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1.
OBJECTIVE: To determine efficacy and safety of percutaneous radiofrequency heat ablation for treatment of hyperthyroidism in cats. DESIGN: Prospective study. ANIMALS: 9 cats. PROCEDURE: Hyperthyroidism was diagnosed via clinical signs and high serum total (TT4) and free thyroxine (fT4) concentrations. One or 2 hyperfunctional cervical thyroid nodules were detected by use of scintigraphy and ultrasonography. If cats had 1 abnormal thyroid lobe, heat ablation was performed on that lobe; if cats had 2 abnormal lobes, heat ablation was applied to the larger lobe. Overall, heat ablation was performed 14 times in the 9 cats. Clinical signs and serum TT4, fT4, and calcium concentrations were monitored daily for 2 days after the procedure, weekly for the first month, and then monthly. Laryngeal function was evaluated and cervical ultrasonography and thyroid scintigraphy were also performed. Monitoring continued for as long as 9 months after heat ablation if a cat became euthyroid or until an owner chose an alternative treatment because of recurrence of hyperthyroidism. RESULTS: Serum TT4 and fT4 concentrations transiently decreased after all 14 heat ablation procedures (< or = reference range after 10 of 14 treatments) within 2 days after the procedure. Cats were euthyroid for 0 to 18 months (mean, 4 months). Hyperthyroidism recurred in all cats. Adverse effects included transient Horner's syndrome (2 cats) and laryngeal paralysis without clinical signs (1 cat). CONCLUSIONS AND CLINICAL RELEVANCE: Percutaneous heat ablation as a treatment for hyperthyroidism in cats is effective transiently but not permanently.  相似文献   

2.
OBJECTIVE: To determine clinical signs, physical examination findings, radiographic features, and concurrent diseases in cats with laryngeal paralysis, as well as evaluate the outcome of medical or surgical management. DESIGN: Retrospective study. ANIMALS: 16 cats. PROCEDURE: Medical records from January 1990 to April 1999 were examined for cats with laryngeal paralysis. Signalment, clinical signs, physical examination findings, cervical and thoracic radiographic findings, laryngeal examination results, and clinical outcome were reviewed. RESULTS: No breed or sex predilection was identified in 16 cats with laryngeal paralysis. The most common clinical signs included tachypnea or dyspnea, dysphagia, weight loss, change in vocalization, coughing, and lethargy. Clinical signs were evident for a median of 245 days. Airway obstruction was apparent on cervical and thoracic radiographic views in 9 cats. Examination of the larynx revealed bilateral laryngeal paralysis in 12 cats and unilateral laryngeal paralysis in 4 cats. The 4 cats with unilateral disease were managed with medical treatment, and 3 of these had acceptable long-term outcomes. Seven of 12 cats with bilateral paralysis underwent surgery; procedures performed included left arytenoid tie back, bilateral arytenoid tie back and ventriculo-cordectomy, and partial left arytenoidectomy. One cat was euthanatized as a result of complications from surgery. CONCLUSIONS AND CLINICAL RELEVANCE: Laryngeal paralysis is an uncommon cause of airway obstruction in cats. Cats with less severe clinical signs (often with unilateral paralysis) may be successfully managed with medical treatment, whereas cats with severe airway obstruction (often with bilateral paralysis) may benefit from surgical intervention.  相似文献   

3.
Three cats were diagnosed as hyperthyroid based on clinical signs, historical findings, laboratory abnormalities, and basal serum thyroxine (T4) concentrations, and/or nuclear thyroid scans. Additionally, a presumptive diagnosis of thyroid carcinoma with pulmonary metastasis was made in each cat based on radiographic or scintigraphic evaluation. All three cats had solitary pulmonary nodules 1.5 to 2 cm in diameter on survey thoracic radiographs; one cat also had chylous pleural effusion and pulmonary lobar consolidation. Focal pulmonary accumulation of sodium pertechnetate (99mTcO4 -) and/or radioiodine (131I) corresponding to radiographic lesions were seen in all cats. Two cats were treated with single ablative doses (1111 to 1480 MBq) of131I; the remaining cat was euthanatized.
One of the treated cats died 8 days later; the other cat was euthanatized 22 weeks following treatment. Histopathologic examination of tissue obtained at necropsy confirmed metastatic thyroid carcinoma in one cat and bronchogenic adenocarcinoma in two cats. Our findings indicate that increased radionuclide uptake in focal pulmonary lesions and cytologic evaluation of tissue obtained by fine-needle aspiration are not specific for thyroid tissue. (Journal of Veterinary Internal Medicine 1993; 7:303–308. Copyright © 1993 by the American College of Veterinary Internal Medicine.)  相似文献   

