Osteonecrosis of the jaw developing during bisphosphonate treatment

The article discusses osteonecrosis of the jaw as a possible side effect of bisphosphonate treatment. It provides practical guidelines for prevention, diagnosis and management of bisphosphonate-associated osteonecrosis according to literature and clinical evidence. Since controlled clinical trials have not been carried out, the recommendations are based on reviews, reports and clinical experience. Osteonecrosis of the jaw (ONJ) is a historical clinical entity, which can potentially develop in cancer patients receiving bisphosphonate therapy. The pathogenesis of ONJ has not been totally revealed yet. A thorough dental/oral surgical examination and counseling is recommended in cases when intravenous bisphosphonate therapy is needed. All required dental and surgical treatment should be carried out before starting bisphosphonate therapy to prevent ONJ. The patient should be informed about the possible side effects, and the importance of good oral home care and regular dental check-ups. Once the intravenous bisphosphonate therapy has started, only conservative manipulations should be carried out in the oral cavity. Even in case of developed ONJ, suspension of bisphosphonate therapy is not necessary. In these cases a non-surgical approach is recommended concerning the treatment of ONJ. Regarding the growing number of ONJ cases in association with bisphosphonate therapy it is important for the professionals treating cancer patients to be aware of this phenomenon and the importance of prevention.     

Long-term anticoagulation. Indications and management.

Each year half a million persons in the United States receive long-term anticoagulant therapy to prevent venous and arterial thromboembolism. Unfortunately, the relative benefits and risks of anticoagulant therapy have not been adequately quantified for many thromboembolic disorders, and the decisions as to whether, for how long, and how intensely to administer anticoagulation are often complex and controversial. Several expert panels have published recommendations for anticoagulant therapy for different thromboembolic disorders; the primary area of disagreement among these panels concerns the optimal intensity of anticoagulation. Recent research and analytic reviews have helped to clarify both the risk factors for and the appropriate diagnostic evaluation of anticoagulant-induced hemorrhage. Clinicians must be aware of the nonhemorrhagic complications of anticoagulant therapy, particularly during pregnancy. The administration of anticoagulants is difficult both in relation to dosing and long-term monitoring. Knowledge of the pharmacology of the anticoagulants, an organized approach to ongoing monitoring, and thorough patient education may facilitate the safe and effective use of these drugs.     

Small Bowel Obstruction Due to Intramural Hematoma During Anticoagulant Therapy—A Non-Surgical Condition

Intramural hematoma of the small bowel should be suspected in any patient with signs or symptoms of small bowel obstruction who is having anticoagulant drug therapy, especially if it is longterm therapy and if the prothrombin time is excessively prolonged. A barium study is indicated and if the roentgen pattern is characteristic, conservative treatment is indicated. Unless there is an associated abdominal lesion requiring operation, most patients will improve in four to six days. Those not improving usually have other complicating conditions.     

Prognostic factors for recurrence and survival in axillary node-negative breast cancer

The question of which node-negative breast cancer patients should be treated with adjuvant systemic therapy is a debatable topic. Our approach in San Antonio is to examine the risk profile for an individual patient and attempt to classify the patient into a good risk group or a high risk group in terms of disease recurrence. Features such as small tumor size (less than 2 cm), diploid tumors with low proliferative rate, and nuclear grade I, all indicate a good prognosis with a disease-free survival of approx. 90% at 5 yr. Examination of the cost vs benefits in this category of patients suggest that routine treatment with systemic adjuvant therapy is not appropriate.     

Accurate,reproducible measurement of blood pressure.

