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[Spontaneous peripelvic urine extravasation associated with ileocecal cancer: a case report].

A case of spontaneous peripelvic extravasation with ileocecal cancer is reported. A 60-year-old man with right flank pain was referred to our department. Dripinfusion pyelography showed right peripelvic extravasation. Neither computed tomography (CT) nor retrograde pyelography revealed any ureteral stones or tumors. Urinary cytology was negative. One month later, right retrograde pyelography demonstrated the filling defect in the right ureter, but no stones, ureteral tumors or other tumors related to the ureter were detected by CT. An exploratory laparotomy was done. We found an ileocecal tumor invading to the right ureter and disseminated to the peritoneum. Histological diagnosis was mucinous carcinoma.

Adenocarcinoma, Mucinous↗

[Clinical study of antalgic drugs].

The assessment of the clinical properties of analgesics is not easy. Some of the difficulties are due to the multiplicity of the aetiologies involved in the pain process, to the complexity of pathophysiological mechanisms modulating the nociception and to the subjectivity of painful sensation. All of these explain the fairly high variability of the criteria available for assessing pain level or pain relief. As a consequence, that variability directly interferes with the pharmacological effect of analgesics to be assessed in clinical trials. Furthermore, the lack of consensus concerning the evaluation criteria does not facilitate the choice of a study design or the comparison of data collected from different clinical trials. Clinicians have to choose between testing the analgesics in healthy volunteers (experimental pain) or in patients suffering from painful disease (spontaneous pain). These two approaches are often complementary for assessing the pharmacological profile of new analgesic compounds. Whatever the choice, the investigators have to pay attention to the methodological aspects to avoid pitfalls and bias in this difficult field of therapeutic research.

Analgesics↗

[To go along with life until death].

We are faced with difficult and complex questions that cannot be answered by stating great principles or ideological convictions, because they refer to painful situations, always singular, in which each individual, in a unique way, faces his life and his death. But the debate can draw on shared convictions and values. Thus, before being a way of assuming death, the Christian faith is fundamentally a way of welcoming the life, in all times and in its fullness, that Christ has given us. The whole Bible and in particular the ministry of Jesus bear witness to that fight for life, against the scandal of suffering and the powers of death that are a denial of the good work of God. Suffering is never, as such, acceptable or justifiable, and truth is never to surrender to it, as if it was a meaningful destiny. And so all suffering that can be avoided must be so. Regarding death, it is often held back in the margins of our lives and societies, as if it was a sort of setback for our human abilities and especially for medicine. Of course those abilities exist but death is not an illness. It's the natural mark of our human finiteness and there is a time when caring is not intended to cure, but to make up for life that defaults, alleviate suffering. That is why what is called to-day palliative caring is so important. Because even when medicine is powerless in front of illness, it can still do something for the sick. Because of all that, the believer can only be opposed to euthanasia which is, after all, only the exact replica of the useless prolongation of life by medical means it pretends to oppose. It's the same activism, the same pretense, the Bible fights, through which human beings want to remain the masters of life and death. But death is not given, except in deathly violence. As life, it is welcomed and is accompanied. The end of a life is still life. To die is to the live to one's last breath. And that questions the claim to die "with dignity" when life can no more be lived in a "dignified way". But what "dignity" are we talking about? To-day, do we not mistake it with the image of the modern individual, master of himself and a match for the world, assured of his physical strength and of his conscientiousness enabling him to consent. As if the image of dignity was always the same, at every age, for all types of illness or simply of existence. When that image of dignity gets shaky, one discovers sorts of dignity that do not answer those criteria, but that testify that any "body" can be a subject, and that we know nothing about it. Lastly, no law or moral authority, be they lax or restrictive, can suppress compassion, nor the ethical responsibility of the patient, of the doctors, of the family circle. None can take the place of the common requirement: go along with life up to death.

Attitude to Death↗

Coronary sinus plasma beta endorphin levels in cardioischemic patients undergoing PTCA.

Plasma beta-endorphin levels were studied in the coronary sinus of 8 patients undergoing percutaneous transluminal coronary angioplasty (PTCA). All the patients had ECG ischemic signs and pain during the inflation of the balloon. No significant changes in plasma beta-endorphin levels were observed during PTCA-induced ischemia. Baseline coronary sinus plasma beta-endorphin levels were found to be elevated when compared with peripheral ones which would suggest an accumulation of beta-endorphin in the ischemic heart.

Aged↗

Surgical treatment of non-responsive cervicogenic headache.

