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Books > Medicine > Clinical & internal medicine > Gynaecology & obstetrics > General
The Interfaces of Perinatal Addiction Ira J ChasnofT In the last few years, problems associated with drug use in pregnancy have become endemic. As cocaine has become the drug of choice for millions of Americans, including pregnant women, as AIDS has become more commonly recognized in women and infants, and as legal cases have begun to raise the question of fetal abuse, no professional group has come forward to serve as advocate for this special population of substance abusers. Meanwhile, however, physicians, nurses, social service agencies and public health officials have all been faced with increasing numbers of infants showing the detrimental effects of their mothers' drug use. Although problems of substance abuse in pregnancy have received increasing attention in the medical literature since the early 1970s, there has recently been a very rapid increase in the number of articles published related to this field. The reasons for this new interest are easily understood when current statistics from the National Institute on Drug Abuse are reviewed 1. Although patterns of abuse of alcohol, marijuana, heroin and other substances by women of childbearing age have changed very little over the last ten years, the incidence of cocaine use in this special population has been rising rapidly, a reflection of cocaine's increasing popularity among the general population of the United States.
The most meaningful reward to clinicians and researchers is the absence of recurrent malignancy in their patients. While in some patients the disease will be cured by resection alone, in other similarly staged cases the disease will recur despite adequate loco regional and systemic therapies. Hence, risk assessment is a complex issue with many related or unrelated prognostic factors determining outcome. The purpose of this volume is to review some of the most relevant prognostic factors of newly diagnosed breast cancer, focusing on fea tures determining the magnitude of risk. The ultimate value of establishing the significance of each prognostic factor in a given patient will be the resulting ability to plan individu alized therapies for patients at different risk of recurrence at the time of diagnosis. To secure the maximum benefit for high-risk patients, while avoiding undue toxicity in those with low-risk lesions, a well-integrated analysis of all known prognostic factors will be essential in the early postdiagnos tic period. In addition to well-established staging criteria such as axillary nodes, tumor size, receptors, scanning and radiographic examinations, the more sophisticated labora tory techniques, as discussed by several authors herein, will playa crucial role in risk assessment. Most of them, - ploidy determination, oncogenes, tumor markers, monoclonal anti bodies, growth factors, etc. -are presently available in only a minority of treatment centers.
The examination of the human fallopian tubes was, until recently, restricted to observations on gross anatomical disposition and tubal patency. These studies, for decades, were the domain of doctors and physiologists whose primary interest was population control and family planning, funded largely by organisations and agencies seek ing alternatives to steroidal contraceptives. For a "worrying" but short period after the birth of Louise Brown in 1978 as the conse quence of successful in-vitro fertilisation and embryo transfer, the fallopian tube was considered to be "dispensable" given that the metabolic milieu in which human fertilisation takes place could be effortlessly reproduced in a Petri dish, in in-vitro fertilisation procedures. However, a number of factors have acted together to renew in terest in the fallopian tube, namely new techniques in cell biology, microinstrument developments (in particular in imaging), an inter disciplinary transfer of skills from interventional radiology and car diology to gynaecology, the surgeon's wish to improve surgical tech niques, and better techniques to monitor early pregnancy. These factors have led surgeons to develop the new diagnostic and ther apeutic strategies and techniques listed here. This volume contains contributions from the majority of keynote speakers at a conference held in London in April 1992 from which its title is derived. Better diagnostic procedures should lead to the implementation of rational effective treatments.
The European School of Oncology came into existence to respond to a need for information, education and training in the field of the diagnosis and treatment of cancer. There are two main reasons }Vhy such an initiative was considered necessary. Firstly, the teaching of oncology requires a rigorously multidisciplinary approach which is difficult for the Universities to put into practice since their system is mainly disciplinary orientated. Secondly, the rate of technological development that impinges on the diagnosis and treatment of cancer has been so rapid that it is not an easy task for medical faculties to adapt their curricula flexibly. With its residential courses for organ pathologies and the seminars on new techniques (laser, monoclonal antibodies, imaging techniques etc.) or on the principal therapeutic controversies (conservative or mutilating surgery, primary or adjuvant chemotherapy, radiotherapy alone or integrated), it is the ambition of the European School of Oncology to fill a cultural and scientific gap and, thereby, create a bridge between the University and Industry and between these two and daily medical practice. One of the more recent initiatives of ESO has been the institution of permanent study groups, also called task forces, where a limited number of leading experts are invited to meet once a year with the aim of defining the state of the art and possibly reaching a consensus on future developments in specific fields of oncology.
