Clinical Treatment Course Research Articles

Pathogenic factors in aminoglycoside-induced nephrotoxicity

Aminoglycoside antibiotics play an integral role in antimicrobial chemotherapy. Unfortunately, these drugs are known to cause nephrotoxicity in man and experimental animals. In fact, the incidence of renal dysfunction during the course of clinical treatment with aminoglycoside antibiotics is approximately 10%. Over the past two decades the elucidation of the pathogenesis of aminoglycoside-induced nephrotoxicity has been the subject of numerous investigations. This review describes the recent theories postulated to play a role in the pathogenesis of antibiotic-induced renal damage. In particular, the importance of aminoglycoside levels in the renal cortex or at the membrane binding site is examined in detail. The relevance of antibiotic tissue levels is reflected in the ability of other drugs to modify nephrotoxicity through an alteration in renal aminoglycoside content. The role of factors including age and diet in drug-induced nephrotoxicity is described. In clinical practice, aminoglycoside antibiotics may often be administered in conjunction with other agents. The influence of aminoglycoside interaction with other drugs including vancomycin, cephalosporins and cytotoxic drugs is examined in the light of reports that nephrotoxicity is potentiated in these situations. In addition, this review focuses on the role of infection (pyelonephritis and septicemia) and bacterial endotoxin as pathogenic factors involved in aminoglycoside nephrotoxicity. Both the direct influence of endotoxin and the indirect effects of vasoactive mediators and inflammatory processes will be discussed. A multiplicity of factors is involved in the pathogenesis of aminoglycoside-induced nephrotoxicity and these are further amplified in the presence of infection.

Secondary biliary cirrhosis. A limiting factor in the treatment of hepatolithiasis.

To investigate whether the coexistence of secondary biliary cirrhosis plays a limiting role in the treatment of hepatolithiasis, we retrospectively compared the clinical course and results of stone treatment in 30 patients with secondary biliary cirrhosis (8 in Child's class A and 22 in Child's class B) (group 1) and 240 patients with noncirrhotic biliary calculi (group 2). The hospital mortality, morbidity of treatment, mortality of treatment, and the percentage of treatment failure in group 1 were 20%, 40%, 6.7%, and 16.7%, respectively. Those in group 2 were 8%, 10%, 3.8%, and 10%, respectively. The modes of treatment for stone removal included surgery with postoperative cholangioscopy and percutaneous transhepatic cholangioscopy. There was a statistically significant difference between these two groups in the hospital mortality and the morbidity of treatment. We conclude that hepatolithiasis and biliary stricture should be treated early, before the development of secondary biliary cirrhosis. However, even after cirrhosis occurs, aggressive treatment does not increase the mortality of treatment or the treatment failure rate.

口蓋裂一次形成術を施行した老人の１症例

In our country, it is very rare to encounter adult patients with unoperated cleft palate. Recently, we had an opportunity to treat a 65-year-old woman with cleft palate and the postoperative course was very excellent. So far as we know in the literature this patient is the oldest unoperated case in our country. In this paper, we report the clinical course of treatment and primary plastic surgery, then discuss the problems of unoperated cleft palate patients.

Handedness Distributions Among Adults Who Stutter

Handedness testing carried out in the course of clinical treatment and research with stutterers has provided no support for an association between left-handedness and stuttering. Stutterers had neither a greater incidence of left-handedness than is usually reported for the general population, nor demonstrated less consistency than fluent speakers in hand preference.

Appendix: Humanitarian use of misoprostol in severe refractory upper gastrointestinal disease

Misoprostol was provided on a humanitarian basis to 157 patients with severe, often life-threatening, refractory upper gastrointestinal (UGI) disease not managed by available medical therapy (cimetidine, ranitidine, antacids, sucralfate, and/or prior surgery). A total of 162 separate clinical treatment courses were evaluated in the 157 patients for the period May 1, 1981 to May 6, 1986. Misoprostol was administered orally or via nasogastric tube, 800 μg to 1,200 μg daily in four to six divided doses, for periods of from one day to 17 months. Patients were considered to have a favorable clinical outcome if they achieved significant improvement in symptoms, hemorrhagic status, or appearance of their condition on endoscopy. Favorable clinical outcomes were observed in 52 of 83 treatment courses (63 percent) involving UGI hemorrhage and in 44 of 79 treatment courses (56 percent) for long-standing nonhemorrhagic UGI disease. A total of 116 treatment courses were for patients with a single UGI entry diagnosis; 28 treatment courses were for patients with two UGI entry diagnoses; four courses were for patients with three UGI entry diagnoses; and 14 treatment courses were for miscellaneous UGI entry diagnoses. Treatment outcomes were analyzed by the four most commonly treated UGI entry diagnoses; patients who had an initial diagnosis of refractory duodenal ulcer (n = 28), refractory gastric ulcer (n = 41), reflux esophagitis (n = 23), or hemorrhagic gastritis (n = 63) had favorable clinical outcomes of 71 percent, 58 percent, 61 percent, and 62 percent, respectively. Misoprostol was well tolerated, with the most common adverse experience being mild to moderate diarrhea. It is concluded that in humanitarian clinical trials, misoprostol was frequently associated with symptomatic relief, with improvement in UGI hemorrhage, or with endoscopic improvement in severe UGI disease that had proven refractory to available medical therapy.