4.
Nineteen cats with abnormally high serum T4 concentrations underwent thyroid scintigraphy using technetium-99m pertechnetate (99mTcO4) before and after 36 +/- 6 days of methimazole administration (approximately 2.5mg PO q 12 h). Thyroid-to-salivary gland ratios (T:S ratios) and percentage thyroidal uptake of injected radioactivity at 20 and 60min after injection of 99mTcO4 were compared before and after methimazole treatment. Serum thyroid stimulating hormone (TSH) concentration was measured before and after methimazole treatment. Quantitatively, there was a positive association between the thyroid uptake of 99mTcO4 and the serum T4 before treatment (r = 0.74-0.83). TSH suppression was present when cats were first evaluated for hyperthyroidism. Methimazole treatment did not relieve TSH suppression in 17 cats. Two cats with unilateral thyroid uptake developed bilateral, asymmetric thyroid uptake of 99mTcO4 after treatment and had the greatest increase in TSH concentration after treatment. Quantitatively, thyroid scintigraphy did not significantly change after methimazole treatment (P>0.1). Evaluation of serum TSH concentration may be helpful in identifying methimazole-induced changes in the scintigraphic features of hyperthyroidism in mildly hyperthyroid cats.  相似文献   

5.
OBJECTIVE: To assess whether the risk of development of hypothyroidism after treatment with iodine 131 (131I) was associated with the pattern of sodium pertechnetate Tc 99m activity in the thyroid gland detected via scintigraphy before treatment in cats with hyperthyroidism. DESIGN: Retrospective study. ANIMALS: 165 cats. PROCEDURE: Medical records of cats with hyperthyroidism that had been treated with 131I (from 1990 to 2002) and had undergone scintigraphy of the thyroid gland before treatment were reviewed; data regarding signalment, scintigraphic findings (classified as unilateral, bilateral-asymmetric, bilateral-symmetric, or multifocal patterns), serum total thyroxine (T4) concentrations before treatment and prior to hospital discharge, and 131I treatment were collected. A questionnaire was sent to each referring veterinarian to obtain additional data including whether the cats subsequently developed hypothyroidism (defined as serum total T4 concentration less than the lower reference limit > or = 3 months after treatment). RESULTS: 50 of 165 (30.3%) 131I-treated cats developed hypothyroidism. Hypothyroidism developed in 39 of 109 cats with bilateral, 10 of 50 cats with unilateral, and 1 of 6 cats with multifocal scintigraphic patterns of their thyroid glands. Cats with a bilateral scintigraphic pattern were approximately 2 times as likely to develop hypothyroidism after 131I treatment than were cats with a unilateral scintigraphic pattern (hazard ratio, 2.1; 95% confidence interval, 1.04 to 4.2). CONCLUSIONS AND CLINICAL RELEVANCE: Cats with hyperthyroidism that have a bilateral scintigraphic pattern in the thyroid gland before 131I treatment appear to have a significantly higher risk of subsequently developing hypothyroidism, compared with cats with a unilateral scintigraphic pattern.  相似文献   

6.
Client-owned cats underwent surgery to remove palpable cervical masses in cats with normal total T4 values and no clinical signs of hyperthyroidism, renal disease, or hyperparathyroidism. Non-functional thyroid and parathyroid adenomas were found and identified by histopathological examination. The significance of these findings is discussed in relation to palpating a goiterous mass in an asymptomatic cat.  相似文献   

