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Concern regarding the use of smallpox for bioterrorism has led to the reintroduction of smallpox vaccination. The historic background leading to protective methods against smallpox disease, the adverse reactions and contraindications associated with vaccination, and the ongoing development of potentially safer smallpox vaccines are reviewed here.
BACKGROUND: Clinically positive axillary nodes are widely considered a contraindication to sentinel lymph node (SLN) biopsy in breast cancer, yet no data support this mandate. In fact, data from the era of axillary lymph node dissection (ALND) suggest that clinical examination of the axilla is falsely positive in as many as 30% of cases. Here we report the results of SLN biopsy in a selected group of breast cancer patients with palpable axillary nodes classified as either moderately or highly suspicious for metastasis. STUDY DESIGN: Among 2,027 consecutive SLN biopsy procedures performed by two experienced surgeons, clinically suspicious axillary nodes were identified in 106, and categorized as group 1 (asymmetric enlargement of the ipsilateral axillary nodes moderately suspicious for metastasis, n = 62) and group 2 (clinically positive axillary nodes highly suspicious for metastasis, n = 44). RESULTS: Clinical examination of the axilla was inaccurate in 41% of patients (43 of 106) overall, and was falsely positive in 53% of patients (33 of 62) with moderately suspicious nodes and 23% of patients (10 of 44) with highly suspicious nodes. False-positive results were less frequent with larger tumor size (p = 0.002) and higher histologic grade (p = 0.002), but were not associated with age, body mass index, or a previous surgical biopsy. CONCLUSIONS: Clinical axillary examination in breast cancer is subject to false-positive results, and is by itself insufficient justification for axillary lymph node dissection. If other means of preoperative assessment such as palpation- or image-guided fine needle aspiration are negative or indeterminate, then SLN biopsy deserves wider consideration as an alternative to routine axillary lymph node dissection in the clinically node-positive setting.
Gene gun immunization has been associated with the induction of a heterologous type of immune response characterized by a T(H)1-like immune reaction on the cellular level, i.e. generation of IFN-gamma secreting CD8(+) T-cells, yet a T(H)2 biased serology as indicated by high IgG1:IgG2a ratios and induction of IgE. Nevertheless, gene gun immunization using the model molecule beta-galactosidase has been argued to prevent IgE induction and to promote T(H)1 cells with respect to allergy DNA immunization. In our current study, we evaluated the potential of gene gun immunization to prevent type I allergic reactions comparing beta-galactosidase with two clinically relevant allergens, and further investigated the effect of gene gun immunization on relevant lung parameters. BALB/c mice were immunized with plasmids encoding the birch pollen allergen Bet v 1, the grass pollen allergen Phl p 5, or the model molecule beta-galactosidase, either by gene gun or intradermal injection followed by sensitization and intranasal provocation with the respective allergen. IgG1 and IgG2a antibody titers were determined by ELISA. IgE levels were evaluated in a rat basophil release assay. The severity of eosinophilia was determined in bronchoalveolar lavages, and the overall infiltrate was analyzed by histology on lung paraffin sections. Gene gun immunization induced a T(H)2-biased immune reaction, which did not prevent from production of IgE after subsequent sensitization. This T(H)2 effect was influenced by the nature of the antigen, with a more pronounced T(H)2-bias for the allergens Bet v 1 and Phl p 5 compared to beta-galactosidase. Gene gun immunization with all three antigens promoted eosinophil influx into the lung and did not alleviate lung pathology after intranasal provocation. In contrast to needle injection of plasmid DNA, which triggers a clearly T(H)1-biased and allergy-preventing immune response, gene gun application fails to induce anti-allergic reactions with all tested antigens and is therefore contraindicated for allergen-specific immunotherapy.
One hundred patients with contraindications to the femoral approach were randomized to undergo diagnostic coronary angiography via percutaneous radial puncture or brachial artery cutdown. Procedure duration, fluoroscopy time, and total radiation dose were significantly less via the radial route, whereas procedural success, complication rates, and pain scores were comparable; we conclude that the radial technique should be the arm approach of choice for new trainees, although there will be occasions when radial access fails and a brachial approach is required.
