Suggestions to social workers for surviving in managed care.
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Aged↗
Biomedical subjects
A W Schneider
Publications and source records attributed to A W Schneider.
Effect of losartan, an angiotensin II receptor antagonist, on portal pressure in cirrhosis.
Administration of angiotensin II causes an increase in portal pressure, and plasma concentration of angiotensin II is elevated in patients with cirrhosis, suggesting that angiotensin II may be involved in the pathogenesis of portal hypertension in cirrhosis. We evaluated the effect of the orally active angiotensin II receptor antagonist, losartan, on portal pressure in patients with cirrhosis and portal hypertension. Thirty patients with severe (hepatic venous pressure gradient [HVPG] >/= 20 mm Hg) and 15 patients with moderate (HVPG < 20 mm Hg) portal hypertension at baseline measurement were treated with an oral dose of 25 mg losartan once daily for 1 week and compared with 15 (HVPG >/= 20 mm Hg) and 10 (HVPG < 20 mm Hg), respectively, cirrhotic controls. On the seventh day, HVPG was determined again, and blood pressure, heart rate, body weight, and parameters of liver and kidney function were recorded. Losartan induced a significant (P <.001) decrease of HVPG in the patients with severe (-46.8% +/- 15.5%) and moderate (-44.1% +/- 14.7%) portal hypertension, while no significant change was seen in the controls. Losartan caused a slight but significant (P <.01) fall in mean arterial blood pressure (-3.1 +/- 5.0 and -3.5 +/- 4.3 mm Hg, respectively). One patient treated with losartan had a short symptomatic hypotensive reaction after the first dose of losartan that did not recur despite continued treatment. No deterioration of liver or kidney function was observed. The present study indicates that angiotensin II blockade with orally administered losartan is safe and highly effective in the treatment of portal hypertension.
Adult↗
Hepatic arterial pulsatility index in cirrhosis: correlation with portal pressure.
BACKGROUND/AIMS: Determination of the pulsatility index by means of duplex sonography provides the opportunity to evaluate the vascular resistance of the hepatic artery noninvasively. The aim of this study was to investigate the relationship between the hepatic arterial pulsatility index and the hepatic venous pressure gradient in cirrhosis. METHODS: In 50 patients with cirrhosis, hepatic venous pressure gradient was determined in the fasting state. Immediately thereafter, hepatic arterial pulsatility index and portal blood flow velocity were measured by duplex sonography with no knowledge of hepatic venous pressure values. In addition, the duplex parameters were determined in 20 controls. RESULTS: Hepatic arterial pulsatility index was significantly higher in patients with cirrhosis than in controls (0.92+/-0.1 vs. 1.14+/-0.18; p<0.001) and directly correlated with the hepatic venous pressure gradient (r = 0.7; p<0.001). Furthermore, weak correlations were found between hepatic arterial pulsatility index and Child-Pugh score (r = 0.49; p<0.01) and between portal blood flow velocity and hepatic venous pressure gradient (r = -0.48; p<0.01). CONCLUSION: In cirrhosis the hepatic arterial vascular resistance seems to increase parallel to the rise of the portal pressure. Therefore, duplex sonographic determination of the hepatic arterial pulsatility index may contribute to the noninvasive evaluation of portal hypertension.
Diastole↗
[Ticlopidine-induced pancytopenia: therapy of agranulocytosis with granulocyte colony stimulating factor].
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Aged↗
Endo-urological cold-knife incision for ureteral stenosis after renal transplantation.
Cold-knife incision of stenoses in the transplant ureter was performed in 11 patients with upper urinary tract obstruction in renal transplants. The operations were complicated by bleeding in 2 patients and the graft had to be removed in 1 of them. The stenoses could be treated successfully in 10 of the 11 patients (91%) and the mean serum creatinine concentration decreased significantly from 3.4 to 1.8 mg./dl. After a mean of 26 months only 1 obstruction recurred, so the long-term success rate was 82%. Because of the favorable long-term results and the low incidence of complications, we recommend endo-urological cold-knife incision of ureteral stenosis as the first-line treatment for upper urinary tract obstruction in renal transplants.