The diagnosis of mild hypertension and the treatment of hypertension require accurate measurement of blood pressure. Blood pressure readings are altered by various factors that influence the patient, the techniques used and the accuracy of the sphygmomanometer. The variability of readings can be reduced if informed patients prepare in advance by emptying their bladder and bowel, by avoiding over-the-counter vasoactive drugs the day of measurement and by avoiding exposure to cold, caffeine consumption, smoking and physical exertion within half an hour before measurement. The use of standardized techniques to measure blood pressure will help to avoid large systematic errors. Poor technique can account for differences in readings of more than 15 mm Hg and ultimately misdiagnosis. Most of the recommended procedures are simple and, when routinely incorporated into clinical practice, require little additional time. The equipment must be appropriate and in good condition. Physicians should have a suitable selection of cuff sizes readily available; the use of the correct cuff size is essential to minimize systematic errors in blood pressure measurement. Semiannual calibration of aneroid sphygmomanometers and annual inspection of mercury sphygmomanometers and blood pressure cuffs are recommended. We review the methods recommended for measuring blood pressure and discuss the factors known to produce large differences in blood pressure readings.     

Pregnancy and inflammatory bowel disease.

Conclusions about the relationship between the pathophysiology and treatment of inflammatory bowel disease and the physiology and management of pregnancy are based on the results of several large physician surveys and retrospective chart reviews. Patients with active disease fare worse than those with inactive disease. There is little evidence that pregnancy affects the course of inflammatory bowel disease or that inactive inflammatory bowel disease affects the course of pregnancy. Judicious medical therapy is effective in controlling inflammatory bowel disease during pregnancy. Sulfasalazine or steroid therapy should not be withdrawn in a patient who needs it to achieve or maintain a quiescent state of inflammatory bowel disease during the course of pregnancy. Immunosuppressive therapy should be avoided. Aggressive medical therapy with total parenteral nutrition in a team approach with a gastroenterologist, surgeon, and perinatologist usually avoids the need for surgical intervention during pregnancy with a good fetal outcome in a patient whose disease is active. Contraception against pregnancy need only be considered in those patients whose disease is so severe that operative therapy is imminent.     

ENDOMETRIOSIS

The cause of endometriosis is not known. The incidence of the disease is greater than was previously suspected and it probably is increasing. Nulliparous women are more likely to have endometriosis than are women who have had children.The commonest symptoms are lower abdominal pain, disturbance of menstruation, and dysmenorrhea, most often of the increasing or acquired type. Relative and absolute sterility are common partners of endometriosis.A better percentage of correct preoperative diagnoses should be obtained in view of present knowledge.Radical operation on women in the premenopausal age groups with endometriosis is resorted to in far too high a percentage of cases. The good results which can be attained with conservative therapy, including surgical and hormone therapy, should be stressed.There is some evidence that endocrine therapy may control endometriosis. The dangers attending these methods have not as yet been determined.     

Endometriosis

The cause of endometriosis is not known. The incidence of the disease is greater than was previously suspected and it probably is increasing. Nulliparous women are more likely to have endometriosis than are women who have had children. The commonest symptoms are lower abdominal pain, disturbance of menstruation, and dysmenorrhea, most often of the increasing or acquired type. Relative and absolute sterility are common partners of endometriosis.A better percentage of correct preoperative diagnoses should be obtained in view of present knowledge.Radical operation on women in the premenopausal age groups with endometriosis is resorted to in far too high a percentage of cases. The good results which can be attained with conservative therapy, including surgical and hormone therapy, should be stressed. There is some evidence that endocrine therapy may control endometriosis. The dangers attending these methods have not as yet been determined.     

NHS Diabetes guideline for the perioperative management of the adult patient with diabetes

These Joint British Diabetes Societies guidelines, commissioned by NHS Diabetes, for the perioperative management of the adult patient undergoing surgery are available in full in the Supporting Information. This document goes through the seven stages of the patient journey when having surgery. These are: primary care referral; surgical outpatients; preoperative assessment; hospital admission; surgery; post-operative care; discharge. Each stage is given its own considerations, outlining the roles and responsibilities of each group of healthcare professionals. The evidence base for the recommendations made at each stage, discussion of controversial areas and references are provided in the report. This document has two key recommendations. Firstly, that the management of the elective adult surgery patients should be with modification to their usual diabetes treatment if the fasting is minimized because the routine use of a variable rate intravenous insulin infusion is not recommended. Secondly, that poor preoperative glycaemic control leads to post-outcomes and thus, where appropriate, needs to be addressed prior to referral for surgery.     

