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[Is there a place for chemotherapy in the initial treatment of cervical cancer? Review of the literature].

Despite their high efficiency in treating cancer of the uterine cervix, surgery and radiotherapy can not cure (local and/or metastatic disease) a certain number of patients with initially adverse risk factors, mostly local or regionally advanced cervical carcinoma (stage III-IVA) or early stage (IB-II) disease with bulky primary lesion or involved regional nodes. Since the 1980s, many investigators have tried to determine whether or not there is any benefit in introducing chemotherapy earlier in the therapeutic plan for these patients: either initially before surgery or radiotherapy (neoadjuvant), or during radiotherapy (concurrent), or after local treatment (adjuvant). In this review we seek to sum up the published data available and to determine if at present there is a place for chemotherapy in the initial treatment of cervical cancer.

Antineoplastic Combined Chemotherapy Protocols↗

Percutaneous fine-needle aspiration of portal vein thrombi as a staging technique for hepatocellular carcinoma. Cytologic findings of 46 patients.

BACKGROUND: Detection of portal vein tumor invasion in patients with hepatocellular carcinoma (HCC) is important in determining therapy and prognosis. Fine-needle aspiration (FNA) of a portal vein thrombus under ultrasound guidance facilitates the distinction of malignant from benign thrombus without resorting to laparotomy. In this study, the FNA findings of 46 patients who underwent this procedure are described. METHODS: Cytologic findings of 48 aspirations from 46 patients who underwent percutaneous ultrasound-guided portal vein FNA were reviewed. RESULTS: Twenty-nine of the 46 patients had a prior or concurrent biopsy-confirmed diagnosis of HCC at the time of portal vein FNA. On cytologic review, 39 of the aspirates were positive for malignancy, 6 were negative, and 3 were suspicious. Histologic follow-up of three of the six patients with negative aspirates confirmed bland thrombi in their portal veins. No complications resulted from the FNA procedure. Of the 39 aspirates positive for HCC, 22 were well differentiated, 5 were well to moderately differentiated, 9 were moderately differentiated, and 3 were poorly differentiated. In all except the poorly differentiated tumors, a trabecular cellular arrangement was detected in either smears or cell blocks. The cytologic findings in these aspirates, in general, mirror those found in aspirates of HCC in the liver proper. CONCLUSIONS: Portal vein FNA is an effective, well tolerated method for disease staging of patients with HCC. When used as the initial diagnostic procedure, in selected patients, it can provide the diagnosis and staging information simultaneously.

Adolescent↗

Cholecystectomy during pregnancy without fetal loss.

Cholecystectomy in the pregnant patient has been generally avoided because of the reported high incidence of associated fetal loss that has been linked to spontaneous and elective abortion during the first trimester and premature labor during the third trimester. Recent developments relating to diagnostic and anesthetic management and the use of tocolytic agents have altered the over-all approach to patients. We have, therefore, retrospectively reviewed the medical records of all women discharged from four area hospitals during 1982 to 1987 with a concurrent diagnosis of cholelithiasis and pregnancy. Twenty-two patients met the review criteria. The incidence of biliary stone disease among gravid patients during the time interval was 0.05 per cent. Of 22 patients, none underwent radiation for diagnosis. Nine patients underwent cholecystectomy while pregnant; two were operated upon during the first trimester, four during the second and three during the third. Three required common bile duct exploration and three had intraoperative cholangiograms. Elective abortion was not recommended to the six patients because of radiation exposure. Two of nine had premature contractions develop that were controlled with tocolytic agents. There were no spontaneous abortions. The mean Apgar scores for neonates born subsequent to cholecystectomy was virtually identical to neonates born to patients in whom cholecystectomy was deferred. It is concluded that the diagnosis and surgical treatment of cholelithiasis can be safely undertaken in the pregnant patient without fetal loss. Delaying appropriate surgical therapy no longer seems warranted.

Adult↗

Validity of certification measures for occupational therapists.

Major factors that can affect the results of validation studies are identified and include reliability, homogeneity of sample, and criterion contamination. An overview and a description of content, predictive, concurrent, and construct validities are presented as well as a review of the recent studies of the validity of the Field Work Performance Report and the Certification Examination for Occupational Therapists. Adequate evidence of content and concurrent validity has been established for the Field Work Performance Report, although evidence for long-range predictive validity is lacking. Content validity alone has been established for the Certification Examination for Occupational Therapists. The evidence indicates that the instruments should not be abandoned, that they are better than no measures at all. The directions research might take in the future are given and the implications of continued use of the instruments are evaluated.

