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PubMed2002

Preoperative chemoradiation treatment strategies for localized sarcoma.

BACKGROUND: Over the past 2 decades, there has been increasing interest in chemoradiation treatment strategies for patients with soft tissue sarcomas. Investigators have evaluated: (1) the optimal route for chemotherapy administration (intra-arterial vs. intravenous); (2) the possible advantages of protracted infusion of the radiosensitizer versus brief infusion; (3) the efficacy and toxicity of various intravenous and oral radiation sensitizers; and (4) the efficacy of sequential versus concurrent combined modality treatment. METHODS: The English-language literature addressing chemoradiation for localized and locally advanced extremity and retroperitoneal sarcomas was reviewed. RESULTS: All studies have been pilot, phase I, or phase II designs. The most commonly used radiosensitizer for concurrent chemoradiation has been doxorubicin, administered intravenously in most recent reports. In the studies that have included assessment of recurrence-free survival, preoperative chemoradiation combined with surgery has resulted in favorable local control rates, often in excess of 90% for patients with localized and locally advanced extremity sarcomas. CONCLUSIONS: The toxicities and recurrence-free outcome with chemoradiation plus surgery for soft tissue sarcoma still need to be compared to these with surgery and pre- or postoperative radiation. However, the generally favorable local control rates reported for chemoradiation justify continued investigation of preoperative chemoradiation strategies for localized sarcoma.

Antineoplastic Agents↗
PubMed1980

Therapists' recognition of psychopathology: a model for quality review of psychotherapy.

In this study 32 randomly selected psychiatric emergency room patients, who were in concurrent psychotherapy, completed the SCL-90 and a clinically oriented questionnaire. Their therapists independently rated the patients' degree of psychopathology on the nine SCL-90 symptom scales. Therapists were highly efficient in recognizing depression (94% of the cases) and anxiety (89%) but not psychotic (35%) and obsessive-complusive (16%) pathology. Variables significantly associated with the therapists' nonrecognition of psychopathology were the diagnosis of borderline, the patient's expression of inadequacy in comparison to the therapist, the patient's fear of offending the therapist, and the patient wanting but not receiving empathy from the therapist. The authors discuss the implications of these findings for peer review and further research.

Adult↗
PubMed2001

Impact of urethral injury management on the treatment and outcome of concurrent pelvic fractures.

OBJECTIVES: Multiple treatment options exist for concurrent posterior urethral trauma and pelvic fractures. Because of the increased risk of contamination, the surgical repair of fractures may be prohibited by suprapubic urologic catheters. To characterize the incidence and long-term outcomes of these management conflicts, we reviewed our experience with concomitant pelvic fractures and posterior urethral injuries. METHODS: For a 42-month period, 61 patients with concurrent lower urinary tract and pelvic trauma, including 23 with posterior urethral injuries, were retrospectively reviewed for conflicts between urologic management and optimal treatment of the associated orthopedic injuries. RESULTS: Of the 23 posterior urethral injuries identified, the management of 8 (35%) was noted to impact the decision regarding the management and outcome of the concurrent pelvic fractures. Although the overall difference in the length of hospitalization and period of immobilization was not statistically significant, of the 4 patients whose suprapubic catheter precluded surgical orthopedic fracture repair, 3 patients (75%) remain disabled because of chronic pelvic pain, and none of those who underwent early endoscopic realignment remain disabled because of their pelvic fracture. CONCLUSIONS: Endoscopic realignment for traumatic posterior urethral injuries associated with pelvic fractures, particularly acetabular fractures, should be attempted to avoid the increased morbidity associated with conservative management of the concurrent orthopedic injuries.

Accidents, Traffic↗
PubMed2000

Cognitive behaviour therapy for schizophrenia.