Thrombotic risk stratification using computational modeling in patients with coronary artery aneurysms following Kawasaki disease

Kawasaki disease (KD) is the leading cause of acquired heart disease in children and can result in life-threatening coronary artery aneurysms in up to 25 % of patients. These aneurysms put patients at risk of thrombus formation, myocardial infarction, and sudden death. Clinicians must therefore decide which patients should be treated with anticoagulant medication, and/or surgical or percutaneous intervention. Current recommendations regarding initiation of anticoagulant therapy are based on anatomy alone with historical data suggesting that patients with aneurysms \(\ge \) 8 mm are at greatest risk of thrombosis. Given the multitude of variables that influence thrombus formation, we postulated that hemodynamic data derived from patient-specific simulations would more accurately predict risk of thrombosis than maximum diameter alone. Patient-specific blood flow simulations were performed on five KD patients with aneurysms and one KD patient with normal coronary arteries. Key hemodynamic and geometric parameters, including wall shear stress, particle residence time, and shape indices, were extracted from the models and simulations and compared with clinical outcomes. Preliminary fluid structure interaction simulations with radial expansion were performed, revealing modest differences in wall shear stress compared to the rigid wall case. Simulations provide compelling evidence that hemodynamic parameters may be a more accurate predictor of thrombotic risk than aneurysm diameter alone and motivate the need for follow-up studies with a larger cohort. These results suggest that a clinical index incorporating hemodynamic information be used in the future to select patients for anticoagulant therapy.     

Tratamiento de los adenomas hipofisarios clínicamente no funcionantes

Clinically nonfunctioning adenomas are the most frequent pituitary macroadenomas in adults. These tumors are characterized by the absence of detectable hormonal hypersecretion and are diagnosed when compression symptoms or hormonal deficiencies occur. The treatment of choice of macroadenomas is surgery, but tumoral resection is often incomplete or the patient develops tumoral recurrence. Medical therapy has been shown to produce modest tumoral reduction in some patients. Postoperative irradiation should be considered in patients with large tumoral remnants or enlargement of remnants during follow-up. Stereotactic radiotherapy has been developed to diminish the long-term complications of radiotherapy. Microadenomas tend to remain small and surveillance alone is recommended. The present article reviews the results of medical, surgical and radiation treatments.     

胰腺假性囊肿手术方式应根据囊肿具体位置制定

为筛选胰腺假性囊肿的手术方法,本研究选取胰腺假性囊肿患者73例,观察各患者手术治疗效果。73例患者中,行囊肿十二指肠吻合术者13例(A组),行囊肿胃吻合术者29例(B组),行囊肿空肠吻合术者19例(C组),行胰腺囊肿切除术者12例(D组)。研究发现,各组间术后复发率、吻合口瘘发生率、吻合口出血发生率、住院时间和治疗费用差异不显著(p>0.05);各组术后72 h丙氨酸氨基转移酶(ALT)、天门冬氨酸转氨酶(AST)和尿素氮(BUN)均较术前显著升高(p<0.05);术后72 h,各组间ALT、AST和BUN差异不显著(p>0.05)。研究表明,可根据胰腺假性囊肿具体位置制定合理的手术方案,取得较好的治疗效果,不同手术方式有其适应条件,不应盲目推崇某种手术方式。     

Thrombosis of Bj?rk-Shiley aortic valve prosthesis: report of three cases.

