Ruptures of double-J ureteral catheter. Our experience and review of the literature

Follicular carcinoma, in association with other prognostic factors, identifies a class of "high-risk" patients in which a more aggressive treatment is indicated. In fact, in patients operated on for follicular carcinoma bone metastases, also many years after primary surgery, are reported. A case of skull metastases in a young women occurred 3 years after a near total lobectomy for follicular thyroid carcinoma is described. After six years the patient underwent total thyroidectomy, resection of skull metastases, radiometabolic therapy with I131 180 m Ci; now she is disease free at three years of follow-up. The biology of metastases in thyroid follicular carcinoma, risk factors and diagnostic and therapeutic controversies are analyzed. Good prognostic factors are considered age < 45 years, good degree of differentiation of primary tumor, small size of bone metastases and early appearance after primary diagnosis. The conclusions is drawn that bone metastases are the worst prognostic factors. In case of single lesion, surgical treatment allows good results.     

Lipoproteins and atherogenesis

Like many complex disease processes, atherogenesis represents the interaction of an array of genetic and environmental factors. From nonhuman animal models to the investigation of epidemiologic factors in man, no single, overriding cause for the development of this indolent vascular disease has been identified. However, the cholesterol-enriched lipoprotein particles are closely tied to the development of the disease. The genetic and environmental influences on the concentrations of specific lipoprotein subspecies provide a context for identifying patients at risk as well as for developing effective therapeutic strategies to influence and prevent the sequelae of atherogenesis.     

Immunosuppressive therapy of vasculitis: current aspects and perspectives

Vasculitides are a set of serious diseases of unknown aetiology with various immunopathogenetic mechanisms, characterized by inflammation and necrosis of the vessel wall with consequent lumen obliteration. They may be primitive or associated with other diseases, have heterogeneous clinical manifestations and different degrees of severity which may be related to the localization of the interested vessels. Although in the last years many classifications have been proposed, a standardized nomenclature of vasculitides is unquestionably still needed to facilitate the diagnosis and management of patients with the disease. Steroids and immunosuppressant are the conventional therapy, whereas other therapeutic strategies are reserved for the refractory vasculitides to conventional therapies or for intolerant recipients to cytotoxic drugs. New approaches are represented by monoclonal antibodies and drugs which could be effective in the treatment of the trigger factors which activate the immunopathological mechanisms. Current data suggest that, rather than pursuing the idea of a single therapy for vasculitides, an oncological model of combined therapy, to induce both the disease control and maintenance of remission, might be adopted. An improvement of our knowledges on the mechanisms underlying the different entities associated to standardized criteria of activity and remission of disease will lead to an improvement of our therapeutic strategies.     

多发性骨髓瘤骨病的靶向治疗进展

多发性骨髓瘤(MM)是血液系统恶件肿瘤,骨破坏是其最常见的并发症,骨相关事件严重影响MM患者的生活质量及预后.目前对于骨髓瘤骨病(MBD)的治疗原则仍以双膦酸盐类药物为主.近年来对MBD发病机制的认识及治疗均取得了新进展.现就目前已知参与MBD发病机制的重要细胞因子及靶向治疗相关进展进行综述.     

Effect of zidovudine therapy in patients with HIV infection on endogenous interferon plasma levels and the hepatic cytochrome P450 enzyme system

The authors describe the genetic, pathophysiology, diagnostic, and therapeutic aspects of total colonic aganglionosis and of aganglionosis extending to the small intestine. The pathogenesis of this disease is genetically determined and is related to the differentiation and migration of cells derived from neural crests. The clinical and radiological features can be useful in the diagnosis but they are not pathognomonic. The histochemical estimation of acetylcholinesterase activity in suction rectal biopsies is useful in establishing the diagnosis; however, the specimens should be examined by an experienced pathologist. The definitive diagnosis of either condition is obtained by performing intraoperative seromuscular biopsies of the rectum, colon, and ileum. From the therapeutic point of view, many surgical techniques have been proposed for the radical treatment of this disease. Some of the techniques have been derived from operations proposed for the treatment of classic Hirschsprung's disease; others have been specifically designed.     

Investigational drug therapies of treatment of multiple sclerosis

The licensing of interferon beta-1b dramatically changed the treatment of multiple sclerosis (MS) in the United States. Although it was the first therapeutic agent shown to affect the natural course of the disease, interferon beta-1b is not appropriate for all patients and is far from being a cure. Several other promising therapies now under study include immunosuppressive and immunomodulatory drugs to limit inflammation; oral administration of myelin to induce tolerance; monoclonal antibodies designed to deliver targeted immunotherapy; potassium channel blockers to facilitate conduction along demyelinated axons; and glial growth factors to promote remyelination. Clinical trials of potential therapeutic agents have proliferated in the past decade in conjunction with rapid advances in our understanding of the immunologic basis of MS. Some investigational therapies are associated with problematic toxicities, others benefit only a minority of patients, and many are still in the early stages of development. Nevertheless, because current therapeutic options are limited, and because the history of MS therapy is one of disappointment and frustration, it is essential that legitimate, scientifically based advances be widely disseminated to the neurologic community. This article reviews some of the most promising current and investigational therapies for MS.     