OBJECTIVE: 102 patients suffering from long-lasting, very severe cervicogenic headache (CEH), non-responsive to physical or drug therapy, were surgically treated. METHODS: Different diagnostic procedures and their significance for determining the advisability of surgery are summarised. The particular importance of the patient history and local anaesthesia together with the clinical examination is outlined. Different surgical approaches are described: ganglionectomy, ventral and dorsal decompressive operation. RESULTS: CEH can be triggered by vascular or scar tissue compression of the C2 root and ganglion and irritation of other upper cervical nerve roots (C3, C4). Vascular compression is caused by: (a) the sinusoidal venous plexus, which surrounds the ganglion and nerve root like a cuff and may be dilated upon raised venous pressure; (b) further on by arterial loops throbbing against the ganglion; and (c) (rarely) by arteriovenous (AV) malformations. Nerve fibre degeneration is demonstrated morphologically by electron optical investigation. Afferences from ganglion C2 to the brain stem, as documented by experimental investigation on cats using the injection of HRP into the C2-ganglion, can explain the reference of pain from the neck to the fronto-ocular region and could at the same time elucidate the genesis of accompanying symptoms. Degenerative diseases such as disc protrusion and retrospondylosis have been shown to be other trigger mechanisms evoking CEH, as is well known from facet joint arthrosis. Degenerative diseases usually cause dura compression with narrowing of the spinal canal and frequently, in addition, instability. Evocation of CEH could be explained by the irritation, by those degenerative diseases, of structures with pain-conducting nerve fibres (facet joint capsule, nerve root, longitudinal ligaments, spinal dura, disc). About 80% of our surgically treated patients were relieved of pain or improved during a long period of follow up. The recurrence of degenerative alterations with new irritation from pain-conducting structures is thought to be responsible for the recurrence of headache. Further surgical approaches for the treatment of patients with the recurrence of pain are discussed. CONCLUSION: Various surgical treatments are suggested to treat long-lasting severe CEH in patients not responsive to any physical or drug therapy.

Decompression, Surgical↗

Comparative study of symptoms and neuroendocrine-immune network mediator levels between rheumatoid arthritis patients and healthy subjects.

OBJECTIVE: In order to understand the disturbances in the neurophysiological, endocrine (including the hypothalamic-pituitary-adrenal axis), and immune systems objectively and in detail, we measured and compared various test items in the peripheral blood which were considered to reflect the state of these systems, in patients with rheumatoid arthritis and in control subjects. METHODS: The levels of beta-endorphin, methionine-enkephalin, epinephrin, norepinephrin (NE), dopamine, corticotropin releasing factor (CRF), adrenocoricotropic hormone (ACTH), cortisol, CD4/CD8 ratio, CD57, NK cell activity and IL-6 in the peripheral blood, which are considered to reflect the activity of this neuroendocrine-immune network, were measured and compared between 49 patients with rheumatoid arthritis (RA) and 54 healthy control subjects. The face scale (to measure mood) and the Cornell medical index (CMI) health questionnaire were administered to both groups, and pain scores were measured using a visual analog scale in the RA group. RESULTS: The serum levels of NE, dopamine, IL-6 and CD4/CD8 ratio were higher, whereas the levels of beta-endorphine, ACTH and NK cell activity were lower in the RA subjects than in the control subjects. On the other hand, the serum levels of Met-enk, epinephrin, CRF, cortisol and CD57 were not significantly different between the two groups. In RA patients a positive correlation was observed between the face scale score and the serum cortisol level and between the pain score and the serum IL-6 level. The more severe the pain, the higher the NK cell activity and IL-6 concentrations in the peripheral blood. On the other hand, in healthy females none of the measured items in the peripheral blood were significantly correlated with the face scale results or the responses to the CMI health questionnaire. CONCLUSION: In RA patients the hypothalamic-pituitary-adrenal (HPA) axis is altered and this condition is correlated to a deterioration in symptoms.

Affect↗

[A case of giant small cell carcinoma of the prostate].

A 64-year-old man having backbone pain was referred to our institute, and laboratory examinations revealed that he was suffering from severe renal failure. Abdomino-pelvic CT revealed bilateral hydronephrosis, a giant prostate over 500 g in weight, and multiple para-aortic lymph node metastasis. Histological diagnosis of the prostate was small cell neuroendocrine carcinoma. Serum neuron-specific enolase (NSE) level was slightly high reflecting the positive immunohistochemical staining, but serum PSA remained within normal limits. The patient was treated with hormone-chemotherapy after successful treatment of the renal failure, but he died on the 74th hospital day. Small cell carcinoma is known to have a high rate of malignancy and metastasis from an early stage. Several giant prostatic tumors have been reported previously, but this case is considered to be the second gigantic small cell carcinoma in the Japanese literature.

Antineoplastic Agents, Hormonal↗

[A case of malignant pheochromocytoma associated with von Recklinghausen's disease].