7.
Basal serum thyroxine (T4) concentration and the thyrotropin-releasing hormone (TRH) stimulation test were used to assess thyroid function in 36 critically ill cats examined between July 1996 and October 1998. Of the 36 cats. hyperthyroidism (as underlying or complicating disease) was suspected in 22 based on clinical signs, palpable thyroid nodules, and abnormal thyroid gland histology (study group). Hyperthyroidism was not suspected in the remaining 14 cats, which served as the control group. Based on serum T4 concentrations, suppression of thyroid function was documented in 14 (64%) cats of the study group and in 10 (71%) cats of the control group. The TRH stimulation test revealed an increase in serum T4 of less than 50% of the baseline concentration in 18 (82%) cats of the study group, and in 6 (43%) cats of the control group. In conclusion, based on the results of serum T4 determinations and the TRH stimulation tests, it was not possible to differentiate between cats with clinical and histologic evidence of thyroid dysfunction (hyperthyroidism) and cats with severe nonthyroidal illnesses.  相似文献   

8.
In 155 cats, both with and without clinical signs of hyperthyroidism, total thyroxine (TT4) concentrations were compared to a sensitive, semi-quantitative thyroid palpation technique. On the basis of TT4 concentrations, 23 of the 155 cats were classified as hyperthyroid. The size of individual thyroid glands was scored between '0' (non-palpable) and a maximum of '6'. One or more enlarged thyroid glands (score >0) were palpated in 22 of the 23 hyperthyroid cats and in 78 of the 132 euthyroid cats. However, none of the 132 euthyroid cats had a thyroid lobe score of greater than '3' whereas 18 of the 23 hyperthyroid cats had a thyroid lobe score of '4' or greater, and in two of the five that had scores below '4' there was evidence of intrathoracic functional thyroid tissue on scintigraphy.  相似文献   

9.
A prospective study was carried out using a combination of propranolol and potassium iodate to assess whether there were beneficial effects in preparing hyperthyroid cats for surgical thyroidectomy. Group A (n = 11) received propranolol from days 1 to 10, followed by propranolol and potassium iodate from days 11 to 20; group B (n = 10) received the reverse regimen. Blood samples were taken daily for subsequent determination of serum total L-thyroxine (TT4), L-triiodothyronine (TT3) and reverse T3 (rT3) concentrations. The signs of hyperthyroidism improved in all cats over the treatment period. At surgery, 36 per cent of the cats in group A had reference range serum TT4 concentrations, while 89 per cent with initially elevated TT3 concentrations had reference range concentrations. In group B, 10 per cent of the cats had reference range TT4 concentrations, while 75 per cent with initially elevated TT3 concentrations had reference range concentrations. The drug regimen used in group A was better tolerated and more effective and offers an alternative before thyroidectomy in cats that cannot tolerate carbimazole.  相似文献   

10.
Serum Thyroid Hormone Concentrations Fluctuate in Cats with Hyperthyroidism   总被引：3，自引：0，他引：3  
We measured serum thyroxine (T4) and 3,3',5-triiodothyronine (T3) concentrations in hyperthyroid cats (hourly for 10 hours in 14 cats, and daily for 15 days in seven cats) to assess fluctuation in thyroid hormone levels. Over the 10-hour study period the coefficient of variation (CV) for serum T4 and T3 concentrations ranged from 6.4-22.6% (mean = 12.0 +/- 4.8%) and from 9.6-33.1% (mean = 17.5 +/- 6.3%), respectively. During the 15-day study period, CV for serum T4 ranged from 6.6-34.8% (mean = 18.4 +/- 9.3%), while CV for serum T3 ranged from 7.8-31.0% (mean = 20.1 +/- 8.6%). These CV values were significantly higher than the expected intra-assay CVs (T4 assay, 5.1%; T3 assay, 7.7%). In addition, some of the cats with mild hyperthyroidism showed one or more normal serum T4 and T3 values during the course of the respective study periods. There was no specific time during the 10-hour study period at which the cats consistently showed peak serum T4 or T3 concentrations. These results suggest that serum thyroid hormone concentrations are subject to a degree of fluctuation that exceeds the usual assay variation, and that cats with mild hyperthyroidism can, at a given time, exhibit normal serum T4 and T3 values. Therefore, a diagnosis of feline hyperthyroidism should not be excluded on the basis of the finding of a single normal serum T4 or T3 value in a cat with clinical signs and physical examination findings consistent with the disease.  相似文献   

