[Diagnosis related groups. Significance for the future of surgery].
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Diagnosis-Related Groups↗
Biomedical subjects
J Stern
Publications and source records attributed to J Stern.
Residual HIV-1 RNA in blood plasma of patients taking suppressive highly active antiretroviral therapy.
CONTEXT: Despite suppressive treatment with highly active antiretroviral therapy (HAART), replication-competent virus can still be isolated from peripheral blood mononuclear cells and genital cells of many individuals receiving suppressive HAART. OBJECTIVE: To determine whether free virion RNA can be detected in the blood plasma and/or genital tract fluids from patients receiving suppressive HAART. DESIGN: Prospective cohort study conducted from November 1998 to May 1999. SETTING: Academic medical center. PATIENTS: Human immunodeficiency virus 1-infected individuals (20 men and 2 women) shown in our laboratories to have fewer than 50 copies/mL of HIV-1 RNA in peripheral blood plasma while taking suppressive HAART. MAIN OUTCOME MEASURES: Free virion RNA levels in peripheral blood plasma and genital fluids, quantified using an ultrasensitive reverse transcriptase polymerase chain reaction able to quantify cell-free virion RNA to a lower limit of 5 copies/mL and qualitatively detect viral RNA below this level. RESULTS: In all 22 patients, residual viral RNA could be detected in the peripheral blood plasma (mean level, 17 copies/mL). The presence of viral RNA suggests that ongoing viral replication is occurring, albeit at low levels, in each patient evaluated. Viral RNA levels were lower in most patients' genital fluids compared with blood plasma and in 12 patients were undetectable. CONCLUSIONS: These data suggest that low-level replication of HIV-1 in patients taking suppressive HAART may be demonstrated not only in peripheral blood mononuclear cells but also in peripheral plasma as cell-free virion RNA. Complete ablation of viral replication may require intensification of antiretroviral therapies beyond standard suppressive HAART.
Anti-HIV Agents↗
Effects of restorative proctocolectomy on renal and adrenal function.
PURPOSE: Restorative proctocolectomy is a standard procedure in the surgical treatment of ulcerative colitis and familial adenomatous polyposis. The radical removal of the colorectum with construction of an ileostomy often results in high stoma losses. These may lead to changes in the electrolyte and acid-base balance and to alterations in renal and suprarenal gland function. METHODS: In this study 33 patients who received an ileoanal pouch before and after proctocolectomy were investigated at different time intervals for electrolyte changes, alteration of the acid-base balance, kidney function, and hormonal changes of the suprarenal glands. Measurements were performed before proctocolectomy, ten days after proctocolectomy with ileal pouch-anal anastomosis under protective loop ileostomy, before ileostomy closure, and 6 to 12 months after ileostomy closure. Neither acute renal failure nor other vital complications were observed. RESULTS: Statistical analysis showed a significant decrease of urine pH to 5.4 +/- 0.22 (before ileostomy closure) and metabolic acidosis (pH 7.32 +/- 0.04; base excess -1.3 +/- 5.6 (before ileostomy closure)). Likewise, we found a decrease in renal clearance to 86 ml/minute (before ileostomy closure) without signs of tubular damage. The most important change during the phase with ileostomy was a functional secondary hyperaldosteronism with aldosterone levels of 63.2 +/- 70.8 ng/dl (before ileostomy closure). In comparison with preoperative levels, there was a ten-fold increase in mineralocorticoid adrenal activity. Additionally, during the period with protective ileostomy, the hepatic synthesis of aldosterone-18-glucuronide was only slightly increased, and the cortisol/cortisone ratio was extremely decreased. CONCLUSIONS: These results show that restorative proctocolectomy with ileal pouch-anal anastomosis and protective loop ileostomy significantly influences fluid, electrolyte, and acid-base balance. Functional secondary hyperaldosteronism is of central importance for subsequent renal recompensation. Approximately one-half year after ileostomy closure, the endogenous hormones with mineralocorticoid effects returned to normal levels.