Three groups of indications exist for postmenopausal estrogen use: relief of symptoms related to estrogen deficiency, osteoporosis prophylaxis and treatment, and cardioprotection. Estrogen replacement therapy enhances a woman's sense of well-being and reduces the morbidity, mortality, and health care costs associated with osteoporosis and atherosclerotic heart disease. There are a few absolute contraindications to estrogen replacement therapy. Many estrogen preparations are currently available in the United States. Establishing equivalencies among the different preparations is complicated by the many physiologic and pharmacologic effects of estrogens and the variety of treatment end points used. Most estrogens have the same biologic effect provided equivalent blood levels are achieved. Estrogen replacement therapy has proved beneficial to selected postmenopausal women.
After vasectomy reversal by vasovasostomy or vasoepididymostomy motile sperm appear commonly in the semen even when only nonmotile sperm are present in the intraoperative vasal or epididymal fluid. We studied patients with bilateral congenitally absent vasa deferentia to see if relief of obstruction by implantation of an alloplastic spermatocele also benefits sperm motility in such patients. A total of 130 alloplastic spermatoceles was implanted in 91 patients. Of 21 patients with only nonmotile sperm in the epididymal fluid intraoperatively only 1 had motile sperm in the postoperative aspirates from the alloplastic spermatocele. The quality of sperm motility in the intraoperative epididymal fluid was predictive of the quality of sperm motility in the postoperative aspirates. Conception postoperatively did not occur whenever less than 20 per cent of the intraoperative epididymal sperm was motile. Thus, poor or absent sperm motility in the epididymal fluid during planned alloplastic spermatocele implantation predicts a poor postoperative result and, therefore, contraindicates implantation of the prosthesis. Pregnancy, which occurred postoperatively in 7 of 91 wives, ended in spontaneous abortion in 3 and progressed to full-term delivery in 4.
Since its introduction in 1997, the 7F "Tail" stent has been used after a variety of endourologic procedures. We describe 2 patients who underwent retrograde endopyelotomy with distal ureteral dilation; in both patients, after placement of a 7F "Tail" stent, a clinically significant urinoma developed. We believe that in the setting of extensive distal ureteral manipulation or distal active ureteral dilation to greater than 10F, placement of a "Tail" stent is contraindicated.
Seventy-four patients undergoing total hip arthroplasty considered to be at high risk for heterotopic ossification were given 75 mg of indomethacin daily for 6 weeks after operation and studied clinically and radiographically for a minimum of 6 months. Twenty-seven patients (37%) could not complete the drug course. Of the 47 (63%) patients completing treatment, only 2 (4%) had grade IIA (mild) and no patients had more severe heterotopic ossification. No major complications were attributed to the use of indomethacin. These findings support the evidence that indomethacin can effectively prevent higher grades of heterotopic ossification following total hip arthroplasty. However, approximately one-third of the patients were unable to complete the course of drug therapy, limiting the overall usefulness of indomethacin. Surgeons prescribing indomethacin must also be aware of its contraindications and adverse effects.
BACKGROUND: The strict limiting criteria for the use of metformin in diabetes mellitus stem largely from reports, in the 1970s, of mortality and lactic acidosis associated with phenformin. Data about metformin are less clear and are based mainly on case reports. The aim of this study was to evaluate the safety of continued use of metformin in patients with contraindications to this agent. PATIENTS: Some 393 patients with type 2 diabetes mellitus (serum creatinine 130-220 &mgr;mol/l) were studied. Among them were 266 patients with coronary heart disease (CHD), 94 with congestive heart failure (CHF), and 91 with chronic obstructive pulmonary disease (COPD), all of whom had been treated with metformin. The patients were randomized to either continue or to stop metformin and were then followed for 4 years. RESULTS: Analysis was by intention-to-treat. The patients who stopped taking metformin showed a rise in body mass index and in hemoglobin A1c significantly greater than those who continued the drug. There were no cases of lactic acidosis. Lactic acid values did not differ in the two groups and correlated only with serum creatinine and body mass index. Microvascular diabetic complications, cardiovascular events, and cardiovascular and total mortality were identical in the two groups. CONCLUSIONS: Diabetic patients who are treated with metformin and who tolerate the drug well may continue taking it, even when mild renal impairment develops, possibly up to serum creatinine levels of 220 &mgr;mol/l. There is also no apparent reason why patients with CHD, CHF, and COPD should discontinue metformin.