New Clinical Classification for Iris Neovascularization

A new classification scheme for neovascularization of the iris (NVI) is presented. This system designates the location of the new vessels by a letter and the number of quadrants involved by a numeral. The presence of elevated intraocular pressure (IOP) is denoted by a “+” sign. It was found to be a reliable method in the evaluation of the clinical course and results of treatment in patients with NVI.

Infiltrating lipoma of the proper digital nerves

Lipomas are one of the most commonly encountered benign soft tissue tumors. Their frequent occurrence and exact anatomic distribution in the hand and upper extremity have been well documented. A review of the current literature shows that these lesions are most often asymptomatic and occur only rarely with the fingers. Our recent experience has been at variance with this is that we have encountered two patients with symptomatic infiltrating lipomas of the proper digital nerves. The following report documents the clinical presentation, treatment, and postoperative course of these patients.

Unifocal eosinophilic granuloma of the temporal lobe

The clinical features, treatment, and two-year postoperative course of a 14-year-old boy with unifocal eosinophilic granuloma of the temporal lobe are presented. A literature review of unifocal eosinophilic granuloma of the brain revealed 11 additional cases, 9 of which involved the hypothalamus and 1 each the frontal and temporal lobes. Four of the 9 patients with involvement of the hypothalamus developed multifocal disease, whereas none of the 3 who had frontal or temporal lobe involvement developed multifocal lesions. Effective therapy for eosinophilic granuloma in a single resectable site in the brain appears to be total excision. Low-dose radiation has been used to eradicate locally recurrent disease.

Outcome of treatment for neonates referred to a supraregional cardiac centre 1976-78.

The clinical course and outcome of treatment for 322 consecutive neonates referred to a supraregional paediatric cardiac unit are reviewed. Two hundred and forty-eight (77%) had structural congenital cardiac defects. The remaining 74 (23%) presented with arrhythmia, nonstructural cardiorespiratory problems, or problems unrelated to the cardiovascular or respiratory system. Transposition of the great arteries and coarctation of the aorta were associated with a good prognosis. Infants with cyanotic cardiac defects associated with a low pulmonary blood flow who required early palliation were found to have a poorer outlook.

A Case of Generalized Wegener's Granulomatosis in Childhood: Successful Therapy With Cyclophosphamide

An 11-year-old white boy had Wegener's granulomatosis, a rare condition in the pediatric age group. The clinical course, pathological findings, and mode of treatment are outlined. The disease is in remission on a regimen of cyclophosphamide therapy as judged by both clinical and pathological criteria. This syndrome with protein manifestations should be considered in children with symptoms of repeated upper respiratory tract infections along with pulmonary and renal involvement. Early renal biopsy helps to establish the diagnosis of generalized involvement and to guide the course of treatment. Follow-up renal biopsies may serve as an indication for the continuation of treatment. Cytotoxic agents, especially cyclophosphamide, dramatically alter the course of the disease.

Pregnancy in Patients with Pituitary Tumors

Thirteen patients with pituitary tumors had a total of seventeen pregnancies. Nine of these patients were treated prior to conception (four by radiation therapy, four by hypophysectomy, and one with lergotrile); four patients received no treatment. The untreated group had a total of six pregnancies, two of which were complicated by visual symptoms which regressed spontaneously after delivery. One of the hypophysectomized patients developed diabetes insipidus at 34 weeks' gestation which resolved spontaneously after delivery. Of the four irradiated patients, one had a child with Down's syndrome and another had a child with multiple congenital anomalies who died. The clinical course and various modes of treatment of these patients are discussed and the pertinent literature is reviewed.

Hospital treatment and diagnosis of Mycoplasma pneumoniae pneumonia.

A study was started in 1972 in order to determine the true etiology of patients who presented with obscure pulmonary infiltrates. Patients who were included in this study had sera drawn on two occasions. Complete testing was performed for the various viruses and also for Mycoplasma pneumoniae antibodies. The study continued through 1975 and a total of 159 patients were included. Of these 159 patients, 28 had positive complement fixation tests for M. pneumoniae antibodies. The clinical profile and treatment course is outlined and discussed.

Mechanism of formation, clinical course, and results of treatment of external biliary fistulae following gunshot wounds

Mechanism of formation, clinical course, and results of treatment of external biliary fistulae following gunshot wounds

Herpes zoster in children with cancer.

