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Refractory Cases (refractory + case)
Selected AbstractsREFRACTORY DIVERTICULAR COLITIS WITH PROGRESSIVE ULCERATIVE COLITIS-LIKE CHANGES EXTENDING TO THE RECTUMDIGESTIVE ENDOSCOPY, Issue 3 2009Tateki Yamane A 68-year-old man visited our department because of diarrhea and bloody stools. Colonoscopy revealed diverticula scattered in the sigmoid colon with localized mucosal edema and reddening. The mucosa became somewhat rough 9 months later, and had an erosive, ulcerative colitis (UC)-like appearance after a further 6 months, with these changes extending to the rectum. These findings led to a diagnosis of diverticular colitis (DC) with UC-like changes. The condition was refractory to treatment including drug therapy and was thus surgically treated. No cases of DC have been reported in Japan, and a refractory case of DC with progressive UC-like changes extending to the rectum is rare even in Europe and the USA. [source] Multimodal management, including precisely targeted irradiation, in a severe refractory case of Evans syndromePEDIATRIC BLOOD & CANCER, Issue S5 2006Thomas D. Miale MD Abstract A challenging case of acute autoimmune thrombocytopenia (ITP) which evolved into a chronic refractory case of Evans syndrome over a period of more than 23 years is presented and may illustrate current therapeutic dilemmas now perplexing patients and clinicians. Newer modalities are being developed and their eventual role in the scheme of clinical management remains to be established. While this development unfolds, highly targeted radiotherapy was applied in this case to reduce platelet uptake by a refractory recurrent splenule with the goal of stabilizing the platelet count until promising investigational thrombopoietic agents or other newer, less toxic therapies might become available for wider application. Pediatr Blood Cancer 2006;47:726,728. © 2006 Wiley-Liss, Inc. [source] Chronic cystic ovarian disease in a Holstein cowAUSTRALIAN VETERINARY JOURNAL, Issue 1-2 2005AM PADULA Cystic ovarian follicles are commonly found during rectal examination of early postpartum dairy cows, usually presenting with anoestrus and occasionally nymphomania. Most cases self cure with time, or respond to exogenous hormonal treatment. This case report describes a refractory case in a Holstein cow in which a novel treatment approach was used. A gonadotrophin releasing hormone agonist implant was inserted for 180 d in an attempt to suppress pituitary gonadotrophin output, arrest abnormal ovarian follicle growth and prevent steroidogenesis. Frequent serial blood samples were collected before and after implant insertion to monitor changes in pulse release of luteinising hormone. Follow up ultrasound scans and blood samples were done to monitor ovarian structures; progesterone and oestradiol were collected at various times over the 180 d period. A normal, cycling herdmate was enrolled as a control. Prior to implant insertion, high frequency and low amplitude luteinising hormone pulses were detected in the cystic cow. Insertion was followed by a sustained surge in the release of luteinising hormone in both cows, but ovulation was not induced in the cystic cow. Plasma oestradiol levels remained consistently elevated and signs of oestrous behaviour were observed. Long term gonadotrophin releasing hormone agonist treatment failed to suppress either ovarian steroid production or cause regression of the cysts by 180 d. [source] Thalidomide for the treatment of multiple myelomaCONGENITAL ANOMALIES, Issue 3 2004Yutaka Hattori ABSTRACT Although thalidomide was withdrawn in the 1960s after its teratogenic property was recognized, it was subsequently found that this drug possesses immunomodulatory and anti-inflammatory effects. Recent studies have also demonstrated that thalidomide has antineoplastic activity via an antiangiogenic mechanism. Observations in the late 1990s that the microenvironment in the bone marrow plays a role in tumor progression in multiple myeloma provided an impetus to use thalidomide for the treatment of this disease. It is known that thalidomide monotherapy is effective in one-third of refractory cases, and in combination with glucocorticoids and/or antineoplastic drugs, thalidomide provides a response rate of more than 50%. Thus, thalidomide therapy is considered a standard approach for the treatment of relapsed and refractory myeloma. The exact mechanism of the antimyeloma effect of thalidomide is not yet clearly understood. Anti-angiogenic effects, direct activity in tumor cells such as the induction of apoptosis or G1 arrest of the cell cycle, the inhibition of growth factor production, the regulation of interactions between tumor and stromal cells, and the modulation of tumor immunity have been considered as possible mechanisms. In addition to its teratogenicity, the adverse effects of thalidomide have been general symptoms such as somnolence and headache, peripheral neuropathy, constipation, skin rash, and other symptoms. Although these