BACKGROUND: Although medication is the mainstay of treatment for schizophrenia, always, some sort of informal or formal talking therapy is indicated. In cognitive behavioural therapy (CBT) links are made between the person's feelings and patterns of thinking which underpin their distress. OBJECTIVES: To review the effects of cognitive behaviour therapy (CBT) for those with schizophrenia compared to standard care, specific medication and non-intervention; also to review the effects of CBT for those with schizophrenia who are concurrently receiving standard care compared to no additional intervention to standard care, specific medication, additional drug interventions to standard care and other additional psychosocial interventions to standard care. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1980-1998), CINAHL (1982-1998), The Cochrane Library (Issue 2, 1998), The Cochrane Schizophrenia Group's Register of Trials (August 1998), EMBASE (1980-1998), MEDLINE (1966-1998), PsycLIT (1887-1998), SIGLE (1990-1998), and Sociofile (1980-1998) were undertaken. All references of articles selected were searched for further relevant trials. SELECTION CRITERIA: Randomised trials of cognitive behaviour therapy for people with a diagnosis of schizophrenia, possible schizophrenia or mental illnesses where specific diagnoses have not been employed. Outcomes such as death, metal state, relapse, psychological well-being and acceptability of treatment were sought. DATA COLLECTION AND ANALYSIS: Studies were reliably selected and assessed for methodological quality. Data were extracted by two reviewers working independently. Dichotomous data were analysed on an intention-to-treat basis and continuous data with 70% completion rate are presented. MAIN RESULTS: Four small trials were identified. All presented data suggested that there was a difference favouring CBT plus standard care over standard care alone in terms of reducing relapse rates (short term OR 0.31 CI 0.1-0.98; medium term OR 0.38 CI 0.17-0.83; long term OR 0.46 CI 0.26-0.83, NNT 6 CI 3-30). These findings were supported within the trials by scale-derived data. CBT, however, did not keep more people in care than a standard approach and there is no data relating to the effect of CBT on compliance with medication. One study also presented data on the effects of CBT when compared to supportive psychotherapy. No effect statistically significantly favoured either group but all were suggestive that the trial may have been underpowered to find an effect in favour of CBT. REVIEWER'S CONCLUSIONS: The results of well conducted and reported ongoing trials are eagerly awaited. Currently, for those with schizophrenia willing to receive CBT, access to this treatment approach is associated with a substantially reduced risk of relapse. However, at present CBT is a fairly scarce commodity, often provided by highly skilled and experienced therapists. Therefore, its application in day to day practice may be restricted by the availability of suitable practitioners. Similarly, the present data provides little indication of how effective CBT procedures might be when they are applied by less experienced practitioners.

Cognitive Behavioral Therapy↗
PubMed2000

Economic and clinical outcomes of microlaparoscopic and standard laparoscopic sterilization. A comparison.

OBJECTIVE: To compare micro-laparoscopic surgical sterilization and standard laparoscopic sterilization with respect to cost effectiveness and patient preferences. STUDY DESIGN: A retrospective study of all laparoscopic surgical sterilizations performed under general anesthesia at Johns Hopkins Bayview Medical Center--16 micro-laparoscopies and 34 standard laparoscopies. Cases selected for review were limited to patients undergoing surgical contraception and not requiring additional, concurrent procedures. Laparoscopic surgical sterilization was performed using a double-puncture technique with silicone band application. In each case either a standard, 10-mm laparoscope or a 2-mm micro-laparoscope was used, and the procedure was performed under general anesthesia. Postoperative pain management was achieved by nonsteroidal antiinflammatory drugs and/or narcotic analgesia. All cases were performed by residents under faculty supervision. Medical records and hospital billing records were reviewed, and a standardized telephone interview was conducted to assess postoperative quality of life and patient satisfaction. RESULTS: Both techniques were comparable in cost effectiveness. There was no significant difference in operating room time, average operating room costs, average ancillary department costs, instrument and supply costs, or length of stay. Postoperative discomfort was significantly less with microlaparoscopy (P = .05), and patient satisfaction was higher in the microlaparoscopy group. CONCLUSION: Microlaparoscopy and the standard laparoscopic approach for surgical sterilization are associated with similar hospital charges. Postoperative pain and overall patient satisfaction were significantly better with microlaparoscopy than standard laparoscopy.

Arizona↗
PubMed2005

Serious adverse events associated with bacille Calmette-Guérin vaccine in Canada.