The desensitization of oxytocin receptors in human myometrial cells is accompanied by down-regulation of oxytocin receptor messenger RNA

Clinicians providing care to elderly patients must appreciate the subtle clinical manifestations that herald the onset of life-threatening infectious disease. Aged patients with an infection may have neither fever nor leucocytosis, making diagnosis challenging. Often, the early features of infectious disease are nonspecific and may resemble inflammatory or neoplastic processes, or there may be insufficient time to await definitive laboratory confirmation, and empirical antimicrobial treatment must be initiated. Aging involves inevitable deleterious alterations in biological processes and, in many elderly patients, this is most strongly characterised by diminished renal functional capacity. This has a major influence on antimicrobial prescribing in the elderly, because therapeutic efficacy must be achieved while minimising the risk of drug-related toxicity. Before prescribing an antibiotic to an aged patient with an infection, the clinician must be cognisant of the patient's drug allergy history and the other drugs that the patient is taking. Ignorance of potential drug-drug interactions can result in ineffective treatment or enhanced toxicity. The therapy of elderly patients with infections is being expanded. To reduce costs and enhance the efficiency of care, systems have been developed to provide antimicrobial care in the home and in long term care facilities. Home healthcare has burgeoned, and drugs that are well tolerated, have a broad spectrum of activity and are simple to administer (e.g. ceftriaxone and fluoroquinolones) appear to be eminently suitable for this therapeutic role. Physicians must also be informed of the factors responsible for the emergence of resistant bacteria that are contributing to infections in institutional and community settings. Clinicians should strive to curb inappropriate antibiotic use to stem the tide of infections that are caused by multidrug-resistant bacteria.     

Absence of modulating effects of cytokines on antioxidant enzymes in peritoneal mesothelial cells

Erectile dysfunction is a common (affecting 10-20 million men in the USA) and multifactorial disease due to organic and/or psychological factors that strongly impairs the quality of life in man. During the past decade many advances in the understanding of the pathophysiology of erectile dysfunction have been made and new therapeutic strategies have become available. It has been established that an insufficient production of nitric oxide by penile nerve terminals and/or vascular endothelium may result in an impaired erection or complete impotence. Nowadays, intracavernous injection of vasoactive drugs represents a standardized approach for the diagnosis, and the treatment of choice, for erectile dysfunction, but is not widely accepted by the patients. The possibility of treating erectile dysfunction with intraurethral administration of prostaglandin-E1 has recently become available in the USA, and is a therapy more acceptable to the patients. Other noninvasive medical therapies are undergoing evaluation.     

Atopic eczema between rationality and irrationality

A topic eczema is one of the most common chronic inflammatory skin diseases. Its treatment is a matter of intensive controversy between rational academic medicine and irrational alternative complementary medicine more than any other skin disease. Rational therapy is based on a sound pathophysiological foundation. The complex pathophysiology of the disease includes interactions between genetic predisposition and exogenous provocation factors, and treatment necessitates an integrated holistic approach. Despite excellent therapeutic results with the methods of conventional medicine, which uses mostly drugs of natural origin such as glucocorticosteroids, patients with atopic eczema and their parents frequently seek complementary treatments that use unproven and unvalidated diagnostic and therapeutic procedures. Treatments based on simplistic theories and irrational ideologies cause unnecessary long-term suffering to patients and are harmful because they withhold effective treatment modalities.     

Pulmonary fibrosis: cytokines in the balance

Pulmonary fibrosis can complicate diverse pulmonary and systemic pathologies. In many cases the underlying cause remains unidentified. Mortality from the disease is increasing steadily in the UK and USA. The clinical features are well-described, but patients frequently present at an advanced stage, and current treatments have not improved the poor prognosis. There is a compelling need to identify the fibrotic process earlier and to develop new therapeutic agents. Increased collagen deposition is central to the pathology and interest over the last decade has focused on the role of cytokines in this process. These polypeptide mediators are believed to be released from both circulating inflammatory and resident lung cells in response to endothelial and epithelial injury. Key cytokines currently implicated in the fibrotic process are transforming growth factor-beta, tumour necrosis factor-alpha and endothelin-1. This article outlines the evidence implicating these mediators in the pathogenesis of pulmonary fibrosis and also considers the possible role of cytokines with antifibrotic effects, such as interferon-gamma. The "balance" of positively and negatively regulating cytokines is discussed, and the potential for interaction with other factors including viruses, hormones and altered antioxidant status is also considered. Finally, potential novel therapeutic approaches are discussed, together with suggestions for future studies and clinical trials. As the outcomes of different avenues of research over the last ten years are brought together, it is clear that there is now a hitherto unrivalled opportunity to begin to tackle the treatment of this devastating disease.     

