Full Course Of Therapy Research Articles

Contribution of long-bone radiographs to the management of congenital syphilis in the newborn infant.

To determine the contribution of long-bone radiographs to the diagnosis and management of newborn infants at risk for congenital syphilis. Historical cohort. Three large hospitals in Houston, Tex. Eight hundred fifty-three live born infants who were evaluated for the presence of congenital syphilis. Long-bone radiographs done as part of the diagnostic evaluation for the presence of congenital syphilis. Changes in diagnostic classification or management decisions that were based on radiographic findings in the long bones. For 450 infants, radiographic results did not affect management because clinical or historical factors were present that dictated treatment: 26 infants had clinical symptoms of congenital syphilis (65% [17] had abnormalities on radiographs); and 424 infants were born to mothers who were untreated or reinfected (5.9% [25] had abnormalities on radiographs). All of these infants required a full course of therapy regardless of radiologic findings. Born to mothers with possibly inadequate therapy (according to 1993 Centers for Disease Control and Prevention guidelines), 237 asymptomatic newborn infants were candidates for a single injection of penicillin G benzathine if the results of their evaluations were normal; of these, 2 (0.8%) had abnormal radiographic findings. Of the 166 infants born to adequately treated mothers with appropriately falling serologic titer levels, 1 (0.6%) had abnormal radiographic findings (P=.99 between groups). The results of the long-bone radiographs did not alter management for any of the 853 infants who were evaluated for congenital syphilis. Long-bone radiographic findings, often abnormal in symptomatic infants, do not differentiate between active infection and past infection. The use of long-bone radiographs should be reconsidered in the routine evaluation of infants for congenital syphilis.

Biofeedback for intractable rectal pain: outcome and predictors of success.

A number of modalities have been used for the treatment of intractable rectal pain, with varying degrees of success. Electromyography (EMG)-based biofeedback therapy has been used in the treatment of this condition during the past six years. Medical records of 86 patients who completed at least one session of biofeedback for rectal pain between February 1989 and August 1995 were retrospectively reviewed. All sessions were one-hour outpatient encounters with a trained biofeedback therapist. There were 31 male and 55 female patients with a median age of 68 (range, 12-96) years. Surgery (19.8 percent) or stress (15.1 percent) were frequently cited as precipitating factors for the development of rectal pain. Eleven patients completed only one session of biofeedback and were excluded from further analysis. Of the remaining patients, 28 complained of concomitant constipation. Assessment of the benefit of therapy was based on the patients' subjective reports of the level of symptoms, aided by a linear analog scale. Twenty six patients (34.7 percent) reported an improvement in symptoms. Outcome was not influenced by patients' ages (P = 0.63), duration of symptoms (P = 1.0), or a prior history of surgery (P = 0.14). Alleviation of symptoms was not significantly related to the presence of paradoxical puborectalis contraction demonstrated on either EMG (P = 1) or defecography (P = 0.12). Importantly, outcome was significantly improved in patients who completed the treatment schedule compared with those who self-discharged (P < 0.001). Although idiopathic rectal pain is difficult to treat, EMG-based biofeedback can produce alleviation of symptoms. However, success depends on patients' willingness to pursue a full course of therapy.

Electron beam total skin irradiation

Total skin low energy electron irradiation (TSEI) remains one of the most effective modes of treatment for generalized superficial lesions. After a brief review of the irradiation beam requirements (treatment of the first few milimeters of skin, uniformity of dose distribution in spite of variations in the shape and size of patients) and the different irradiation methods, the autors present the technique used at Henri Mondor hospital and some other french centers. It consist of 3 vertical adjacent fields with patient lying alternatively in prone then supine position. An custome-made lucite scattering screen used together with incident electran beams of 7–9 MeV provides an homogenous dose distribution in patient's parts of large radius of curvature. The dosimetric study performed essentially with TLD dosimeters and films has shown that the lucite screen was the best choice because its transparency makes easier patient positionning and it induces a very low X-ray contamination. It also shown that the screen has to be set close to the patient both to increase the skin dose and to keep an acceptable dose-rate at the patient's level. Besides experiments performed with a semi-infinite fiat phantom made of equivalent-tissue material and an Alderson Rando phantom simulating the human body, experiments were carried out with layered flat phantoms of small thicknesses and cylindrical phantoms (radii varying from 1 to 9 cm) simulating hand and lower limb cross sections. Results obtained at 4 MeV (mean energy at the patient's surface) have shown that the overdosage in anatomical structure of large radius of curvature but small thickness (palme of hands) is 200% of the prescribed dose for 1 cm thickness, 160% for 2 cm and becomes normal for thicknesses ≥3 cm. Large variations of dose have also been measured in cylindical phantoms simulating fingers, ankle or wrist. They depend on both the radius of the structure and the incidence angle of the beam at the skin surface. Some examples are presented. Such results confirmed by in vivo measurements can explain the complications in anatomical regions of small radii of curvature and/or small thickness (erythematous skin, swelling of feet, ankles and hands) reported by different authors. It is the reason why shields for the hands or feet have to be provided well before the full course of therapy is completed, and thus irrespective of the irradiation technique used.