BACKGROUND: Targeted Bacille Calmette-Guérin (BCG) vaccination is offered to neonates in some First Nations and Inuit (FNI) communities in Canada. Serious adverse events associated with BCG vaccine prompted a review to assess causality. METHODS: The Immunization Monitoring Program Active (IMPACT), a pediatric hospital-based active surveillance network, reported admissions for BCG-related adverse events between 1993 and April 2002. The Canadian Advisory Committee on Causality Assessment (ACCA) reviewed the reports to assess causality. Data between 1987 and September 2002 from the Vaccine-Associated Adverse Event Surveillance (VAAES) Program, a passive national reporting system, were also reviewed. RESULTS: IMPACT identified 21 pediatric cases; 19 were Canadian-born, and 18 were FNI. Six disseminated BCG cases were identified; 5 were FNI infants who subsequently died. All had immunodeficiencies and concurrent infections. Other adverse events included 2 cases of osteomyelitis, BCG abscesses and lymphadenitis. ACCA reviewed the 21 cases and determined that 14 were very likely associated with the vaccine, including the 6 disseminated BCGs; 5 were probably associated and 1 was possibly associated with the vaccine; 1 was unclassifiable. The VAAES program identified 157 adverse events. No additional serious systemic adverse events (disseminated BCG or osteomyelitis) were identified. CONCLUSIONS: Serious BCG vaccine-associated complications continue to occur in Canada. The numbers of FNI children with disseminated disease was greater than expected from reported rates in the literature.

Adverse Drug Reaction Reporting Systems↗
PubMed2004

The metabolism of neuronal iron and its pathogenic role in neurological disease: review.

Neurons need iron, which is reflected in their expression of the transferrin receptor. The concurrent expression of the ferrous iron transporter, divalent metal transporter I (DMT1), in neurons suggests that the internalization of transferrin is followed by detachment of iron within recycling endosomes and transport into the cytosol via DMT1. To enable DMT1-mediated export of iron from the endosome to the cytosol, ferric iron must be reduced to its ferrous form, which could be mediated by a ferric reductase. The presence of nontransferrin-bound iron in brain extracellular fluids suggests that neurons can also take up iron in a transferrin-free form. Neurons are thought to be devoid of ferritin in many brain regions in which there is an association between iron accumulation and cellular damage, for example, neurons of the substantia nigra pars compacta. The general lack of ferritin together with the prevailing expression of the transferrin receptor indicates that iron acquired by activity of transferrin receptors is directed toward immediate use in relevant metabolic processes, is exported, or is incorporated into complexes other than ferritin. Iron has long been considered to play a significant role in exacerbating degradation processes in brain tissue subjected to acute damage and neurodegenerative disorders. In brain ischemia, the damaging role of iron may depend on the inhibition of detoxifying enzymes responsible for catalyzing the oxidation of ferrous iron. Brain ischemia may also lead to an increase in iron supply to neurons as transferrin receptor expression by brain capillary endothelial cells is increased. Pharmacological blockage of the transferrin receptor/DMT1-mediated uptake could be a target to prevent further iron uptake. In chronic neurodegenerative settings, a deleterious role of iron is suggested since cases of Alzheimer's disease, Parkinson's disease, and Huntington's disease have a significantly higher accumulation of iron in affected regions. Dopaminergic neurons are rich in neuromelanin, shown to be more redox-active in Parkinson's disease cases. Iron-containing inflammatory cells may, however, account for the main portion of iron present in neurodegenerative disorders. More knowledge about iron metabolism in normal and diseased neurons is warranted as this may identify pharmaceutical targets to improve neuronal iron management.

Animals↗
PubMed2000

A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding.