The decision-making process for the treatment of abnormal uterine bleeding

This pilot study was conducted to investigate the treatment decision-making process of patients and physicians for abnormal uterine bleeding (AUB). Frequently, women with AUB are referred for hysterectomy without diagnostic workup, alternative therapeutic management, or patient input (i.e., patient treatment preferences). Variations in treatment strategies used for patients may be related to a number of factors external to the patient's underlying disease. However, little is known about which factors are most influential or about the extent to which they influence physicians' and patients' decisions. We prospectively followed the management and treatment of 52 women with complaints of AUB and examined differences in treatment among these patients. Extensive previsit interviews were conducted with these women to identify each patient's symptoms, health status, functional status, and preferences for and expectations of treatment. We then conducted telephone interviews within a week of the visit and again 9-12 months later to determine the treatment plan, patient level of participation in and satisfaction with the treatment, symptoms, and functional status. Overall, our findings suggest that patients want to be involved in making treatment decisions and that when women were presented with alternatives to hysterectomy, many chose alternative medical therapy or other surgical procedures. In addition, women reported that these alternative treatments produced significant improvement in symptom intensity and functioning. Increased patient participation in decision making enhanced patient satisfaction. These findings suggest that hysterectomy rates may be decreased by offering women alternative treatments and by finding ways to increase women's participation in their treatment decisions.     

Hypertension: patient evaluation, indications for treatment

Hypertension in older adults is a prevalent problem with significant morbid consequences, including cerebrovascular, cardiac, and renal disease. Recent studies have established a firm rationale for drug therapy in this population, and therapeutic developments have made effective treatment possible. Patient evaluation includes searches for secondary causes, risk factors for cardiovascular disease, and comorbidity. Antihypertensive therapy requires lifestyle interventions aimed at addressing overall cardiovascular risk factors. Drug therapy decisions are based on level of hypertension, side effects, and comorbid conditions. Older patients can be treated safely and effectively with any of the available antihypertensive agents, but drug selection should be individualized.     

Clonal expansion of T-cells in measles

Videolaparoscopic cholecystectomy is considered the treatment of choice for simple cholelithiasis. Now many surgeons consider the laparscopic procedure usable also in the complicated biliary lithiasis like acute cholecystitis and choledocholithiasis. The authors report their recent experience of the laparoscopic treatment of biliary lithiasis, regarding 221 non-selected patients (69% symptomatic cholelithiasis, 20% chronic cholecystitis, 4.5% acute cholecystitis, 4.5% coledocolithiasis, 2% hydrops). The diagnostic-therapeutic protocol and the results are described and compared with the beginning of their experience, when they treated only symptomatic gallbladder stone disease, and with the reports of the literature. The authors concluded that the laparoscopic procedure is a good chance for the surgeon in the treatment of all cases of benign biliary disease. But, in particular for patients with choledocholithiasis, he has be able to know all the diagnostic and therapeutic possibilities, to choose the best in every single case.     

Cytokines in rheumatoid arthritis: new therapeutic possibilities

The ingress of inflammatory leukocytes into the synovium is important for the pathogenesis of rheumatoid arthritis. Soluble inflammatory mediators regulate the inflammatory, chemotactic, adhesive, angiogenic events, as well as osteopenia associated with this disease. In this review authors discuss the role of a number of inflammatory mediators, such as cytokines, chemokines and growth factors in these processes. The outcome of arthritis is highly dependent on the imbalance between pro-inflammatory and anti-inflammatory mediators. Cytokine-related research also has important clinical relevance. Many of these proteins are detectable in the serum of rheumatoid patients and may eventually serve as useful laboratory markers of disease activity. Antirheumatic therapy currently used for the treatment of rheumatoid arthritis is often limited. Therefore, we need to consider alternative therapeutic regimens, such as the inhibition of cytokines and other soluble mediators, in order to prevent severe joint destruction. While there are many complex interactions involving cytokine networks and cascades in the arthritic joint, there are promising attempts to eliminate a single cytokine in clinical trials, such as ablation of tumor necrosis factor-alpha. Hopefully, the study of cytokines and their networks will lead to specific immunomodulatory therapies that will benefit rheumatoid patients by preventing joint destruction.     

