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At least 1,207 records · Page 67Linked to original sources
PubMed1995

Conservative treatment of overanticoagulated patients.

STUDY OBJECTIVE: To determine the outcome of over-anticoagulated patients who were treated with vitamin K and those who were treated conservatively by holding doses and increasing monitoring frequency. A secondary objective was to compare conservative management with American College of Chest Physicians (ACCP) treatment guidelines when followed. DESIGN: Retrospective chart review of all patients with international normalized ratios (INRs) of 6 or greater and concurrently receiving warfarin between November 1993 and February 1994. SETTING: A Veterans Affairs Medical Center providing inpatient and outpatient care. Patients receiving warfarin are managed by an established anticoagulation clinic. PATIENTS: Fifty-one consecutive patients receiving warfarin who had an INR of 6 or greater were reviewed. INTERVENTIONS: Data collection included INR, risks for bleeding, indication for anticoagulation, interventions, and patient outcomes. RESULTS: INRs ranged from 6.1 to 81.8. Forty-eight patients (94%) did not receive vitamin K; they were treated by withholding doses and increasing monitoring frequency. One developed minor bleeding. Three patients (6%) received vitamin K. Two of these patients died of unrelated problems. The third patient required 47 days of heparin therapy prior to achieving therapeutic oral anticoagulation. CONCLUSION: This trial showed that conservative treatment of nonbleeding overanticoagulated patients is safe. A prospective trial comparing the ACCP guidelines with a conservative approach is needed.

Administration, Oral↗
PubMed2003

Stereotactic radiosurgery in the management of intracranial gliomas.

Glial neoplasms are the most common primary intracranial malignancies. Treatment of high-grade gliomas has been frustrating, with less than 5% of patients surviving 5 years after a diagnosis of glioblastoma multiforme (GBM). Stereotactic radiosurgery (SRS) and fractionated strereotactic radiotherapy (F-SRT) provide means to either escalate the dose in primary treatment or to palliate recurrences. Because of their lower alpha/beta ratios and more focal nature, low-grade gliomas (LGG) are more attractive targets for stereotactically focused radiation. Results of available phase I-II data are reviewed for both low and high-grade gliomas. In the case of high-grade gliomas disappointing preliminary phase III data from RTOG 93-05 are discussed. Toxicity of SRS is discussed. Acute treatment toxicity of significance is unusual and generally self-limited. Occasionally an exacerbation of existing symptoms occurs. Late complications attributable to SRS are usually defined as necrosis within the treatment volume. The rate of necrosis can be hard to define in high-grade gliomas as tumor cells are often present in surgical specimens. New strategies in the application of stereotactic radiation are touched upon, these include: changes in planning and fractionation, concurrent use of chemotherapy, use of radiation modifiers and biologic agents. After reviewing the current data for high-grade gliomas, it appears that any apparent improvement in outcome seen in phase I-II trials is attributable to patient selection. The best evidence available does not support the use of SRS for primary high-grade gliomas. The somewhat limited experience in LGG also indicates a lack of benefit for patients treated with stereotactic radiosurgery or F-SRT. For a very select group of patients with small recurrent lesions, F-SRT may represent a safe, reasonable treatment.

Astrocytoma↗
PubMed1999

Radiosensitization of advanced squamous cell carcinoma of the head and neck with cisplatin during concomitant radiation therapy.

Treatment regimens for advanced squamous cell carcinoma of the head and neck require both attention to local tumor burden as well as contingencies for control of disseminated disease. Relatively new protocols utilizing cisplatin for radiosensitization of tumor cells during concomitant radiotherapy have shown progress in providing effective tumor control. Cisplatin as a chemotherapeutic agent induces DNA changes in malignant cells that may be mutagenic or lethal. Additionally, when used concurrently with radiation therapy, cisplatin acts as a radiosensitizer, increasing damage to malignant nuclear DNA to enhance the anti-neoplastic capability of radiotherapy. The mechanisms by which this radiosensitization occurs remain controversial, although one leading theory involves cisplatin's ability to inhibit sublethal damage repair in radiated tumor cells. Recent investigations utilizing cisplatin with concurrent radiation for treatment of advanced squamous cell carcinomas of the head and neck are reviewed. The variations in protocols presented include route of administration, dosing, scheduling, timing with surgery, and combination therapy with 5-fluorouracil and radiation. Higher response rates, prolonged mean survival, increased survival rates, longer local recurrence-free survival rates, and considerable organ preservation with the use of concurrent cisplatin and radiation have been demonstrated by these studies. Further investigation of concurrent cisplatin and radiotherapy in patients with advanced disease is justified.