The authors of this book have a goal-to describe the management of infertility from the perspective of physiology and anatomy gone awry. To accomplish this goal, the chapters devoted to the causes of infertil ity begin with a description of the normal structure and function of the organ or system causing the infertility. We believe that under standing the normal will result in rational and effective diagnosis and treatment of infertility. Our intent is that this book be a useful re source for those who care for infertile couples. For an infertile couple, success is the delivery of a normal and healthy infant. Chapters that describe the causes and treatment of habitual abortion and the reproductive performance of previously infertile couples emphasize the hazards that exist between conception and birth. Our environment is one of these hazards, one that may also affect reproduction before conception. A chapter is devoted to a de scription of environmental agents that affect reproduction, the mech anisms of their effect, and methods to predict those present and future environmental agents which might also affect reproduction."
Contraceptives have always provided ground for controversy. This book describes and discusses latest findings concerning the advantages as well as hazard and risk factors of contraception. The clinical impact of oral contraceptives on metabolism is particularly highlighted. In addition, behavioral methods, intrauterine devices, implants and modern approaches in animal and clinical research in the field of immunization against pregnancy are considered. Last, but not least, the book summarizes the complex ethical, religious and political aspects of family planning and contraception.
In the last decade of the 15th century a new and deadly disease called Morbus Gallicus, or syphilis, appeared and spread rapidly throughout Europe. The effects of syphilis were so severe that it, and those suffering from it, where regarded with horror and despair. It is difficult for the modern reader to appreciate the fog of confusion which surrounded sexually transmitted diseases in earlier times. Those suffering with these diseases were often condemned as victims of their own "sinful lust of the flesh"; a judgement attitude which hindered most of the early attempts at control and treatment. Despite this general attitude, there were some doctors who persevered in their attempts to understand the causes and discover treatments for syphilis and other sexually transmitted diseases. The Scars of Venus is illustrated with pictures of people, places, instruments and documents. It presents the historical background and achievements of the early venereologists through to the current venereologists' fight against HIV. This book will be of interest to anyone concerned with venereal diseases: doctors, nurses, counsellors, laboratory workers, medical historians, and those working in the areas of public/world health and the spread of infectious diseases.
During the past ten years numerous new findings have been documented in the field of gynecological pathology, especially in respect of neoplasms. These findings have been generated by the application of recently developed techniques of immunology and molecular biology. However, clinicopathologic examinations. are still an absolute requirement for the morphologic evaluation of neoplasms, including gynecological tumors. The International Society of Gynecological Pathologists (ISGYP) has contributed greatly to the progress within gynecological pathology. The ISGYP Nomenclature Committee has promoted the International Histological Classification of Gynecological Tumors under the auspices of the W orid Health Organization. A new edition of the classification of tumors and tumor-like conditions of trophoblastic disease, uterine corpus, cervix, vagina, and vulva is currently in press. A second volume covering the ovaries, fallopian tubes, broad ligament, and female peritoneum will be published later. Organization of scientific symposia and seminars has also been an important activity of the ISGYP. The present editor organized and chaired a symposium entitled "Recent Progress in Diagnostic Pathology of Gynecological Tumors" held in Sendai, Japan on 11 April 1986 in close cooperation with Prof. T. Okagaki, University of Minnesota Medical School, and under the joint auspices ofthe ISGYP and the Japanese Society of Pathology. The following topics were discussed at this symposium: - Immunocytochemistry of gestational trophoblastic disease (Dr. R.J."
