Usual Medical Treatment Research Articles

Bilateral Internal Carotid Artery Occlusion: Natural History and Surgical Alternatives

Purpose and background: Bilateral internal carotid artery occlusion is an extremely rare entity, therefore, studies of the natural history of this disease are lacking in the English literature. The purpose of this study is to analyze the natural history and surgical alternatives for patients with bilateral internal carotid artery occlusion. Patient population and methods: Twenty-one patients with bilateral internal carotid artery occlusion were encountered with a mean age of 61 years (range of 48–73 years). Their clinical presentations included eight with hemispheric transient ischemic attacks, three with amaurosis fugax, five with strokes and five with non-hemispheric transient ischemic attack. Diagnosis was confirmed using carotid duplex ultrasound and angiography. The majority of patients had more than one risk factor for atherosclerosis: smoking in 100%. hyperlipidemia in 14/21 (67%), hypertension in 17/21 (81%), coronary artery disease in 15/21 (71%) and diabetes mellitus in 7/21 (33%). In addition to the usual medical treatment, 13 patients underwent surgical intervention: eight had an external carotid endarterectomy, four had a carotid—subclavian bypass (to increase external carotid or vertebral flow for tight stenosis or occlusion of the common carotid or subclavian artery) and one patient had an ascending aorta to innominate artery bypass. At a mean follow-up of 6 years (range 1–11 years), the overall mortality rates were 11/21 (52%). in the surgical group it was 5/13 (38%) and 6/8 (75%) in the medical group. The causes of death included seven myocardial infarctions (four in the surgical group and three in the medical group) and four strokes (one in the surgical group and three in the medical group). In the surgical group, 2/13 (15%) had late neurological deficits (one hemispheric transient ischemic attack and one stroke), in contrast to 6/8 (75%. three strokes and three hemispheric transient ischemic attacks) in the medical group. Conclusions: Bilateral internal carotid artery occlusions have grave prognoses and should be considered a marker for severe systemic disease. Various cerebrovascular reconstructive procedures, if feasible, may be beneficial for some of these patients.

Evaluation of Open Lung Biopsy in Critically Ill, Ventilator Dependent Intensive Care Unit Patients

OBJECTIVE: Evaluation of the benefits and risks of performing open lung biopsy (OLB) in critically ill, ventilator dependent intensive care unit patients.DESIGN: Retrospective chart review from 1990 to 1995.SETTING: A tertiary care teaching hospital intensive care unit.INTERVENTION: OLB in patients requiring mechanical ventilation for respiratory failure.MEASUREMENTS: Data collected included preoperative investigations, lung injury score, diagnosis, treatment and eventual outcome.RESULTS: Twenty-seven patients (14 male, 13 female) were mechanically ventilated before OLB for a median duration of seven days. A change in clinical management occurred in 85% of the patients as a result of new information obtained from the OLB. There was no statistical difference in overall outcome whether OLB was performed early or later in the course of respiratory failure once the patient was mechanically ventilated. The incidence of perioperative complications was 37%. Ten patients eventually left hospital.CONCLUSIONS: In a small percentage of intensive care patients refractory to the usual medical treatment modalities, open lung biopsy intervention is required to attempt to obtain a specific diagnosis.

Exercise training and heparin pretreatment in patients with coronary artery disease

The purpose of this study was to evaluate whether combined treatment with a cardiovascular exercise rehabilitation program and low doses of heparin can induce changes in ergometric parameters of ischemia in patients with coronary artery disease (CAD). Heparin may potentiate the development of new vessels promoted by ischemia and therefore may produce important clinical improvement. Thirty-six patients with stable CAD and evidence of myocardial ischemia on exercise testing were randomized into three groups: a control group ( n = 11) received the usual medical treatment; another group ( n = 11) underwent three exercise sessions per week during 12 weeks; and a third group ( n = 14) undertook this exercise program and also received calcium heparin 12,500 IU subcutaneously 20 to 30 minutes before each exercise session. Pretreatment and posttreatment exercise tests were compared. Patients who underwent the rehabilitation program had an increase in exercise duration and workload at the onset of 1 mm ST-segment depression, but only patients who received calcium heparin showed a significant increase in rate—pressure product at the ST-segment ischemic threshold ( p = 0.035). This result suggests that higher levels of myocardial oxygen consumption were now tolerated, a change that may be related to an improvement in myocardial perfusion.

