ANDRIOL (ORGANON NV)

Organon NV (maker of ANDRIOL) was bought by SCHERING.PLOUGH which then merged with MERCK.

In ONTARIO, ANDRIOL is provided FREE to men over 65y (on medical advice).

ADDENBROOKE'S Hosp.CAMBRIDGE,UK. ADVICE to PATIENTS on LAPAROSCOPY

Patient Information
Department of Urology
66/Urol_04_09
Laparoscopic removal of the adrenal gland
Page 1 of 7
Laparoscopic removal of the adrenal gland: procedure-specific information What is the evidence base for this information? This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence-based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your GP or other healthcare professionals. Alternative treatments are outlined below and can be discussed in more detail with your Urologist or Specialist Nurse. What does the procedure involve? This involves removal of the adrenal gland through several keyhole incisions. It requires placement of a telescope and operating instruments into your abdominal cavity using 3-4 small incisions. One incision may need to be enlarged to remove the adrenal gland What are the alternatives to this procedure? Observation, open surgery
Laparoscopic removal of the adrenal gland
Page 2 of 7
What should I expect before the procedure? You will usually be admitted on the same day as your surgery. You will normally receive an appointment for pre-assessment, approximately 14 days before your admission, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the Consultant, Specialist Registrar, House Officer and your named nurse. You will be asked not to eat or drink for 6 hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy. Please be sure to inform your Urologist in advance of your surgery if you have any of the following:
 an artificial heart valve
 a coronary artery stent
 a heart pacemaker or defibrillator
 an artificial joint
 an artificial blood vessel graft
 a neurosurgical shunt
 any other implanted foreign body
 a prescription for Warfarin, Aspirin or Clopidogrel (Plavix®)
 a previous or current MRSA infection
What happens during the procedure? Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure. In some patients, the anaesthetist may also use an epidural anaesthetic which improves or minimises pain post-operatively. A bladder catheter is normally inserted during the operation to monitor urine output and a drainage tube may be placed through the skin into the bed of the adrenal gland.
Laparoscopic removal of the adrenal gland
Page 3 of 7
What happens immediately after the procedure? You will be given fluids to drink from an early stage after the operation and you will be encouraged to mobilise as soon as you are comfortable to prevent blood clots forming in your legs. The wound drain and catheter are normally removed after 24-48 hours. The average hospital stay is 3-5 days. Are there any side-effects? Most procedures have a potential for side-effects. You should be reassured that, although all these complications are well-recognised, the majority of patients do not suffer any problems after a urological procedure. Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction: Common (greater than 1 in 10)  Temporary shoulder tip pain  Temporary abdominal bloating  Temporary insertion of a bladder catheter and wound drain  Conversion to open surgery or requiring blood transfusion (approximately 14%) Occasional (between 1 in 10 and 1 in 50)  Bleeding, infection, pain or hernia of the incision requiring further treatment Rare (less than 1 in 50)  Entry into lung cavity requiring insertion of a temporary drain  The histological abnormality may eventually turn out not to be cancer  Recognised (or unrecognised) injury to organs/blood vessels requiring conversion to open surgery (or deferred open surgery)  Involvement or injury to nearby local structures (blood vessels, spleen, liver, kidney ,lung, pancreas, bowel) requiring more extensive surgery  Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death) Hospital-acquired infection (overall risk for Addenbrooke’s)  Colonisation with MRSA (0.9%, 1 in 110)  Clostridium difficile bowel infection (0.2%; 1 in 500)  MRSA bloodstream infection (0.08%; 1 in 1,250) (These rates may be greater in high-risk patients e.g. with long-term drainage tubes, after removal of the bladder for cancer, after previous infections, after prolonged hospitalisation or after multiple admissions)
Laparoscopic removal of the adrenal gland
Page 4 of 7
What should I expect when I get home? There may be some discomfort from the small incisions in your abdomen but this can normally be controlled with simple painkillers. All the wounds are closed with absorbable stitches which do not require removal. It will take 10-14 days to recover fully from the procedure and most people can return to normal activities after 2-4 weeks. When you leave hospital, you will be given a “draft” discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge. What else should I look out for? If you develop a temperature, increased redness, throbbing or drainage at the site of the operation, you should contact your GP immediately. Are there any other important points? A follow-up outpatient appointment will normally be arranged for you 6-12 weeks after the operation. At this time, we will be able to inform you of the results of pathology tests on the removed adrenal gland. It will be at least 14-21 days before the pathology results on the tissue removed are available. It is normal practice for the results of all biopsies to be discussed in detail at a multi-disciplinary meeting before any further treatment decisions are made. You and your GP will be informed of the results after this discussion. Your remaining adrenal gland will serve the full function originally carried out by the pair of glands. It is sometimes necessary, however, to take medications to help the remaining gland recover (usually in patients with Cushing’s syndrome). If both glands have to be removed (this is very rare), medications will need to be taken to replace their function. Is there any research being carried out in this field at Addenbrooke’s Hospital? All laparoscopic procedures are subject to continuous audit by the British Association of Urological Surgeons Section of Endourology. In addition, the National Institute of Health & Clinical Excellence (NICE) requires that we maintain a careful review of laparoscopic procedures.