Concise, recent data are presented on obstetric problems arising in patients with cardiovascular diseases (not only congenital and acquired valvular heart diseases and hypertension, but also uncommon heart lesions) and on cardiological complications encountered in pregnant women. The goal of the book is to provide obstetricians with necessary cardiological information and cardiologists with essential obstetric information to enable both specialists to make optimal decisions regarding the permissibility of pregnancy, management of pregnancy and labour, or termination of pregnancy, and selection of an adequate form of contraception in women with heart and vascular diseases. Along with recent scientific findings, the book contains practical recommendations for examination diagnosis and treatment that is effective for the mother and safe for the fetus.
The anticipation of seeing and having to manage patients suffering from sensory disorders of the urinary tract brings dismay and foreboding to the urologist. This stems from his experience of the time that these patients take up, both at the stage of initial interview and subsequently during numerous consultations over periods of months and years. This and the largely unsatisfactory response to various forms of therapy in the past are reason enough for this bold attempt to define with objectivity the notoriously subjective disorders of interstitial cystitis, urethral syndrome and prostatodynia. In writing this book the principal aim of the authors has been to define these three entities concisely and to describe the investiga tional methods which are required to establish the diagnosis in each case. The importance of this cannot be overestimated since, when the label of one or other of these conditions is attached to a patient, further objective consideration of the case is-endangered. The casual attribution of these sensory diagnoses to inappropriate cases is already on record as having dulled clinical awareness and led to oversight of progressive disease and its sometimes avoidable conse quences."
The Organon Symposia have actually become a tradition, keeping up with exciting developments in reproductive medicine. The purpose of this symposium on "Fertiliza tion of the Human Egg in Vitro" was to bring together the stilllimited number of elinical specialists in the field and to stimulate another group of basic research people to exchange their experiences and knowledge, hopefully promoting elose cooperation between the two groups. It was a kind of scientific "first" that all research teams so far successful in achieving the birth of a healthy baby, fertilized in vitro came together at a workshop conference without a large audience of spectators and reporters, but with a small number of highly critical colleagues from the fields of basic reproductive physiology and comparative developmental biology. This atmosphere allowed for the elose exchange of results, hypotheses, diagnostic and therapeutic procedures, criticism, and respect, and created very productive discussions, all of which furthered the aim of the method: To help more childless couples to have their own babies by the ultima ratio procedure of in vitro fertilization and embryo replacement. The book that has emerged from this symposium will help to disseminate the great amount of information and experience gathered among the scientifically and clinically interested colleagues of many other hospitals and universities who could not be invited to the meeting. At the same time, it will prove that there is much more work to be done in the basic and clinical sciences of human embryology and reproductive biology."
The many advances in breast cancer research, as well as the large quantity of published material, make it very difficult to gain insight into the global aspects of cancer management. To follow and understand all the new developments is becoming a major challenge. For this reason, the editors decided to bring together a group of top researchers in breast cancer to provide a comprehensive, yet readable conceptual review of the state of the art of breast cancer diagnosis and therapy. The proposal to focus the review on the quantitative assessment of the risk at diagnosis, the determination of which may permit selective therapies for individual patients, was met with enthusiastic approval, resulting in the present volume with contributions by the leading investigators in the field. While the volume relating to diagnosis, published re cently, focused on efforts leading to refinement at diagnosis of risk criteria sensitive enough to reliably distinguish the low- and high-risk categories, the second volume, by provid ing a review of the main problems and results of therapy given to high-risk patients, can be considered as a continua tion of the first book. A refined risk assessment at diagnosis and the application of the most suitable treatments to well selected individuals are the most important steps towards avoiding the present worrisome reality of overtreating the low risk and undertreating the high-risk patients. The first few chapters of the present volume offer an insight into the general management of early breast cancer.