Medical treatment of squamous hyperplasia and lichen sclerosus of the vulva

Objective: To evaluate the efficacy of medical treatment in patients with lichen sclerosus (LS), squamous hyperplasia (SH) and lichen sclerosus with associated squamous hyperplasia. Methods: Forty-eight patients with non-neoplastic epithelial disorders of the vulva, SH in 23 (47.9%), LS in 20 (41.6%) and LS with associated SH in five (10.5%) were diagnosed and treated in our clinic. Patients with LS were treated with 2% testosterone ointment. Topical fluorinated corticosteroids was the treatment of choice in patients with SH. Patients with LS with associated SH were treated with topical fluorinated corticosteroid application followed by testosterone propionate ointment. Results: The clinical response rate of SH to first-line therapy was 95.6% with a correlation of 90.5% with histological reversal; this rate was 80% with a histological correlation of 81.3% in LS. The remission rates of SH and LS patients following a full course of therapy were 100% and 90%, respectively. In LS with associated SH patients, 90% responded to standard therapy with a remission rate of 100% after completion of a full course of therapy. Conclusion: Medical therapy of lichen sclerosus and squamous hyperplasia was very effective with a good clinical and histologic correlation.

Testicular doses in definitive radiation therapy for localized prostate cancer

To measure the dose received by the unshielded testes during a conventional course of 18 MV photon radiotherapy for localized prostate cancer and to identify the factors influencing it. For each of four patients, a wax block containing thermoluminescent chips was attached to the posterior aspect of the scrotum in close proximity to the testes on each day of treatment during a full course of radical radiotherapy, and dose measurements were obtained. The distances between the thermoluminescent chips and the beam edge were verified by measurement from port films. The accuracy of the in vivo measurements and the factors influencing the testis dose were studied using a phantom arrangement. Six factors were considered: (a) the relative contributions from primary and scattered radiation, (b) the amount of buildup required for the thermoluminescent chips that monitored testis dose, (c) the position of the testes within the scrotum, (d) field size, (e) distance from the field lower border, and (f) the effect of port films. Median daily doses to the testes in four patients ranged from 5 to 7 cGy. Daily doses for the four patients ranged from 4 to 14 cGy. The total dose to the testes over the full course of therapy ranged from 1.8 to 2.4 Gy. The daily dose depended primarily on the distance from the field lower border. This was increased by approximately 2.5 cGy when a 6 MV port film was taken. The relative contributions from primary and scattered radiation were found to be similar. Dose measurements at the posterior aspect of the scrotum overestimated the testis dose by approximately 15%. The most important factors influencing the dose received by the testis are the distance from the testes to the field lower border and the occasion of a port film. A knowledge of the number of port films and the average distance from the field lower border to the testes allows a reasonable prediction of testes dose without daily measurement.

