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Objective: To examine the potential value of a theory-based, interactive decision support tool in clinical practice for patients with rheumatoid arthritis who are candidates for biologic agents., Methods: We conducted an 8-week, 2-arm, parallel, single-blind pilot trial in which candidates for treatment escalation with a biologic agent were randomized to receive either a link to a web-based tool or usual care. Outcomes included changes in objective knowledge, subjective knowledge, values clarification, and satisfaction with risk communication as well as the proportion of subjects defined as making an informed choice to escalate care at 2 weeks., Results: A total of 125 subjects were randomized. Significant between-group differences at 2 weeks favoring the intervention group were seen for changes in objective knowledge, subjective knowledge, and values clarification. No significant between-group differences were found in subjects' satisfaction with risk communication. Among those deciding to escalate care, a greater percentage met the criteria for an informed choice at 2 weeks in the intervention group compared to the control group (32% versus 13%; P = 0.02). Improvements in subjective knowledge and values clarification persisted at 8 weeks. There were no between-group differences in objective knowledge at 8 weeks., Conclusion: In this study, use of a decision support tool at the time of decision-making resulted in improved objective and subjective knowledge, as well as values clarity, compared to usual care. Not all improvements were sustained, emphasizing the need to offer educational support should additional escalation of care be required over the course of the illness., (© 2015, American College of Rheumatology.)

Background: Small-bowel obstruction (SBO) is responsible for approximately 12 to 16 percent of surgical hospital admissions and more than 300,000 operations annually in the United States. This has resulted in more than $2.3 billion in health care delivery per year. SBO is a serious complication, carrying a 10 percent risk of mortality., Case Description: The authors report a case of SBO resulting from inadvertent ingestion of polysulfide impression material. A 74-year-old man visited the emergency department with diffuse, nonradiating, colicky periumbilical pain. The patient was admitted to the general surgery service of the hospital, and after four days of supportive therapy without evidence of progression of the foreign body, he underwent an exploratory laparotomy. The authors later identified the foreign body as polysulfide impression material., Practical Implications: SBO is a rare but significant complication that can result from a procedure that clinicians perform on a routine basis. Dentists should consider this complication whenever they are concerned that a high-risk patient may have ingested dental materials.

A specific and regimented approach to the diagnosis and management of patients with disease of the parotid gland is necessary for correct diagnosis and management. Patient morbidity or mortality may result if there is a delay in the diagnosis of a malignant parotid tumor. This article reviews the diagnosis and management of parotid disease, with a particular concentration on neoplastic processes. An overview of the superficial parotid mass is emphasized because most neoplastic processes occupy the superficial lobe of the parotid gland., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose of Review: The purpose of this review is to discuss current reconstructive options in anterior skull base reconstruction., Recent Findings: Free tissue transfer has superseded regional myocutaneous flaps in the reconstruction of large anterior skull base defects. Local flaps remain the mainstay for smaller defects. A host of nonautologous biomaterials are also used in the setting of small-to-moderate-sized defects requiring rigid support. They should not be used in the setting of radiation owing to the high extrusion rate. Lastly, the advent of endoscopic tumor resection has introduced a variety of local flaps amenable to endoscopic reconstruction., Summary: The last decade has experienced a growth in anterior skull base reconstructive options owing to improvements in microvascular technique, endoscopic equipment, image guidance, and biomaterials. As a result, the choices in reconstructive technique have expanded, allowing for more radical tumor extirpations.

We present a case of pharyngeal perforation from a nasogastric tube mistakenly diagnosed as esophageal atresia with tracheoesophageal fistula in a full term infant female. The correct diagnosis was identified with rigid bronchoscopy and esophagoscopy immediately prior to the planned thoracotomy which was aborted. After one week of oral restriction and antibiotics, the healed perforation did not demonstrate leakage on a contrasted pharyngoesophagogram and bottle feeds were initiated. The infant was discharged to home on day of life 13 without any further complications.