adverse effects are generally reversible and mild, grade 3 and 4 toxicities such as peripheral neuropathy, deep venous thrombosis, neutropenia, and toxic dermal necrosis have occasionally been reported. The application of thalidomide therapy in patients with multiple myeloma is being broadened to include not only cases of refractory myeloma, but also previously untreated cases, as well as for maintenance therapy after hematopoietic stem cell transplantation and for the treatment of other hematological diseases. The safe use of this drug will depend on the establishment of diagnostic and treatment guidelines. In addition, the establishment of a nation-wide regulation system is urgently needed in Japan. [source] Felbamate in Experimental Model of Status EpilepticusEPILEPSIA, Issue 2 2000Andrey M. Mazarati Summary: Purpose: To examine the putative seizure-protective properties of felbarnate in an animal model of self-sustaining status epilepticus (SSSE). Methods: SSSE was induced by 30-min stimulation of the perforant path (PPS) through permanently implanted electrodes in free-running male adult Wistar rats. Felbarnate (FBM; 50, 100, and 200 mg/kg), dizepam (DZP; 10 mg/kg), or phenytoin (PHT; 50 mg/kg) were injected i.v. 10 min after SSSE induction. Electrographic manifestations of SSSE and the severity of SSSE-induced neuronal injury were analyzed. Results: Felbamate injected during the early stages of SSSE (10 min after the end of PPS), shortened the duration of seizures in a dose-dependent manner. Total time spent in seizures after FBM and 290 ± 251 min (50 mg/kg), 15.3 ± 9 min (100 mg/kg), and 7 ± 1 min (200 mg/kg), whereas control animals spent 410 ± 133 min seizing. This effect of FBM was stronger than that of DZP (10 mg/kg, 95 ± 22 min) and comparable to that of PHT (50 mg/kg, 6.3 ± 2.5 min). In the applied doses, FBM (200 mg/kg) was more effective than PHT (50 mg/kg) or DZP (10 mg/kg) in shortening seizure duration and decreasing spike frequency, when administered on the pleateau of SSSE (injection 40 min after the end of PPS). Anticonvulsant action of FBM was confirmed by milder neuronal injury compared with control animals. Conclusions: Felbamate, a clinically available AED with a moderate affinity for the glycine site of the NMDA receptor, displayed a potent seizure-protective effect in an animal model of SSSE. These results suggest that FBM might be useful when standard AEDs fail in the treatment of refractory cases of SE. [source] Factor V deficiency: a concise reviewHAEMOPHILIA, Issue 6 2008J. N. HUANG Summary., Factor V (FV; proaccelerin or labile factor) is the plasma cofactor for the prothrombinase complex that activates prothrombin to thrombin. FV deficiency can be caused by mutations in the FV gene or in genes encoding components of a putative cargo receptor that transports FV (and factor VIII) from the endoplasmic reticulum to the Golgi. Because FV is present in platelet ,-granules as well as in plasma, low FV levels are also seen in disorders of platelet granules. Additionally, acquired FV deficiencies can occur in the setting of rheumatologic disorders, malignancies, and antibiotic use and, most frequently, with the use of topical bovine thrombin. FV levels have limited correlation with the risk of bleeding, but overall, FV-deficient patients appear to have a less severe phenotype than patients with haemophilia A or B. The most commonly reported symptoms are bleeding from mucosal surfaces and postoperative haemorrhage. However, haemarthroses and intramuscular and intracranial haemorrhages can also occur. Because no FV-specific concentrate is available, fresh frozen plasma remains the mainstay of treatment. Antifibrinolytics can also provide benefit, especially for mucosal bleeding. In refractory cases, or for patients with inhibitors, prothrombin complex concentrates, recombinant activated FVIIa, and platelet transfusions have been successfully used. Some patients with inhibitors may also require immunosuppression. [source] Etiology and Management of Chylothorax Following Pediatric Heart SurgeryJOURNAL OF CARDIAC SURGERY, Issue 4 2009Michael Milonakis M.D. The purpose of this study was to review our experience with the management of chylothorax following congenital heart surgery. Methods: Between September 1997 and August 2006, of 1341 pediatric patients undergoing correction of congenital heart disease in our institution, 18 (1.3%) developed chylothorax postoperatively. Surgical procedures included tetralogy of Fallot repair in 10 patients, ventricular septal defect closure (one), atrial septal defect with pulmonary stenosis repair (one), Fontan procedure (three), coarctation of the aorta repair (one), aortopulmonary shunt (one), and ligation of patent ductus arteriosus in one patient. All patients followed a therapeutic protocol including complete drainage of chyle collection and controlled nutrition. Somatostatin was used adjunctively in six (33.3%) patients. Surgical intervention was reserved for persistent lymph leak despite maximal therapy. Following