Successful Helicobacter pylori eradication incorporating a one‐week antibiotic regimen

The optimum regimen for the eradication of Helicobacter pylori remains unclear. The aim of this study was to determine the efficacy and tolerability of omeprazole 40 mg daily given for 2 weeks, plus amoxycillin 500 mg t.d.s. and metronidazole 400 mg t.d.s. given for the first 7 days, in the treatment of H. pylori associated peptic ulcer disease. One hundred and thirty-two consecutive patients with peptic ulcer disease were entered into the study (89 male, 41 female; median age 47 years; inter-quartile range: 36-58 years). H. pylori was eradicated successfully in 109 of 130 patients (intention-to-treat: 83%; 95% confidence limits: 76-89%); per protocol: 85% (95% CI: 78-91%)). Ninety per cent of patients completed the full course of therapy. Only four patients (3%) stopped treatment as a result of side effects although these occurred in 41% of patients. One patient developed pseudomembranous colitis requiring hospital admission. Omeprazole combined with one week of treatment of amoxycillin and metronidazole is an effective and well tolerated Helicobacter eradication regimen. Occasional severe side effects remain a risk, even when the duration of antibiotic exposure is reduced.

Phase II Study of Intravenous Idarubicin in Unfavorable Non-Hodgkin's Lymphoma

Idarubicin, a new analogue of daunorubicin, was administered intravenously at a dose of 15 mg/m2 to 31 patients with previously treated patients with unfavorable non-Hodgkin's lymphoma. Clinical characteristics included median age 69 years, performance status 1, and prior chemotherapeutic regimens 1. Twenty of the patients were relapsing after prior therapy and 11 were refractory; 29 had received prior anthracycline or anthracenedione. Responses were observed in 43% of patient (3 CR and 10 PR) with a median duration of 10+ months (2-29+ months). Idarubicin was well tolerated with non-hematologic toxicities (nausea/vomiting, mucositis, and anorexia) seen in < 50% of patients. Median hematologic values during the first cycle for this dosage included WBC 1300/mm3, platelets 129,000/mm3, and hemoglobin 10.9 mg/dl. With dose escalation, hematologic toxicity was dose-limiting. Symptomatic cardiac toxicity was observed in one patient who had received maximum dose doxorubicin and radiotherapy. Median values for the cardiac ejection fraction during the full course of therapy for the entire group of patients were 0.62 (initial) and 0.60 (final). Idarubicin in intravenous form is an active drug in previously treated patients with unfavorable non-Hodgkin's lymphoma. Further studies employing idarubicin in non-Hodgkin's lymphoma should be considered. Cardiac function should be followed in trials utilizing anthracycline-type chemotherapeutic agents.

Preoperative chemotherapy and radiotherapy for esophageal carcinoma

From October 1986 to January 1991, 47 patients with esophageal cancer (29 squamous, 18 adenocarcinoma) were treated with simultaneous radiotherapy (3000 or 3600 cGy) and chemotherapy (infusional 5-fluorouracil, cisplatin) delivered during a 5-week period. This treatment was well tolerated; 44 patients (94%) completed a full course of therapy, 40 (85%) had relief from dysphagia, and 21 (45%) noted either weight gain or no net weight loss. One patient (2%) died of complications (tracheoesophageal fistula, perforated ulcer) during chemotherapy and radiotherapy. The remaining 46 patients were referred for operation. Six refused because of excellent relief of their dysphagia, and one was denied operation. Thirty-nine patients went to operation, and 34 (83%) had lesions that were resectable. Eight of the 39 surgically treated patients (21%) had no evidence of residual tumor identified in the resected specimens. One of these complete responders died 7 weeks postoperatively after multiple complications (3% operative mortality rate). Three of the remaining seven have also died since the operation, one of recurrent cancer and two with no known recurrent disease. Actuarial survival in this present series was significantly better than that of our 1980 to 1985 historical control patients (p less than 0.005). There was no difference between patients with squamous carcinoma and those with adenocarcinoma with regard to the prevalence of complete response or long-term survival. Survival of the seven patients who did not undergo operation was comparable with that of the 34 patients in whom esophagectomy was performed. This study suggests that combined preoperative chemotherapy plus radiotherapy for esophageal cancer is well tolerated, provides excellent palliation of symptoms, allows for a high rate of resectability, is equally effective for squamous carcinoma and adenocarcinoma, and provides encouraging early results with regard to long-term survival. The data also call into question the role of esophagectomy, particularly in patients who have a complete response to preoperative therapy.