This study measured unconscious cathexis and conscious association with dream content, using the Kahn Test of Symbol Arrangement (KTSA), with subjects reporting recurring, past-recurring, and nonrecurring dreams. Unconscious cathexis of dream content was noted for recurring dreamers; conscious association with dream content was not. The results suggest that the KTSA is a valuable instrument for the empirical study of unconscious processes and that the contents of recurring dreams are particularly salient in a dreamer's unconscious.

Subjects reporting a recurring dream at least 4 times a month for a year or more were assigned to a dream recording control group and an experimental group which used muscle testing to guide dream interpretation. Dream frequency was recorded prior to and following a dream interpretation intervention (experimental subjects) or dream reporting session (control subjects). Dream frequency declined in the experimental group, suggesting that recurring dream frequency is a useful dependent variable, and that psychological kinesiology dream interpretation is a powerful intervention.

The systemic administration of recombinant interleukin-2 (IL-2) either alone or in combination with lymphokine activated killer cells is a new approach to the immunotherapy of metastatic cancer in man. Renal toxicity is often a dose-limiting side effect of IL-2 administration. This prospective study of 17 consecutive patients receiving parenteral high dose IL-2 documents a reversible syndrome of hypotension, oliguria, fluid retention, azotemia and very low urinary excretion of sodium (median FeNa of 0.04%). The median nadir urinary uric acid to urinary creatinine ratio during IL-2 therapy was 0.2. This IL-2 regimen induces a reversible renal hypoperfusion syndrome (pre-renal azotemia) without evidence of acute uric acid nephropathy. Hypophosphatemia [median serum phosphorus of 1.9 mg/dl (0.61 mmol/l)] prompted further study of tubular function. Urinary excretions of phosphorus, calcium and magnesium were very low. Arterial blood gases revealed hyperventilation without alkalemia. The hypophosphatemia probably reflects increased utilization of inorganic phosphorus by rapidly proliferating lymphoid cells.

Systemic administration of interleukin-2 and lymphokine-activated killer cells is a new approach to the immunotherapy of advanced cancer. Metastatic renal cell cancer is one of the histological types of tumors particularly susceptible to this treatment approach although renal toxicity often is a dose-limiting side effect. We compared the renal functional changes observed during interleukin-2 therapy in 52 consecutive patients with advanced renal cancer to that of 83 consecutive patients with metastatic nonrenal cancer. Of the 52 patients with renal cancer 41 had recently undergone nephrectomy. The over-all peak serum creatinine values and the percentage increase of serum creatinine over baseline for all patients studied were significantly higher in cycle 2 of interleukin-2 therapy than in cycle 1: 3.8 +/- 0.2 versus 2.6 +/- 0.1 mg. per dl. and 241.7 +/- 16.5 versus 140.3 +/- 11.0 per cent, respectively. In patients with pre-therapy serum creatinine values of 0.4 to 0.9 mg. per dl. there were no significant differences in the mean peak serum creatinine nor in the percentage increase over baseline between renal and nonrenal cancer patients during cycle 1. In cycle 2 of therapy these values were higher in the renal cancer group (3.6 +/- 0.8 versus 2.4 +/- 0.2 mg. per dl. and 310.4 +/- 103.5 versus 214 +/- 30.4 per cent, respectively) but they did not reach statistical significance (P2 = 0.08 and 0.25, respectively). Renal and nonrenal cancer patients with pre-therapy serum creatinine levels of 1.0 to 1.4 mg. per dl. achieved similar high values in cycle 2 of interleukin-2 therapy (3.9 +/- 0.3 versus 3.9 +/- 0.4 mg. per dl. and 222.7 +/- 23.2 versus 248.7 +/- 33.5 per cent, respectively), although the initial increase (cycle 1) was higher in the renal cancer patients (3.3 +/- 0.3 versus 2.4 +/- 0.2 mg. per dl. and 172.3 +/- 25.9 versus 116.1 +/- 18.0 per cent, respectively). Baseline serum creatinine greater than or equal to 1.5 mg. per dl. was associated with an over-all higher peak serum creatinine and higher percentage increase of serum creatinine over baseline than that below 1.5 mg. per dl. baseline: 4.4 mg.per dl. and 171.1 +/- 36.3 per cent in cycle 1 and 6.5 +/- 0.7 mg. per dl. and 296.1 +/- 44.0 per cent in cycle 2, respectively (p less than 0.01). There was no association between peak serum creatinine and interval from nephrectomy to interleukin-2 therapy.(ABSTRACT TRUNCATED AT 400 WORDS)

