Therapeutic Adequacy Research Articles

A clinical case of metastatic osteosarcoma in the heart cavity

Tumors of the heart are catalogued as a poorly studied area of clinical oncology because of an extreme rarity of this pathology, absence of pathognomonic symptoms, a large variety of clinical manifestations, and diagnostic complexity. In order to achieve diagnostic and therapeutic adequacy, clinicians need to be aware of cancer heart diseases and their frequently atypical clinical manifestations. The report presents a clinical case of tumor spreading through the vascular system and malignant lesions of the right atrium of the heart in a patient with osteosarcoma of the humerus, where osteosarcoma metastases are resected and plasty of the right atrium is performed by using a pericardial patch. Received 22 August 2017. Revised 7 December 2017. Accepted 11 December 2017. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest.

Hypofractionated Re-irradiation after Maximal Surgical Resection for Recurrent Glioblastoma: Therapeutic Adequacy and Its Prognosticators of Survival.

PurposeTo evaluate the adequacy of retreatment, including hypofractionated re-irradiation (HFReRT), after surgery for recurrent glioblastoma (GBM) and related prognosticators of outcomes.Materials and MethodsFrom 2011 to 2014, 25 consecutive patients with recurrent (n=17) or secondary (n=7) disease underwent maximal surgery and subsequent HFReRT after meeting the following conditions: 1) confirmation of recurrent or secondary GBM after salvage surgery; 2) Karnofsky performance score (KPS) ≥60; and 3) interval of ≥12 months between initial radiotherapy and HFReRT. HFReRT was delivered using a simultaneous integrated boost technique, with total dose of 45 Gy in 15 fractions to the gross tumor volume (GTV) and 37.5 Gy in 15 fractions to the clinical target volume.ResultsDuring a median follow-up of 13 months, the median progression-free and overall survival (OS) were 13 and 16 months, respectively. A better KPS (p=0.026), no involvement of the eloquent area at recurrence (p=0.030), and a smaller GTV (p=0.005) were associated with better OS. Additionally, OS differed significantly between risk groups stratified by the National Institutes of Health Recurrent GBM Scale (low-risk vs. high-risk, p=0.025). Radiologically suspected radiation necrosis (RN) was observed in 16 patients (64%) at a median of 9 months after HFReRT, and 8 patients developed grade 3 RN requiring hospitalization.ConclusionHFReRT after maximal surgery prolonged survival in selected patients with recurrent GBM, especially those with small-sized recurrences in non-eloquent areas and good performance.

Comparative neurocognitive effects of lithium and anticonvulsants in long-term stable bipolar patients

BackgroundThe aim of choosing a mood-stabilizing drug (lithium or anticonvulsants) or a combination of them with minimal neurocognitive effects is to stimulate the development of criteria for a therapeutic adequacy, particularly in Bipolar Disorder (BD) patients who are clinically stabilized. MethodThree groups of BD patients were established according to their treatment: (i) lithium monotherapy (n=29); (ii) lithium together with one or more anticonvulsants (n=28); and (iii) one or more anticonvulsants (n=16). A group of healthy controls served as the control (n=25). The following tests were applied: Wechsler Adult Intelligence Scale, Trail Making Test, Wechsler Memory Scale, Rey Complex Figure Test, Stroop color-word test, Wisconsin Card Sorting Test, Tower of Hanoi, Frontal Assessment Battery, and Reading the Mind in the Eyes Test. ResultsRelative to healthy controls, BD patients showed the following: (i) those on lithium monotherapy, but not other BD groups, had preserved short-term auditory memory, long-term memory, and attention; (ii) those who took only anticonvulsants showed worse findings in short-term visual memory, working memory, and several executive functions; and (iii) all BD patients showed worse performance in processing speed, resistance to interference, and emotion recognition. LimitationsMedication alone cannot explain why all BD patients showed common cognitive deficits despite different pharmacological treatment. ConclusionThe impairment on some executive functions and emotion recognition is an inherent trait in BD patients, regardless of their pharmacological treatment. However, while memory, attention, and most of the executive functions are preserved in long-term stable BD patients, these cognitive functions are impaired in those who take anticonvulsants.

