SUBCLINICAL HYPOTHYROIDISM—Recognition and Treatment

Often patients in whom there is little to suggest myxedema or cretinism have subclinical hypothyroidism. Once the condition is suspected, it can be diagnosed by determination of protein-bound iodine and, if the PBI is low, by response to therapy with thyroid hormone.Patients in the following categories should have protein-bound iodine determination: Those having (1) a history of previous treatment for hypothyroidism; (2) suboptimal development in children; (3) ovarian dysfunction, infertility, habitual abortion or unusual menopausal disorders; (4) symptoms of malaise and debility, such as undue fatigue, somnolence, mental asthenia and anxiety; (5) unexplained anemia; (6) colloid goiter, adenomatous goiter and cancer of the thyroid gland.If hypothyroidism is diagnosed, administration of thyroid hormone in increasing amounts, as determined by serial serum PBI tests, should be carried out indefinitely. Instruction of the patient is essential.     

Part III – Treatment of Ureterovesical Reflux

Of 134 girls with demonstrable ureterovesical reflux, 61 (105 ureters) had the reflux surgically corrected with an overall surgical cure rate of 97 percent. In the remaining 73 children (112 ureters), the reflux was treated conservatively with medical management alone. During the follow-up period no significant differences were demonstrated in the overall incidence of urinary tract infection; two years following corrective operation or medical treatment more than 50 percent of both medically and surgically treated children were still experiencing infections. A pronounced decrease, however, occurred in the incidence of clinical pyelonephritis among the surgically treated group. Following correction of reflux, the incidence of pyelonephritis was similar in both medically and surgically treated cases and was approximately the same as that found in a comparable group of children without reflux.In approximately two-thirds of refluxing renal units in which there was evidence of clubbing and scarring before medical or surgical therapy, deterioration progressed during the follow-up period. In most of these cases infection control was felt to be inadequate with episodes of clinical pyelonephritis occurring during the period of medical management, or, in the surgically treated group, occurring just before corrective operation and the scar appearing within two years after operation.The majority of renal units in which calyceal clubbing and parenchymal scarring was present had the most severe grades of reflux.     

COCCIDIOIDOMYCOSIS—Treatment with Isonicotinic Acid Hydrazide

Since coccidioidal granulomas are histologically indistinguishable from tuberculous granulomas, a long course of isonicotinic acid hydrazide therapy was tried experimentally in three cases of coccidioidomycosis, with good results. In two cases the disease was far advanced and prognosis poor before INH therapy was begun. In one case the disease was mild and symptoms abated after a short course of small doses of INH. It recurred when INH therapy was discontinued, and again resolved when larger doses of INH were given over a longer period.INH seemed to have an effect on appetite also, although the patients were taking B-complex vitamins both before and during INH treatment. The three patients ill with coccidioidomycosis averaged a weight gain of four and a half pounds a month during the period of INH therapy. Six well persons who were underweight and lacked appetite were given INH without other drugs, and they then had an increase in appetite and in weight.     

CARCINOMA OF THE PROSTATE—Diagnosis and Treatment

About 28 per cent of men between the ages of 71 and 75 have cancer of the prostate. Many of them do not die of the disease, but with the life span ever increasing, this problem is becoming more important.In the early stages the condition is asymptomatic; when the symptoms of urinary obstruction arise, the cancer is usually too advanced for cure. Cure depends on early diagnosis and, therefore, on routine rectal examination. The solitary hard nodule of early prostatic cancer becomes a stony hard fixed prostate as the condition progresses. X-ray and acid phosphatase studies are of help only after the cancer has metastasized. As many as 50 per cent of patients with rectally palpable early carcinoma of the prostate can be cured by radical perineal prostatectomy. Often, simple enucleation or transurethral resection is sufficient to effect cure in the case of occult carcinoma. However, some observers believe that when cancer is detected by microscopic examination of a prostate that has been removed, a radical operation should be done as soon after the initial operation as feasible. Early orchidectomy and estrogen therapy are of considerable help in slowing the process of advanced prostatic cancer and may postpone the need of transurethral resection to relieve obstruction. When these measures fail, bilateral adrenalectomy, cortisone therapy, pituitary irradiation, and pituitary extirpation have been employed, with moderate success, in an effort to diminish the androgen level.     

TETANUS—Prophylaxis and Treatment of the Disease

Cleansing and debridement is paramount in dealing with tetanus-prone wounds (severe crushing injuries, piercing wounds, blisters and burns are outstanding examples, particularly if contaminated with dirt, grass or other debris).Prophylaxis then is relatively easy in persons who have been actively immunized by toxoid injections. For them, a “booster” injection is indicated.Use of antitoxin, however, is hazardous, whether for prophylaxis or for treatment of the disease. Since it may in itself cause severe disease, including anaphylactic reaction and serum sickness, decision to use it must be weighed against the possibility of the development of tetanus in each case.To prepare for use of it, careful history should be taken, with particular reference to sensitivity to horse dander. Dermal tests, and perhaps ophthalmic tests, for sensitivity to the serum should be carried out. Even the tests may be hazardous and precautions should be taken accordingly.If it is decided that the use of antitoxin is necessary even though the patient is sensitive to the material, desensitization must be carried out promptly, with adequate preparation for severe reaction.There is experimental evidence that antibiotics of the tetracycline group, given soon after injury, may have prophylactic effect against tetanus.     