TREATMENT EPSTEIN-BARR VIRUS (HHV-4)

An update on the management of glandular fever (infectious mononucleosis) and its sequelae caused by Epstein–Barr virus (HHV-4): new and emerging treatment strategies
(95) Article views
Authors: A Martin Lerner, Safedin H Beqaj, Ken Gill, et al
Published Date September 2010 , Volume 2010:2 Pages 135 - 145 DOI 10.2147/VAAT.S6749
A Martin Lerner1, Safedin H Beqaj2, Ken Gill3, James Edington3, James T Fitzgerald4, Robert G Deeter5
1Department of Medicine, William Beaumont Hospital, Royal Oak, MI, USA; 2DCL Medical Laboratories, Indianapolis, IN, USA; 3The Dr A Martin Lerner, Chronic Fatigue Syndrome Foundation, Beverly Hills, MI, USA; 4Department of Medical Education, University of Michigan, Medical School, Ann Arbor, MI, USA; 5Hematology-Oncology, Global Health Economics, Amgen Inc, Thousand Oaks, CA, USA

Purpose: Beginning in 1993 at a single chronic fatigue syndrome (CFS) treatment center, we began studies that demonstrate Epstein–Barr virus (EBV) nonpermissive replication. In the most recent study performed, EBV nonpermissive replication is the cause of 28.3% of 106 consecutive CFS cases, and is etiologic with human cytomegalovirus (HCMV) and/or human herpes virus 6 (HHV-6) as a coinfection in an additional 52.8% of CFS cases. Therefore, EBV is causally involved in 81% of cases of CFS. Further, EBV CFS is effectively treated with long-term valacyclovir. Coinfection HCMV and HHV-6 CFS requires valganciclovir with valacyclovir.
Patients and results: The validated Energy Index Point Score® (EIPS®) monitors severity of CFS illness and its recovery. A specific CFS diagnostic panel identifies EBV CFS subsets. Four separate EBV CFS therapeutic studies of several hundred CFS patients describe valacyclovir (VALTREX) administration and long-term patient recovery. With valacyclovir, serum EBV titers (EBV, early antigen (diffuse); EBV, viral capsid antigen, immunoglobulin M); 24-hour electrocardiography Holter monitors; and cardiac dynamic studies improve.
Conclusion: Nonpermissive EBV infection is causal in a significant proportion of CFS cases. EBV CFS is safely and effectively treated with long-term valacyclovir.

Keywords: valacyclovir (VALTREX) treatment, chronic fatigue syndrome, Epstein–Barr virus, EIPS, Energy Index Point Score
Post to:
Cannotea Citeulike Del.icio.us Facebook LinkedIn Twitter


Other articles by Dr Ann Cavanagh
Subset-directed antiviral treatment of 142 herpesvirus patients with chronic fatigue syndrome

MAYO CLINIC: DIAGNOSIS of PRIMARY ALDOSTERONISM

Primary Aldosteronism: The Role of Adrenal Venous Sampling

The triad of hypertension, hypokalemia, and an aldosterone-producing adenoma (APA) of the adrenal gland was first reported by Jerome W. Conn, M.D., in 1955.

Unilateral adrenalectomy in patients with an adrenal adenoma normalizes hypokalemia in all patients, normalizes blood pressure in at least a third of patients, and improves hypertension in nearly all patients.

