP-43 protein deposits in the limbic portion of the brain." }, { "id": "pubmed23n0783_9659", "title": "Unusual features of Creutzfeldt-Jakob disease followed-up in a memory clinic.", "score": 0.011264432554210082, "content": "Sporadic Creutzfeldt-Jakob disease (sCJD) generally manifests itself by cognitive or rapidly progressive motor symptoms. An atypical onset or an unusual evolution may delay the diagnosis. Among patients with a confirmed diagnosis of sCJD following a post-mortem neuropathological examination at the Neuropathology Centre of Lille, France, those who had presented with atypical cognitive disorders at onset were included in the study. Four patients were included. The first patient (64-years-old) presented early language disorders, later accompanied by apathy and behavioral disorders. The prolonged course suggested a diagnosis of progressive primary aphasia. The second patient (68-years-old) presented with aphasia, apraxia, and ataxia of the right upper limb with parkinsonian syndrome, suggesting corticobasal degeneration. In the two last patients (58- and 61-years-old), the onset was marked by an anxiety-depression syndrome, falls, visual hallucinations, extra-pyramidal syndrome, and fluctuating cognitive decline. The diagnosis raised was probable Lewy body dementia. The 14.3.3 protein was found in two of the four cases. The clinical elements found may initially suggest focal atrophy or Lewy body dementia. A very rapid clinical deterioration generally suggests sCJD, but in the last case, the evolution was particularly slow. The diagnosis of sCJD must be considered in cases of rapid-onset dementia, even if all of the clinical criteria are not present. The detection of the 14.3.3 protein and multifold increase in total-Tau with normal or slightly increased phosphorylated-Tau in the CSF are additional arguments to reinforce the diagnosis. The post-mortem neuropathological examination is important to confirm the diagnosis." }, { "id": "pubmed23n0517_24022", "title": "Miliary brain metastases presenting as rapidly progressive dementia.", "score": 0.01125382262996942, "content": "We report the case of a 79-year-old woman who developed a rapidly progressive dementia (RPD) with severe memory impairment, early visual hallucinations and extrapyramidal signs. Symptoms started suddenly after hip replacement surgery following an accidental fall. Motor epileptic seizures appeared at the end of the illness. Dementia worsened gradually leading to akinetic mutism. She died five and a half months after the onset of symptoms. MRI showed cerebral atrophy but failed to detect any other lesion. Results of all laboratory tests performed were negative. After the most frequent treatable diseases were excluded, the diagnosis of dementia with Lewy bodies was initially considered. CJD was also suggested based on the rapid evolution of the disease and the positivity of 14-3-3 protein in CSF. Neuropathological examination revealed an extensive miliary metastatic dissemination from an unknown primary adenocarcinoma. Pulmonary origin was suggested according to the immunohistochemical profile. Histopathological changes of Alzheimer's disease were also observed in the cerebral cortex and hippocampus. Neither Lewy bodies nor PrP deposits were found. The sudden onset of the dementia just after the hip replacement surgery raises the possibility of a pathological fracture with secondary tumoral microembolic dissemination. Despite its rarity, this entity should be included in the differential diagnosis of RPD. This case illustrates the definite importance of neuropathological post-mortem examination in order to elucidate the different types of dementia." }, { "id": "wiki20220301en024_102296", "title": "Frontotemporal dementia", "score": 0.011217817176940545, "content": "See also Alcoholic dementia Lewy body dementia Logopenic progressive aphasia Mini-SEA Proteopathy Transportin 1 Vascular dementia References Further reading External links OMIM on Frontotemporal Dementia and/or Amyotrophic Lateral Sclerosis and Chromosome 9 Open Reading Frame 72; C9ORF72 Cognitive disorders Dementia Frontal lobe Temporal lobe de:Frontotemporale Demenz" }, { "id": "pubmed23n1137_16468", "title": "Clinical Manifestations of Early-Onset Dementia With Lewy Bodies Compared With Late-Onset Dementia With Lewy Bodies and Early-Onset Alzheimer Disease.", "score": 0.011137427395251791, "content": "Early-onset dementia, presenting in individuals younger than 65 years, is a diagnosis with significant social and financial implications. The early-onset form of dementia with Lewy bodies (DLB) is poorly understood. To investigate clinical features that distinguish early-onset DLB (onset and diagnosis at age &lt;65 years) from late-onset DLB (onset at age ≥65 years) and from early-onset Alzheimer disease (AD) dementia. This is a retrospective case-control study on patients with pathologically confirmed DLB or AD enrolled in the National Alzheimer's Coordinating Center database from January 2005 to July 2017. The National Alzheimer's Coordinating