Of 1,132 children treated for malignant neoplasias at St. Jude Children's Research Hospital, 101 developed herpes zoster. This population was studied retrospectively to determine frequency of infection, relationship to cancer therapy, clinical course, complications, and results of treatment. The incidence of infection was highest (22%) in patients with Hodgkin disease and lowest (0.7%) in patients with acute myelogenous leukemia. The overall incidence was 9%. Mortality was low in these children—3% for those with infection and 0.3% for the total population. Complications included pneumonitis, meningoencephalitis, chronic thrombocytopenia, iritis, keratitis, and progressive and prolonged cutaneous zoster. Cobalt-60 irradiation produced no significant changes in zoster incidence, and no specific chemotherapeutic drugs could be implicated as instigating factors in infection. Rates of survival and recurrence of malignant neoplasm were not affected by the presence of herpes zoster infection.

Emotional responses of burned children in a pediatric intensive care unit.

A thirty-bed hospital for acute and reconstructive treatment of thermal injuries in children has afforded an opportunity to investigate: 1) early development and personality in the pre-burn child, 2) emotional responses to the injury and hospitalization, 3) the role of emotions in the clinical course of treatment, and 4) long-term adjustment to the physical and emotional trauma of burns. The focus is on clinical observations and evaluations made by a consultant in child psychiatry on a four-bed intensive care unit. The role of the intensive care unit environment, immobilization, and the interplay of patients on one another, as well as the environment-mind-body interrelationships, are illustrated by four case vignettes. Psychological thoughts regarding somatic responses of ulcers, hypertension, and central nervous system manifestations of hallucinatory-like and seizure-like phenomena are made. These vignettes attempt to show how the emotional needs of a burned child, especially in an intensive care unit, must receive the same emphasis as his physical needs.

Schizophrenia-Like Psychosis in Thyroid Crisis

Very few cases of thyrotoxic psychoses have been reported during the last twenty years. Recent authoritative reviews on the management of thyrotoxicosis and its complications (Ingbar, 1966; Trotter, 1967) scarcely mention psychotic reactions. It seems that such conditions have become increasingly rare since the advent of modern anti-thyroid treatment. The present report attempts to summarize what is known about these disorders, and describes the clinical features, treatment and subsequent course of a schizophrenia-like psychosis which developed during thyroid crisis.

A case of giant hemangioma with thrombocytopenia.

SUMMARYDescription of a case of large hemangioma with thrombocytopenia, hemorrhage, and anemia, reacting well to X‐ray treatment. Forty‐nine cases from the literature are reviewed. These show‐great variation in the localisation and histological findings, clinical course and type of treatment. This disease should not be regarded as harmless in view of the possibility of serious hemorrhages and the not negligible chance of underlying malignancy. An acceptable concept, combining regression of the tumor and simultaneous increase in platelet count, is not known. Until now, radiation treatment and surgical removal of the tumor have been the only successful methods of treatment. Where possible, surgical treatment is to be preferred, since high doses of radiation seem to be required and relapses may follow. In some cases spontaneous regression appears to occur. Fibrinogenopenia of not fully understood etiology has been noted in some cases.

Discogenetic disease

There is no constant interrelation between thinning of the intervertebral discs and hypertrophic spondylitis and spondylarthritis. The production of clinical symptoms depends neither on these bony changes nor on the amount of thinning of the discs, but on the localization of the entire process and the stage of the disease. In degenerative thinning, the lower cervical and lower lumbar regions are most commonly involved, wherefore, under certain conditions discussed in some detail, a group of clinical symptoms occurs frequently as a result of this affection. The clinical course, roentgenologic aspect, and mode of treatment are described. Since spondylitis and spondylarthritis are neither characteristic of this disease nor responsible for all the clinical symptoms, it is suggested that this group of anatomic findings and clinical manifestations be designated by the term “discogenetic.”

INCIDENCE OF ACUTE OTITIS MEDIA IN INFANTS AND IN YOUNG CHILDREN DURING 1930-1931: VARIATIONS IN THE CLINICAL PICTURE

In a group of 402 infants and young children admitted to the Infant's Ward of the St. Louis Children's Hospital during the six month period between October, 1930, and April, 1931, 194 were found to have acute otitis media. The cases presented wide variations in the clinical course and requirements of pediatric and otologic treatment. The general diagnosis of associated systemic conditions included pneumonia, septicemia, meningitis, pyuria, nephritis, secondary anemia, anhydremia, athrepsia, diarrhea, birth injuries, congenital defects, asthma and others. As a general approach to the group, the following points in the history of the onset or course are presented: One hundred and thirty-three patients had indications of, or a history of, infection of the upper respiratory tract. One hundred and sixty-seven had fever; in 112 the temperature was above 39 C. (102.2 F.). Vomiting occurred in 76, diarrhea in 60 and weight loss in 61. Forty-four had had measles,