Presentation and management of choriocarcinoma after nonmolar pregnancy

To ascertain the mode of presentation and treatment outcome for women with choriocarcinoma after a nonmolar pregnancy. Retrospective analysis of case records between 1985 and 1994. A referral centre for trophoblastic disease. One hundred women with choriocarcinoma: 62 after a live birth, six after a live birth preceded by a molar pregnancy and 32 after a nonmolar abortion. Choriocarcinoma after nonmolar pregnancies represent 17% of the total gestational trophoblastic tumours requiring treatment. Vaginal bleeding was the commonest symptom in all groups, but symptoms from metastatic disease were important in the group presenting after a live birth. Metastatic disease was present in 31% of cases after live birth and 43% post-abortion. The median interval between the antecedent pregnancy and choriocarcinoma was five and six months, respectively. High risk multi-agent chemotherapy was required in 82% and 60% of cases, respectively. The mortality rate was significantly higher after a live birth than a nonmolar abortion (21% vs 6%). Treatment of choriocarcinoma after a live birth is associated with an unacceptably high mortality rate. Vaginal bleeding is an important early symptom and a pregnancy test should be performed if it persists after usual medical treatment.

Ménière’s Syndrome and Allergy

The role of allergic and autoimmune factors in both the production and amplification of symptoms of Ménière's disease has yet to be clearly defined. Reasons to suspect an allergic factor influencing Ménière's disease include a relationship with symptoms to seasons or a suspect food, a known history of allergy in a Ménière's patient, bilaterality of symptoms, and refractoriness to the usual medical and surgical treatments. The majority of patients tested in this study were found to have rather low levels of sensitivity to inhalant allergens as measured by SET, and to have food reactions to very common "hidden" foods that are frequently ingested in the diet. By proper recognition and treatment of the underlying allergic factors affecting Ménière's disease, significant clinical improvement may be obtained even in longstanding or refractory cases.

Indometacina en el tratamiento del ductus arterioso persistente en recién nacidos prematuros

The effectiveness of indomethacin versus usual medical treatment with fluid restriction to 75% of the volume given in the previous days, with or without frusemide (UMT), for the closure of hemodynamically significant patent ductus arteriosus (HSPDA) was retrospectively studied in 87 premature infants under 2,000 g admitted to our nursery from year 1978 throughout 1988. Among 16 babies, treated from the beginning with indomethacin and UMT, HSPDA was closed 72 h later in 14 (87.5%), versus only 14 closures in 71 babies (19.7%) treated by UMT alone (p < 0.01). Of the 57 babies whose HSPDA failed to close with UMT alone, 23 were given indomethacin and successful closure was seen in 16 (69.6%), while among 34 babies remaining on UMT alone, closure resulted in only 7 (20.6%) (p < 0.01). Intravenous route for administration and early use of indomethacin (before age 7 days) proved to have significantly higher success rates than oral route and use of the drug after age 7 days.

Surgical management for cardiovascular lesions in Kawasaki disease

SummarySummary Myocardial revascularization is now an accepted therapeutic modality for severe coronary arterial obstructive disease produced by Kawasaki disease which is amenable to usual medical treatment. The mortality rate of myocardial infarction is surprisingly high in this setting, and surgery may be able to prevent many of these deaths. This article focuses on current issues in surgical treatment of ischemic heart disease in children secondary to Kawasaki disease. Coronary arterial obstructive disease is, apparently, a leading problem followed by valvar and myocardial involvements. Introduction of bypass grafting using the internal thoracic artery in children was a major recent advance, because this graft has an excellent capability to adapt to the increments of increased flow and growth of the patient. The saphenous vein is less satisfactory when used as a graft in terms of its long-term patency, particularly in young children less than 8 years old. Although longer follow-up is certainly required, the current results of surgery have been excellent in improving myocardial perfusion, in ameliorating symptoms, and improving the quality of life.

Role of indomethacin in ductus closure: an update evaluation.

Patent ductus arteriosus (PDA) in premature infants is a current challenge to pediatricians. Pharmacological closure of PDA with indomethacin, a prostaglandin synthetase inhibitor is an effective drug therapy, along with usual medical treatment. Administration of indomethacin may decrease mortality and morbidity (e.g. bronchopulmonary dysplasia) among very small premature infants (less than 1,000 g). Co-administration of furosemide with indomethacin may lessen the transient renal side effects of indomethacin. The therapeutic efficacy of indomethacin in closure of PDA depends largely on understanding and manipulation of the pharmacokinetic characteristics of the drug in preterm infants. Maintaining a therapeutic level of the drug in plasma is essential to achieve an optimal therapeutic response. Compared to surgical ligation, indomethacin is a noninvasive, less expensive and safer therapy for ductus closure.