Carcinoma, Squamous Cell↗
PubMed2001

A history and review of quantitative electroencephalography in traumatic brain injury.

The electroencephalogram (EEG) is a physiologic measure of cerebral function that has been used by some to assess coma and prognosticate survival and global outcome after traumatic brain injury (TBI). Surface recordings of the brain's electrical activity reveal distinct patterns that indicate injury severity, depth of unconsciousness, and patient survival. The data produced with traditional qualitative studies, however, does not allow resolution and quantification of the wave frequency spectrum present in the brain. As a result, conventional EEG typically has only been used for gross and qualitative analyses and is not practical for use in long-term patient monitoring or as a sophisticated prognostic tool. One area of investigation that is working to address the limitations of conventional EEG has been the development and implementation of Fourier Transform (FT) EEG which resolves and quantifies frequency bands present in the brain. When FT analysis is applied to EEG, it provides concurrent and continuous monitoring, resolution, and quantification of all frequencies emitted. This review discusses the history and significance of conventional EEG and provides a review of how FT-EEG, commonly referred to as Quantitative EEG (QEEG), is being used in the clinical setting. The specific applications and significance of QEEG methods regarding treatment of patients with TBI are discussed in detail. The advantages, disadvantages, and future directions of QEEG in TBI are also discussed.

Brain Injuries↗
PubMed1994

Carotid artery stenosis. Selecting candidates for surgical management.

Many patients with significant carotid artery stenosis are candidates for endarterectomy, a procedure now proved to reduce the incidence of future stroke and death. In this article, Drs Jaigobin and Perry describe an approach to patients with both symptomatic and asymptomatic carotid stenosis and review current indications for surgical referral. They also emphasize the importance of recognizing and managing concurrent coronary artery disease.

Carotid Stenosis↗
PubMed1997

Combined topical calcipotriene ointment 0.005% and various systemic therapies in the treatment of plaque-type psoriasis vulgaris: review of the literature and results of a survey sent to 100 dermatologists.

BACKGROUND: Plaque-type psoriasis may at times require systemic therapy. There are limited data as to whether topical calcipotriene ointment 0.005% can be used to increase the efficacy and improve the risk/benefit ratio of concurrent systemic antipsoriatic therapy. OBJECTIVE: We attempt to answer this question by means of a literature review and results of a written survey that was sent to 100 international psoriasis treatment experts. METHODS: The survey was sent to academic and psoriasis treatment center-based dermatologists who treat approximately 3000 to 4000 patients with psoriasis per month. The survey requested that dermatologists relate their experience regarding the safety and efficacy of topical, systemic, and combined topical/systemic agents in psoriasis after 8 weeks of therapy. RESULTS: The results of the survey support the experience in the literature regarding the favorable use of calcipotriene ointment combined with systemic therapy for the treatment of psoriasis. CONCLUSION: Combination therapy with calcipotriene ointment and acitretin/etretinate, cyclosporine, methotrexate, or phototherapy usually enhances efficacy while improving the risk/benefit ratio by decreasing exposure to the potentially hazardous systemic agent.

Acitretin↗
PubMed1996

MDR1 reversal: criteria for clinical trials designed to overcome the multidrug resistance phenotype.