The subject of the Sixth Symposium on Clinical Oncology of the Royal College of Radiologists held in February 1984 was ovarian cancer. This publication presents the collected papers delivered at that meeting, but excludes much useful discussion which also took place. The annual clinical oncology symposia have been designed to re- view topics of current interest in cancer therapy from a multidis- ciplinary point if view. It was gratifying to the organisers and all who took part that the aims were so well met by both the contrib- utors and discussants. We believe that this can only be to the ad- vantage of future research and our present and future patients. Ovarian cancer is a common gynaecological cancer which freqently presents late. Its clinical management is bedevilled by the variable referral routes through which patients present for treatment. Thus, many are first seen by general abdominal sur- geons who may not be expert in their treatment, rather than gynaecologists or gynaecological oncologists. There are many in- teresting features about it which have been discussed by the var- ious speakers. Early spread within the abdomen is common, spread outside the abdomen less common. There is a variety of histopathological types, each with distinct aetiological, prognos- VI Preface tic and therapeutic assocations. In contrast to most cancers, sur- gical debulking of tumour is considered valuable even when there is no possibility of removing all tumour by the knife.
It is about 15 years since the first presentation on uteroglobin was given to a group of developmental biologists, reproductive physiologists, and geneticists who had gathered in November 1966 at Konstanz (Germany). In the following decade so much knowledge was accumulated that a special symposium seemed appropriate. This was organized as a satellite symposium to the International Congress of Endocrinology at Hamburg and brought together 50 scientists at Aachen. These scientists, working in the field of pro teins and steroids, in early pregnancy, recognized the impact of what had been reported, and many of them later agreed to contribute to this booN. and thus to present their research d, ta available until December 1980. The present volume covers a relatively broad spectrum of data and observations which shed some light on preimplantational embryonic life and on the supports and obstacles provided by the maternal organism with respect to final accomplishment of normal im plantation and establishment of pregnancy. The book will serve both as a textbook and as a scientific dictionary for Ph.D. students, postdoctoral fellows and advanced scientists working in this area. The course of early pregnancy depends very much on a proper balance of steroid hor mones, and the induction of protein synthesis by steroid hormones is one of the well known fundamental processes in cellular differentiation and embryonic development."
I am honored to have been invited to write a foreword for this book, because tumors of the yolk sac have been a preoccupation of mine since the days of my residency, now more than 3 decades ago. At that time, a 3-year-old boy died of a testicular cancer of unknown histo genesis. It was bad enough that the child died, but it bothered me even more that medical science did not know the histogenesis of the tumor that destroyed him, and I decided to study testicular cancer. For re search training I sought out F. J. Dixon, who had written the Armed Forces Fascicle on testicular tumors. Dr. Dixon and I showed that embryonal carcinoma was a multipoten tial malignant stem cell that differentiated into the three embryonic germ layers of murine teratocarcinoma. This led to the idea that the normal counterpart of embryonal carcinoma must also be multi potent, and we focused on the preimplantation embryo for the histo genesis of the tumor. This idea was strengthened by the discovery that embryonal carcinoma cells made embryoid bodies in the ascites and it was possible to observe the development of these bodies in vitro. These observations led to the idea that embryonal carcinoma was a caricature (gross misrepresentation) of early development, and car cinomas in general were a caricature of the process of renewal of their normal counterpart."
In 1909 a short contribution entitled "Geriatrics" was published in the New York Medical Journal. According to this article, old age represents a distinct period oflife in which the physiologic changes caused by aging are accompanied by an increasing number of pathologic changes. We now know that the organs of the body age neither at the same rate nor to the same extent and that physiologic alterations are indeed superimposed by pathologic changes; as a result of the latter phenomenon the origins and course of illnesses in the elderly can present unusual characteristics. The frequency of concurrent disorders in the elderly entails the danger of polypragmatic pharmacotherapy, i. e., the use of various drugs to combat various disorders while neglecting the possibly adverse combined effects of these drugs. To obviate this danger, special knowledge in the field of geriatrics, the medical branch of gerontology, is necessary. Geriatrics is constantly increasing in importance owing to the near doubling of life expectancy over the past 130 years and to the improved diagnostic and therapeutic techniques made available by medical pro gress. The rapid recent development of experimental gerontology has played an essential role in enabling us to understand the special features of geriatrics. This progress has, however, been accompanied by such a vast increase in the volume of literature on the subject that specialists in the field can scarcely maintain an overall perspective of new publications."