Adoptive transfer of autologous lymphokine-activated killer cells in conjunction with recombinant interleukin-2 in patients with advanced cancer has produced significant regression of metastatic disease in selected patients. We analyzed the effects of interleukin-2 regimens on renal function in 99 consecutive patients. Interleukin-2 therapy with or without lymphokine-activated killer cells was associated with varying degrees of hypotension, fluid retention, azotemia, oliguria, and low fractional sodium excretion. After the patients completed the interleukin-2 regimens, their renal function improved promptly. Renal function values returned to baseline levels within 7 days in 62% of patients, within 14 days in 84%, and within 30 days in 95%. Pretherapy serum creatinine values above 1.4 mg/dL predicted the severity of azotemia and prolonged duration of renal functional recovery, interleukin-2 therapeutic regimens induce prerenal azotemia. Careful selection of patients and early detection of adverse physiologic changes may alleviate the side effects of interleukin-2 therapy.

Renal proximal tubules secrete p-aminohippurate (PAH) and other endogenous anionic metabolites into the urine. The extent to which organic anion excretion is regulated is unknown, but recent studies indicate that peritubular serum proteins may have a role. We determined the relative effects of serum proteins and metabolic substrates (citrate, lactate, and alanine) on net PAH secretion in isolated perfused rabbit S2 proximal tubules. Net PAH secretion was calculated from the bath-to-lumen flux of [3H]PAH and the isotope specific activity. We corrected the flux for the important difference in PAH binding between rabbit serum proteins and bovine serum albumin (BSA); rabbit serum proteins (5.7 g/dl) and BSA (6 g/dl) bound 10 microM PAH 21 and 37%, respectively. BSA had no effect, but rabbit serum proteins reversibly inhibited PAH secretion in the presence of metabolic substrates in the bath (40.8%), the perfusate (42.6%), and both media (31.5%). In the absence of metabolic substrates, rabbit serum proteins decreased PAH secretion by only 16.8%. PAH secretion was inhibited by 1 g/dl rabbit serum proteins as effectively as 5.7 g/dl (30.3 and 31.5%, respectively), indicating that PAH transport is very sensitive to inhibition by rabbit serum proteins. In the absence of rabbit serum proteins, metabolic substrates in the bath had no effect on PAH secretion. We conclude that rabbit serum proteins inhibit basolateral membrane transport of PAH in proximal tubules. Inhibition by serum proteins is enhanced by bath or lumen citrate, alanine, and lactate, suggesting that peritubular plasma proteins and tubule cell metabolism may interact to modulate proximal tubule organic anion secretion and urinary excretion.

Four patients with a chronic fatigue syndrome experienced five episodes of acute renal insufficiency associated with high-dose (500 mg/m2) intravenous acyclovir administered intravenously as one-hour infusions. Nephrotoxicity developed despite precautions to avoid volume contraction. Examination of the urinary sediment of three patients by polarizing microscopy showed birefringent needle-shaped crystals within leukocytes. In the most severely affected patient, a serum creatinine concentration of 8.6 mg/dl developed and the patient underwent percutaneous renal biopsy that revealed foci of interstitial inflammation without tubular necrosis. Urine, blood, and renal tissue levels of acyclovir were high. One patient was rechallenged with low-dose intravenous acyclovir and the four patients later received oral acyclovir, all without adverse effect. The combined data from these patients support crystalluria and obstructive nephropathy as a mechanism of acyclovir-induced renal failure in humans. This experience emphasizes the importance of maintaining adequate hydration during high-dose acyclovir therapy.