Multidrug resistance (MDR) is a widely studied mechanism of cellular resistance to structurally unrelated cytotoxic agents. The MDR phenotype is related to the overexpression of the MDR1 gene product, P-glycoprotein (P-gp), a transmembrane drug efflux pump. The capacity to compete with the cytotoxic drug for the active outward transport process, thus inhibiting the activity of the P-gp pump, has been demonstrated for numerous non-cytotoxic compounds, termed MDR modulators. The possibility of modulating the activity of the P-gp pump has initiated numerous clinical trials, using a wide range of chemosensitizers. This article reviews these substances, discusses problems that may arise in connection with the concurrent administration of P-gp modulators and chemotherapeutic agents and provides guidelines for the design of future clinical trials. Furthermore, now data are presented concerning the potential of idarubicin to overcome the MDR phenotype.

ATP Binding Cassette Transporter, Subfamily B, Mem↗
PubMedDate not supplied

Combined modality treatment for esophageal cancer.

This paper describes the mechanisms of action of ionizing radiations combined with antineoplastic drugs. Some relevant drugs for the combined modality treatments of locally advanced lung cancer are reported. The meta-analyses including randomized trials comparing single agent (radiotherapy or chemotherapy) versus combined chemotherapy and radiotherapy in patients with unresectable non small cell lung cancer and limited small cell lung cancer are then reviewed. The clinical outcome in relation to different schedules of chemoradiotherapy (sequential, alternating and concurrent) is also focussed.

Chemotherapy, Adjuvant↗
PubMed2004

A retrospective analysis of quetiapine in the treatment of pervasive developmental disorders.

BACKGROUND: The purpose of this study was to examine the effectiveness and tolerability of quetiapine for aggression, hyperactivity, and self-injury in pervasive developmental disorders (PDDs). METHOD: The medical records of all patients with PDDs diagnosed according to DSM-IV criteria and treated with quetiapine were retrospectively reviewed. Patients who received quetiapine for at least 4 weeks and who were not concurrently treated with another antipsychotic or mood stabilizer were included. Improvement was measured with the Clinical Global Impressions-Improvement scale (CGI-I), with response determined by ratings of "much improved" or "very much improved." Data were collected from May 15, 2003 through November 30, 2003. RESULTS: Of 857 records reviewed, 20 patients (16 male, 4 female) (mean +/- SD age = 12.1 +/- 6.7 years; range, 5-28 years) received a quetiapine trial (mean +/- SD dosage = 248.7 +/- 198.4 mg/day; range, 25-600 mg/day) over a mean duration of 59.8 +/- 55.1 weeks (range, 4-180 weeks). Eight (40%) of 20 patients were judged "responders" to quetiapine; the mean CGI-I score for the entire group was 3.0 +/- 1.1 (minimally improved). A statistically significant improvement (p = .002) was found between a mean pretrial CGI-Severity of Illness scale (CGI-S) score of 5.1 +/- 0.6 (markedly ill) and a posttrial CGI-S score of 4.2 +/- 1.1 (moderately ill). Adverse effects occurred in 50% (N = 10) of patients and led to drug discontinuation in 15% (N = 3) of patients. CONCLUSION: Quetiapine was modestly effective for maladaptive behavior in patients with a PDD. Controlled studies are needed to further assess these preliminary findings.

Adolescent↗
PubMed2002

Complications in surgical patients.