11.
OBJECTIVE: To determine the effect of hyperthyroidism on serum fructosamine concentration in cats. DESIGN: Cohort study. ANIMALS: 22 cats with overt hyperthyroidism. PROCEDURE: Hyperthyroidism was diagnosed on the basis of clinical signs, detection of a palpable thyroid gland, and high total serum thyroxine (T4) concentrations. Hyperthyroid cats with abnormal serum albumin, total protein, and glucose concentrations were excluded from the study. Samples for determination of serum fructosamine concentration were obtained prior to initiating treatment. Results were compared with fructosamine concentrations in healthy cats, cats in which diabetes had recently been diagnosed, and cats with hypoproteinemia. In 6 cats, follow-up measurements were obtained 2 and 6 weeks after initiating treatment with carbimazole. RESULTS: Serum fructosamine concentrations ranged from 154 to 267 mumol/L (median, 198 mumol/L) and were significantly lower than values in healthy cats. Eleven (50%) of the hyperthyroid cats had serum fructosamine concentrations less than the reference range. Serum fructosamine concentrations in hyperthyroid, normoproteinemic cats did not differ from values in hypoproteinemic cats. During treatment, an increase in serum fructosamine concentration was detected. CONCLUSIONS AND CLINICAL RELEVANCE: In hyperthyroid cats, concentration of serum fructosamine may be low because of accelerated protein turnover, independent of blood glucose concentration. Serum fructosamine concentrations should not be evaluated in cats with overt hyperthyroidism and diabetes mellitus. Additionally, concentration of serum fructosamine in hyperthyroid cats should not be used to differentiate between diabetes mellitus and transitory stress-related hyperglycemia.  相似文献   

12.
Absorbed thyroid dose and effective half-life were determined in 46 hyperthyroid cats after treatment with a low dose (mean 111MBq) of radioiodine intravenously. Thirteen of these cats had received iohexol for glomerular filtration rate (GFR) measurement within 24h before treatment with radioiodine in view of another ongoing study at our institution. Pre-therapy values were obtained for total thyroxine (TT(4)) and for the thyroid to salivary gland ratio with sodium pertechnetate gamma-camera imaging. All cats underwent post-therapy scans at 24, 48 and 120 h for evaluation of radioactive iodine uptake (RAIU) and the effective half-life of radioiodine. The absorbed dose was calculated from the cumulative activity with Olinda software. Both groups were comparable in age, TT(4) and the ratio of thyroid activity to salivary gland activity. Statistical analysis revealed a significant decreased absorbed dose in the thyroid in the iohexol group. This decreased uptake was not accompanied by an decreased effective half-life of the radioiodine. The variation of inter-individual RAIU decreased in this group and more homogenous absorbed doses were obtained. No significant difference in outcome could be demonstrated. However, a tendency towards a higher number of residual hyperthyroidism in the iohexol group was noted (15 versus 6% in control group). This study demonstrates that iohexol interferes with the uptake of radioiodine in the hyperthyroid cat but does not provoke increased turnover. In this study, albeit including a small number of cats, outcome did not seem to be significantly affected.  相似文献   

13.
Although feline hyperthyroidism has become a commonly diagnosed disorder of older cats, the underlying etiology remains unknown. Pathological findings of adenomatous hyperplasia involving both thyroid lobes in most hyperthyroid cats suggests the possibility that feline hyperthyroidism may be similar to human Graves' disease, which results from high circulating levels of thyroid stimulating immunoglobulins (TSIs). To exclude high circulating levels of TSIs as the cause of feline hyperthyroidism, we measured intracellular concentrations of cyclic adenosine monophosphate (cAMP) in functioning rat thyroid cells (FRTL-5) incubated with IgG extracted from hyperthyroid cat serum. Since TSIs stimulate thyroid hormone secretion through activation of cAMP, their presence can be evidenced in vitro by generation of high cAMP concentrations in cultured thyroid cells. No significant difference was found in intracellular cAMP concentrations in FRTL-5 cells incubated with IgG from normal versus hyperthyroid cats. In contrast, IgG from a human patient with Graves' disease caused substantially more cAMP generation than either normal human IgG or IgG from the cats of this study. These results indicate that feline hyperthyroidism does not result from high circulating concentrations of TSI and, in that respect, is not analogous to Graves' disease.  相似文献   