Reevaluation of tumor classification, differential diagnosis and differential therapy based on modern knowledge. Revision of all chapters to incorporate new facts based on recent discoveries.
In few areas of medicine is progress more spectacular than in the field of prenatal diagnosis. New clinical techniques such as chorion villus sampling, detailed ultrasound scanning and cordocentesis are being evaluated by obstetricians, and refinement of biochemical testing is widening the scope of maternal serum screening. In the laboratory, dramatic advances in molecular biology are occurring: families at risk of genetic disease can be investigated with gene probes, and preimplantation diagnosis of the embryo is now becom ing a reality. These technical advances have important ethical and practical implications, among which will be a further increase in public expectations of the standards required of antenatal services. Clini cians will need a high degree of skill to inform healthy women about the options for screening normal pregnancies, and to counsel high-risk women about the benefits and limitations of prenatal diagnosis. Obstetricians, scientists and health service managers will face the difficult task of deciding how prenatal diagnosis can be made available to women in a caring and cost-effective way. Recognising the rapid progress in this field, the Royal College of Obstetricians and Gynaecologists made prenatal diagnosis the subject of its 23rd Study Group. An international panel of leading researchers, whose expertise ranged from molecular biology to philosophy, was invited to participate in a three day workshop, with time for in-depth discussion as well as the presentation of papers.
In the past decade fetal heart rate monitoring has become a generally ac cepted method for fetal surveillance during pregnancy and labor. Although its importance has been doubted recently, I personally feel that this method has become an important obstetric tool. It has not only improved our knowledge about fetal behavior and fetal condition throughout gesta tion, but it has especially improved fetal surveillance during labor; the most dangerous period of human life has never been as safe as nowadays. The only people who can question the advantage of fetal heart rate moni toring are those who did not experience the period before fetal heart rate monitoring was generally introduced. The first paper on the history of fetal heart rate monitoring takes us back to the beginning of fetal surveillance and provides an introduction to the different aspects of fetal observation which are covered later in this volume. Common practices of fetal surveillance in different countries are discussed, and the paths that future developments will take are suggested. An outline of the physiological aspects of fetal heart rate regulation is fol lowed by discussion of the pathophysiology with which the obstetrician is very often confronted."
A variety of new techniques that promise to revolutionize the clinical management of early pregnancy are fully detailed in this state-of-the-art book. Leading international researchers describe fast-moving topics such as embryo manipulation and the diagnosis of congenital abnormalities. The technology of assisted reproduction has made it possible to study living embryonic material for the first time, which has led to rapid advances in our understanding of the human embryo's early development. For example, study of the embryo in the test tube has pointed to early pregnancy loss as a possible cause of later infertility. Even more important, diagnostic tests using sophisticated techniques of molecular biology can be run on single cells before the embryo is replaced in the uterus. Another area of advance is the diagnosis of congenital abnormalities in the first and second trimesters of pregnancy. Great improvements have been made in the techniques of chorion villus biopsy and ultrasound imaging. A spectrum of simple biochemical tests performed on the mother's blood can greatly improve the detection of Down syndrome and other chromosome defects. Together with other developments in the fields of molecular biology and endocrinology, these new diagnostic techniques are the beginning of a new age in clinical human genetics and embryology.
Important contributions about the treatment modalities of breast cancer are presented in this book. The risks and limitations of breast conserving therapy of mammary carcinoma are dealt with. Newest findings show that this form of therapy has the same outcome as conservative treatment modalities. The book also considers controversial issues such as the treatment of mastopathy, precancerous, and non-invasive lesions of the breast. New, but not yet approved, regimes for the prevention of mammary carcinoma and open questions concerning adequate operative treatment are discussed. Latest results presented here show that all modern palliative chemotherapy has a certain but limited effect on outcome and that early detection and preventive therapy (surgical and hormonal) will be of great importance for improved chances of survival of breast cancer.