Pregnancy in ulcerative colitis.

The course of pregnancy in 97 women with ulcerative colitis was studied over a 12-year period. During this period they had 173 pregnancies and delivered 136 children. There were two gemellary deliveries. Nine women had a spontaneous and 16 an induced abortion, of which 4 were performed on therapeutic indication. For a woman with ulcerative colitis the risk of an exacerbation of the bowel disease was 32% per year in her fertile years, whereas it was 34% per year during pregnancy. This difference is not statistically significant. As compared with women with an inactive bowel disease, women in whom the disease was active at the start of pregnancy had a small but significantly greater risk of spontaneous abortion and premature delivery. The frequency of malformations, prematurity, and neonatal hyperbilirubinaemia was not higher in the children of ulcerative colitis mothers than in those of healthy mothers. Treatment with sulphasalazine, salazosulphadimidine, and corticosteroids had no influence on the course and outcome of pregnancy. Birth length and weight of the children of mothers with ulcerative colitis equalled those for children of healthy mothers. In conclusion, pregnancy does not necessitate any change in the usual medical treatment of ulcerative colitis. Women with ulcerative colitis should be advised preferably to conceive at a time when their bowel disease is inactive. Generally, ulcerative colitis constitutes no indication for induced abortion.

Effects of indomethacin in premature infants with patent ductus arteriosus: Results of a national collaborative study

Among 3559 newborn infants with birth weight less than 1750 gm, 421 developing a hemodynamically significant patent ductus arteriosus were entered into a randomized trial to evaluate the role of indomethacin in the management of PDA. Indomethacin given concurrently with usual medical therapy at the time of diagnosis resulted in ductal closure in 79%, versus 35% with placebo (P less than 0.001). Indomethacin as backup to usual medical treatment resulted in similar closure rates. To assess overall effects through hospital discharge, three management strategies were compared. Although mortality did not differ significantly, infants given indomethacin only if usual therapy failed (strategy 2) had a lower incidence of bleeding than those to whom indomethacin was given with initial medical therapy (strategy 1) and lower rates of pneumothorax and retrolental fibroplasia than those to whom no indomethacin was administered, with surgery the only backup to medical therapy (strategy 3). Thus the administration of indomethacin only when medical treatment fails appears to be the preferable approach for the management of symptomatic PDA in premature infants.

The physiologic properties and therapeutic potential of coherin

Coherin, a peptide isolated from the bovine neurohypophysis, has been shown to be an effective therapeutic agent in post-gastric surgery physiologic obstruction and regional ileitis. Of twenty-four patients with post-gastric surgery physiologic obstruction, coherin relieved symptoms in twenty-three, a 96 per cent efficacy rate. The efficacy of coherin with ileitis was based on the fact that ten of twenty-seven patients treated have required coherin on a continuing basis to stay functional. These patients have requested coherin treatment for an average of five years each, and have each on multiple occasions tried to discontinue coherin treatment with prompt return of symptoms and cessation of symptoms when coherin was reinstituted. All of the ileitis patients had previously failed to respond to standard and usual medical treatment.

Combined Calcitonin and Oral Phosphate Treatment for Hypercalcemia in Multiple Myeloma

Hypercalcemia of multiple myeloma has been discussed widely in the medical literature. The role of calcitonin and phosphate in the treatment of hypercalcemia of multiple myeloma has not yet been studied to our knowledge, although experimental animal models have been pointing to the role of phosphate supplement to calcitonin treatment in multiple myeloma. A patient had multiple myeloma and hypercalcemia. The usual medical treatment for hypercalcemia failed; however, the treatment with combined orally administered phosphate and calcitonin was successful. The role of phosphate depletion in this setting is brought up as an important factor in the failure of calcitonin therapy.

The treatment of recurrent ventricular tachycardia with bilateral cervico-thoracic sympathetic-ganglionectomy. A report of two cases.