A Chewable Pediatric Fixed-dose Combination Tablet of Stavudine, Lamivudine, and Nevirapine

Pediatric fixed-dose combinations (FDCs) are needed to facilitate antiretroviral therapy in children. We evaluated the relative bioavailability, safety, and therapeutic adequacy of a novel chewable pediatric FDC tablet of stavudine (7 mg), lamivudine (30 mg), and nevirapine (50 mg), referred to as GPO-VIR S7, and compared it with the individual original brand-name liquid formulations in human immunodeficiency virus-infected Thai children. The International Maternal Pediatric Adolescent AIDS Clinical Trials group (IMPAACT) P1056 study was a phase I/II, 2-arm, randomized, open-label, multidose pharmacokinetic cross-over study. Children ≥6 to ≤30 kg receiving nevirapine-based HAART for at least 4 weeks were randomized to receive GPO-VIR S7 chewable tablets or the equivalent liquid formulations. Children were stratified by weight and dosing was weight-based. Intensive 12-hour blood sampling was performed on day 28, and subjects then crossed-over to the alternate formulation at equal doses with identical 12-hour sampling on day 56. Pharmacokinetic indices were determined by noncompartmental analysis. Thirty-four children completed the study. While taking Government Pharmaceutical Organization (GPO)-VIR S7 the geometric mean (90% CI) area under the curve was 1.54 μg·hr/mL (1.42-1.67) for stavudine, 6.39 (5.82-7.00) for lamivudine, and 74.06 (65.62-83.60) for nevirapine. Nevirapine drug exposure for GPO-VIR S7 was therapeutically adequate. Geometric mean area under the curve ratios (90% CI) of GPO-VIR S7/liquid formulation for stavudine, lamivudine, and nevirapine were 0.97 (0.92-1.02), 1.41 (1.30-1.53), and 1.08 (1.04-1.13), respectively. No serious drug-related toxicity was reported. The chewable FDC was safe and provided therapeutically adequate plasma drug exposures in human immunodeficiency virus-infected children. Substituting the FDC for liquid formulations can simplify antiretroviral therapy.

Meropenem removal in critically ill patients undergoing sustained low-efficiency dialysis (SLED)

The purpose of this study was to examine the removal of meropenem during an 8-h sustained low-efficiency dialysis (SLED) session. Using a minimum inhibitory concentration (MIC) = 2 microg/mL as our reference point, we also evaluated the therapeutic adequacy of dosing meropenem as 1 g every 12 h during SLED. This was a prospective, open-label study involving 10 intensive care unit patients with renal failure needing SLED. Meropenem was dosed as 1 g every 12 h. To ensure a steady state, the patients received at least two doses prior to the study. SLED was initiated at least 2 h after the last meropenem dose, and each session was at least 8 h. Blood samples were collected during SLED at 0, 2, 4 and 8 h. The 8-h sample approximated the trough level. After centrifuging the samples, the supernatants were analysed by high-performance liquid chromatography. Most patients were male with a mean age of 63.7 years and a mean weight of 88.9 kg. The SLED prescription was based on each patient's needs, and the blood flow, dialysate flow and ultrafiltration rates varied by up to 150 mL/min. The mean reduction of plasma meropenem concentration was 79.1 +/- 7.3%, and the mean half-life was 3.6 +/- 0.8 h during the 8-h SLED. Significantly more meropenem was removed in the first 4 h of SLED compared with the rest of the sessions. The mean plasma trough concentration was 4 +/- 1.6 microg/mL. Meropenem was significantly removed from the blood compartment during SLED. Dosing 1 g of meropenem every 12 h during a typical 8-h SLED session maintains adequate plasma concentrations.

Revue de pertinence des fluoroquinolones en Lorraine : résultats de la première évaluation

Objectives The Antibiolor network assessed the good use of fluoroquinolones (FQ) in the French Lorraine region by a relevance review. Methods At the beginning of 2008, the experts in voluntary hospitals filled out a standard card mentioning the indication, FQ name, route, and duration according to prescriptions in the last 3 months. Two experts checked the relevance of prescriptions according to the local Antibioguide, and determined a score of therapeutic adequacy index for each card. Each establishment was given its results. Corrective measures were adopted at a meeting of the regional antibiotics commission in January 2009. Results One hundred and twenty-four units (61 medical, 33 surgical, 17 ICU, 2 ER, 11 long-stay hospital) in 28 hospitals filled 1538 cards. The most frequent indications were: pulmonary (632), urinary (445), digestive (130). The FQ indication was non-conform for 36% of the cards ( n = 554). When the FQ indication was justified (984 cards), the chosen molecule was non-conform in 222 cases (23%), dose in 115 cases (12%), duration in 250 cases (25%), and route of administration in 83 cases (8%). The prescriptions were entirely conform for 425 cards (28%). Conclusion The Lorraine hospitals massively took part in this study. The second survey will use the same methodology. The objective will be to reduce the number of unjustified FQ prescriptions and to increase the number of conform cards.