resolution of chylothorax, a medium-chain triglyceride diet was implemented for six weeks. Results: There were no deaths. Fifteen patients (83.3%) responded to conservative therapy. Lymph leak ranged from 2.5 to 14.7 mL/kg per day for 8 to 42 days. Three patients with persistent drainage required thoracotomy with pleurodesis to achieve resolution, in two of which previously attempted chemical pleurodesis with doxycycline proved ineffective. Duration of lymph leak in this subgroup ranged from 15 to 47 days with 5.1 to 7.4 mL/kg per day output. Conclusions: Postoperative chylothorax is an infrequent complication of surgery for congenital heart disease and can occur even after median sternotomy in the absence of pathologically elevated venous pressure or Fontan circulation. Although hospitalization can be prolonged, conservative therapy is effective in most cases, while surgical pleurodesis proved successful in the refractory cases. [source] ETFAD/EADV eczema task force 2009 position paper on diagnosis and treatment of atopic dermatitisJOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY & VENEREOLOGY, Issue 3 2010U Darsow Abstract Background, The diagnosis of atopic dermatitis (AD) is made using evaluated clinical criteria. Management of AD must consider the symptomatic variability of the disease. Methods, EADV eczema task force developed its guideline for atopic dermatitis diagnosis and treatment based on literature review and repeated consenting group discussions. Results and Discussion, Basic therapy relies on hydrating topical treatment and avoidance of specific and unspecific provocation factors. Anti-inflammatory treatment based on topical glucocorticosteroids and topical calcineurin antagonists is used for exacerbation management and more recently for proactive therapy in selected cases. Topical corticosteroids remain the mainstay of therapy, but the topical calcineurin inhibitors, tacrolimus and pimecrolimus are preferred in certain locations. Systemic anti-inflammatory treatment is an option for severe refractory cases. Microbial colonization and superinfection may induce disease exacerbation and can justify additional antimicrobial/antiseptic treatment. Systemic antihistamines (H1) can relieve pruritus, but do not have sufficient effect on eczema. Adjuvant therapy includes UV irradiation preferably of UVA1 wavelength or UVB 311 nm. Dietary recommendations should be specific and given only in diagnosed individual food allergy. Allergen-specific immunotherapy to aeroallergens may be useful in selected cases. Stress-induced exacerbations may make psychosomatic counselling recommendable. ,Eczema school' educational programmes have been proven to be helpful. [source] Position paper on diagnosis and treatment of atopic dermatitisJOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY & VENEREOLOGY, Issue 3 2005U Darsow ABSTRACT The diagnosis of atopic dermatitis (AD) is made using evaluated clinical criteria. Management of AD must consider the symptomatic variability of the disease. It is based on hydrating topical treatment, and avoidance of specific and unspecific provocation factors. Anti-inflammatory treatment is used for exacerbation management. Topical corticosteroids remain the first choice. Systemic anti-inflammatory treatment should be kept to a minimum, but may be necessary in rare refractory cases. The new topical calcineurin inhibitors (tacrolimus and pimecrolimus) expand the available choices of topical anti-inflammatory treatment. Microbial colonization and superinfection (e.g. with Staphylococcus aureus, Malassezia furfur) can have a role in disease exacerbation and can justify the use of antimicrobials in addition to the anti-inflammatory treatment. Evidence for the efficacy of systemic antihistamines in relieving pruritus is still insufficient, but some patients seem to benefit. Adjuvant therapy includes ultraviolet (UV) irradiation preferably of UVA wavelength; UVB 311 nm has also been used successfully. Dietary recommendations should be specific and only given in diagnosed individual food allergy. Stress-induced exacerbations may make psychosomatic counselling recommendable. ,Eczema school' educational programmes have proved to be helpful. [source] Exploring the clinical utility of the Development And Well-Being Assessment (DAWBA) in the detection of hyperkinetic disorders and associated diagnoses in clinical practiceTHE JOURNAL OF CHILD PSYCHOLOGY AND PSYCHIATRY AND ALLIED DISCIPLINES, Issue 4 2009David Foreman Background:, The clinical diagnosis of ADHD is time-consuming and error-prone. Secondary care referral results in long waiting times, but primary care staff may not provide reliable diagnoses. The Development And Well-Being Assessment (DAWBA) is a standardised assessment for common child mental health problems, including attention deficit/hyperactivity disorder (ADHD), which can be rapidly scored by skilled specialist clinicians, who may be remote from the interview, thus avoiding referral. Method:, A representative clinic sample of routine