BACKGROUND: Human breastmilk provides complete nutrition for infants and helps protect against certain childhood diseases. Despite this, rates of initiation of breastfeeding in the UK remain low relative to other countries. In 'Our healthier nation' action report, the government has highlighted the promotion of breastfeeding in order to assist improvements in health and to reduce the health inequalities of mothers and children in the UK. OBJECTIVES: The primary aim of this systematic review was to evaluate existing evidence to identify which promotion programmes are effective at increasing the number of women who start to breastfeed. In addition, the review aimed to assess the impact of such programmes on the duration and/or exclusivity of breastfeeding and the intermediate and process outcomes. Where the strength and quality of the evidence permitted, the review aimed to identify implications for practice within the UK and priority areas for future research. METHODS DATA SOURCES: A range of electronic databases were searched from inception to November 1998, several relevant journals were hand-searched, and references of retrieved papers were examined. Relevant experts, organisations and lay groups were contacted to help identify further published or unpublished material. Additionally, an expert panel was consulted. SELECTION CRITERIA: Four types of criteria were used to select eligible studies for this review: STUDY DESIGN - randomised controlled trials (RCTs), non-RCTs with concurrent controls, and before-after studies (cohort or cross-sectional). PARTICIPANTS - pregnant women, mothers in the immediate postpartum period before the first breastfeed, any participant linked to pregnant women or new mothers, or any participant who may breastfeed in the future, or be linked to a breastfeeding woman in the future. INTERVENTIONS - any type of intervention designed to promote the uptake of breastfeeding was included; control groups could receive an alternative breastfeeding promotion programme or standard care. OUTCOMES - the primary outcome was initiation of breastfeeding; secondary outcomes (duration and exclusivity of breastfeeding) were included if initiation was reported in the same study; intermediate and process outcomes were also included, and need not necessarily be associated with reported initiation rates. DATA EXTRACTION AND VALIDITY ASSESSMENT: Data were extracted into structured tables. All included studies were checked against a comprehensive methodological checklist. Different checklists were used for RCTs, non-RCTs and before-after studies. Data extraction and validity assessment were independently checked by a second reviewer. DATA SYNTHESIS: The studies were grouped according to intervention type, and were combined using a narrative synthesis. For individual RCTs and non-RCTs reporting initiation of breastfeeding, relative risks with associated 95% confidence intervals were estimated, with calculations performed on an intention-to-treat basis where possible. Pooling of relative risks was considered inappropriate owing to the lack of similarity across the studies. RESULTS: A total of 59 studies met the selection criteria, comprising 14 RCTs, 16 non-RCTs and 29 before-after studies. Interventions were grouped into the following categories: health education, health sector initiatives (HSI) - general, HSI - Baby Friendly Hospital Initiative (BFHI), HSI - training of health professionals, HSI - US Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), HSI - social support from health professionals, peer support, media campaigns, multifaceted interventions. In many cases, studies were dissimilar in terms of the type of intervention(s), participants and the definitions of outcomes. Methodological problems of some studies also limited interpretation of findings. (ABSTRACT TRUNCATED)

Breast Feeding↗
PubMed1998

Methodological challenges to prospective study of an innovation: interregional nursing care management of cardiovascular patients.

This paper discusses the methodological challenges of conducting an interregional intersystem study in a highly competitive health care environment. Nurses from a three-hospital rural health consortium and an urban tertiary medical centre collaborated in a two-phase study (a) to describe current interregional cardiovascular health care process (phase I) and (b) to test an interregional nurse-coordinated cardiovascular health care model (phase II). Phase I was a 1-year exploratory descriptive retrospective study involving patient interviews and chart reviews. Findings from the phase I study suggested a pattern of patient health problems occurring weeks and months following successful tertiary centre interventions. Phase II was a quasi-experimental prospective study with 90 intervention subjects and 64 comparison group subjects who completed pencil and paper survey tools over a 12-month period following discharge from the tertiary centre. Nurse and doctor providers completed a satisfaction survey twice, at an interval of 1 year. Concurrent data collection via telephone calls (comparison group) and a retrospective record review (intervention group) provided data on cost, resource use and system efficiency. Initial results of phase II are presented, together with tests of significance for hypotheses related to interregional nurse care management and patient outcomes, patient satisfaction, cost/system efficiency, and provider satisfaction. Methodological considerations and recommendations related to phases I and II of this interregional collaborative cardiovascular project are presented and discussed.

Adult↗
PubMed1995

The use of placebos in clinical trials for acute schizophrenia.

This review examines the scientific and ethical justification for the use of randomized concurrent placebo-controlled trials in the treatment of acute relapse in chronic schizophrenia. A literature search was conducted, and the national regulatory authority was consulted. Many placebo-controlled studies of acute or chronic schizophrenia are being published and it is the official position of both the Canadian and US regulatory authorities that such studies are required for both scientific and ethical reasons. The specific strengths and limitations of placebo-controlled studies are reviewed. Examples, drawn from Canadian studies, are presented to illustrate their benefits. It is concluded that the use of placebos in the particular situation of acute or chronic schizophrenia is ethically and scientifically justified. It forms an essential component of a comprehensive drug evaluation for new antipsychotic medications.