Pharmacotherapy of tension-type headache (TTH)

Background: Tension-type headache (TTH) is a highly prevalent condition, yet it requires less medical attention than migraine, mostly because the pain and disability burden are milder. Methods: Proper diagnosis is a paramount step in therapeutic adequacy. It comes from careful history, thorough physical examination and use of ancillary investigations when appropriate to rule out underlying causes of secondary headaches that could mimic TTH, as there is no biological marker for the condition. Results: Research in TTH is insufficient. Thus, pathophysiologic understanding and therapeutic innovations are lagging. In that context, the clinicians should not be surprised by the paucity of pharmacotherapeutic options. Conclusion: In this article, we review the existing literature on medications and make practical recommendations based on the evidence of their efficacy. We review both abortive and prophylactic medications (such as tricyclic antidepressants and non-steroidal anti-inflammatory drugs, respectively). Both are used for chronic TTH and abortive medications only for infrequent episodic TTH (ETTH). As far as frequent ETTH, abortive medications are used and prophylactic medications often but not systematically. We comment and advise on general therapeutic principles of TTH management.

Evaluation of Purulent Pleurisy Activity from Results of Analysis of Passive Electrical Properties of Biological Samples

Purulent pleurisy is a secondary disease aggravating inflammation of soft tissues. Purulent pleurisy is most fre� quently caused by acute lung abscess. The pleural cavity is infected lymphogenically or as a result of abscess protru� sion in the pleural cavity with pneumothorax formation. Primary purulent pleurisy results from a penetrating wound to the thoracic cavity (1, 2). Diagnosis of purulent pleurisy is fairly obvious based on physical and Xray examination of a patient. Purulent pleurisy is indicated by high body temperature, severe intoxication, and modified blood count (leucocytosis, increased blood sedimentation rate). Elucidation of purulent pleurisy diagnosis, identification of the infection agent, and optimal antibacterial therapy requires diag� nostic puncture of the pleural cavity and acquisition of a biological sample for laboratory analyses (2). Therapy for purulent pleurisy is usually performed using closing techniques without pleural cavity dissec� tion. The therapy includes daily therapeutic pleural cavi� ty puncture. If this is not successful, a draining tube is inserted into the pleural cavity for continuous aspiration. Closing therapeutic methods usually result in positive effect. However, in some cases (in the presence of dense pus, fibrin, or lung tissue sequester in pleural cavity) closed methods fail and there is a risk of disease transition from acute to chronic form. In this case, thoracotomy is required. In purulent pleurisy therapy treatment tactics effica� cy should be monitored for timely correction, because disease outcome depends on therapeutic adequacy. Presently used Xray, laboratory, and bacteriological methods of examination are timeconsuming and do not provide sufficient periodicity. Therefore, development of operating diagnostic methods providing evaluation of purulent pleurisy dynamics is rather urgent. Methods based on passive electrical properties are comparatively inexpensive, safe, effective, and thus fairly

Survival Prognosis and Surgical Management of Ischemic Mitral Regurgitation

Ischemic mitral regurgitation (IMR) has an adverse prognosis, but survival characteristics and management are controversial. This study reviewed a 20-year series of IMR patients managed with multiple approaches to assess and refine surgical strategies. Patients having surgery for primary coronary disease from 1986 to 2006 were divided into group 1 (no IMR; bypass grafting only; n = 16,209), group 2a (IMR; bypass only; n = 3,181), group 2b (IMR; mitral repair; n = 416), and group 2c (IMR; mitral replacement; n = 106). Cox proportional hazards modeling adjusted for baseline differences, and therapeutic adequacy was quantified by area under each survival curve expressed as a percentage of group 1. Group 2 patients were older than group 1 patients and had worse baseline characteristics. Group 2a had less severe MR and group 2b had the most comorbidity. Assuming group 1 provided the best adjusted outcome at a given baseline risk, group 2a achieved 97.7%, 2b achieved 93.7%, and 2c achieved 79.1% of potential survival (hazard ratio 1.1, 1.4, and 1.6, respectively; p < 0.003). Most of the survival difference was perioperative. Worse baseline risk is a major factor reducing long-term survival in IMR. Current algorithms in which mild to moderate IMR is managed with bypass only (group 2a) generally produced good late results. In patients with moderate and severe IMR, repair achieved 93.7% of full survival potential; valve replacement was less satisfactory, primarily owing to higher operative mortality. Future therapeutic refinement, emphasizing reparative procedures and better perioperative care, could enhance the surgical prognosis of IMR.