Adult↗
[Urologic complications after kidney transplantation. Experiences in a center with 539 recipients].
A total of 539 renal transplantations were performed at the Department of Urology of the University Hospital of Hamburg between 1984 and 1991. 132 (24.5%) patients developed urological complications (by definition, complications occurring as a result of the operative procedure). In 31 cases the transplants had to be removed secondary to urological complications, and 4 patients died of such complications (mortality 0.7%, lethality 3.0%). Urinary tract infections occurred in 13.2% of all patients during the first postoperative year and were by far the most frequent complication, followed by haematomas, which occurred in 9.6%. The incidence of urinary tract and wound infections was significantly reduced during the 8-year period studied by improving antibiotic prophylaxis and adopting a strategy of early removal of indwelling catheters (P < 0.05). Stenting the ureteroneocystostomy with a double-J stent instead of an external ureteral catheter resulted in a definite decrease in the incidence of ureteral leaks (P < 0.05). Continuous control of operative results and efforts to improve operative and perioperative strategies make it possible to reduce the incidence of urological complications in renal transplantation and thus result in an improved graft function and patient survival.
Adolescent↗
[Thrombocytopenia in digitoxin poisoning].
Because she felt unwell, an 80-year-old woman who was receiving treatment with digitoxin (0.07 mg daily) raised the dose on her own initiative to twice or three times the previous level. She then experienced faintness, visual abnormalities and bradyarrhythmia (rate about 40/min). The ECG showed 2 degrees AV block. The digitoxin level was 70.8 ng/ml--far above the upper limit of the therapeutic range (7.5-25 ng/ml). One striking abnormality was thrombocytopenia (33,000/microliters), though the white and red cell counts were normal. Petechiae were not present and there was no evidence of internal bleeding. As the AV block had not produced any critical fall in ventricular rate, there was no need to start treatment with digitalis-binding antibody fragments (Fab fragments). Instead, the patient was given cholestyramine 4 g three times daily with the aim of interrupting the enterohepatic circulation of digitoxin. From then on the rise in platelet count paralleled the fall in digitoxin level. Seven days after discontinuing digitoxin the platelet count reentered the normal range (147,000/microliters). However, the digitoxin level (39.5 mg/ml) was still well above the therapeutic range.
Aged↗
[Obstructive uropathy after kidney transplantation. Experiences with endourologic incision of ureteral stenoses].
Between 1985 und March 1991 we have managed 8 upper urinary tract obstructions in kidney transplants using an endourological approach. After a graft rejection was excluded an obstruction was initially diagnosed by nephrosonography and further confirmed by IVP or antegrade pyelography. To investigate the urodynamic relevance of the stenosis, all patients underwent preoperative diuretic isotope renography. In all cases a percutaneous pyelostomy was done to preserve renal function. 7 of these 8 patients demonstrated a stenosis of the ureter, while in one case, the obstruction was caused by a coagulum in the renal pelvis. Incision of the stricture then was performed with a flexible knife antegrade or retrograde and stented for 4-6 weeks. In 6 out of 7 cases with a proven stenosis of the ureter, the cold knife incision lead to a successful outcome, while in one patient, the kidney had to be removed due to uncontrolled bleeding 12 days after successful percutaneous incision. Our results indicate, that the cold-knife-technique for the management of upper urinary tract obstructions in kidney transplants is a promising, fast and in most of the cases effective method. Due to its minimalinvasive character and excellent results, this approach is able to replace open reintervention in most cases.
Adolescent↗
The cold-knife technique for endourological management of stenoses in the upper urinary tract.