HYPOTHESIS: Complications are common in hospitalized surgical patients. Provider error contributes to a significant proportion of these complications. DESIGN: Surgical patients were concurrently observed for the development of explicit complications. All complications were reviewed by the attending surgeon and other members of the service and evaluated for the severity of sequelae (major or minor) and for whether the complication resulted from medical error (avoidable) or not. SETTING: University teaching hospital with a level I trauma designation. PATIENTS: All inpatients (operative or nonoperative) from 4 different surgical services: general surgery, combined general surgery and trauma, vascular surgery, and cardiothoracic surgery. MAIN OUTCOME MEASURES: Total complication rate (number of complications divided by the number of patients) and the number of patients with complications. Complications were separated into those with major or minor sequelae and the proportion of each type that were due to medical error (avoidable). Rates of complications in a recent Institute of Medicine report were used as a criterion standard. RESULTS: The data for the respective groups (general surgery, vascular surgery, combined general surgery and trauma, and cardiothoracic surgery) are as follows. The number of patients was 1363, 978, 914, and 1403; number of complications, 413, 409, 295, and 378; total complication rate, 30.3%, 42.4%, 32.3%, and 26.9%; minor complication rate, 13.3%, 19.9%, 13.5%, and 13.0% (percentage of minor complications that were avoidable, 37.4%, 59.0%, 51.2%, and 49.5%); major complication rate, 16.2%, 21.1%, 18.1%, and 12.9% (percentage of major complications that were avoidable, 53.4%, 60.7%, 38.8%, and 38.7%); and mortality rate, 1.83%, 3.33%, 2.28%, and 3.34% (percentage of mortality that was avoidable, 28.0%, 44.1%, 19.0%, and 25.0%). CONCLUSIONS: Despite mortality rates that compare favorably with national benchmarks, a prospective examination of surgical patients reveals complication rates that are 2 to 4 times higher than those identified in an Institute of Medicine report. Almost half of these adverse events were judged contemporaneously by peers to be due to provider error (avoidable). Errors in care contributed to 38 (30%) of 128 deaths. Recognition that provider error contributes significantly to adverse events presents significant opportunities for improving patient outcomes.

Cardiac Surgical Procedures↗
PubMed1992

Measuring and managing quality of surgery. Statistical vs incidental approaches.

New rules for quality assurance provoked a comparison of effects of two approaches used concurrently for 14 years. In an incidental approach, a multidisciplinary conference reviewed all postoperative complications as they occurred and attributed each to one of six causes. Remedies were instituted and data were filed. In a statistical approach, death and complication rates were computed annually and compared with previous years' rates and with rates reported to Congress as national norms. Statistics suggested acceptable quality in each specialty but calculations were tedious and differences achieved significance too rarely or too slowly to identify problems, protect patients, and improve care. The incidental approach was popular and produced immediate improvements in patient care. Conferees attributed one half of complications to errors. Frequent acknowledgment of susceptibility to error may contribute to the safety and quality shown by our statistics.

Humans↗
PubMed1996

Atypical squamous cells of undetermined significance qualified: a follow-up study.

The Bethesda System recommends that the diagnosis of "atypical squamous cells of undetermined significance" (ASCUS) be qualified when possible to indicate whether a reactive process, or a squamous intraepithelial lesion (SIL), is favored. In order to evaluate the utility of this recommendation, 308 cervicovaginal smears diagnosed as ASCUS favoring a reactive (FR) or dysplastic (FD) process were identified. Concurrent or follow-up biopsies and cervicovaginal smear results were reviewed and compared to the follow-up of 103 cervicovaginal smears diagnosed as ASCUS without qualification. A follow-up diagnosis of SIL was found in 46.5%, 29.5% and 26.2% of the ASCUS FD, ASCUS FR, and ASCUS unqualified cases, respectively. A repeated ASCUS diagnosis was found in 20.4%, 21.8%, and 18.4% of the ASCUS FD, ASCUS FR, and ASCUS unqualified cases, respectively. Follow-up of each group was negative for dysplasia in 30.0%, 48.7%, and 54.4% of the ASCUS FD, ASCUS FR, and ASCUS unqualified cases, respectively. These results support the use of an ASCUS FD category for the increased detection of patients with dysplasia. The ASCUS FR category was not helpful in our laboratory. Follow-up studies of qualified ASCUS cases in individual practice settings may be useful in guiding patient management.

Carcinoma, Squamous Cell↗
PubMed1998

Anesthetic considerations for hepatic cryotherapy.

The evolution of hepatic cryotherapy as an accepted treatment for patients with non-resectable hepatic malignancy has required concurrent evaluation and development of perioperative anesthetic management of these cases. Review of published and institutional experience demonstrates that hepatic cryotherapy presents the anesthesiologist with an array of challenges, all of which are not intuitively apparent. Specifically, such issues as management of coexisting physiologic perturbations of the oncology patient, heat conservation during the procedure, and readiness for a more extensive procedure would be readily anticipated by most clinicians. Description and reasonable management of problems ranging from mild or moderate postoperative thrombocytopenia to the so-called cryoshock syndrome with the possibility of severe postoperative coagulopathy, renal dysfunction, and pulmonary complications, however, could emerge only with the education of experience. The goal of this article is to address the key issues faced by anesthesiologists consulted in the perioperative care of patients undergoing hepatic cryotherapy.