Electrode Placement and Ictal EEG Indices in Electroconvulsive Therapy

The authors determine whether quantitative electroencephalography (EEG) indices in electroconvulsive therapy (ECT) seizures correlate with stimulus electrode placement. The authors analyzed data from ECT seizures involving three electrode placements on 37 different quantitative EEG measures. Though there were a few statistically significant comparisons, no consistent pattern of differences was discerned among the three electrode placements. Though many different EEG analytical indices are available on modern ECT machines, the clinical or neurophysiologic relevance has yet to be established. These data provide a groundwork for future research on the neurophysiological aspects of ECT.

Adecuación terapéutica en una residencia sociosanitaria

Adecuación terapéutica en una residencia sociosanitaria

Use of whole blood platelet lumi‐aggregometry to optimize anti‐platelet therapy in patients with chronic myeloproliferative disorders

Twenty-seven patients with chronic myeloproliferative disorders and in vitro evidence of platelet hyperactivity on whole blood platelet lumi-aggregometry were commenced on anti-platelet therapy comprising aspirin, clopidogrel, and/or odorless garlic and the studies were repeated to assess the efficacy of the therapeutic agent(s). Only 8 patients showed clear evidence of anti-platelet effect while receiving the standard low-dose (100 mg/day) aspirin therapy. Thirteen patients required a higher dosage of aspirin and/or an additional anti-platelet agent to achieve therapeutic adequacy. Lumi-aggregometry also proved useful to optimize therapy in the 6 patients who received clopidogrel or odorless garlic because of aspirin intolerance.

Le rôle des prescriptions médicamenteuses dans la société française du XVIIIe siècle

Abstract In order to evaluate the existence of a potential gap between current society's medicalization and that from the past, the analysis of an original corpus ofxvmth century's prescriptions has been used as prescriptions themselves formalize the relationship between the patient and the physician. The analysis of the above mentional corpus was carried out taking into account that the implication of the three main actors (prescribing physician, patient and pharmacist) is reflected in the prescription itself This led us to consider the form of the prescription within the context of the seek for recognition of the medical profession 's social status at this period of time. We have beforehand excluded the analysis of the therapeutic adequacy of the prescriptions and we have concentrated on the "work of appearances" reflected by the redaction of the medical prescription. We noted the identification of the three actors defined above, and we have considered the prescription 's recipient. As for the form itself, we have considered the language used, including the tongue, as well the gra- phism and the writing style. The initial goal of prescriptions is of course remedies' prescription, and so have we noticed the kind of prescribed remedies, the preparation that was recommended, and the kind of prescribed remedies, the operating mode if any, as well as any accompanying recommendations. We noticed, as a result, the premises of an evolution towards a standardisation of the prescriptions. Yesterday like today, the medical prescription ends the "singular seminar" , and is ever its sole perceptible representation at the XVIIIth century. The medical prescription allowed and still allows to segregate profane and professional by formalising an unbalanced relationship between those who own a certain knowledge and those to whom it is applied; that latter asking to being prescribed by people whose status ascertains a reasuring médicalisation of the society.

Lokale Anwendung von Nitroglycerin-Salbe zur Behandlung von Analfissuren. Eine Alternative zur chirurgischen Therapie?

Patients suffering from anal fissures are commonly treated by lateral sphineterotomy. This surgical treatment includes the risk of postoperative incontinence, especially in young women with a possible vaginal delivery in their future. Glyceryl trinitrate, a nitric oxide donor, was shown to be effective to induce reversible chemical sphineterotomy. Nitric oxide is an important neurotransmitter mediating relaxation of the internal anal sphincter. The clinical evidence for therapeutic adequacy was examined in a prospective randomized study.