Rheumatoid polyarthritis: therapeutic management

AN OPEN QUESTION: Developing a therapeutic strategy for rheumatoid arthritis is a difficult and much debated task. Recent clinical trials have confirmed the importance of initiating treatment at the onset of disease in all patients with rheumatoid arthritis in order to limit the degree of later progression. INDIVIDUALIZED REGIMENS: Treatment for patients with early-stage rheumatoid arthritis should be adapted individually taking into consideration the expected benefit and risks of drug therapy, the degree of joint inflammation and factors predictive of disease severity which are becoming more and more well understood. PATIENTS IN REMISSION: Treatment should be continued if well tolerated. Treatment should not be discontinued (and then only progressively) unless complete remission has been achieved for a long period. LONG-STANDING DISEASE: The precise therapeutic strategy in patients with long-standing disease remains a question of debate, but does require full-dose combination regimens.     

Physical therapy in low back pain

We report on physical measures in the treatment of patients with lower back pain due to mechanical factors. Acute low back pain improves mostly without specific measures. Intervention for this condition is useful for prevention of relapses. More demanding and difficult is the treatment of chronic lumbar back pain. After an exact diagnosis, information about the disease, the therapeutic procedure and the prognosis follow in order to agree on a common therapeutic goal. To this goal, a close cooperation between physician, physiotherapist, possibly a psychologist and a social worker, is optimal. The employer should be involved in the rehabilitation on the workplace. Patients should become mobilized inspite of pain, and the return to their workplace should be prepared step by step. The most important physiotherapeutic modalities are demonstrated.     

Pharmacologic management of peripheral vascular disease

Although our understanding of the pathophysiology of atherosclerosis and peripheral vascular disease continues to grow, we have yet to discover a medication that can safely and efficaciously be given to most claudicants that will alleviate their symptoms to prevent disease progression. Many patients with intermittent claudication improve or remain stable without therapy if they attempt to alter their risk factors (e.g., control of diabetes, smoking cessation, lowering of cholesterol levels). However, many require concomitant drug therapy to alleviate symptoms of PVD, and some require surgical intervention. Even with the recent advances in therapeutic development and the promise of agents currently in clinical trials, the questions of who to treat, when treatment should begin, and which agent to use remain uncertain.     

Diet and gene expression in the intestine

Gene expression is central to the pathogenesis of many disorders. An ability to alter the expression of genes would, if their relationship to disease processes were fully understood, constitute a new modality of treatment. This review examines the evidence that nutritional factors can regulate genes in the gastrointestinal epithelium and it discusses the physiological relevance of such alterations in gene expression. Dietary regulation of the genes expressed by the epithelium confers three fundamental advantages for mammals. It enables the epithelium to adapt to the luminal environment to digest and absorb food better; it provides the means whereby mother's milk can influence the development of the gastrointestinal tract; when the proteins expressed by the epithelium act on the immune system, it constitutes a signalling mechanism from the intestinal lumen to the body's defences. Each of these mechanisms is amenable to manipulation for therapeutic purposes.     

Menopause: when hormone replacement therapy is not an option. Part I

Although the perimenopausal period is often experienced as a positive life transition, it is frequently accompanied by a variety of distressing physical and emotional sequelae. Hormone replacement therapy (HRT) has been hailed as the first-line treatment for many of these symptoms. A significant number of women, however, are unable to take exogenous hormones because of absolute or relative contraindications to therapy. Other women are unwilling to use this treatment for a variety of reasons, including reluctance to use unnatural exogenous hormones and fear of unknown risks of HRT. This two-part review discusses the physiology of menopause and its related symptoms, as well as the risks and benefits of both oral and non-oral routes of hormone administration. Self-help measures and alternative therapeutic options are recommended for the treatment of menopausal symptoms, which include vasomotor instability, urogenital atrophy, psychologic disturbances, and risk of osteoporosis and cardiovascular disease.     

Vulnerability to schizophrenia and psychotherapeutic treatment of schizophrenic patients: towards an integrated view

My approach to schizophrenia and its treatment has evolved gradually over my forty-year experience as a family researcher and a psychotherapist to schizophrenic patients. I am convinced that we must maintain a comprehensive view, both with regard to the factors contributing to vulnerability to schizophrenia and concerning our treatment activities, and not limit our views with studies focusing on restricted spheres of interest. I will present some viewpoints concerning both the biological and the psychosocial factors contributing to the vulnerability to schizophrenia. My aim is to indicate that these factors are heterogeneous and differently weighted in different cases. However, an integrated notion of the pathways leading to schizophrenia can be proposed. I will also review the therapeutic approach-the need-adapted treatment of schizophrenic psychoses-which I and my coworkers have developed in Finland and which, in many respects, is related to these views.