cases suspected of ADHD underwent an assessment which included the DAWBA alongside a confirmatory assessment with a skilled clinician. Another clinician provided DAWBA-based diagnoses blind to the clinic view. Bayesian statistical modelling was used to include clinic diagnostic uncertainty in the analyses. Results:, Eighty-four cases were assessed. For ADHD, the predictive value of a positive or negative DAWBA diagnosis was greater than .8, with negligible bias. Non-hyperkinetic behaviour disorders had higher, emotional and autistic disorders lower predictive values, though all greater than .75: there was, however, evidence of bias. Conclusions:, Diagnoses of ADHD based on senior clinician review of the DAWBA completed by parents, teachers and young people aged 11 plus may be sufficiently accurate to permit clinical diagnosis without direct patient contact by the diagnosing clinician. This could improve access to accurate diagnoses of ADHD in primary care while freeing up senior clinicians to focus on complex and refractory cases in secondary care. [source] Treatment of canine leproid granuloma syndrome: preliminary findings in seven dogsAUSTRALIAN VETERINARY JOURNAL, Issue 1 2001R MALIK Objective To determine effective treatment strategies for patients with refractory canine leproid granuloma syndrome. Design Multi-institutional retrospective/prospective case series using client-owned dogs. Procedure Seven dogs (four Boxers, one Dobermann, one Bullmastiff and one Bullmastiff cross-bred; ages 3 to 11 years) with leproid granulomas were treated successfully using a variety of treatment regimens. These cases were recruited because: lesions were either widely distributed over the dog; progressive, despite routine therapy, or were associated with particularly disfiguring lesions. The treatment regimen evolved during the course of the clinical study. Results Combination therapy using rifampicin (5 to 15 mg/kg PO, every 24 h) and clarithromycin (8 to 24 mg/kg PO daily; dose divided every 8 or every 12 h) was used most frequently and proved to be effective and free from side effects. Total daily doses of clarithromycin in excess of 14 mg/kg were considered optimal and long treatment courses, in the order of 1 to 3 months, were used. Combination therapy using rifampicin (25 mg/kg; that is, higher than the recommended dose) and clofazimine was effective in one case, but resulted in hepatotoxicity. A topical formulation of clofazimine in petroleum jelly was used as an adjunct to oral rifampicin and doxycycline in another patient treated successfully. Conclusion Based on our evolving clinical experience, a combination of rifampicin (10 to 15 mg/kg PO, every 24 h) and clarithromycin (15 to 25 mg/kg PO total daily dose; given divided every 8 to 12 h) is currently recommended for treating severe or refractory cases of canine leproid granuloma syndrome. Treatment should be continued (typically for 4 to 8 weeks) until lesions are substantially reduced in size and ideally until lesions have resolved completely. A topical formulation, containing clofazimine in petroleum jelly may be used as an adjunct to systemic drug therapy. Further work is required to determine the most cost effective treatment regimen for this condition. [source] 3415: Treatment of postoperative macular edemaACTA OPHTHALMOLOGICA, Issue 2010I PETROPOULOS Purpose Cystoid macular edema (CME) is a frequent complication of a number of interventions in ophthalmology, such as cataract surgery (Irvine-Gass syndrome), laser procedures, and trabeculectomy. The purpose of this talk is to present the latest bibliographic data regarding the appropriate treatment of postoperative CME. Methods A review of the existing literature concerning the treatment of postoperative CME is performed. Characteristic personal cases are presented. Results In more than two-thirds of the cases, postoperative CME resolves spontaneously within weeks or months. Prophylactic topical treatment with indomethacin or flurbiprofen seems to reduce the frequency of clinical and angiographic CME, but its beneficial effect on final visual acuity is not established. Curative therapy includes topical corticosteroids; topical non-steroidal anti-inflammatory drugs (e.g. ketorolac); oral acetazolamide; sub-Tenon or intravitreal injection of triamcinolone acetonide; intravitreal injection of anti-VEGF drugs; and pars plana vitrectomy. The indications, role, and efficacy of each of the above treatment modalities are discussed, based on the latest bibliographic data. Conclusion Most cases of postoperative CME are mild and resolve spontaneously. In refractory cases, sub-Tenon or intravitreal injection of triamcinolone acetonide can be effective, but the risk of ocular hypertony is high. Intravitreal injection of anti-VEGF drugs offers promising results, yet large-scale randomized studies are necessary to validate their utility. Finally, pars plana vitrectomy is the treatment of choice when vitreomacular traction and/or epiretinal membrane is present. [source] | ||||||||||