The largest Lyapunov exponent of the EEG during ECT seizures as a measure of ECT seizure adequacy

Attributes of the electroencephalogram (EEG) recorded during electroconvulsive therapy (ECT) seizures appear promising for decreasing the uncertainty that exists about how to define a therapeutically adequate seizure. In the present report we study whether one promising and not yet tested ictal EEG measure, the largest Lyapunov exponent (λ1), is useful in this regard. We calculated λ1 from 2 channel ictal EEG data recorded in 25 depressed subjects who received right unilateral ECT. We studied the relationship of λ1 to treatment therapeutic outcome and to an indirect measure of treatment therapeutic potency, the extent to which the stimulus intensity exceeds the seizure threshold. We found λ1 could be reliably calculated from ictal EEG data and that the global mean, maximum, and standard deviation of λ1 were smaller in the more therapeutically potent moderately suprathreshold ECT and in therapeutic responders. These results imply a more predictable or consistent pattern of EEG seizure activity over time in more therapeutically effective ECT seizures. These findings also suggest the promise of λ1 as a marker of ECT seizure therapeutic adequacy and build on our previous work suggesting that λ1 may be useful for classifying seizures and for reflecting the relative physiologic impact of seizure activity.

Cardiac Tumors: A Current Clinical and Pathological Perspective

Cardiac tumors, primary or secondary, are rare but important cardiovascular abnormalities. Their potentially lethal course and the possibility of cure with propitious excision makes their diagnosis challenging and consequential. Therefore, in order to achieve diagnostic and therapeutic adequacy, clinicians should be knowledgeable of cardiac tumor pathology as well as their frequently atypical clinical presentations. For centuries, neoplasias of the heart have been considered a rarity and a postmortem diagnostic curiosity. Their incidence in autopsy series varies between 0.0017 and 0.19% in unselected patients (Heath, 1968; Straus et al., 1945; Wold et al., 1980). Antemortem recognition of intracardiac tumors by clinical and electrocardiographic findings was not recognized until 1934 (Barnes et al., 1934). In 1951, the diagnosis of an intracavitary left atrial tumor was confirmed with angiography (Goldberg et al., 1952), and the first successful excision of a heart tumor, a left atrial myxoma, was reported in 1955 (Crafoord, 1955). It was only later in the 1970s, when M-mode and 2-D echocardiography became available together with other imaging techniques such as CT and MRI, that antemortem diagnosis of intracardiac tumors became more feasible.

Surgical margins after needle-localization breast biopsy

Background: The use of needle-localization breast biopsy (NLBB) for the early diagnosis of breast cancer is common. The therapeutic adequacy of tumor-free margins following NLBB is unknown. We hypothesized that the presence of residual tumor after reexcision (mastectomy, tylectomy, or quadrantectomy) does not depend on the margin status following NLBB. Patients and methods: Retrospective cohort analysis was performed on 890 consecutive NLBBs executed between January 1990 and June 1994. Patients with invasive breast neoplasia were divided into two groups based on the tumor margins after NLBB. Group 1 were the women with positive margins, and group 2 had negative margins. Breast specimens after reexcision were reviewed for evidence of residual invasive carcinoma. Results: Invasive neoplasia was present in 107 patients (12%). Surgical margins and definitive records of care were avaliable for 96 of them (90%). All 45 patients in group 1 and 38 (75%) of 51 patients in group 2 underwent reexcision of the initial biopsy site ( P = 0.36). Residual invasive carcinoma was present in 10 patients (22%) in group 1 and 3 (8%) in group 2 ( P = 0.13). Conclusion: Invasive breast neoplasia diagnosed by NLBB requires reexcision regardless of tumor margins to achieve complete local surgical eradication of tumor.

Free thyroid hormones in evaluating persistently elevated thyrotropin levels in children with congenital hypothyroidism on replacement therapy.

Some children with congenital hypothyroidism receiving L-T4 therapy have elevated serum TSH levels despite having normal serum T4 concentrations, suggesting that they have a higher threshold for the feedback regulation of TSH release. To further study this possibility, we determined serum free T4 (FT4) and T3 (FT3) concentrations in two groups of L-T4-treated hypothyroid children. Group A consisted of 10 patients with high serum TSH levels; group B consisted of 10 patients with normal TSH levels. All patients were clinically euthyroid, and serum total T4 and T3 concentrations were similar in the two groups. A third (control) group (C) consisted of randomly selected normal children. The three groups were age matched. Serum FT3 and FT4 were significantly lower in group A compared to group B. Serum FT4 and T4 were higher and TSH was lower in group B compared to group C. The T4/T3 ratio wash higher in both groups of children with hypothyroidism than in group C. We conclude that in most patients a high serum TSH was due to inadequate L-T4 therapy, as shown by free hormone concentrations (low) but not by total hormone levels (normal). This suggests that L-T4 therapy should be monitored by measurement of TSH and free hormone concentrations. The latter also can be used to indicate moderate overdosage, not clinically detectable, as shown by the comparison between groups B and C. Measurement of serum total T4, as indicated by the lack of difference between groups A and B and also by T4/T3 ratio, cannot be considered a reliable index of therapeutic adequacy in such children.