Treatment of melanoma; success or failure?

The treatment of melanoma should be by radical surgical excision of the primary lesion and dissection of the regional nodes. Where possible this should be done in anatomic continuity; otherwise in physical discontinuity but at the same time. If maximum salvage is to be achieved the nodal dissection must be effected before there is clinical evidence of involvement by metastasis. Amputation of extremities should be reserved for cases in which there is evident metastasis between the original focus and the regional lymph node areas.     

HIV Treatment as Prevention: Modelling the Cost of Antiretroviral Treatment��State of the Art and Future Directions

Policy discussions about the feasibility of massively scaling up antiretroviral therapy (ART) to reduce HIV transmission and incidence hinge on accurately projecting the cost of such scale-up in comparison to the benefits from reduced HIV incidence and mortality. We review the available literature on modelled estimates of the cost of providing ART to different populations around the world, and suggest alternative methods of characterising cost when modelling several decades into the future. In past economic analyses of ART provision, costs were often assumed to vary by disease stage and treatment regimen, but for treatment as prevention, in particular, most analyses assume a uniform cost per patient. This approach disregards variables that can affect unit cost, such as differences in factor prices (i.e., the prices of supplies and services) and the scale and scope of operations (i.e., the sizes and types of facilities providing ART). We discuss several of these variables, and then present a worked example of a flexible cost function used to determine the effect of scale on the cost of a proposed scale-up of treatment as prevention in South Africa. Adjusting previously estimated costs of universal testing and treatment in South Africa for diseconomies of small scale, i.e., more patients being treated in smaller facilities, adds 42% to the expected future cost of the intervention.     

Dupuytren's Contracture—Etiology and Principles of Treatment

Although Dupuytren''s contracture was first described more than 300 years ago, the cause is not yet certainly known. It is only agreed that the disease process affecting the palmar fascia is most commonly found in older-aged males of Caucasian descent.Conservative or non-surgical treatment is usually ineffective. Surgical treatment includes fasciotomy, partial fasciectomy and total fasciectomy. Fasciotomy is indicated for localized disease or for patients with medical conditions which preclude more extensive operation. Subtotal fasciectomy with or without skin graft is the most commonly employed procedure. Total palmar fasciectomy is seldom indicated. Improved function of the hand can be anticipated after adequate surgical intervention.     

RECURRENT CARCINOMA OF THE RECTUM—Surgical Treatment

Following operations on the rectum for carcinoma, approximately half of the patients have recurrence in the perineum, pelvis, abdomen or at the suture line of anastomosis. The prognosis is almost uniformly poor and although the problems of management are complicated, dealing with them may give the patient worthwhile physical, emotional and economic benefits. Surgical procedures used in the treatment of the common types of recurrence are discussed.     

BRONCHIAL ASTHMA IN ADULTS—Causes and Treatment

Food and inhalant allergens were of about equal importance in producing bronchial asthma in 907 adults between the ages of 15 and 55 years.Drug and especially bacterial allergens were infrequent causes.Psychogenic factors may activate or exaggerate causes mentioned but were not the sole cause of any case in this series.Food allergens are best studied and controlled by the standardized cereal-free elimination diet and at times other elimination diets. Test-negative diets usually fail because of the fallibility of both negative and positive skin tests.Inhalant allergy is controlled by the elimination of causative allergens by varying degrees of environmental control and often by pollen and dust filters in the window. Desensitization is necessary against those allergens that cannot be removed from the environment. Dilutions in the millions and billions may be required.Morphine and other opiates, Demerol, chloral, paraldehyde and large or moderate doses of barbiturates are contraindicated in bronchial asthma, as emphasized by deaths resulting from the use of them.Bronchoscopy is indicated for bronchial obstruction due to inspissated mucous plugs, but the danger of the procedure, especially with much sedation, must be recognized.When secondary infection is probable, the use of sulfadiazine, penicillin, aureomycin and chloramphenicol must be considered.     

VARICOSE VEINS—A Practical Approach to Treatment

Adequate treatment of varicose veins requires thorough mapping of perforating veins, communicating veins and “blow out” areas. Combined ligations, stripping and injection of sclerotic substances after operation is the most effective regimen of therapy.The technique of stripping is facilitated by isolating the saphenous vein at the ankle, inserting the stripper from below upward, then making a transverse groin incision over the palpable stripper. The tip of the stripper should be twice the diameter of the vein to be removed. Stripping should be done with the patient in the Trendelenburg position.All patients must be examined at regular intervals after operation and injection of sclerosing material carried out as necessary.