Thrombotic malfunction of a Björk-Shiley aortic valve prosthesis occurred in three patients 6 to 16 months postoperatively. None of the patients had been taking anticoagulants. Although the presentation was acute, prodromal symptoms could be identified retrospectively in two of the patients. Two patients survived thrombectomy. Postoperative anticoagulant therapy is recommended in patients with these prostheses despite factors that may make such therapy riskier in specific patients. Attention to the character of murmurs and of the closure sound of the prosthetic valve must be part of the routine follow-up. In the emergency situation, when delay must be avoided, catheterization and angiography are unnecessary. The operative approach consists of complete thrombectomy without replacement of the valve or any of its components unless there is obvious periprosthetic leak or prosthetic wear.     

Hemorrhage During Long-Term Anticoagulant Drug Therapy—Part IV: Selection and Management of Patients

Most serious hemorrhages that occur during long-term anticoagulant drug therapy are due either to poor patient selection or to poor management of the patient, or both.In each patient being considered for treatment, the risk of bleeding must be evaluated and classified as high, moderate or low.The clinician must especially assess the risk of intracranial hemorrhage in hypertensive patients, and must screen all patients for potential sources of gastrointestinal bleeding. There is ample time for such investigations, since initiating long-term anticoagulant therapy is not an emergency procedure.The desired level of prothrombin activity must be adjusted to the risks determined for each individual patient. There is no single “therapeutic range” applicable to all patients with their varying hemorrhagenic risks.Proper management includes sufficient laboratory testing to maintain the desired prothrombin level, and continued vigilance to detect signs of early bleeding.Preventable hemorrhage cannot be cited as evidence against the value of anticoagulant drug therapy.     

Heparin-induced thrombocytopenia

Thrombocytopenia is a frequent and sometimes insidious complication of anticoagulant therapy with heparin. Two types of heparin-induced thrombocytopenia with a distinct aetiology have been recognized. Type I is characterized by a mild thrombocytopenia of early onset which requires careful monitoring but usually not the cessation of heparin therapy. The mild thrombocytopenia is probably due to the mild pro-aggregatory properties of heparin and can be more severe in the presence of other predisposing factors, e.g. sepsis. Type II heparin-induced thrombocytopenia is more severe and usually occurs after a period of 7-10 days. Heparin therapy should be ceased immediately and other anticoagulant therapy initiated. The thrombocytopenia is believed to be due to the development of a heparin-dependent antibody that causes platelet aggregation and release. The precise mechanism of heparin-dependent antibody-platelet interaction is still not entirely clear but probably involves the binding of an antibody-heparin immune complex to the platelet Fc receptor.     

Not telling the truth in the patient-physician relationship

The presence of truth and honesty is a permanent demand, and becomes vital the more committed and intimate a relationship is. Medical practice is relevant to this discussion when one questions whether or not a physician should always tell their patient the truth in the face of a progressive or potentially fatal disease, regarding their diagnosis, outcome, therapy and evolution of the specific disease. From this discussion we aim, with the present report, to look at the truth applicable to the patient-physician relationship, and its ethical and moral implications; and also to look at where the Brazilian Code of Medical Ethics (BCME) and the medical literature stand regarding this issue. One concludes that there are only two moments not to tell a patient the truth: when the patient does not want to be informed, and when the truth could be iatrogenic. The question now is, when would the truth be iatrogenic? Physicians, in our opinion, would not be able to judge solitarily when the truth might be deleterious to their patient. Alternatively, we proposed the appointment of a multidisciplinary commission to help the doctor with such a decision.     

INDICATIONS FOR OPERATION IN GLAUCOMA

Prompt surgical operation is indicated in angle-closure glaucoma and in infantile glaucoma. Open-angle glaucoma is properly considered a disease for which conservative treatment should be tried.Operation is indicated in open-angle glaucoma when, despite maximal medical therapy, the intraocular pressure reaches a level at which the optic nerve is going to be damaged. Many factors must be considered in making a decision as to whether or not to operate in such circumstances, among them the condition of the eye, the result of previous operation if one has been done, the reliability of the patient with regard to carrying out a prescribed regimen, the age and physical condition of the patient, perhaps the race of the patient, the presence of cataracts and the attitude of both patient and surgeon toward surgical treatment.     