In patients with idiopathic hyperaldosteronism (IHA), however, a unilateral or bilateral adrenalectomy seldom corrects hypertension. Patients with IHA should be treated not surgically but medically with a mineralocorticoid receptor antagonist.(BLOG: ALDACTONE spironolactone). Therefore, determining the subtype of primary aldosteronism (PA), APA vs IHA, is critical in directing treatment.
Distinguishing between APA and IHA

Selective adrenal venous sampling (AVS) for aldosterone was first proposed in 1967 as a test to distinguish between APA and IHA. However, it is an invasive and difficult technique, and both adrenal veins must be sampled for meaningful comparison.

Computed tomography (CT) was initially thought to be a good test to distinguish among the subtypes of PA. Because of the prevalence of nonfunctioning cortical adenomas, however, hormonal hyperfunction cannot be inferred simply from the presence of an adrenal nodule. Additionally, APAs that are 3 or 4 mm in diameter may escape detection on CT, and patients with a unilateral APA may have bilateral adrenal nodules on CT—one that is nonfunctional and one that is hypersecreting aldosteron

An algorithmic approach to subtype evaluation of a patient with primary aldosteronism helps determine when AVS is needed in patients with PA. Because adrenal incidentalomas are uncommon in young patients, when a solitary unilateral macronodule (>1 cm) and a normal contralateral adrenal are found on CT in a patient with PA, unilateral adrenalectomy is reasonable to consider. In addition, many patients prefer pharmacologic therapy and, therefore, do not require AVS. Using this approach, AVS is done in approximately 20% of patients with PA at Mayo Clinic.

Patients with an APA have more severe hypertension, more frequent hypokalemia, higher plasma (>25 ng/dL) and urinary (>30 μg/24 h) levels of aldosterone, and are younger than those with IHA. Patients with these findings are considered to have a high probability of APA. These findings, however, are not absolute predictors of unilateral (vs bilateral) adrenal disease. Therefore, AVS is an essential diagnostic step in most patients with PA, to distinguish between unilateral and bilateral adrenal aldosterone hypersecretion.

During the procedure, the adrenal veins are sequentially catheterized through the percutaneous femoral vein approach under fluoroscopic guidance, and correct catheter tip location is confirmed with injection of a small amount of contrast medium. Blood is obtained by gentle aspiration from both adrenal veins.

Successful catheterization may require an array of catheter configurations, either available from manufacturers or custom-made with steam shaping during the procedure to facilitate access to the adrenal veins. The placement of side holes very close to the catheter tip may enhance the progress of the blood draw.

At centers with experience with AVS, the complication rate is 2.5% or less. Complications may include:

* Symptomatic groin hematoma
* Adrenal hemorrhage
* Dissection of an adrenal vein

Aldosterone and cortisol concentrations are measured in the blood from all 3 sites (right adrenal vein, left adrenal vein, and inferior vena cava). All blood samples should be assayed at 1:1, 1:10, and 1:50 dilutions—absolute values are mandatory. Accurate laboratory assays for cortisol and aldosterone are keys to successful interpretation of the AVS data.

Mayo Clinic has now performed AVS in more than 400 patients. For patients with PA who want to pursue the surgical treatment option, AVS is an essential diagnostic step.

* Primary aldosteronism (PA) affects between 5% and 10% of all patients with hypertension.
* PA has more than one cause, and most patients with PA have bilateral idiopathic hyperaldosteronism (IHA).
* Because patients with IHA should be treated medically not surgically, distinguishing between aldosterone-producing adenoma (APA) and IHA is critical in directing treatment.
* For patients with PA who want to pursue the surgical treatment option, adrenal venous sampling (AVS) is an essential diagnostic step.

In a 37-year-old woman with poorly controlled hypertension and primary aldosteronism who had a CT scan and AVS radiographs: The cortisol concentrations from the adrenal veins and inferior vena cava are used to confirm successful catheterization; the ratio of adrenal vein cortisol to inferior vena cava is typically more than 10:1 when the protocol for continuous cosyntropin infusion is followed. Dividing the plasma aldosterone concentrations (PACs) of the right and left adrenal veins by the respective cortisol concentrations corrects for the dilutional effect of blood from the inferior phrenic vein flowing into the left adrenal vein; these quotients are termed cortisol-corrected aldosterone ratios. In patients with aldosterone-producing adenoma (APA), the mean cortisol-corrected aldosterone ratio (the ratio of APA-side PAC/cortisol concentration to normal adrenal PAC/cortisol concentration) is 18:1. A cutoff for the cortisol-corrected aldosterone ratio from high side to low side of more than 4:1 is used to indicate unilateral aldosterone excess. The lateralization ratio in this patient of 20.5:1 is consistent with a right adrenal APA.