Evaluation of carboprost tromethamine in the treatment of cyclophosphamide-induced hemorrhagic cystitis

The treatment of cyclophosphamide-induced hemorrhagic cystitis has been difficult, with overall poor results using intensive and costly therapy. The authors evaluated the treatment of this problem in four patients with prostaglandin intravesical therapy. Each patient had failed to respond to conservative management. Carboprost tromethamine (Hemabate) was instilled into the bladder, with dwell times ranging from 45 to 60 minutes, three to four times a day for 4 to 5 days. Two of the patients required a second course with carboprost tromethamine at an increased concentration. A third patient's treatment was stopped after the first 5-day course because of intractable bladder spasms and persistent hematuria. In the three patients who completed the full course of therapy the hematuria resolved completely. The only side effect noted was bladder spasms, which were controlled in three of the four patients with oxybutynin chloride. This preliminary evaluation suggests that carboprost tromethamine may be a safe and effective bedside treatment of cyclophosphamide-induced hemorrhagic cystitis.

Smear-negative, Culture-positive Pulmonary Tuberculosis: Six-month Chemotherapy with Isoniazid and Rifampin

We have shown in Arkansas that 9 months of therapy with isoniazid (INH) and rifampin (RIF) can achieve lasting success in 95% of cases with sputum-smear-positive pulmonary tuberculosis. It seemed likely that when the tubercle bacilli were less numerous, i.e., could not be seen on microscopy, less therapy would suffice. Thus, in January 1980, we began giving only 6 months of treatment to patients in whom at least one sputum culture showed M. tuberculosis but at least three sputum smears showed no organisms. The regimen for adults is INH 300 mg and RIF 600 mg daily for 1 month followed by INH 900 mg and RIF 600 mg twice weekly for another 5 months. To date, 286 patients with an average age of 68.2 yr have been treated in this manner. Associated medical conditions were present as "risk factors" in 23.7%. The full course of therapy could not be completed in 75 patients (26.2%), largely because of side effects of the drugs and non-TB deaths in this group of elderly patients. Side effects of the drugs requiring change of drug(s) occurred in 33 patients (11.5%), but major side effects occurred in only eight (2.8%), four (1.4%) with toxic hepatitis and four with hematologic toxicity. The side effects in 25 patients (8.7%) were not life-threatening and were due to drug intolerance. Treatment failed during therapy in only one patient. The full 6-month course of therapy was completed by 211 patients. During follow-up from 3 to 107 months (median, 45 months), five of 211 patients (2.4%) relapsed, all with drug-susceptible organisms.(ABSTRACT TRUNCATED AT 250 WORDS)

Smear- and culture-negative pulmonary tuberculosis: four-month short-course chemotherapy.

Patients with positive tuberculin reaction, abnormal chest radiograph, and negative bacteriology are often treated empirically for tuberculosis (TB) after exclusion of other causes. Therapy generally consists of two bactericidal drugs (rifampin [RIF] and isoniazid [INH]) for 9 months or INH for 9 to 12 months. With such a small bacillary population, even less therapy might suffice. Thus we began in January 1980 to discontinue therapy at 4 months when there was sufficient evidence of a paucity of bacilli demonstrated by at least three negative smears and cultures for TB at the start of therapy. To date, 452 such patients have been so treated. Radiographic abnormalities included pulmonary infiltration of varying extent, pleural residuals, and hilar adenopathy. The full course of therapy could not be completed in 38 (8.4%) patients due to death, relocation, or drug toxicity. Side effects of the drugs occurred in 21 (4.7%) patients, but toxic hepatitis occurred in only four (0.9%) patients. Thus, 414 patients completed the full 4-month course of therapy. Of these, 126 (30.4%) patients showed radiographic and/or clinical response suggesting active infection. The remainder showed no such improvement, suggesting either a mistake in diagnosis or dormant TB. During follow-up of the 414 patients from 6 to 78 months (median, 44 months), five (1.2%) patients relapsed: three among responders and two among nonresponders. Thus, among persons suspected of having TB but with negative bacteriology, 4 months of chemotherapy with INH and RIF gave results comparable to those achieved with 9 months of therapy in smear- and culture-positive cases.

Aclacinomycin

Aclacinomycin-A was evaluated in a phase II trial for advanced head and neck cancer. A weekly infusion of 65 mg/m2 was used. Eighteen patients were entered. Fifteen patients were evaluable for response and toxicity. One was evaluable for toxicity only and two died before completion of a full course of therapy. One patient without previous chemotherapy achieved a PR in a neck node for a short time. Six patients had stable disease with a median to progression of 6 weeks. Major toxicity encountered was bone marrow suppression. Aclacinomycin-A appears to have no activity in squamous cancer of the head and neck.