Acid-Base Equilibrium↗
[Stoma physiology].
In addition to psychological stress, stomas may lead to metabolic consequences. Colostomies normally cause only minor physiological problems; however, patients with ileostomies are at risk for severe metabolic disturbances. The small intestine essentially manages the balance of water and electrolytes and the absorption of nutrition. In special circumstances such as "high output" or short-bowel syndrome, dangerous consequences like kidney disorders may arise. Basic therapeutic strategies such as enteral or parenteral substitution are discussed.
Colostomy↗
[Distal choledochal cyst in hydro-spiral CT].
Bile duct cysts are rare abnormalities of the biliary tract. Surgical therapy has been recommended because of possible complications such as cholestasis with jaundice and the risk of bile duct carcinoma. Accurate preoperative radiological imaging is available for surgical planning. In addition to direct imaging of the biliary system in ERCP, high-resolution axial computerized imaging techniques are necessary. The use of MRCP is becoming more frequent in diagnostic imaging of the biliary tract. Similar to the diagnosis of pancreatic tumors with hydro-spiral CT technique, we demonstrate the benefits of hydro-CT in imaging of a distal choledochal cyst, the problems of differential diagnosis and the classification in the generally accepted Todani system in a case in which accurate clarification with MRCP and ERCP was not possible.
Adult↗
Indications for and results of surgical therapy for male gynecomastia.
BACKGROUND: The objective of our study was to analyze factors determining diagnostic versus cosmetic indication and postoperative results in the treatment of gynecomastia. PATIENTS AND METHODS: Data from 100 patients and 141 breasts were analyzed retrospectively, and reevaluated by questionnaire (n = 81) and clinical examination (n = 33). Except for 2 patients, all underwent subcutaneous mastectomy through various incisions. RESULTS: Diagnostic surgery was exclusively performed in unilateral, nodular gynecomastia being preferentially of grade I. Higher grade, bilateral gynecomastia led mainly to cosmetic surgery. Minor complications (skin retraction, hypertrophic scars, hypesthesia, skin redundancy) occurred in 53% of patients and significantly more often in grade III or II gynecomastia. Each incision was preferentially associated with specific sequelae. However, 86% of patients were satisfied with surgical results. CONCLUSIONS: Laterality, consistency, grade, and age at onset of symptoms determine surgical indication. Despite the high number of sequelae due to preoperative grade and selected incision, most patients are satisfied with postoperative results.
Adult↗
Teleconsultation in otolaryngology: live versus store and forward consultations.
OBJECTIVE: To evaluate the relative strengths and weaknesses of interactive and delayed teleconsultations in otolaryngology. SETTING: Ambulatory clinic at an urban tertiary care facility. SUBJECTS: Forty-five adult patients with known or suspected upper aerodigestive tract pathology. INTERVENTION: Patients were interviewed by an otolaryngology chief resident (CR) using a standardized protocol; the results were presented to a board-certified otolaryngologist present locally (LBCO) and a remote physician viewing the encounter by video-conferencing elsewhere in the hospital (RBCO). The CR performed a complete otolaryngologic examination, including fiberoptic nasopharyngolaryngoscopy. The CR and LBCO viewed the examination on a video monitor; the RBCO viewed the same image on the video-conferencing monitor. Each physician independently recorded findings and rendered a diagnosis. A third board-certified otolaryngologist, who reviewed the stored data file (text and stored images) in a delayed fashion (DBCO), documented his findings and made a diagnosis. RESULTS: The CR and LBCO agreed on diagnosis in 92% (36 of 39) of cases. The LBCO and RBCO arrived at the same diagnosis in 29 of 34 (85%) cases. The DBCO agreed with the LBCO for 18 of 28 (64%) diagnoses. Agreement on management recommendations between the LBCO/DBCO pair were also lower than for the LBCO/RBCO pair. CONCLUSIONS: Both interactive and delayed techniques can be used to provide relatively accurate clinical consultations in otolaryngology. Telemedicine can be applied for subspecialty consultations, screening programs, remote emergency triage, second opinions, and resident education.