Acute Disease↗
PubMed2004

Adjuvant radiotherapy with and without concurrent chemotherapy for locally advanced transitional cell carcinoma of the renal pelvis and ureter.

PURPOSE: Transitional cell carcinoma of the upper urinary tract is a relatively uncommon malignancy. The role of adjuvant radiation therapy and chemotherapy is not well defined. We retrospectively reviewed the records of 31 patients who underwent surgery followed by adjuvant radiotherapy with or without concurrent chemotherapy to determine overall outcome as well as impact of concurrent chemotherapy administration. MATERIALS AND METHODS: Between 1970 and 1997, 31 patients with nonmetastatic transitional cell carcinoma of the upper urinary tract (renal pelvis in 13, ureter in 15, and renal pelvis and ureter in 3) were treated with radiotherapy following attempted curative resection. Most patients (28 of 31) had T3/4 and/or N+ disease. The median radiation dose was 46.9 Gy. Nine patients received methotrexate, cisplatin and vinblastine chemotherapy for 2 to 4 cycles, followed by concurrent cisplatin with radiation. RESULTS: Median followup was 2.6 years in all patients and 8.5 years in survivors. Median survival in all patients was 2.4 years. Of the patients 16 (52%) experienced disease relapse, including 9 (29%) with distant metastases alone. Seven patients (23%) experienced locoregional failure with distant metastases developing in all except 1 within 8 months of locoregional failure diagnosis. Five-year actuarial overall survival, disease specific survival, locoregional control and metastasis-free survival rates were 39%, 52%, 67% and 48%, respectively. On univariate analysis patients had improved 5-year actuarial overall and disease specific survival with the administration of concurrent chemotherapy (27% vs 67%, p = 0.01 and 41% vs 76%, p = 0.06, respectively). CONCLUSIONS: Our series suggests that the addition of concurrent cisplatin to adjuvant radiotherapy improves the ultimate outcome in patients with resected, locally advanced upper tract urothelial malignancies. This regimen should be considered in patients with T3/4 and/or node positive upper tract transitional cell carcinoma.

Actuarial Analysis↗
PubMed1995

Dosage of gadoteridol and adverse reactions relative to gadopentetate.

Compliance with an institution's dosage guidelines for gadoteridol was determined, and adverse reactions to gadoteridol and gadopentetate were compared. Departmental policy in March 1993 set the standard dose of gadoteridol at 0.1 mmol/kg. A dose of 0.05 mmol/kg was set for patients with suspected acoustic neurinomas or pituitary microadenomas. Guidelines allowing a high dose of 0.2 or 0.3 mmol/kg were also established for specific indications involving suspected metastatic disease or inadequate contrast enhancement at the standard dose. Data on gadoteridol use were collected concurrently from May 1993 to January 1994 and included the dose, the indication for the dose, and any adverse reactions. Safety data for patients who had received gadopentetate between June 1988 and March 1990 were also collected and reviewed. The subjects in this retrospective analysis represented the same broad population as those involved in the concurrent evaluation of gadoteridol use. The frequency and types of adverse events in the two groups were compared. During the gadoteridol-review period, 8377 patients underwent magnetic resonance imaging studies; 3558 (42.5%) of them received gadoteridol. Of the 3558 doses given, 3375 (94.9%) were 0.1 mmol/kg (the standard dose). Compliance with the guidelines for nonstandard doses was 90% for the 0.3-mmol/kg dose, 74% for the 0.2-mmol/kg dose, and 39% for the 0.05-mmol/kg dose. There were 101 adverse reactions to gadoteridol in 75 (2.1%) of the 3558 recipients. The reactions were mild to moderate and self-limiting. Records for 4892 gadopentetate recipients were analyzed. There were adverse reactions in 62 patients (1.3%). Again, most reactions were mild to moderate. The use of gadoteridol at a medical center generally complied with institutional guidelines. Gadoteridol was well tolerated whether given in standard or high doses. The frequencies and types of adverse reactions to gadoteridol and gadopentetate were similar.

Contrast Media↗
PubMed2001

[Structural and functional aspects of the human saphenous vein used as aorto-coronary graft in myocardial revascularization].

