Behavioral and pharmacologic treatment of delirium.

Delirium is an acute confusional state with a fluctuating course. Since the syndrome of delirium is associated with derangements of cognition, attention and level of consciousness, it can cause behaviors that are difficult to manage. Hallucinations, agitation, insomnia and anxiety are common in the delirious patient. Behavioral and pharmacologic interventions can be used while the underlying etiology of delirium is sought. Nonpharmacologic measures include frequent reassurance, environmental cues to reorient the patient and the judicious use of physical restraints. Haloperidol, which has negligible anticholinergic effects, is the drug most often used to treat the symptoms of delirium. Short-acting benzodiazepines may be useful in patients with delirium caused by alcohol withdrawal, but these agents may cause increased agitation in elderly patients and patients with hepatic dysfunction.

Relationship of estrogen and progesterone receptors to prognosis in breast cancer.

To ascertain the role of estrogen (ER) and progesterone (PR) receptors as prognostic indicators of resectable breast cancer, the records of 204 patients were analyzed whose receptor studies were done at the Maimonides Medical Center from 1975 to 1983. All patients had radical or modified radical mastectomies and did not show any evidence of distant metastases at the time of operation. Median follow-up was 37 months. An additional 117 patients received some form of adjuvant therapy, mainly chemotherapy, and were analyzed separately. Life table analysis using the log rank test for measuring significance, and a Cox multivariate analysis was performed. At 48 months, 22% of the ER positive (ER+) group versus 33% of the ER negative (ER-) group had recurred as compared to 16% and 35% for the PR+ versus PR- groups, respectively. Life table analysis of the disease free interval (DFI) showed that the difference between the ER+ and ER- groups was not significant (p greater than 0.1), while the difference in DFI between the PR+ and PR- groups was significant (p less than 0.05). Multivariate analysis revealed that the most important factors in predicting the DFI were nodal status (p less than 0.001), tumor size (p less than 0.025), and progesterone receptor status (p less than 0.05). Estrogen receptor status was not found to be significant. In conclusion, PR- patients have a shorter DFI than PR+ patients and that PR status is a more valuable predictor of DFI than ER status.

The role of progesterone receptors in the management of advanced breast cancer.

The identification of steroid receptors in human breast cancer tissues has provided biochemical markers to predict hormone responsiveness. Analysis of tumors from 328 patients for the estrogen receptor protein (ERP) revealed significant levels in 225 patients (68%). Fifty-five patients with advanced disease were subjected to hormonal manipulation. Thirty patients underwent ablative surgery consisting of adrenalectomy or adrenalectomy and oophorectomy. Twenty-five patients were treated with additive therapy utilizing the new antiestrogen Tamoxifen. The ECOG criteria for an objective response were applied to all patients. Fifteen of the 24 estrogen receptor-positive patients (63%) subjected to endocrine ablation responded. Eleven of twenty (55%) ERP-positive patients responded to Tamoxifen therapy. Only one ERP-negative patient responded in the total group. Simultaneous analysis of these same specimens for the progesterone receptor protein (PgRP) revealed that 151 patients were ERP and PgRP positive (46%); 74 (23%) were ERP positive and PgRP negative; 90 (27%) were ERP and PgRP negative, and 13 (4%) were ERP negative and PgRP positive. In the two treatment groups the overall response rate when both receptors were positive was 77% with a higher percentage of responders in the endocrine ablative group (88% vs. 64%). In addition, a greater duration of response was achieved in those patients treated with endocrine ablation.