Adult↗
The Kaiser Permanente prenatal smoking-cessation trial: when more isn't better, what is enough?
INTRODUCTION: The effectiveness of low-cost smoking interventions targeted to pregnant women has been demonstrated, although few gains in absolute cessation rates have been reported in the past decade. Under conditions of typical clinical practice, this study examined whether outcomes achieved with brief counseling from prenatal care providers and a self-help booklet could be improved by adding more resource-intensive cognitive-behavioral programs. DESIGN: Randomized Clinical Trial. SETTING: A large-group-model managed care organization. PARTICIPANTS: 390 English-speaking women 18 years of age or older who self-reported to be active smokers at their initial prenatal appointment. INTERVENTION: Participants were randomized to one of three groups: (1) a self-help booklet tailored to smoking patterns, stage of change, and lifestyle of pregnant smokers; (2) the booklet plus access to a computerized telephone cessation program based on interactive voice response technology; or (3) the booklet plus proactive telephone counseling from nurse educators using motivational interviewing techniques and strategies. No attempt was made to change smoking-related usual care advice from prenatal providers. MAIN OUTCOME MEASURE: Biochemically confirmed abstinence measured by level of cotinine in urine samples obtained during a routine prenatal visit at approximately the 34th week of pregnancy. RESULTS: Twenty percent of participants were confirmed as abstinent with no significant differences found between intervention groups. Multivariate baseline predictors of cessation included number of cigarettes smoked per day, confidence in ability to quit, exposure to passive smoke, and educational level. No differential intervention effects were found within strata of these predictors or by baseline stage of readiness to change. Cessation rates among heavier smokers were strikingly low in all intervention groups. CONCLUSION: Neither a computerized telephone cessation program nor systematic provision of motivational counseling improved cessation rates over a tailored self-help booklet delivered within the context of brief advice from prenatal providers. Innovative strategies need to be developed to increase the effectiveness of existing prenatal smoking interventions. Special attention should be paid to the needs of heavier smokers.
Adult↗
Origins of the Creutzfeldt and Jakob concept.
A review of the publications of Hans Creutzfeldt and Alfons Jakob pertaining to the concept which bears their name (CJD) reveals that they described a neuropathological syndrome and were opposed to its classification as a neurological disease. The evidence on which Creutzfeldt and Jakob based their view is reevaluated, and studies by other workers are cited in which a range of environmental and genetic factors generated the CJ syndrome, challenging the proposition that CJD is a disease with a single cause.
Creutzfeldt-Jakob Syndrome↗
An interactive, computer-based program to educate patients about genital herpes.
BACKGROUND AND OBJECTIVES: Education and counseling constitute a substantial portion of management of patients with genital herpes. Innovative methods for education about genital herpes are needed. GOAL: To test the ability of an interactive, computer-based program to educate patients about genital herpes. STUDY DESIGN: Persons seeking care at five urban offices were asked to participate. A knowledge test about genital herpes was administered before and after participation. Participants' satisfaction was assessed with a questionnaire. RESULTS: Four hundred thirty-five participants enrolled, and 428 completed the herpes knowledge test. Of six questions evaluated, a statistically significant increase in the proportion of correct answers was noted on five of six questions. Fifty-one percent of participants answered all the questions correctly after the program, compared with 39% before the program. Satisfaction with the program was very high. CONCLUSIONS: Innovative, computer-based programs can provide education and assist in the management of chronic sexually transmitted infections.
Adolescent↗
Manifestations of AIDS in the head and neck.