The human saphenous vein (HSV) is currently used as a graft in coronary revascularization as well as in some other vascular beds, namely those of the inferior limbs. Since a significant proportion of HSV grafts develop stenosis, many studies have focused on the factors that could promote graft failure. This article reviews the results on structural and functional features that might be concurrent in the production of saphenous vein graft stenosis. The reactivity of HSV to several physiological agonists is analyzed, including those derived from the endothelium with contractile or relaxing properties, since these are relevant inducers of graft spasm and/or modifiers of the expression of graft factors involved in either tissue growth or thrombotic-atherosclerotic processes. Mechanisms that regulate vascular smooth muscle contractile state, in particular the activity of K+ channels of the plasma membrane, are described.

Coronary Artery Bypass↗
PubMed2002

Many faces of the minimal clinically important difference (MCID): a literature review and directions for future research.

The minimal clinically important difference (MCID) for an instrument is a much sought after, but elusive figure. In this review we will highlight new findings in this area, including taxonomy of MCID, methods used to ascertain MCID, the perspective taken for evaluating importance, and other sources of variation for MCID values. In the end we believe the MCID will be a context-specific value rather than a fixed number. The review highlights the need to do methodological research in this area, especially concurrent comparisons between approaches, or across different patient groups. There are many faces to the MCID, it is not a simple concept, nor simple to calculate.

Clinical Medicine↗
PubMed1994

Retroperitoneal plexiform neurofibromas: CT findings.

OBJECTIVE: CT findings in retroperitoneal plexiform neurofibromas have been described previously only in a few case reports. This study was performed to characterize the CT features in a larger group of patients with this benign neoplasm and to delineate those findings that suggest the presence of concurrent malignant tumors of the nerve sheath. MATERIALS AND METHODS: From a review of CT scans showing retroperitoneal masses in 25 patients with neurofibromatosis type 1, we identified 16 patients whose clinical and CT features suggested the diagnosis of plexiform neurofibromas. The diagnosis was confirmed by biopsy of the mass in three patients. In the remaining 13 patients, the diagnosis was supported by long-term follow-up in eight and by biopsy confirmation of either a neurofibroma or a plexiform neurofibroma elsewhere in the body in the other five patients. Concurrent retroperitoneal malignant tumors of the nerve sheath were confirmed by biopsy in five patients. RESULTS: CT showed bilateral, remarkably symmetric masses extending along the medial and posterior aspects of the psoas muscles in 15 of the 16 patients. Parapsoas masses tended to be long and cylindrical. In addition to parapsoas masses, eight patients had bilateral, symmetric masses extending along the anterior aspect of the sacrum in a sheetlike fashion. Masses were identified in the region of the celiac axis and the origin of the superior mesenteric artery in four patients. Only one patient had an isolated celiac/superior mesenteric artery mass without associated parapsoas or presacral masses. Retroperitoneal masses were of homogeneous, low attenuation when compared with adjacent muscle on CT images of 14 patients. Two patients had an unusual swirling and serpiginous pattern of increased attenuation superimposed on a low-attenuation background. Asymmetry in size and attenuation was due to malignant nerve sheath tumors in five patients. CONCLUSION: Retroperitoneal plexiform neurofibromas have a characteristic appearance on CT scans. They are typically bilateral, symmetric, low-attenuation masses in a parapsoas or presacral location. Asymmetry in size and attenuation of a larger mass suggests the possibility of a malignant tumor of the nerve sheath. Recognition of the CT features of a retroperitoneal plexiform neurofibroma can obviate the expense, pain, and risk of an unnecessary biopsy. Conversely, detection of findings suggestive of malignant tumor can lead to appropriate recommendation of biopsy.

Adult↗
PubMed1994

Improved renal function following aggressive treatment of urolithiasis and concurrent mild to moderate renal insufficiency.