14.
OBJECTIVE: To evaluate response of euthyroid cats to administration of recombinant human thyroid-stimulating hormone (rhTSH). ANIMALS: 7 healthy cats. PROCEDURE: Each cat received each of 5 doses of rhTSH (0, 0.025, 0.050, 0.100, and 0.200 mg), IV, at 1-week intervals. Serum concentration of total thyroxine (TT4) and free thyroxine (fT4) was measured immediately before each injection (time 0) and 2, 4, 6, and 8 hours after administration of each dose. RESULTS: Overall TT4 response did not differ significantly among cats when administered doses were > or = 0.025 mg. Serum TT4 concentrations peaked 6 to 8 hours after administration for all doses > or = 0.025 mg. For all doses > or = 0.025 mg, mean +/- SEM TT4 concentration at 0, 6, and 8 hours was 33.9 +/- 1.7, 101.8 +/- 5.9, and 101.5 +/- 5.7 nmol/L, respectively. For all doses > or = 0.025 mg, mean fT4 concentration at 0, 6, and 8 hours was 38.7 +/- 2.9, 104.5 +/- 7.6, and 100.4 +/- 8.0 pmol/L, respectively. At 8 hours, the fT4 response to 0.025 and 0.050 mg was less than the response to 0.100 and 0.200 mg. Adverse reactions after rhTSH administration were not detected. CONCLUSIONS AND CLINICAL RELEVANCE: The TSH stimulation test can be performed in cats by IV administration of 0.025 to 0.200 mg of rhTSH and measurement of serum TT4 concentrations at time of injection and 6 or 8 hours later. Clinical validation of the TSH stimulation test would facilitate development of additional tests of thyroid gland function, such as a TSH assay.  相似文献   

15.
Thyroid scintigraphy is currently the reference standard for diagnosing and staging cats with hyperthyroidism, but few studies describing the scintigraphic characteristics in a large number of cats have been reported. The objective of this study was to better characterize thyroid scintigraphy findings by evaluating 2096 consecutive cats with hyperthyroidism that were referred over a 3.5‐year period. Of these cats, 2068 (98.7%) had a high thyroid‐to‐salivary ratio (>1.5), whereas 2014 (96.1%) were found to have a high thyroid‐to‐background ratio (>6.1). When the patterns of the cats’ thyroid disease were recorded, 665 (31.7%) had unilateral disease, 1060 (50.6%) had bilateral‐asymmetric disease (two thyroid lobes unequal in size), 257 (12.3%) had bilateral‐symmetric disease (both lobes similar in size), and 81 (3.9%) had multifocal disease (≥3 areas of increased radionuclide uptake). The number of areas of 99mTcO?4 uptake in the 2096 cats ranged from 1 to 6 (median, 2), located in the cervical area in 2057 (98.1%), thoracic inlet in 282 (13.5%), and in the thoracic cavity in 115 (5.5%). Ectopic thyroid tissue (e.g. lingual or mediastinal) was diagnosed in 81 (3.9%) cats, whereas thyroid carcinoma was suspected in 35 (1.7%) of the cats. The results of this study support conclusions that most hyperthyroid cats have unilateral or bilateral thyroid nodules, but that multifocal disease will develop in a few cats that have ectopic thyroid disease or thyroid carcinoma. Both ectopic thyroid disease and thyroid carcinoma are relatively uncommon in hyperthyroid cats, with a respective prevalence of ～4% and ～2% in this study.  相似文献   

16.
The diagnosis of hyperthyroidism, one of the most common disorders affecting elderly cats, is usually straightforward and considered routine by most practitioners. Nowadays, however, most cats suffering from hyperthyroidism tend to be diagnosed earlier and at a milder stage of the disease than those cats diagnosed 10 to 25 years ago. There are, in fact, a growing number of cats with clinical signs of hyperthyroidism and palpably large thyroid glands whose baseline serum total thyroid hormone concentrations are within the normal or borderline range, making diagnosis problematic. This paper reviews the available tests used to confirm a diagnosis of hyperthyroidism in cats and discusses their overall usefulness.  相似文献   