A one year follow-up of the multimodal treatment for chronic pain

Twenty-three outpatients with chronic pain began a 3-part treatment package designed to provide symptom control, stimulus control and social system modification. Fourteen patients completed the full course of therapy. The remaining 9 patients were designated as partial completers. A mean of 22.9 weekly hour long therapy sessions resulted in statistically significant decreases in pain, depression, anxiety and medication intake. These improvements were maintained at 1 year follow-up. This study is consistent with the notion that chronic pain is maintained by a combination of inter- and intrapersonal factors. A controlled comparison of this treatment program with other threatments for chronic pain is indicated.

Antibiotic Use in a Rural Community in Bangladesh

Antibiotic use by 175 000 people in the Matlab rural surveillance area (MSA) of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) was studied to identify practices which might affect microbial drug resistance. We surveyed a 3% sample of drug purchases from pharmacies in the MSA over a four-week period in August and September 1980. Fifty-seven drug purchases were made per thousand Matlab residents per week; 9% of these were of tetracycline and 26% were antibiotics. Forty-eight per cent of the antibiotic tablets or capsules for persons aged 15 years or more were purchased in quantities which represented less than a single day's dose and rarely was a full course of therapy purchased at one time. The rate of tetracycline purchase for young children--in whom it is usually contraindicated--equalled the rate for older children and young adults. These practices have probably not led to improvements in health and may have promoted the emergence and persistence of drug-resistant micro-organisms. To optimize antibiotic use, control measures at government, producer, prescriber and consumer levels need to be pursued.

EXPERIENCE WITH ANTITHYMOCYTE GLOBULIN (ATG) IN PEDIATRIC RENAL TRANSPLANT RECIPIENTS

The efficacy of ATG (ATGAMR-Upjohn Co.) in prolonging patient + cadaver renal allograft survival was studied in 21 patients,age 5 to 19 yrs receiving transplants from May 1977 to Oct.1979. Of the 9 patients randomly selected to receive ATG, 3 were given a fixed dose for the 28 day period of therapy; the daily doses of 3 were altered in relation to the percentage of rosette forming cells. Six of the selected patients received the full course of therapy; 1 patient had a positive skin test to ATG; 2 had untoward reactions to the first (and only) administered dose. Of those receiving ATG 1 had irreversible rejection 1 mo after transplantation, and 1 kidney was rejected after 3 mo. Three control patients experienced irreversible rejection within 1 mo, + 2 kidneys were rejected after 3 mos. All patients except 1 experienced threatened rejection episodes during the first mo. One patient died at 2 wks and 2 died within 1 yr after transplantation. All 3 were controls. The 5 treated patients with functioning allografts 4 mos to 2 yrs after surgery had creatinine clearances from 42 to 91 m1/min/1.73M2; 7 controls had clearances from 22 to 120 m1/min/1.73M2. Conclusions: Although the number of patients was very small, there appeared to be no correlation between patient and graft survival and ATG therapy. There was a correlation between graft survival and HLA matching.

Short-Course Treatment Regimens for Patients With Tuberculosis

For about 20 years, the recommended duration of daily chemotherapy for tuberculosis has been 18 to 24 months. Indeed, it seemed very unlikely that the duration could be shortened without a considerable increase in relapses. The difficulties with such prolonged daily therapy are many: (1) cooperation and compliance are difficult to maintain for such a prolonged course of therapy; (2) ingestion of drugs for 18 months to two years is psychologically demanding on the patient, long after his apparent clinical recovery; (3) potential drug toxicity increases with duration of therapy; (4) the cost of therapy increases with its duration; (5) developing countries are unable to afford such prolonged therapy; and (6) relapses increase as patients fail to take the full course of therapy, thus risking an increase in resistant bacilli in the population. Recently, an important advance has been made by the discovery that a combination of the two bactericidal

Intracavitary amphotericin B in the treatment of symptomatic pulmonary aspergillomas