Good Crops Favor Food Conditions

INCREASED availability of manpower from graduate and medical schools, expansion in laboratory facilities, and increased financial support of basic and applied research all combined to accelerate research in foods and nutrition notably during the year. Favorable crop conditions in most sections of the world fortunately served to alleviate critical shortages of food in the areas not chronically embarrassed by overpopulation and low earning capacity. Advances in Nutrition Isolation of vitamin B 12 , followed by clinical, animal, and microbiologic studies of its role, led to general agreement concerning its therapeutic adequacy in treating pernicious anemia. Disturbances of the central nervous system had been of frequent occurrence in such patients after treatment with folic acid (without liver extract). Each of the two nutrients appears to overlap the other at certain points, but there is already much evidence that each has independent functions also. The simpler macrocytic anemias associated with sprue and ...

Experiences in the management of subacute bacterial endocarditis treated with penicillin

Experiences are related in the management of thirty-five patients with subacute bacterial endocarditis treated solely with penicillin on the wards of the Johns Hopkins Hospital. Attention is called to the difficulty of establishing a clinical diagnosis at an early stage of the disease due to the nonspecific or misleading character of the presenting symptoms, the frequent absence of classical physical findings and the prevalence of the infection in individuals with only a minimal degree of cardiac disease. The importance of early diagnosis and institution of treatment is emphasized, as continuation of infection may result in irreparable damage to the heart or kidneys or allow the occurrence of fatal emboli, although in several instances a successful therapeutic result was achieved despite a long lapse of time from the onset of disease until commencement of therapy. It is suggested that any patient with a cardiac murmur and a persistent fever should be suspected of having bacterial endocarditis until careful bacteriologic studies and clinical observations have proved otherwise. The necessity of retaining, both aerobically and anaerobically, all blood cultures for a period of not less than three weeks before they are considered sterile is emphasized as is the importance of searching for unusual organisms such as the genus Bacteroides. The course of these patients during treatment is described and the complications encountered are analyzed relative to adequacy or inadequacy of treatment received. The conclusion is reached that the two major causes of death were the underlying cardiac disease and the persistence of bacterial endocarditis. Hence, the major therapeutic concern is that adequate penicillin be given for an adequate period of time and prior to the development of unalterable cardiac abnormalities. The fact that evidence of active bacterial endocarditis was found upon autopsy examination of three patients who died while receiving treatment commonly regarded as adequate has led to critical appraisal of present criteria of therapeutic adequacy. A plan of therapeutic management is described which is thought to assure adequate therapy for the maximum number of patients. In it the penicillin dosage is based primarily upon clinical evidence of satisfactory response. Such factors as the penicillin sensitivity of bacteria, penicillin blood levels and sterilization of blood cultures have been found to have only limited value. The necessity of continuing treatment for an adequate period of time is discussed and the recommendation is made that 100,000 units of penicillin given intramuscularly every two hours for eight weeks be considered the basic and minimal treatment schedule. The pros and cons of initiating treatment before a bacteriologic diagnosis is completed are stated with the conclusion that a reasonable period of delay is justified provided the condition of the patient does not contraindicate such treatment. It is advised that blood cultures be obtained before antibiotic therapy is given to any patient with valvular or congenital heart disease who has a localized bacterial infection, lest a latent bacterial endocarditis be obscured. The value of prolonged convalescence to allow maximal healing of damaged valves is indicated. Consideration is given to the need for adequate prophylaxis against the development of subacute bacterial endocarditis not only during dental extractions but during any type of procedure which might result in transient bacteremia. The elimination of foci of infection which might serve as a reservoir of infection or reinfection is recommended. In conclusion, the immediate results of treatment are discussed and the course of surviving patients over a three to thirty-six months' period is described. An evaluation is attempted of the influence upon the ultimate outcome of certain factors, including the presence of cardiac failure before, during and after the onset of bacterial endocarditis. The final determinants of failure or success in the treatment of subacute bacterial endocarditis with penicillin appear to be the degree of cardiac damage resulting either from the bacterial infection or an underlying disease process, the severity of the embolic occurrences and the resistance of the infecting organisms.