Certification↗

Physician reporting compared with medical-record review to identify adverse medical events.

OBJECTIVE: To assess the effectiveness of housestaff physician reporting as a method for identifying adverse events on a medical service and to compare the physician reporting mechanism with a retrospective record review mechanism. SETTING: Medical service of an urban, university-affiliated teaching hospital. DESIGN: Concurrent physician reporting mechanism using the hospital electronic mail system compared with a retrospective record review using a screening mechanism followed by structured, implicit physician review of the record. PATIENTS: All 3146 admissions to the medical service from 13 November 1990 to 14 March 1991. RESULTS: The housestaff physician reporting method identified nearly the same number (89) of adverse events as did the record review (85). However, the two methods identified only 41 of the same patients (kappa = 0.52). No statistically significant clinical or socioeconomic differences occurred between the patients identified as having had an adverse event, using the two reporting methods (physician versus record review). The housestaff did report statistically more preventable adverse events (62.5% compared with 32%; P = 0.003). The physician reporting mechanism was also less costly (approximately $15,000 compared with $54,000). CONCLUSION: An adverse event identification strategy based on physician self-referral uncovers as many adverse events as does a record review and is less costly. In addition, physician-identified events are more likely to be preventable and, thus, are targets for quality improvement.

Adolescent↗

Management of patients with concurrent primary tumors of bladder and prostate.

The clinical course of 33 male patients presenting with concurrent primary tumors of the bladder and prostate was reviewed. Twenty-four of 33 patients were treated by radical cystoprostatectomy. The remaining 9 patients were treated by more conservative means. Seventy-four per cent of the patients survived five years. A rationale for management of concurrent primary tumors of the bladder and prostate is presented.

Adult↗

Cystoenteric conversion and reduction cystoplasty for treatment of bladder dysfunction after pancreas transplantation.

PURPOSE: Bladder drainage of pancreatic exocrine secretions during pancreas transplantation can lead to significant urological complications. Our experience with cystoenteric conversion (CEC) is reviewed with respect to safety and efficacy. Select patients underwent concurrent reduction cystoplasty. MATERIALS AND METHODS: A total of 255 pancreas transplantations were performed at the University of Washington between 1990 and 2001, of which 236 were bladder drained and 33 required enteric conversion of bladder drainage. An additional patient from an outside institution required conversion. These cases were reviewed retrospectively. Of the patients 21 with large capacity (greater than 500 ml) bladders underwent concurrent reduction cystoplasty. RESULTS: Mean age of the 20 male and 14 female patients was 44 years (range 33 to 60) and mean interval between transplantation and CEC was 4.3 years (0.6 to 9). The most frequent indication for CEC was recurrent urinary tract infections (15 of 34 cases, 44%). Mean followup after CEC was 2.5 years (range 0.3 to 6.5). Six complications requiring reoperation were seen in 5 of the 34 patients (15%), one of which led to death (3%). Normal pancreatic graft function persisted in 30 of the 34 cases (88%). After reduction cystoplasty mean bladder capacity in all 34 cases decreased from 900 to 465 ml intraoperatively (p <0.0001) and from 650 to 362 ml in 9 according to urodynamics (p <0.015). Of the patients 30 (88%) experienced resolution of symptoms, while 3 (9%) experienced improvement and 1 (3%) continued to have recurrent infections. CONCLUSIONS: Although we advocate maximal conservative treatment of the urological complications of pancreas transplantation, CEC offers safe and effective management of these complications, and can easily be combined with reduction cystoplasty in select cases to optimize postoperative voiding function.

Adult↗

Current controversies in high-dose-rate versus low-dose-rate brachytherapy for cervical cancer.