The optimal treatment of pulmonary aspergillomas is not established. Surgical resection is often impossible because of severe, underlying pulmonary impairment, and medical treatment has given negative or inconclusive results. Six patients with symptomatic pulmonary aspergillomas were treated with percutaneous instillation of intracavitary amphotericin B. Four patients who received the full course of therapy showed improvement and stabilization or reversal of progressive roentgenographic changes. Also, follow-up serologic studies of Aspergillus spp. precipitins were obtained in three and were negative. One patient did not tolerate this treatment because of repeated systemic reactions. Another patient did not respond clinically or roentgenographically. Intracavitary amphotericin B therapy should be considered in patients with symptomatic pulmonary aspergilloma, particularly when surgical resection is not feasible.

A trial of antilymphocyte globulin in the treatment of chronic progressive multiple sclerosis

Twenty-three patients with chronic progressive multiple sclerosis (MS), resistant to steroid therapy, were treated with antilymphocyte globulin (ALG) and prednisone (30 mg by mouth daily). Twelve patients completed a full course of therapy (2 ml ALG i.m. daily for 2 weeks and 2 ml i.m. on alternate days for 2 weeks) and 6 others completed at least 2 weeks of daily injections. Six patients experienced an overall improvement of at least 15%, using a comprehensive neurological scoring system. Three other patients had limited, but functionally useful improvement in specific neurologic functions. Six months after the completion of therapy, no patient had deteriorated to a level of function below that noted prior to treatment. Adverse reactions, which often necessitated stopping treatment, included fever, local inflammatory reactions, local rash, general malaise, mild anaphylactoid reactions, and enlargement and tenderness of regional lymph nodes. Because of the short duration of immunosuppression and the toxic side effects of ALG, we do not feel that ALG treatment yet deserves to be introduced as a standard treatment in clinical practice. However, the improvement or arrest of progression seen in these patients who were deteriorating progressively despite steroid therapy would seem to justify a continued search for a safer method of suppressing immunity in MS patients.

Antibiotic Management of Acute Osteomyelitis and Septic Arthritis in Children

Optimal antibiotic management of children with acute bone and joint infections depends on early clinical diagnosis, careful search for the infecting organism, and institution of vigorous surgical therapy. Because antibiotic treatment must be initiated before confirmatory laboratory data are available, clues to the bacteriologic etiology must be sought. Knowledge of the patient's age, the clinical circumstances of the infection, and the associated physical findings may provide a presumptive bacteriologic diagnosis. Gram-staining of the surgical aspirate or tissue may provide immediate information about the nature of the pathogen. Definitive culture results and antibiotic sensitivities may be useful in modifying therapy, if necessary. It is advocated that antibiotics be given parenterally for the full course of therapy because of the seriousness of the infection and the importance of high blood and tissue levels. To determine a response to therapy, frequent careful physical examinations along with periodic roentgenograms and sedimentation rate determinations are indicated. Because long-term, high-dose antibiotic-therapy can produce side effects, it is essential that studies be done to monitor any potentially harmful effects on organ systems.

Split-cobalt60 irradiation for treatment of advanced carcinoma of the lung.

Abstract:A survey was made of the cases of lung carcinoma referred to the Radiology Department for cobalt60 therapy during the first five years after installation of the cobalt unit at Creighton Memorial St. Joseph's Hospital in Omaha. After elimination of 27 cases in which there had been other conjunctive therapy such as surgery, chemotherapy or x‐ray irradiation, there were 85 cases for study. Two cases were lost to follow‐up, so the data pertain to 83 patients (mean age 60, range 30–78).The complete planned course of cobalt60 irradiation delivered a total dose of 4,000–5,000 r during six to eight weeks, with half the dose given in the first two weeks, followed by a two‐week rest period. Only 39 of the patients were able to complete the planned course of 4,000–5,000 r. The mean length of survival for all the patients was fourteen and a half months after starting therapy. Two patients are still living at seventy‐five and seventy months, and 1 at thirty months. The overall survival rate was 4 per cent, but for the group receiving the full course of therapy it was 7.5 per cent. About three quarters of the 83 patients obtained moderate to marked relief of symptoms.These results are similar to several reported in the literature, and serve to emphasize the benefits of cobalt teletherapy in otherwise incurable cancers of the lung.