A 48-year-old woman suffering from chest and lumbar pain was referred to our clinic for treatment. She had a history of von Recklinghausen's disease with multiple café-au-lait spots and neurofibromatosis. Computed tomography demonstrated a large tumor in the left adrenal gland and a small lesion in the liver, with the levels of plasma and urinary catecholamines being elevated. 131I-metaiodobenzylguanidine (MIBG) scintigraphy showed abnormal accumulations in the left adrenal tumor and multiple-bone lesions. A diagnosis of malignant pheochromocytoma with liver and bone metastases was made, and the patient received chemotherapy. Seven months after the diagnosis of malignant pheochromocytoma, she died of pulmonary edema due to disease progression. Autopsy revealed malignant pheochromocytoma with liver, lung, bone and lymph nodes metastases. We reviewed the literature on pheochromocytoma associated with von Recklinghausen's disease. To our knowledge, only 7 cases of malignant pheochromocytoma associated with von Recklinghausen's disease have been reported in Japan.

Adrenal Gland Neoplasms↗

[Sociodemographic predictors of therapeutic results in patients with chronic, non-malignant pain].

INTRODUCTION: Chronic pain is in its nature multidimensional and is most successfully treated by a multidisciplinary approach. Some patients do not benefit from treatment, and psychological and socio-economic factors may play a major role. The present study investigated the ability of sociodemographic variables to predict the short-term effect of multidisciplinary treatment in patients with chronic pain who where referred consecutively to a Danish multidisciplinary pain centre. METHOD: Pain scores (VAS) and health-related quality of life (HRQL) were assessed. On entry and three and six months later HRQL was evaluated by medical outcome short form (SF-36) and the psychological general well-being scale (PGWB). Sociodemographic variables were: age, gender, educational level, civil status employment status, and disability pension (DP) status. RESULTS: Of the sociodemographic variables evaluated, only the DP status seemed to be a significant outcome predictor. Patients applying for a DP do not improve. Patients receiving a DP and those who do not achieved moderate improvements, but these were significantly larger. The same pattern was seen for changes in psychological well-being and social functioning. The DP status predicted improvement in pain and social functioning. DISCUSSION: The present study indicates that the multidimensional problems experienced by patients applying for a DP are dominated by sociodemographic factors. Focus on the solution of these socio-economic problems is important, if patients with chronic pain are to benefit from multidisciplinary pain treatment.

Adult↗

Unruptured aneurysm of the right coronary sinus of Valsalva with type B aortic dissection.

A seventy-two year-old man, who complained of severe back pain, was referred to our hospital. Digital subtraction angiogram (DSA) delineated an extracardiac unruptured aneurysm of the right coronary sinus of Valsalva and acute type B aortic dissection. Patch plasty of the right coronary sinus with reimplantation of the right coronary artery using a Dacron graft was performed. Postoperative DSA confirmed successful reconstruction of the aortic root and the patent right coronary artery.

Aged↗

Embryos.

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Embryo Research↗

Joint accumulations of FDG in whole body PET scans.

PURPOSE: To retrospectively evaluate FDG accumulations in major joints in a large series of non-absorption corrected partial body and whole body FDG-PET scans, and to determine the frequency and intensity of accumulation. MATERIALS AND METHODS: 354 consecutive PET partial- and whole body non-transmission corrected scans of patients obtained for tumor staging were examined with respect to FDG accumulations in the acromio-clavicular (AC)-, gleno-humeral-, hip-, knee- and talo-tibial joints. FDG-uptake was graded using a semi-quantitative scale from 0 (no accumulation) to 4 (very strong accumulation comparable to brain uptake). RESULTS: Joint activity of grade 1-2 was noted frequently, while grade 3 was rare, occurring only in the knee and shoulder joints, and grade 4 was inexistent. The 43 patients with grade 3 accumulations or with at least 4 joints showing grade 2 uptake were interviewed, but all denied pain specifically referred to a joint. Joint accumulations were seen in 50% of the acromio-clavicular-, 80% in the glenohumeral-, 50% in the hip-, 90% in the knee and 80% in the talo-tibial joints. The intensities of joint accumulations correlated positively and significantly with patient age, ranging from r = 0.7 and p < 0.05 in the knee to r = 0.96 and p < 0.0001 in the AC joint. CONCLUSIONS: FDG accumulations in the joints in whole body FDG-PET scans are frequent and are very likely not related to symptoms. As there is a strong age correlation, and FDG is known to accumulate in inflammatory lesions, the findings are most likely a result of sub-clinical inflammatory synovial proliferation or other chronic inflammatory processes occurring in aging joints.

Adolescent↗

Proton magnetic resonance spectroscopy of the thalamus in patients with chronic neuropathic pain after spinal cord injury.