Center Uniform Data Set comprised deidentified data collected by Alzheimer disease centers in the United States. Of patients fulfilling criteria for all-cause dementia at enrollment (n = 1152), those who at post mortem received a pathological diagnosis of either AD (n = 848) or Lewy body disease (n = 218) were selected. Excluding 52 patients owing to missing data and 12 diagnosed with Parkinson disease dementia, remaining patients were classified by age of symptom onset into early-onset AD, early-onset DLB, and late-onset DLB subgroups. Data were analyzed from June to December 2018 and from November to December 2021. Demographics, cognitive, behavioral, and motor features recorded at first clinic visit and neuropathological characteristics at autopsy were analyzed by disease subgroup. Concordance between initial etiologic diagnosis of dementia and final pathological diagnosis was assessed, as was time to death. A total of 542 individuals were categorized as having early-onset AD (n = 363; mean [SD] age, 53.0 [5.8] years; 208 [57.3%] male), early-onset DLB (n = 32; mean [SD] age, 57.9 [3.2] years; 23 [71.9%] male), and late-onset DLB (n = 147; mean [SD] age, 73.5 [5.5] years; 103 [70.1%] male). Early-onset DLB was clinically misdiagnosed in 16 individuals (50%). Features that predicted a diagnosis of early-onset DLB over early-onset AD included visual hallucinations (15 [46.9%] vs 42 [11.6%]), slowness (23 [71.9%] vs 95 [26.2%]), apathy (23 [71.9%] vs 189 [52.1%]), and motor deterioration that preceded cognitive and behavioral symptoms (7 [21.9%] vs 6 [1.7%]). Late-onset DLB had more amnestic features, but this was accounted for by a higher proportion of neocortical neuritic plaques and diffuse plaques (frequent in 79 [53.7%] vs 8 [25%]) than seen in early-onset DLB. This study found that early-onset DLB has clinical features that distinguish it from early-onset AD, whereas features of late-onset DLB are associated with a higher burden of AD copathology." }, { "id": "article-24236_3", "title": "Lewy Body Dementia -- Introduction", "score": 0.011031875179477362, "content": "There continues to be a debate between the relationship between Parkinson disease and LBD. The latest LBD consortium has set an arbitrary 12-month rule to differentiate LBD from Parkinson disease with dementia. If the patient has Parkinson disease for 12 months or longer before any cognitive impairment is noticed, then the disorder is most likely Parkinson disease with dementia, if the time period is shorter then the disorder is LBD. In most cases of LBD, dementia precedes the motor signs, particularly episodes of diminished responsiveness and visual hallucinations." }, { "id": "pubmed23n0304_11261", "title": "Differential diagnosis of Alzheimer's disease.", "score": 0.01094017094017094, "content": "Accurate diagnosis of dementia is essential to provide appropriate treatment as well as patient and family counseling. It may be difficult to differentiate dementia from delirium. In addition, several features distinguish dementia from depression, but the two can coexist and the distinction may be uncertain. Dementias can be grouped into two categories: dementia that presents without prominent motor signs and dementia that presents with prominent motor signs. Dementias without prominent motor signs include Alzheimer's disease, frontotemporal dementia, and Creutzfeld-Jakob and other prion diseases. Dementias characterized at onset by prominent motor signs include dementias with Lewy bodies, idiopathic Parkinson's disease, progressive supranuclear palsy, cortico-basal ganglionic degeneration, hydrocephalus, Huntington's disease, and vascular dementia. Routine diagnostic steps include a careful history, mental status screening, laboratory and imaging studies, and neuropsychologic testing. Genetic testing is available, but its use is controversial and raises complex ethical questions." }, { "id": "pubmed23n1003_4304", "title": "Diagnostic diversity among patients with cognitive complaints: A 3-year follow-up study in a memory clinic.", "score": 0.010873671145647834, "content": "To describe the distribution and estimate the mortality risks of degenerative dementias and nondegenerative conditions in a memory clinic. We enrolled 727 consecutive patients with cognitive complaints who visited the memory clinic in Buddhist Tzu Chi General Hospital during 2013 to 2016. Three main diagnostic groups were defined: pure type dementia, in which only one type of dementia was diagnosed, such as Alzheimer disease (AD), vascular dementia (VaD), Parkinson disease with dementia (PDD), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD); mixed type dementia; and nondegenerative conditions. We described the frequency of different diagnoses and employed Cox proportional hazards regression models to examine the mortality risks for each diagnostic group after adjusting for age, sex, education, and cognitive status. All patients alive on or after September 30, 2018, were censored in the analysis. Two-thirds of patients (n = 496, 68.2%) were diagnosed with