BACKGROUND: A significant number of patients with the acquired immunodeficiency syndrome (AIDS) are initially seen with symptoms related to the head and neck. It is becoming increasingly challenging for clinicians to accurately diagnose new lesions, considering the vast array of manifestations of AIDS in this region and their many atypical presentations. A comprehensive review is a valuable clinical tool. METHODS: A MEDLINE search of the English language literature from 1984 to the present was done for this study. RESULTS: Dermatologic, otologic, nose/paranasal sinuses/nasopharynx, oral cavity/oropharynx, laryngeal, and neck manifestations are reviewed. The gross and microscopic appearances of lesions are described, with particular emphasis on various presentations of the same lesion and lesions that may mimic the appearance of others. Practical treatment strategies are also discussed. CONCLUSIONS: Accurate and early recognition of the many common and uncommon manifestations of AIDS in the head and neck is of critical importance to the timely and effective management of these patients.
Acquired Immunodeficiency Syndrome↗
Lack of prognostic significance of SPECT abnormalities in non-demented elderly subjects with memory loss.
OBJECTIVE: To determine if hypoperfusion abnormalities on single photon emission computed tomography (SPECT) are associated with poorer cognitive function at baseline or increased risk of decline in cognitive function and progression to dementia in memory-impaired but non-demented elderly subjects meeting the criteria for aging associated cognitive decline (AACD). DESIGN: Cross sectional study of 36 AACD subjects comparing hexamethyl propylene-amine oxime (HMPAO) SPECT results rated by visual inspection with base line cognitive functioning. Prospective study of these AACD subjects with clinical and neuropsychological follow-up over 35 months. SETTING: The memory clinic and nuclear medicine unit of a university teaching hospital. SUBJECTS: Thirty-six subjects meeting the criteria for AACD recruited from patients seen on a physician referral basis. MAIN OUTCOME MEASURES: 1) Baseline cognitive function as measured by the Mini Mental State Examination (MMSE), Boston naming, Logical Memory I subtest of the WAIS-R, and verbal fluency, correlated with SPECT status. 2) Decline in cognitive function as measured by clinical exam and the MMSE, with progression to dementia on follow-up being correlated with SPECT status at baseline. RESULTS: 18 of the 36 subjects progressed to dementia (probable Alzheimer's Disease) over follow-up. No correlation was found between the presence or absence of SPECT abnormality and MMSE or other cognitive measures. There was no correlation between the presence or absence of SPECT abnormality at initial examination, and cognitive decline according to the MMSE, or with the occurrence of clinical dementia on follow-up. CONCLUSIONS: We conclude that SPECT abnormalities assessed by visual inspection do not correlate with severity of impairment in AACD individuals, and are not useful in predicting progression to dementia in AACD subjects.
Aged↗
Improving diagnostic staging laparoscopy using intraperitoneal lavage of delta-aminolevulinic acid (ALA) for laparoscopic fluorescence diagnosis.
BACKGROUND: Lymph node metastases and peritoneal carcinosis, occurring as a result of gastrointestinal cancer, reduce the likelihood that conventional therapy will be adequate to remove the cancer. Although diagnostic techniques have greatly improved, it is not always possible to diagnose the entire extent of the metastases. Often, peritoneal micrometastases are not visible and may be missed during laparoscopic or open surgery. METHODS: Peritoneal carcinosis was induced in WAG-Rij rats (n = 6), by laparoscopically implanting 1,2-dimethylhydrazine-induced colon carcinoma tumor cells (CC531, 5 x 10(5)) at multiple sites within the peritoneal cavity. After 12 days of tumor growth, the animals were given delta-aminolevulinic acid (ALA) (5 mL, 3% solution in 0.17 mol/L NaHCO3) by peritoneal lavage. The tumors were visualized laparoscopically using both white and blue light (D-light, Karl Storz, Tuttlingen, Germany). Fluorescence was detected by using a modified CCD camera and a special observation filter incorporated into the laparoscope. RESULTS: Peritoneal carcinoma foci ranging in size from 0.05 to 2.0 cm were clearly visible laparoscopically with conventional white light (n = 142). After blue light excitation, all 142 tumors identified with white light were also identified by fluorescence. There were an additional 30 tumors that could only be identified by blue light-induced fluorescence and were histologically confirmed to be derived from colon carcinoma tumor cells. CONCLUSIONS: Peritoneal colonic carcinoma foci were detected laparoscopically after intraperitoneal lavage with delta-aminolevulinic acid (ALA) and excitation with blue light. These experiments demonstrate that fluorescence laparoscopy is an important technique for the staging of gastrointestinal cancer, including colorectal cancer, because of the enhanced ability to detect small cancerous foci.