To our knowledge the prevalence of urinary stone disease and concurrent mild to moderate renal insufficiency has never been reported. A review of our last 2,000 urinary stone patients identified 33 (1.65%) with serum creatinine levels of 2.0 mg./dl. or greater at presentation. Chemical composition, location and complexity of the calculi, types of procedures required to render the patient stone-free and the effect of surgical intervention (independent of relief of obstruction) on renal function were evaluated. Mean serum creatinine level before surgical intervention and after placement of a ureteral stent or percutaneous nephrostomy tube in patients with evidence of obstruction was 3.2 mg./dl. (range 2.0 to 7.5). Complete or partial staghorn calculi were found in 21 of the 33 patients (64%), including 8 with bilateral staghorn calculi. Seven patients required 1 procedure, 1 required urinary alkalization alone and the other 25 required an average of 3.5 procedures each. Stone analysis revealed struvite, mixed calcium and uric acid to be the most common types. Followup creatinine values (the latest available within 1 year) and corresponding creatinine clearances showed remarkable improvement. The mean decrease in serum creatinine level was 1.2 mg./dl. (p < 0.001). There was no statistically significant difference in the rate of decrease between patients with pretreatment serum creatinine levels of 2.0 to 2.9 mg./dl. and those with initial values of 3.0 or more. Renal calculi and concurrent mild to moderate renal insufficiency warrant aggressive treatment. Patients demonstrate significant improvement in renal function independent of relief of obstruction.

Adult↗
PubMed2001

A systematic review of antistreptococcal interventions for guttate and chronic plaque psoriasis.

BACKGROUND: Guttate psoriasis is closely associated with preceding or concurrent streptococcal infection. Some authorities have claimed that chronic plaque psoriasis may also be made worse by infection. In view of this many dermatologists have recommended using antibiotics for psoriasis, particularly guttate type. Some dermatologists have also recommended tonsillectomy for psoriasis in patients with recurrent streptococcal pharyngitis. OBJECTIVES: This review aims to assess the evidence for the effectiveness of antistreptococcal interventions, including antibiotics and tonsillectomy in the management of acute guttate and chronic plaque psoriasis. METHODS: Studies were identified by searching the Cochrane Clinical Trials Register (Cochrane Library, Issue 3, 1999), Medline (1966-September 1999), Embase (1988-September 1999), the Salford Database of Psoriasis Trials (to November 1999) and the European Dermato-Epidemiology Network (EDEN) Psoriasis Trials Database (to November 1999) for terms (STREPTOCOCC* or ANTIBIOTIC* or TONSIL*) and PSORIASIS using the Cochrane Skin Group search strategy. RESULTS: Only one trial met the selection criteria. This compared the use of two oral antibiotic schedules in 20 psoriasis patients, predominantly of guttate type, who had evidence of beta-haemolytic streptococcal colonization. Either rifampicin or placebo was added to the end of a standard course of phenoxymethylpenicillin or erythromycin. No patient in either arm of the study improved during the observation period. No randomized trials of tonsillectomy for psoriasis were identified. CONCLUSIONS: Although both antibiotics and tonsillectomy have frequently been advocated both for patients with guttate psoriasis and for selected patients with chronic plaque psoriasis, there is to date no good evidence that either intervention is beneficial.

Anti-Bacterial Agents↗
PubMed2003

Managing the comorbidities of postherpetic neuralgia.

PURPOSE: To discuss the impact of pain and its associated comorbidities in elderly patients with postherpetic neuralgia (PHN). To review the pharmacologic treatments available for patients with chronic pain and concurrent sleep disturbance, depression, and/or anxiety. DATA SOURCES: Relevant clinical literature pertaining to the management of common comorbid conditions in patients with PHN and chronic pain syndromes. CONCLUSIONS: Chronic pain strongly influences physical and psychological function in elderly patients. Comorbid illnesses, such as insomnia, depression, or anxiety, often develop in patients with chronic pain and complicate overall pain management and worsen prognosis. Pharmacologic treatment strategies that reduce pain frequently result in concurrent improvements in common pain-associated comorbidities. Pharmacologic treatment should be selected based on the efficacy of the selected agent(s), potential for adverse effects, and impact on pain-associated comorbidity. A multidisciplinary pain care management approach is essential to alleviate pain, manage pain-associated comorbidities, and improve function and quality of life. IMPLICATIONS FOR PRACTICE: Elderly patients who often deny their chronic pain are at increased risk for such conditions as sleep disturbance, depression, and/or anxiety. Nurses and nurse practitioners are in a unique position to improve pain care management by recognizing pain and its associated comorbidities early, educating patients regarding their perception of pain, and facilitating rational pharmacotherapy with the goal to improve function and quality of life.

Aged↗