The use of brachytherapy in the treatment of cervical cancer has increased worldwide since its initial introduction over 100 years ago. However, certain aspects of the use of high-dose-rate (HDR) versus low-dose-rate (LDR) brachytherapy continue to be controversial, particularly the role of HDR in FIGO Stage III cervical cancer and the use of HDR with concurrent chemotherapy. This study represents a systematic literature review of prospective and retrospective series of patients with cervical carcinoma treated with external-beam radiation (EBRT) followed by either HDR or LDR radiation. The local control rates, survival rates, and treatment-related complications in patients with Stage III cervical cancer treated with HDR or LDR and those treated with concomitant chemotherapy are examined. Patients with Stage III cervical cancer treated with EBRT and brachytherapy have a local control rate of >50% in most series. Randomized prospective and retrospective studies show overall statistically equivalent local control, overall survival, and complication rates between HDR and LDR. However, LDR may be preferable for large, bulky tumors at the time of brachytherapy. Retrospective studies of HDR and concurrent chemotherapy are limited but have demonstrated toxicity rates similar to those with LDR. Selected patients with Stage III cervical carcinoma who have an adequate response to EBRT and concomitant chemotherapy may be treated with HDR brachytherapy. The existing literature shows no significant increase in complications in patients treated with HDR and concurrent chemotherapy; however, sufficient tumor shrinkage prior to HDR and careful monitoring of the dose to the normal tissues are imperative.

Brachytherapy↗

Morphine use and adverse effects in a neonatal intensive care unit.

Prescribing patterns and appropriateness of morphine use in a neonatal intensive care unit (NICU) were evaluated in a concurrent drug-use evaluation (DUE). Data were collected for 99 infants who received morphine over a six-month period. Patient charts were reviewed to collect the following data: patient's age, weight, dosage schedule, concurrent sedatives, ventilatory status, whether adequacy of analgesia was documented, and descriptions of adverse drug reactions (ADRs). The physicians' orders were reviewed to determine whether NICU morphine dosage guidelines were followed and whether the indication for use was noted. Seven ADRs occurred in six of the patients; three of the ADRs occurred after ophthalmic cryosurgery. Indications for use were noted in 79 of 285 physician orders (27.7%). The adequacy of sedation or analgesia was documented on 60 of the 360 patient days (16.7%). The DUE results prompted several changes: physicians were asked to select indications from a list in the computerized order-entry system, an analgesia or sedation assessment scale was added to nursing flow sheets, and endotracheal intubation became a requirement before ophthalmic cryosurgery. A follow-up DUE showed nearly complete compliance with the new guidelines for morphine use and a reduction in the number of adverse reactions to morphine. A DUE prompted policy changes that improved documentation of indications for and efficacy of morphine use and reduced adverse reactions to the drug in an NICU.

Analgesia↗

Idiopathic acute interstitial nephritis and uveitis in the adult. Report of 1 case and review of the literature.

In a 59-year-old female, concurrence of acute interstitial nephritis and uveitis was observed. While the clinical signs resolved after a few weeks, signs of renal tubular dysfunction persisted for 9 months, and creatinine clearance was still impaired (22 ml/min) more than 2 years after beginning of the symptoms. This is the 5th case of idiopathic interstitial nephritis with concomitant uveitis reported in adult patients. In contrast to the benign evolution observed in children, the renal function may remain impaired in adults.

Creatinine↗

The foundation of Piaget's theories: mental and physical action.