Aminolevulinic Acid↗
Epstein-Barr virus-associated adult respiratory distress syndrome in a patient with AIDS: a case report and review.
BACKGROUND: Epstein-Barr virus (EBV) infection has been associated with fatal pneumonitis in immunocompetent patients. We present a case of fatal adult respiratory distress syndrome caused by EBV infection in a patient with acquired immunodeficiency syndrome (AIDS), to our knowledge the first such reported case, along with a survey of archival autopsy cases to assess baseline expression of EBV in AIDS patients. DESIGN: The case patient's autopsy material was studied exhaustively for infectious agents by culture, histochemistry, and immunohistochemistry, with negative results. Formalin-fixed paraffin-embedded lung, spleen, lymph node, and liver tissue were further studied by in situ hybridization using a probe for EBV early RNA (EBER, Kreatech). The same method was applied to lymphoid tissues from eight other archival AIDS autopsy cases. Case patient tissues were also examined by electron microscopy. RESULTS: Strikingly numerous lymphocytes were positive for EBV early RNA in the case patient's spleen, lymph nodes, and hepatic portal areas. In addition to positive lymphocytes in the lung, EBV-infected pneumocytes were also present. Electron microscopy also demonstrated viral material in lymphocytes and pneumocytes. Of the archival cases studied, only one spleen was found to have rare positive lymphocytes. CONCLUSION: Primary or reactivation EBV infection may represent a previously underreported cause of morbidity and mortality in AIDS patients. Autopsy tissues from AIDS patients do not routinely show overexpression of EBV early RNA by in situ hybridization, making this technique ideal for assessing the contribution of EBV to terminal events in these patients.
Acquired Immunodeficiency Syndrome↗
Countertransference and limits of therapy in war situation.
Psychotherapy of war traumas and their specific emotional and psychological experiences is a challenge for the therapist. The two partners of the therapeutic dyad may undergo the same difficulties and suffer from the same anxieties, and be affected by the transference and countertransference processes. The conditions of neutrality that should be maintained in the treatment are thus prone to changes. The therapist may protect himself/herself from unconscious guilt, omnipotent fantasies and feelings of being overwhelmed by different modes of defenses. The historical and social context of the trauma have to be taken into account. A chronology to be introduced in the narrative is the first step in the process of reindividuation as the victim's identity has been attacked by the trauma as well as his/her physical integrity. The therapist may find in this intervention a reflection of his/her own needs. The aims of psychotherapy in war situations may be close to those of crisis intervention and at the same time deal with the reactivation of previous infantile traumas. The past plays a significant part in the readaptative process as much as it is relevant to the present. The therapeutic intervention is in essence a message of hope as it implies a potential future to be created.
Adult↗
Impact of comorbidity on outcome of young patients with head and neck squamous cell carcinoma.