Two patients had bilateral cervico-thoracic sympatho-ganglionectomy for treatment of disabling symptoms due to refractory ventricular tachycardia. In both patients treatment with antiarrhythmic drugs singly, in combination, or together with pacemaker overdrive had been ineffective in controlling this arrhythmia. Both patients had normal coronary arteriograms. Bilateral thoracic sympathectomy appears to facilitate medical management of ventricular tachycardia in selected patients who are refractory to the usual medical treatment.

LANGUAGE LEARNING AND COMMUNICATION DISORDERS IN CHILDREN, by Gertrud L. Wyatt. New York: The Macmillan Company, 1969, 372 pp., $11.50

This volume, by a psychologist who has devoted much of her interest and attention to problems of language and communication, goes far beyond the usual medical treatment of speech and language development. Wyatt has dealt, in a manner thoroughly useful to pediatricians, with the social and interpersonal bases of speech and language. Besides explicating the general viewpoint of normal language development as a transactional phenomenon in which emotional sharing and repetitive feedback play crucial early roles, she presents two extensive case histories which portray the vicissitudes of speech development in its personal-emotional context.

Double internal mammary artery-myocardial implantation. Clinical evaluation of results in 150 patients.

A total of 248 double internal mammary artery-myocardial implantations have been performed at the Cleveland Clinic up to October 31, 1967. This report presents an analysis of the clinical experience with the first 150 patients. The majority of the patients were between 40 and 60 years of age. The overall hospital mortality was 9.3%. The lowest mortality rate (4.9%) was among patients between 51 and 60 years of age. The most common complication encountered in this series (22 patients) was atrial fibrillation. Acute myocardial infarction developed in 14 patients; all of them recovered with the usual medical treatment. All of the patients have been studied by Sones's technique of selective coronary angiography and left ventriculography. We believe that this is mandatory in the selection of patients for coronary artery operations. The postoperative evaluation shows significant clinical improvement in the majority, 116 patients. Thirty-one have undergone postoperative angiographic studies. Of 61 opacified arteries, 58 remained patent, and 37 showed definite communication with coronary arteries. We believe our present operative technique allows us to increase myocardial perfusion in any region of the left ventricle.

Systematic preparation of patients for psychotherapy- I. Effects on therapy behavior and outcome

OUR PREVIOUS studies have suggested that certain effects of psychotherapy and placebos on psychiatric outpatients may depend on the potentiation and activation of the patient’s favorable expectations.(Q) GOLDSTEIN(~) has pointed out the important role played by the patient’s expectations that he will improve, that he will receive a certain type of treatment, and that. he and the thergpist will behave in ctrtain ways. This paper reports a controlled study of the effects on psychiatric outpatients of a pre-treatment interview designed to clarify their expectations of psychotherapy and to increase the congruence of their behavior with therapists’ expectations as to how psychiatric patients should act. We tested the hypotheses that such an interview would favorably affect patient’s behavior during therapy and the outcome after four months of treatment. Because of the diversity and ambiguities of public conceptions of mental illness and psychotherapy, psychiatric patients reach the psychiatrist’s office with a wide variety of attitudes and expectations. Only the most sophisticated are perfectly clear about why they are there and what they expect (Ref. 4. p. 128). Less sophisticated patients may have unrealistic expectations for improvement: they may not understand their role in the therapeutic process@) and may be bewildered by a procedure that differs not only from usual medical treatment but from customary social interactions. As LENNARD and BERNSTEIN comment (Ref. 6, p. 26) : “Dissymetry of expectations not only interferes with the therapeutic task, but can actually lead to the premature death of a therapeutic system.” This might be an important reason why patients who are less educated and have a different cultural background than most therapists tend to terminate treatment prematurely.(‘W)