BACKGROUND AND PURPOSE: Spinal cord injury (SCI) results in a number of consequences; one of the most difficult to manage is chronic neuropathic pain. Thus, defining the potential neural and biochemical changes associated with chronic pain after SCI is important because this may lead to development of new treatment strategies. Prior studies have looked at the thalamus, because it is a major sensory relay station. The purpose of our study was to define alterations in metabolites due to injury-induced functional changes in thalamic nuclei by using single-voxel stimulated echo acquisition mode MR spectroscopy. METHODS: Twenty-six men were recruited: 16 patients with SCI and paraplegia (seven with pain, nine without pain) and 10 healthy control subjects. Pain was evaluated in an interview, which included the collection of information concerning the location, quality, and intensity of pain, carefully identifing the dysesthetic neuropathic pain often seen in SCI. Localized single-voxel (8-cm(3) volume) proton spectra were acquired from the left and right thalami. RESULTS: The concentration of N-acetyl (NA) was negatively correlated with pain intensity (r = -0.678), and the t test showed that NA was significantly different between patients with pain and patients without pain (P =.006). Myo-inositol was positively correlated with pain intensity (r = 0.520); difference between patients with pain and those without pain was almost significant (P =.06). CONCLUSION: The observed differences in metabolites in SCI patients with and pain and in those without pain suggest anatomic, functional, and biochemical changes in the thalamic region.

Adult↗

[GASTRIC CANCER IN PERUVIAN ANDES: 170 CASES IN HUARAZ]

As a contribution to the knowledge of gastric cancer, a study took place at "Victor Ramos Guardia Hospital" in the city of Huaraz (3,100 meters above sea level), from August 1992 to July 1998. 170 cases were reported. All of them had biopsy exam.The accumulated incidence was of 138.2 cases per 100,000. The annual mean was 35.8 cases per year. The endoscopy incidence was of 16.7%. And 100% were advanced cancer. All of them were from the sierra of Ancash. 52.4% were males. 80% came from rural zones. And 91.7% were dedicated to agriculture. Food was mainly tubers, vegetables, ham and other salad meats. Ingestion of fruits was very scarce. Mean age was 60.6 years (32?90). 61.6 for females and 59.8 for males. When diagnosis was made 81.2% referred abdominal pain, 67.4% were pale, 38.2% had hematemesis/ melena, abdominal tumor was found in 37.7% and 28.8% had pyloric syndrome.97.7% of the biopsies were reported as adenocarcinoma. And 2.3% as linfomas. Of the 166 adenocarcinomas, 72.9% were of the intestinal type and 27.1% the diffuse type. The intestinal type was more frequent on males (77.6%) that on females (67.9%). Otherwise the diffuse type was more frequent on females (32.1%) that on males (22.4%). Lesions were classified as Bormann: I (0.6%), II (22.9%); III (62.4%) and IV (14.1%).Gastric cancer was found in the distal body in 41.7% of cases. In 2 regions: antrum and body in 26.5% and in the proximal body in 11.2%. 8.4% was localized in the cardias. The intestinal type was more frequently found an the distal body (77.5%). And on the medium body (73.3%). The diffuse type was mostly found on the proximal body (42.1%). On the following up 30 patients were lost and by April 1999, 95% were dead.We conclude that gastric cancer, probably, has a high incidence in the sierra of Ancash. The onset is of advanced gastric cancer. The intestinal type is predominant. And it is an important cause of disease and mortality in risk population.

Journal Article↗

Phase I trial of an infrared pulsed laser device in patients with advanced neoplasias.

PURPOSE: The objective of this study was to evaluate the toxicity/radiant exposure/time relationship of an infrared pulsed laser device (IPLD) treatment in patients with advanced neoplasias. Karnofsky performance status (KPS), Spitzer quality of life index (QLI), and potential antitumor activity, if any, were also assessed. EXPERIMENTAL DESIGN: Seventeen patients (n = 17) received a daily IPLD radiant exposure of 4.5 x 10(5) J/m(2) (904 nm pulsed at 3 MHz) under a one-dose schedule and procedure design. Toxicity was evaluated under the parameters of the WHO; indirect toxic ocular effects were also monitored. KPS and QLI measurements were conducted before treatment and at six 3-months intervals. Scores for the seventh interval are the last available (range, 19-39 months). For statistical purposes, patients were classified into group 1, those alive at the end of the study, and group 2, those who had died. RESULTS: Dose-limiting toxicity was not observed. Five patients (n = 5) reported occasional headaches (grade 2), and four (n = 4) referred local pain (grade 2). In group 1 (n = 7), statistically significant increases in KPS and QLI were observed in all of the follow-up intervals compared with pretreatment values. One patient had a complete response, 1 a partial response, 4 stable diseases > or =12 months, and 1 progressive disease. In group 2 (n = 10), statistically significant increases in QLI were observed during the first two intervals. Eight patients had stable disease > or =6 months and 2 had uninterrupted progressive diseases. CONCLUSIONS: The IPLD treatment studied is safe for clinical use and may have potential effects on KPS, QLI, and antitumor activity in patients with advanced neoplasias.

Adult↗