Piaget's late theory of action and action implication was the realization of a long history of development. A review of that history shows the central place of action in all of his theoretical assertions, despite the waxing and waning of other important features of his theories. Action was said to be the primary source of knowledge with perception and language in secondary roles. Action is for the most part not only organized but there is logic in action. Action, which is at first physical, becomes internalized and transformed into mental action and mental representation, largely in the development of the symbolic or semiotic function in the sensorimotor period. A number of alternative theories of cognitive development place primary emphasis on mental representation. Piaget provided it with an important place as well, but subordinated it to mental action in the form of operations. In this, as Russell claims, he paralleled Schopenhauer's distinction between representation and will. Piaget's theory of action was intimately related to the gradual development of intentionality in childhood. Intentions were tied to actions by way of the conscious awareness of goals and the means to achieve them. Mental action, following the sensorimotor period, was limited in its logical form to semilogical or one-way functions. These forms were said by Piaget to lack logical reversibility, which was achieved only in the sixth or seventh year, in concrete operations. Mental action was not to be fully realized until the development of formal operations, with hypothetical reasoning, in adolescence, according to the classical Piagetian formulation. This view of the child's logical development, which relied heavily on truth-table (extensional) logic, underwent a number of changes. First from the addition of other logics: category theory and the theory of functions among them. In his last theory, however, an even more radical change occurred. With the collaboration of R. Garcia, he proposed a logic of meanings that would require a recasting of his earlier truth-table-based operatory logic that he claimed explained the development of logical thought and problem solving. The new logic of meanings, influenced by Anderson and Belnap's (1975) logic of entailment, placed new emphasis on inferential processes in the sensorimotor period, introduced protological forms in the actions of the very young child, and proposed that knowledge has an inferential dimension. The consequence was that the late theory shifted emphasis to intentional (qualitative) logic and meaning from the earlier extensional (quantitative) logic and truth testing. The profound changes in Piaget's late theory requires a serious reevaluation of Piaget's entire corpus of research and theory; a task which is yet to be done. Seen in a new light, the late theory is much closer to intellectual currents associated with hermeneutic and semiotic traditions in their concern with meaning and interpretation and less, if at all, with truth. This, despite Piaget's couching of the new theory in a logical mode. The late theory added significant new elements to the theory of action and action-implication, and suggest that Piaget's, and his collaborator's, new research data, which were interpreted within the new theoretical framework, require corroboration and review. The question as to whether Piaget's assertions are at root metaphorical and lack psychological reality, which has followed his theories from its earliest days, arises as well with the assertions of the late theory. Possibly, even more so, since even a limited historical review of his theories points to a considerable concurrence between changes in the fundamental assumptions of his theories and intellectual currents of the times. In hindsight, Piaget's theories appear as "works in progress," down to his last theory. Yet, even in the end, he charted the direction of possible further progress.

Child↗

Antepartum fetal surveillance.

In recent years the advances in prenatal diagnosis of fetal asphyxia have been dramatic and increasing at a remarkable pace. Now that a solid base of multivariable testing has been accepted as the method of choice for assessment of fetal health, the focus of clinical research has shifted towards identification of factors and signs that might predict not only risk of death and immediate morbid outcome but also the quality of life after delivery. The papers reviewed here outline the scope of the problem of cerebral palsy and offer clues as to how fetal disease may become manifest as child or adult sustained neurological injury. Concurrently, the advances in refinement of the testing methods are reviewed. Clearly a better understanding of the etiology, physiology, and range of fetal responses to asphyxia will be the key to effecting not only better survival rates but also a higher quality of survival.

Cerebral Palsy↗

Association between topical prostaglandin analog use and development of choroidal neovascular membranes in patients with concurrent glaucoma and age-related macular degeneration.

PURPOSE: Matrix metalloproteinases (MMPs) are a family of enzymes that act to degrade extracellular matrix (ECM) molecules, such as collagen, elastin, and gelatin. The glaucoma medication latanoprost, and possibly other topical prostaglandin analogs, increase uveoscleral outflow and lower intraocular pressure (IOP) in primary open-angle glaucoma (POAG) by activating MMPs 1, 2, 3, and 9 in the ciliary body. It has been reported that latanoprost may also gain access to the posterior segment and induce cystoid macular edema, although the mechanism is unknown. In the choroid, activation of some of the same subtypes of MMPs (particularly subtypes 2 and 9) has been implicated in the formation of choroidal neovascular membranes (CNVMs) in age-related macular degeneration (AMD). This study examined whether topical prostaglandin analog use is associated with a greater risk of CNVM formation in patients diagnosed with both AMD and POAG. METHODS: A retrospective record review was performed to identify patients with a concurrent diagnosis of AMD and POAG between 1998 and 2004. Four hundred and eighty-four (484) eyes were identified and grouped as wet (n = 65) or dry (n = 419) AMD. Prostaglandin usage was compared between the two groups. Usage of other glaucoma medications was also compared. A minimum of 1 year of topical glaucoma medication was required for inclusion in the study. Exclusion criteria included a history of CNVM prior to starting glaucoma medications and a previous history of glaucoma surgery. RESULTS: Fifty-six percent (56%) of dry AMD and 62% of wet AMD eyes were using a topical prostaglandin (P > 0.10; not significant). Analysis of specific topical prostaglandin analog usage in the wet versus dry AMD groups revealed no statistically significant differences in the percentage of eyes treated with latanoprost (37.7% versus 41.5%), bimatoprost (12.9% versus 10.8%), or travoprost (9.2% versus 5.3%), respectively. No significant differences in the use of other glaucoma medications were observed between the two groups. CONCLUSIONS: No association between long-term topical prostaglandin use and CNVM development was found in patients with AMD and POAG.