BACKGROUND: Comorbid conditions have a significant impact on the actuarial survival of patients with head and neck cancer. However, no studies have evaluated the impact of comorbidity on tumor- and treatment-specific outcomes. This study was performed to evaluate the impact of comorbidity, graded by the Kaplan-Feinstein comorbidity index (KFI) on the incidence and severity of complications, disease-free interval, and tumor-specific survival in patients undergoing curative treatment for head and neck cancer. METHODS: A multi-institutional, retrospective cohort of 70 patients 45 years of age and under with head and neck squamous cell carcinoma (SCC) presenting over an 11-year period was studied. RESULTS: Advanced comorbidity (KFI grade 2 or 3) was present in 21 patients (30%). Patients with advanced comorbidity did not differ from patients with low-level comorbidity (KFI grades 0 or 1) in sex distribution, race, presence of human immunodeficiency virus (HIV) infection, tobacco use, location of primary lesion, stage at presentation, pathologic differentiation of the tumor, or type of initial treatment. The overall incidence of treatment-associated complications was similar between the groups (57% versus 49%; p > 0.05), but a higher proportion of patients with advanced comorbidity developed high-grade complications (24% versus 6%; p = .04). The median disease-free interval (11.1 months versus 21.6 months; p = .045) and tumor-specific survival (13.7 months versus 57.6 months; p = .03) was poorer for patients with advanced comorbidity. The effects of comorbidity on survival remained significant even after adjusting for the confounding effects of HIV status and tumor stage (p = .05). CONCLUSIONS: The presence of comorbid conditions has a significant impact on tumor- and treatment-specific outcomes. Although the presence of advanced comorbid conditions is not associated with an increase in the rate of treatment-associated complications, complications tend to be more severe in this population. More importantly, advanced comorbidity has a detrimental effect on the disease-free interval and tumor-specific survival in patients with head and neck cancer, independent of other factors. This suggests that comorbidity may impact on tumor behavior, presumably by altering the host's response to cancer. Accordingly, to be more predictive and reliable, the current staging system for head and neck cancer should include a description of the patient's comorbidity.
Adult↗
[Pre- and postoperative quality of life of patients with ulcerative colitis and familial adenomatous polyposis with ileoanal pouch operation].
After ileal pouch-anal anastomosis in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP), in addition to postoperative morbidity and functional outcome quality of life is a relevant factor for assessment of the operation's success. Between 1982 and 1997 restorative proctocolectomy was performed in 602 patients (UC: n = 424; FAP: n = 178) at the Department of Surgery, University of Heidelberg. The assessment of pre- and postoperative quality of life was done through a prospective study (before restorative proctocolectomy, before and 1 year after closure of ileostomy). This study (UC: n = 27; FAP: n = 7) revealed a poor preoperative quality of life in patients with ulcerative colitis. Proctocolectomy is the decisive factor for the improvement of quality of life in the surgical treatment in UC. Quality of life could not be further significantly improved by ileostomy closure. Before proctocolectomy, FAP patients showed a quality of life, activity and function similar to that of healthy controls. In FAP patients proctocolectomy led to a significant loss of quality of life. This loss could only partly be regained by ileostomy closure. Quality of life and activity comparable to that of healthy controls can be achieved in UC patients by restorative proctocolectomy.
Activities of Daily Living↗
Contraception with two levonorgestrel rod implants. A 5-year study in the United States and Dominican Republic.
A 5-year trial of a two-rod contraceptive implant, which releases the progestin levonorgestrel (LNG rod), was conducted at four clinics with 594 women. Mean age and weight at admission were 25.5 years and 62.4 kg, respectively. Consent to continue through 5 years was sought and obtained when the 3-year cumulative pregnancy rate proved to be 0.8 per 100. No pregnancies occurred in the fourth or fifth years. The 5-year cumulative pregnancy rate was, therefore, 0.8 per 100 with an annual average pregnancy rate below 2 per 1000 women. Prolonged bleeding/spotting (8.2% of subjects) and irregular bleeding (5.6%) were the most frequently cited medical reasons for removal. Removals for headache (4.7%) and weight change (4.0%) were the next most frequent medical reasons. Between 1% and 2% of subjects during the 5-year trial sought removals for each of the following conditions: mood changes, lower abdominal pain, depression, or pain at the implant site. The mean annual continuation rate during the study was 77 per 100. Use per woman averaged 2.96 years. Mean removal time was 5.9 +/- 0.6 min. These data indicate that, for a 5-year period, the two LNG rod implants are equivalent to the six Norplant capsule implants with respect to safety and efficacy parameters, but permit easier and more rapid implant removal.
Adolescent↗