1. The arterial switch procedure is now the operation of choice for typical D-transposition of the great arteries at The Children's Hospital, Boston, USA, the operative mortality rate since 1985 being 3%. 2. There are many anatomic considerations suggesting the morphologically left ventricle (LV) may well be a better systemic pump than the morphologically right ventricle (RV) which, if true, would favor the arterial switch procedure as opposed to an atrial switch operation: (1) The LV consists almost entirely of the sinus or pumping portion, and has only a minimal distal infundibular (conal) component. The RV, by contrast, has a relatively much larger infundibular component, the primary function of which is to prevent regurgitation rather than to pump. (2) Phylogenetically, the LV is the ancient "professional" pump. By contrast, the RV is a comparatively recent modification of the bulbus cordis. (3) The LV is a two-coronary ventricle, whereas the RV is a one-coronary ventricle. (4) The LV has relatively much more compact myocardium (stratum compactum) than does the RV. (5) The mitral valve leaflets are better designed to occlude a circular systemic atrioventricular orifice than are the tricuspid valve leaflets. (6) The papillary muscles of the LV are large, paired, well balanced, and both arise from the same ventricular wall--the LV free wall. By contrast, the papillary muscles of the RV are comparatively small, numerous, unbalanced, and arise from both ventricular septal and free walls. Hence, dilatation of the LV does not pull the LV papillary muscles apart, whereas dilatation of the RV does pull the RV muscles apart, favoring the development or exacerbation of tricuspid regurgitation. (7) The LV has two conduction system radiations, whereas the RV has only one. 3. The current anatomic contraindications to the arterial switch operation in typical D-TGA include the following: (1) an unprepared LV; (2) an aortic intramural left coronary artery arising from the right coronary sinus of Valsalva; (3) pulmonary outflow tract stenosis (with small annulus and subvalvar obstruction) or atresia; (4) aortic outflow tract stenosis (with small annulus and subvalvar obstruction) with tubular hypoplasia of the aortic arch and preductal coarctation; (5) tricuspid or mitral atresia; (6) marked underdevelopment or absence of either the RV sinus or the LV sinus; and; (7) 2 major anomaly of the systemic and/or pulmonary veins, as in the heterotaxy syndrome with asplenia.(ABSTRACT TRUNCATED AT 400 WORDS)
Chorioamnionitis has generally been thought to be a contraindication to attempting a delayed interval delivery in a multiple gestation. We present a twin gestation in which a delay of 88 days between the birth of the two infants occurred. Chorioamnionitis observed immediately after the delivery of Twin A was successfully treated with antibiotic therapy.
The results of 230 retrograde phlebographies of the V. spermatica int., 165 percutaneous sclerotherapies and 60 follow-up phlebographies on subfertile patients are presented. In 24 patients (10%) complications occurred, yet in none of the cases clinical damage became evident. Percutaneous sclerotherapie is contraindicated, when selective probing of the V. spermatica int. is impossible or massive collaterals to other venous systems could lead to an uncontrolled spread of the sclerosing agent. Treatment of idiopathic varicocele in subfertile men by percutaneous sclerotherapy is a safe and effective method, which can be performed on an outpatient basis. In our opinion the so far used surgical treatment can be replaced by it as a method of choice.
69 years after the introduction of x-ray examination of the seminal duct, the indication and contraindication are reviewed according to current interdisciplinary aspects, basing on 31 cases studied over a period of two years. The procedure followed in the roentgenological visualization of carcinoma of the prostate is generally recognized, whereas controversial opinions are held with regard to patients with occlusive azoospermia. The possibility of lesions and damage caused by some contrast media is an established fact. Differences in the lumen of the ductus epididymidis prevented complete visualization of the epididymis when using the previous, highly concentrated, sticky contrast media which were insoluble in water. These drawbacks have been eliminated by Amipaque. Today epididymograms are no longer considered necessary, although there are exceptions. Experience and a sophisticated technique are mandatory. If refertilization is envisaged, it is permissible during operation only to effect a descending x-ray for the purpose of clarifying the outflow conditions.