degenerative dementias. Pure type to mixed type dementia ratio was about 2: 1. AD remained the most common pure dementia subtype, followed by VaD and PDD. Among all nondegenerative conditions, depression/anxiety and subjective cognitive decline were the most common diagnoses. During a mean follow-up of 3.4 years, 150 deaths were documented, and the mortality risk was 61 deaths/1000 person-years. Mortality risks were associated with age, sex, education, and cognitive function at diagnosis but did not differ by diagnostic group. Clinical diagnoses for patients with cognitive complaints are diverse, and nearly one-third are of nondegenerative conditions. Baseline cognitive function is a stronger predictor for survival than clinical diagnosis." }, { "id": "wiki20220301en001_276322", "title": "Dementia", "score": 0.010761238337574214, "content": "In some types of dementia, such as dementia with Lewy bodies and frontotemporal dementia, personality changes and difficulty with organization and planning may be the first signs. Middle As dementia progresses, initial symptoms generally worsen. The rate of decline is different for each person. MMSE scores between 6–17 signal moderate dementia. For example, people with moderate Alzheimer's dementia lose almost all new information. People with dementia may be severely impaired in solving problems, and their social judgment is usually also impaired. They cannot usually function outside their own home, and generally should not be left alone. They may be able to do simple chores around the house but not much else, and begin to require assistance for personal care and hygiene beyond simple reminders. A lack of insight into having the condition will become evident." }, { "id": "pubmed23n0394_7879", "title": "[Dementia with Lewy bodies].", "score": 0.01034341152918228, "content": "Dementia with Lewy bodies (DLB) is the second most frequent neuropathologically diagnosed degenerative dementing illness. The clinical characteristics are progressive dementia, Parkinson syndrome, fluctuations of cognitive functions, vigilance and attention, visual hallucinations (usually detailed and well described), depression, REM-sleep behavior disorder, adverse responses to standard doses of neuroleptics, falls, syncopes, systematized delusions, and non-visual hallucinations. Mean age at disease onset ranges between 60 and 68 years. Male persons are more frequently affected than female. Disease duration is six to seven years. The differential diagnoses of DLB are dementia of the Alzheimer-type, Parkinson's disease, subcortical arteriosclerotic encephalopathy, progressive supranuclear palsy, multiple system atrophy, and, in rare cases, Creutzfeldt-Jakob disease. The genetic background of the disease is unclear. Magnetic resonance imaging and single photon emission tomography can contribute to the diagnosis. The disease is treated with L-dopa, atypical neuroleptics, acetylcholine esterase inhibitors, antihypotensive agents, and peripheral anticholinergic and alpha-receptor-blocking medicaments to improve neurogenic bladder dysfunction." }, { "id": "wiki20220301en011_99597", "title": "Dementia with Lewy bodies", "score": 0.01009440813362382, "content": "Differential Many neurodegenerative conditions share cognitive and motor symptoms with dementia with Lewy bodies. The differential diagnosis includes Alzheimer's disease; such synucleinopathies as Parkinson's disease dementia, Parkinson's disease, and multiple system atrophy; vascular dementia; and progressive supranuclear palsy, corticobasal degeneration, and corticobasal syndrome. The symptoms of DLB are easily confused with delirium, or more rarely as psychosis; prodromal subtypes of delirium-onset DLB and psychiatric-onset DLB have been proposed. Mismanagement of delirium is a particular concern because of the risks to people with DLB associated with antipsychotics. A careful examination for features of DLB is warranted in individuals with unexplained delirium. PET or SPECT imaging showing reduced dopamine transporter uptake can help distinguish DLB from delirium." }, { "id": "wiki20220301en001_276351", "title": "Dementia", "score": 0.009900990099009901, "content": "Imaging A CT scan or MRI scan is commonly performed to possibly find either normal pressure hydrocephalus, a potentially reversible cause of dementia, or connected tumor. The scans can also yield information relevant to other types of dementia, such as infarction (stroke) that would point at a vascular type of dementia. These tests do not pick up diffuse metabolic changes associated with dementia in a person who shows no gross neurological problems (such as paralysis or weakness) on a neurological exam. The functional neuroimaging modalities of SPECT and PET are more useful in assessing long-standing cognitive dysfunction, since they have shown similar ability to diagnose dementia as a clinical exam and cognitive testing. The ability of SPECT to differentiate vascular dementia from Alzheimer's disease, appears superior to differentiation by clinical exam." } ] } } }