Between 1985 and October 1989 we managed 13 patients with primary and 43 with secondary obstruction of the upper urinary tract with the endourological cold-knife technique. We treated 26 patients with stenosis of the ureteropelvic junction, 9 with infundibular stenosis, 12 with ureteral obstruction after inflammation or radiation therapy, 7 with stricture of the ureter in kidney transplants and 2 with stenosis of the ureter after ureterosigmoidostomy. Endourological management was successful in 42 of 56 cases with a decrease or total elimination of obstruction. Stenosis recurred in 9 patients. Our results indicate that the cold-knife technique should be attempted as the initial approach in all cases of primary or secondary obstruction of the upper urinary tract.
Adolescent↗
Quantitative immunocytology in the management of patients with superficial bladder carcinoma. I. A marker to identify patients who do not require prophylaxis.
We used monoclonal antibody 486P 3/12 to monitor 55 patients after transurethral resection of stages Ta and T1 transitional cell bladder carcinoma. The method has a high sensitivity (89%) in detecting grades 1 to 3 lesions. We examined voided urinary specimens taken every 4 weeks after transurethral resection for a mean of approximately 2 years. Of the 55 patients 22 remained negative for marker without prophylaxis and only 2 of them had another tumor. Only 6 of 33 patients who were positive for marker after transurethral resection were negative for marker at least once immediately after transurethral resection. Of the 33 patients 14 had a recurrent tumor. In all 14 patients a marker-positive urine specimen preceded visible tumor recurrence by several months. Monoclonal antibody 486P 3/12 is a safe marker to identify patients with superficial bladder carcinoma after transurethral resection who do not require prophylaxis. The 22 patients who remained negative for marker after transurethral resection had an almost equal distribution of stages Ta to T1 lesions (9 versus 13) and equal distribution of grades 1 and 2 lesions (11 versus 11).
Antibodies, Monoclonal↗
Recombinant alpha-2 or gamma interferon in the treatment of metastatic renal cell carcinoma: results of two phase II/III trials.
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Animals↗
[Long-term results in the treatment of metastasizing kidney carcinoma using recombinant alpha-2 or gamma interferon].
To evaluate whether response to alpha-2- or gamma-interferon in metastatic renal cell carcinoma is associated with a prolonged survival, we studied a total of 65 patients being treated in two phase-II- or phase-III-trials between 1984 and 1986 with one of these interferons. After a median follow-up of 3 years for the alpha-interferon-treated patients and of more than 4 years for gamma-interferon-therapy, respectively, there is a significantly increased duration of survival for patients showing an objective response or stabilisation of the disease due to either therapy compared to those with continuing progression. Therapy with alpha-interferon leading to objective remissions in 26% or with gamma-interferon with an objective response rate of 36% therefore is beneficial for responding patients and can be performed with moderate side effects on an out-patient basis.
Adult↗
[Use of electronic data processing at a urologic polyclinic--a program packet for recording and evaluating data of specialized consultations].
A software package was developed for computerized recording and processing of clinical data in a urological out-patient clinic. In a pilot study this program proved to be useful for the rapid evaluation of all important clinical and laboratory results of patients with renal cell carcinoma, and its use also accelerated the preparation of medical reports. The experience gained in this initial project shows that the application of this newly developed concept of data processing can easily be extended to routine out-patient followup in other special areas within the field of oncology.
Aftercare↗
[Tumor markers and prognostic parameters in urinary bladder cancer].
Ideal tumor markers for use in the primary diagnosis or follow up of superficial or invasive cancers have not yet been found. Nonetheless, the literature contains references to parameters that are relevant to prognosis and to markers for bladder tumors, and many of these are certainly of value when specific questions are addressed. Urinalysis has been considerably refined and yields information on superficial tumors. Quantitative immunocytology is used to check whether prophylactic treatments are indicated and, if so, for how long; conventional cytology is helpful in the clinical follow up after BCG treatment of carcinoma in situ. In the present paper all important markers for urothelial cancer are reviewed and their value in diagnosis and treatment is discussed.
Biomarkers, Tumor↗
[Papaverine-induced priapism. Experiences with a new urologic emergency].