The first edition of "Testosterone: Action, Deficiency, Substitu tion" was published in 1990. Since then our understanding of the hormone that turns males into men has tremendously increased. Therefore, the editors felt that a second extended edition of the book is warranted in order to summarize established and recent findings in the field and to present the reader with an up-to-date is reflected by the textbook. The increased mass of knowledge growth of the volume from 14 to 20 chapters. In the updated edition the biochemistry and metabolism of androgens have been complemented by extensive information on the molecular biology of the androgen receptor and its disorders. The key role of testosterone in spermatogenesis is now better de fined. We have a more complete understanding of the psychotro pic effects of testosterone and know so much about the different target organs and functions that individual chapters deal with testosterone and the prostate, lipids and the cardiovascular sys tem, hair, bones and muscles. The general chapter on pharmacol ogy and clinical uses of testosterone, in particular in male hypo gonadism, is extended by pharmacokinetic studies on testoster one preparations and individual substitution modalities using testosterone esters as well as implants and advanced trans dermal applications. The physiologic basis and possible clinical applica tions of testosterone in non-gonadal diseases, in male senes cence, in hormonal male contraception and in transsexuals are discussed. The last chapter describes the role of "investigative" steroid biochemistry applied to tracking anabolic steroid abuse."
Infertility, as with many aspects of medicine, is at the mercy of rapid technological advance. Many of these developments initially seem attractive to both clinicians and patients, but need to be rigorously assessed if their real value is to be understood and clinical practice is to develop. In this book issues of importance to the management of infertile patients are discussed. The gaps in our knowledge which prevent a better understanding of the condition are identified, and recent developments, both clinical and scientific, are subjected to peer review and discussion. An important feature of the book is an acceptance that training in infertility practice is a real problem. This is perceived not only by the practising clinicians, both doctors and nurses, but particularly by the clinical scientists, including embryologists, who now provide such an essential part of the service. Similarly the provision of the clinical service has been examined in detail from a variety of standpoints, in an attempt to make sensible recommendations which balance real need with limited resource. The book is based on the papers presented and discussed at the 25th RCOG Study Group held in April 1992. The discussion after each paper was civilised but uncompromising and forms an important part of this publication. The rapid processing of the written and recorded material by the staff at the RCOG, and particularly Miss Sally Barber, has ensured that the book has been produced while the issues are live, the reviews contemporary and the discussion relevant.
It will be a long time before the quality of this profusely illustrated book is overtaken and the present spate of books on the subject of obstetric ultrasound may, as a result, suffer a numerical set-back - especially with translation into English which will "deliver the milk on everyone's doorstep". Two of the authors studied in our department in Glasgow and worked like If there are any rewards for teaching, then we humble Scots who demons. have had the privilege have had more than our share as a result of the pride with which we regard our pupils. In my own old age and looking back over the last thirty years, the innumer able difficulties, set-backs and disappointments have been more than compen sated for by those who have turned the subject from a laughable eccentricity (as I have at one time experienced) into a science of increasing exactitude. This transformation has come about, not by any efforts of mine, but by the enthusiasm and ingenuity of those who would probably have achieved as much on their own if given the encouragement which I ultimately received in Glasgow University life. Limbo must be the expected lot of most of us ordinary mortals but the work lives on. And so, in this reminiscent and philosophical mood I beg leave to quote a little poem which I wrote at an age when young men do that sort of thing.
Key questions involved in the treatment of disseminated breast cancer are discussed in this well-presented overview. It is the result of an initiative taken by the Swiss Group for Clinical Cancer Research to reveal the most recent developments in experimental and clinical research. The topics discussed include: the comparison of in vitro cultures of epithelial cells with breast cancer cells, the effect of steroids and their antagonists, the involvement of suppressor genes in tumour progression, the modulation of transforming growth factors by estrogen, and prognostic factors such as cERB-2 and EGF-R in breast cancer. |
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