An initial dosis of 40 mg followed by 40 mg propranolol (Dociton) t.i.d. for 4 weeks was administered to 16 hypertensive patients with manifest arterial vasoocclusive disease of the pelvic and thigh type (stage II according to Fontaine). Blood pressure decreased 90 minutes after the first oral administration from 174/106 to 155/93 mm Hg. Cardiac frequency was lowered significantly from 75 to 66/min. Occlusion plethysmography and Doppler pressure estimation were not changed significantly either in the acute nor in long-term assessment. The painfree walking distance remained constant 90 minutes after propranolol initially (baseline value 230 m, after 90 minutes 220 m). It rose to 330 m after two weeks and to 350 m after four weeks. Use of beta receptor blocker in arterial vasoocclusive disease is thus not contraindicated, at least as far as stage II is concerned.
Potassium iodide (KI) is a useful drug in the dermatologic armamentarium. It is successfully used for inflammatory dermatoses, most notably erythema nodosum, subacute nodular migratory panniculitis, nodular vasculitis, erythema multiforme, and Sweet's syndrome. KI is also successfully used for cutaneous and lymphocutaneous sporotrichosis. The precise mechanism by which KI acts is unknown. Although many minor side effects are common with this drug, major side effects can occur in pregnant patients and those with a history of kidney or thyroid disease. This article reviews the pharmacology, mechanism of action, indications, contraindications, and adverse effects of KI as a therapeutic agent.
A few of the recent researchers of kinesthetic aftereffect (KAE) as an index of augmenting/reducing have continued to employ a two-session procedure. Findings that have accrued in the past decade indicate (a) The first administration of KAE is a reliable (internally consistent) and valid index of augmenting-reducing; (b) there are carry-over effects from the first to the second administration that bias the second session's preinduction scores; (c) KAE scores from sessions after the first do not relate to first-session scores (low retest reliability) and do not measure augmenting/reducing; and (d) unless special procedures are undertaken to avoid using the biased second- (or later-) session preinduction scores, a KAE procedure involving more than one session is contraindicated. When we reached a similar conclusion earlier (Baker et al., 1974), Petrie (1974) disagreed, arguing that a two-session procedure was needed to identify and eliminate an atypical subgroup, the "stimulus governed." The case for determining which subjects are stimulus-governed is assessed and found wanting. Except in special circumstances, a one-session KAE procedure, in which all preinduction trials precede the first exposure to aftereffect induction, is indicated.
A primipara affected by late-onset diabetes and sensory deafness because of mitochondrial myopathy was hospitalized for threatened preterm delivery. Magnesium sulfate was started for tocolysis, resulting in general muscle damage, although the mitochondrial myopathy did not deteriorate during pregnancy. Magnesium sulfate may be contraindicated in pregnancy with mitochondrial myopathy.
Fifty male patients older than 65 years of age (mean 66.3) underwent a symptom-limited exercise test on an average of 34 days after acute myocardial infarction. After 4 weeks of supervised rehabilitation training and after one-year follow-up, the patients underwent controlled exercise tests. The ergometric parameters were compared with respective values in 10 healthy males (mean age 66.4, range 65-75). The rehabilitation training induced a substantial improvement in physical capacity (total work from 3149 +/- 1326 to 4791 +/- 1403 kg; P less than 0.001) with a better cardiovascular response: increased maximum oxygen pulse (from 8.97 +/- 2 to 10.7 +/- 2; P less than 0.001), decreased heart rate (from 120.5 +/- 16.1 to 111.3 +/- 14.7 beats min-1; P less than 0.05) and a decreased double product at a 75 W work load (from 22 866 +/- 4005 to 20 472 +/- 3982 beats min-1 mmHg; P less than 0.05). The recovery of physical capacity and cardiovascular tolerance in the physical exercise was nearly complete as compared with healthy subjects of the same age. During the training period one patient died from heart failure. In all the other patients the same improvement was still maintained one-year later. In conclusion, old age does not seem to be per se a contraindication to cardiac rehabilitation. Physiological beneficial effects from cardiac rehabilitation can also be received by patients older than 65 years of age.