Administration, Topical↗

The elderly travellers.

As the population increases, older people have the opportunity to travel for longer periods and to destinations that are quite different from what they are used to. Older people do indeed have more ongoing medical issues and some limitations due to the aging process. Most of the time these chronic conditions are not a contraindication to travel. Preparing for travel frequently involves starting an exercise program, updating routine immunizations such as tetanus, pneumonia, and influenza as well as getting destination specific immunizations such as hepatitis, yellow fever and typhoid. Medications should be reviewed as they relate to altitude, climate and concurrent travel medications including malaria prophylaxis. There are many organizations and foundations that deal with travel and specific medical problems such as diabetes, asthma, dialysis and for those with spinal cord injuries. The traveler would be wise to seek the advice of specialists related to their specific medical condition as well as a travel medical physician. One should also be sure that their medical insurance would cover them in a foreign country.

Adult↗

Drug utilization review of concomitant use of specific serotonin reuptake inhibitors or clomipramine with antianxiety/sleep medications.

Side effects of some antidepressants include anxiety and insomnia. A retrospective drug utilization review was conducted to determine the amount of concurrent use of an antidepressant with medication that may counteract these side effects. Texas Medicaid claims data for 1993 included more than 30,000 patients receiving a specific serotonin reuptake inhibitor (SSRI) or clomipramine. A total of 35.0% of these patients were also taking a medication that could be used to relieve anxiety or induce sleep, and 15.2% of the total were receiving once-daily dosing of the latter type of medication. Concomitant use of SSRIs or clomipramine with trazodone occurred in 7.7% of the patients.

Anti-Anxiety Agents↗

Phthirus pubis as a predictor for chlamydia infections in adolescents.

BACKGROUND: Providers not skilled in the evaluation of sexually transmitted infections (STIs) may treat pubic lice infestation without considering other organisms. This study compared the rate of chlamydia and gonorrhea infections in adolescents with and without pubic lice. GOAL: The goals of the study were to compare the rate of chlamydia and gonorrhea infections between adolescents infested or not infested with pubic lice and to evaluate lice infestation as a predictor for concurrent chlamydia or gonorrhea infection. STUDY DESIGN: A retrospective chart review of sexually active adolescents at a juvenile detention center in the Midwest between July 1998 and June 2000 was conducted. The index group was 62 adolescents with pubic lice screened for concurrent STIs. The control group included 201 randomly selected adolescents without pubic lice who underwent STI screening. RESULTS: In the entire study population (263 subjects), there were 60 cases of chlamydia (23% of all subjects) and 29 cases of gonorrhea (11%). Neisseria gonorrhoeae infection was present in 18% of index subjects and 9% of controls. Chlamydia trachomatis infection was noted in 39% of index subjects and 18% of controls. Pubic lice infestation predicted C trachomatis infection (odds ratio = 3.31). CONCLUSIONS: Pubic lice infestation is predictive of a concurrent C trachomatis infection in this population. Adolescents infested with pubic lice should be screened for other STIs, including chlamydia and gonorrhea.

Adolescent↗

Neoadjuvant therapy of esophageal cancer.

Locally advanced esophageal cancer, potentially curable with surgery or radiotherapy-based treatment, has a poor prognosis because of the eventual development of systemic metastatic disease in the majority of patients. Local recurrence of disease after local treatment modalities is equally problematic. The use of systemic chemotherapy in the surgical and radiation-based treatment of esophageal cancer is reviewed, including the approach of preoperative chemotherapy, preoperative concurrent chemotherapy plus radiotherapy, and chemoradiotherapy as definitive treatment without surgery. The use of chemoradiotherapy has clearly been shown to be superior to radiotherapy alone in the nonsurgical management of locoregional esophageal cancer. Recent trials suggest that preoperative chemoradiotherapy may be superior to surgery alone but trials are ongoing to better define the role of combined modality therapy in the surgical management of esophageal cancer.

Antineoplastic Combined Chemotherapy Protocols↗