Ethical issues in recommending and offering fetal therapy

Fetal therapy should be offered and recommended for a viable fetus when these criteria are met: invasive therapy is reliably judged to have a high probability of being life-saving or of preventing serious and irreversible disease, injury, or disability for the fetus and for the child it can become; such therapy is reliably judged to involve low mortality risk and low or manageable risk of serious disease, injury, or disability to the viable fetus and the child it can become; and the mortality risk and the risk of disease, injury, or disability to the pregnant women is reliably judged to be low or manageable. When one or more of these criteria are not satisfied, intervention is experimental and can only be offered, not recommended, on the basis of benefit to future patients and the autonomy of the pregnant woman.     

Biogenic amines modulate synaptic transmission between identified giant interneurons and thoracic interneurons in the escape system of the cockroach.

In the escape system of the cockroach, Periplaneta americana, a population of uniquely identifiable thoracic interneurons (type A or TIAs) receive information about wind via chemical synapses from a population of ventral giant interneurons (vGIs). The TIAs are involved in the integration of sensory information necessary for orienting the animal during escape. It is likely that there are times in an animal's life when it is advantageous to modify the effectiveness of synaptic transmission between the vGIs and the TIAs. Given the central position of the TIAs in the escape system, this would greatly alter associated motor outputs. We tested the ability of octopamine, serotonin, and dopamine to modulate synaptic transmission between vGIs and TIAs. Both octopamine and dopamine significantly increased the amplitude of vGI-evoked excitatory postsynaptic potentials (EPSPs) in TIAs at 10(-4)-10(-2) M, and 10(-3) M, respectively. On the other hand, serotonin significantly decreased the vGI-evoked EPSPs in TIAs at 10(-4)-10(-3) M. These results indicate that octopamine, serotonin, and dopamine are capable of modulating the efficacy of transmission of important neural connections within this circuit.     

Venous thromboembolism and anticoagulant therapy in pregnancy

Background:Venous thromboembolism (VTE) is a leading cause of maternal mortality in western countries. Many of these deaths could be prevented by optimal prophylaxis and management.Objective:The aim of this study was to examine the current literature to assess the risk of VTE in pregnant women and to identify the most effective and safe anticoagulant therapy.Methods:A search was conducted using the major electronic databases of PubMed and MEDLINE 1996–October 2005 using the following key words: Pregnancy, venous thrombosis, thrombophilia, prosthetic heart valves, anticoagulants, heparin, low-molecular-weight heparin, coumarin, and warfarin.Results:The common risk factors for VTE during pregnancy are age >35 years, obesity, operative delivery, thrombophilia, and a family or personal history of VTE. Coumarins are unsuitable for use during pregnancy because of embryopathy and risk of fetal bleeding. Low-molecular-weight heparins (LMWHs), such as enoxaparin and dalteparin, are safer and more convenient than unfractionated heparin (UFH). LMWH is now the agent of choice for pharmacologic thromboprophylaxis and treatment of VTE during pregnancy. Women with a suspected VTE should receive anticoagulant therapy until an objective diagnostic test is performed, unless there is a clear contraindication to anticoagulation. If a VTE is confirmed, anticoagulant treatment should be continued throughout pregnancy. These patients usually, require at least 6 months of anticoagulation, and treatment should be continued until at least 6 weeks postpartum. Management of women with prosthetic heart valves in pregnancy is controversial; while coumarin treatment is more effective than UFH for thromboprophylaxis in the mother, UFH is associated with a better outcome for the fetus. Coumarin embryopathy can be avoided if heparin is substituted by 6 weeks' gestation. The limited data on LMWH in women with prosthetic heart valves suggest that it compares favorably with UFH.Conclusions:LMWH is now the anticoagulant of choice for the treatment and prevention of VTE in pregnancy. However, the management of women with prosthetic heart valves requiring anticoagulation in pregnancy remains controversial as coumarins appear safer for the mother, but heparin is associated with less fetal morbidity and data on LMWH are limited.