Anesthesia, Inhalation↗
PubMed2003

Concurrence of fragile X syndrome and 47, XYY in an individual with a Prader-Willi-like phenotype.

We report on a 34-year-old developmentally disabled man referred to our clinic for evaluation of possible Prader-Willi syndrome on the basis of obesity and voracious appetite. Cytogenetic and molecular analysis revealed a 47, XYY karyotype and the presence of a trinucleotide repeat expansion resulting in fragile X syndrome. To our knowledge, this is the first report of concurrence of XYY and fragile X syndrome in the medical literature. Review of sex chromosome abnormalities associated with fragile X syndrome and phenotypic considerations are presented.

Abnormalities, Multiple↗
PubMed1994

Subperiosteal hematoma of the orbit associated with subfrontal extradural hematoma: case report.

A patient admitted to hospital with a painful proptosis, diminished visual acuity, and mental status changes was proven to have a large left subfrontal epidural hematoma and an associated subperiosteal orbital hematoma. Surgical intervention resulted in complete recovery of neurologic function and visual acuity. This case demonstrates the unique and previously unreported concurrent diagnosis of epidural and subperiosteal orbital hematoma. The literature is reviewed and surgical management is discussed.

Adult↗
PubMed1993

Use of mathematical models for understanding the dynamics of gene amplification.

Recently it has been suggested that high levels of cancer drug resistance and poor prognosis are strongly associated with gene or oncogene amplification (GA). It has been further suggested that the molecular mechanisms underlying GA may be different for different genes, and that different amplification mechanisms may function concurrently or sequentially in the same gene. The aim of this review is to demonstrate the use of mathematical models in studying these intricate dynamics. We have provided mathematical models for the generation of extrachromosomal elements, their autonomous replication and equal or unequal mitotic segregation, the integration of the extrachromosomal elements within the chromosomes, and chromosomal GA in one or many unlinked genes. Using this formal description one can examine the potential role of each GA mechanism in the generation of specific distributions of gene-copy number in a cell population, under various levels of selection stringency. Thus one can specify the conditions for the emergence of drug-resistant mutants prior to selection, as well as the relationships between the stringency of the selecting environment and the characteristics of the resultant cellular phenotype.

Animals↗
PubMed2006

Duplex ultrasound scanning is reliable in the detection of endoleak following endovascular aneurysm repair.

OBJECTIVE: To investigate the value of duplex ultrasound scanning (DUSS) in the routine follow up of patients following EVAR. METHODS: Imaging was reviewed for 310 consecutive patients undergoing EVAR at a single centre. Concurrent ultrasound and CT scans were defined as having occurred within 6 months of each other. There were 244 paired concurrent DUSS and CT scans which were used for further analysis. These modalities were compared with respect to sensitivity, specificity, positive and negative predictive values and level of agreement (by Kappa statistics) using CT as the 'gold standard'. RESULTS: DUSS failed to detect a number of endoleaks which were seen on CT and the sensitivity of this test was therefore poor (67%). However, the specificity of DUSS compared more favourably with a value of 91%. Positive predictive values ranged from 33-100% but negative predictive values were more reliable with values of 91-100% at all time points post operatively. There were no type I leaks, or endoleaks requiring intervention which were missed on DUSS. Overall, there was a 'fair' level of agreement between the two imaging modalities using Kappa statistics. CONCLUSION: Although DUSS is not as sensitive as CT scanning in the detection of endoleak, no leaks requiring intervention were missed on DUSS in this study. DUSS is much cheaper than CT and avoids high doses of radiation. DUSS therefore remains a valuable method of follow up after EVAR and can reduce the need for repeated CT scans.

Aneurysm↗