「リハビリテーション」殊にリウマチを中心にして

Rehabilitation, in a general sense, has developed as a counter measure against both physical and mental functional disturbances which have remained or nearly stabilized by usual medical treatments given on a disease or a trauma. Accordingly, it is apt to be regarded as a measure which should be started after confirmation of symptomatic stabilization or the stabilization of functional disturbances. Rheumatoid arthritis is a disease difficult to expect symptomatic stabilization and its functional disturbances are always progressive causing an important problem in the social rehabilitation of such patients. It is a disease, moreover, difficult to decide when to start rehabilitation. This is the reason why patients of rheumatic disorders occupy only 2% of the total patients of physical disturbances taken care by the rehabilitation centers existing in each districts all over Japan. On the contrary, 16.9% of heavy cases of physical disturbances hospitalized in wo national sanatoria, which are taking care of medical rehabilitation, are the patients of rheumatic origin. Rehabilitation of rheumatic disorders, therefore, should be performed in conjunction with general medical treatments.Patients of rheumatoid arthritis are apt to become depressed by severe pain and stiffness, and it has become difficult to motivate them for rehabilitation. This depressed state, however, is symptomatic and disappears in most cases by removal of pain and stiffness. For this purpose, adreno-cortico-steroids are positively effective. These steroids, moreover, have a psychomotor stimulating effect, and their intra-articular injections facilitate rehabilitation as well. Prolonged administration of steroid hormons may sometimes invite development of side effects. In a considerable number of cases, administration of steroids has become indispensable. Even intra-articular injections may cause aggravation of weight loaded joints by an excessive use of such joints.Some people prefer salicylates or butazolidin preparations to steroids.Physiotherapies, especially hot water and massage are the measures indispensable for removal of pain in rheumatic patients though both of them have begun to lose their positions as the most valuable measures in rehabilitation program.The next is orthopedic surgery like synovectomy or to provide a window. There is a lot to expect from the orthopedic surgery of deformed joints. Further developments of counter measures against deformed joints are strongly desired.It is not easy to set a goal of rehabilitation for patients of rheumatic disorders. If expected too much, the patient must suffer from a heavy psychological burden and may precipitate reccurence or exacerbation and sometimes even cardic complication. Too much burden may spoil invalid joints involved. On careful investigation of the daily lives of rheumatic patients, it was found that they do not always have an optimisitic future.At present, in Japan, there exists a considerable gap between the progress in medical insurance and the socio-economical programs of rehabilitation causing the patients of chronic diseases like rheumatoid arthritis to remain in medical facilities without having adequate employments. It is considered to be an utmost imprortance to provide ways to accept these patients in society, and also to establish hospitals specialized in rheumatic disorders including rehabilitainon.

Stokes-Adams syndrome precipitated by emotional stress. Report of a case.

This paper presents a psychiatric study of a 28-year-old man with frequent Stokes-Adams episodes in whom demonstrable cardiac pathology is limited to the intermittent conduction abnormalities. Regular psychiatric interviews led the authors to conclude that there was a close connection between the patient's intense unsatisfied dependency strivings and precipitation of his complete heart block. Each Stokes-Adams episode occurring during the interviews was immediately preceded by the expression of intense grief and resentment over disappointed dependency strivings. The theory is advanced that these emotions cause intense vagal stimulation and thus precipitate the heart block. The authors conclude that psychiatric treatment in conjunction with usual medical treatment has a synergistic therapeutic effect by modifying the precipitating emotional disorder.

A New Technique for Rapid Control of Cirrhotic Ascites

Ascites in patients with cirrhosis is most commonly a sign of hepatic decompensation, but in some patients may be the result of progression of hemodynamic changes leading to an outflow block in an otherwise well-compensated liver.1-4The high mortality of major surgical operations in either type of patient, with rapidly accumulating or uncontrolled chronic ascites, is well known. Unfortunately, the usual medical treatment, consisting of salt restriction, diuretics, high-protein diet, and, recently, prednisolone5and aldosterone antagonists,6usually requires several weeks or months for stabilization or disappearance of ascites. It has been shown that a reduced surgical mortality follows operations in patients whose ascites has been eliminated or controlled prior to operation.7Failure to accomplish such control is all too commonly followed by extensive edema in the wound and the bowel, poor wound healing, progressive hepatic decompensation, and death. In the past, the usual method of approaching

A Case of Choline Poisoning in Cattle

IN cattle at Kiriat Anavim (Palestine) the following pathological symptoms were observed. After the first calving the uterus did not contract but remained open and atonic for a considerable time, thus forming a source of secondary infections. This condition, which could not be influenced by the usual medical treatment, resulted frequently in inability to conceive and in abortions. No primary infectious disease could be found nor did anatomical or histological examinations of the sexual organs yield any result. The foodstuffs given were the same as employed, usually in Palestine dairy farming. They were not deficient in nutrients, minerals and vitamins. The only unusual foodstuffs given were wet brewer's grains, which formed a considerable part of the rations for some years. Infected barley is known to have had detrimental effects in some cases, owing to an excessive content of amines1, especially free choline2. Since normal barley generally does not contain appreciable amounts of free choline, we undertook to compare the brewer's grains with normal barley in respect to their choline contents.