Ten patients with priapism after self-administered intracavernous papaverine injection for erectile impotence had to be treated as emergencies between September 1985 and February 1988. In half the patients it was possible to achieve penile detumescence by puncture of the corpora cavernosa, injection of 2-5 mg metaraminol or both, but failed in the remainder, requiring the intracavernous injection of 10-30 mg metaraminol in 500 ml physiological saline. Surgical treatment was necessary in one case. Papaverine-induced priapism constitutes a urological emergency which, because of the danger of hypertensive crises, demands treatment in hospital.
Adult↗
[Quantitative immunocytology as a marker for indications and follow-up of recurrence prevention of superficial urinary bladder cancers].
In 1985, we initiated a prospective clinical trial to evaluate the risk of recurrence for superficial bladder cancer. Up to now, 41 patients subjected to TUR have subsequently been monitored by immunocytology with a monoclonal antibody (mab 486 p) recently developed in our laboratory. Of these patients, 15 (36.6%) remained marker-negative and received no prophylactic therapy. There was only one recurrence (6.7%) in this subset of patients, whereas 10 out of 26 (38.5%) marker-positive patients have so far developed recurrent malignancies. In all cases, the conversion of immunocytological characteristics preceded visible recurrence by 2-5 months. These preliminary results indicate that immunocytology might make it possible to identify patients at low risk of recurrence more accurately than has so far been feasible with standard cytology or flow-cytometry.
Administration, Intravesical↗
Recombinant interferon gamma in the treatment of metastatic renal cell carcinoma. Results of a phase II trial.
A clinical Phase II study was performed to evaluate the efficacy and safety of treatment with interferon gamma in patients with metastatic renal cell carcinoma. Patients received interferon gamma by two different regimens: 1. 100 micrograms/m2 3x/week i.v. over 4 h every other week--low dose. 2. 500 micrograms/m2 5x/week i.v. over 24 h every other week--high dose--for non-responders to regimen 1. The response rate, duration of response, survival and toxicity in the two regimens were evaluated. Treatment with interferon gamma resulted in an overall response rate of 31%, with a duration of response ranging between 2 and 44+ months. Patients responding objectively to interferon gamma or showing stable disease survived significantly longer than non-responders (p = 0.0056).
Adult↗
Breathing pattern during induced bronchoconstriction.
The breathing patterns of normal subjects monitored with respiratory inductive plethysmography were investigated after mild increases in respiratory resistance provoked by aerosolized methacholine during natural breathing and while breathing on a mouthpiece to a pneumotachograph. First, during natural breathing, comparisons of inspiratory ventilation (VI), tidal volume (VT), frequency (f), inspiratory time (TI), fractional inspiratory time (TI/TT), and mean inspiratory flow (VT/TI) were made before and after aerosolized buffered saline and methacholine in a dose that reduced specific airway conductance (sGaw) by 35% (PD35). There was a significant increase in VT/TI and VI after methacholine, whereas VT, f, TI, and TI/TT were not consistently modified by saline or methacholine. Pretreatment with bronchodilators prevented changes in respiratory resistance (Rrs) as well as in breathing pattern after PD35 methacholine. On another day, Rrs, end-expiratory lung volume level, and breathing pattern during natural breathing were monitored after administration of predetermined doses of methacholine that reduced sGaw by 25% (PD25), PD35, and 55% (PD55). Increases in VT/TI and end-expiratory lung volume level paralleled the increases in Rrs after each dose of methacholine but not with saline control. VI increased along with Rrs at the PD25 and PD35 doses but plateaued at the PD55 dose while Rrs continued to rise. There were no changes in breathing pattern in subjects who breathed on a mouthpiece to a pneumotachograph after PD55 methacholine. Thus alterations of the breathing pattern due to mild-to-moderate degrees of bronchoconstriction are characterized by progressive rises of mean inspiratory flow (an index of respiratory center drive) and end-expiratory lung volume level (a measure of pulmonary hyperinflation), but VI plateaus at the more severe degree of bronchoconstriction.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