17.
Background: Iatrogenic hypothyroidism can occur after treatment of hyperthyroidism, and is correlated with a reduced glomerular filtration rate in humans and dogs. Hypothesis: Cats with iatrogenic hypothyroidism after treatment for hyperthyroidism will have a greater incidence of azotemia than euthyroid cats. Animals: Eighty client owned cats with hyperthyroidism. Methods: Two retrospective studies. (1) Longitudinal study of 12 hyperthyroid cats treated with radioiodine (documented as euthyroid after treatment), to assess changes in plasma thyroid stimulating hormone (TSH) concentration over a 6‐month follow‐up period, (2) Cross‐sectional study of 75 hyperthyroid cats (documented as euthyroid) 6 months after commencement of treatment for hyperthyroidism to identify the relationship between thyroid status and the development of azotemia. Kaplan‐Meier survival analysis was performed to identify relationships between thyroid and renal status and survival. Results: Plasma TSH concentrations were not suppressed in 7 of 8 cats with hypothyroidism 3 months after radioiodine treatment. The proportion of cats with azotemia was significantly (P= .028) greater in the hypothyroid (16 of 28) than the euthyroid group (14 of 47). Twenty‐eight of 41 cats (68%) with plasma TT4 concentration below the laboratory reference range had an increased plasma TSH concentration. Hypothyroid cats that developed azotemia within the follow‐up period had significantly (P= .018) shorter survival times (median survival time 456 days, range 231–1589 days) than those that remained nonazotemic (median survival time 905 days, range 316–1869 days). Conclusions and Clinical Importance: Iatrogenic hypothyroidism appears to contribute to the development of azotemia after treatment of hyperthyroidism, and reduced survival time in azotemic cats.  相似文献   

18.
The clinical presentation and biologic behavior of thyroid tumors vary widely among dogs, cats, and human beings. Although thyroid tumors in dogs are rare, they are most likely to be malignant. Clinical signs are usually the result of impingement on surrounding structures, and clinical hyperthyroidism is rare. In contrast, hyperthyroidism resulting from benign thyroid proliferation is relatively common among older cats. Malignant tumors are extremely uncommon but have high metastatic potential. Irrespective of the tumor's ability to produce functional thyroid hormone, scintigraphy is often helpful in the diagnosis and staging of thyroid tumors in all three species. Treatment with surgery is a reasonable treatment option for noninvasive tumors. Iodine 131 is a well-established treatment for thyroid nodules in cats, but its effectiveness in dogs is controversial. In dogs, external beam radiation therapy has produced more consistent results in affording local tumor control when surgery is not possible.  相似文献   

19.
Thyroidectomy in cats is most commonly indicated to treat hyperthyroidism because of adenomatous hyperplasia of the thyroid glands. Preoperative stabilization of the hyperthyroid cat with antithyroid drugs is preferred to minimize anesthetic and surgical complications. Multiple surgical techniques for thyroidectomy have been reported, and results of surgery and complications differ between techniques. The extracapsular technique offers the most complete removal of abnormal thyroid tissue, while still being associated with a low incidence of postoperative hypoparathyroidism. Important postoperative considerations are to carefully monitor serum calcium concentrations and treat hypocalcemia if necessary, and to monitor the cat for evidence of relapse of hyperthyroidism.  相似文献   

20.
Objective— To describe the signalment, history, clinical signs, surgical technique, and outcome for cats with laryngeal paralysis that had arytenoid lateralization.
Study Design— Case series.
Animals— Cats with laryngeal paralysis (n=10).
Methods— Medical records (1996–2002) for cats with laryngeal paralysis that had arytenoid lateralization were reviewed for signalment, history, clinical signs, degree of paralysis, cause, concurrent medical conditions, surgical technique, and outcome. Follow-up information was obtained from owners or referring veterinarians.
Results— Of 10 cats, 9 had bilateral and 1 had unilateral laryngeal paralysis. Arytenoid lateralization were unilateral (n=7), bilateral (1), and staged bilateral procedures (2), 10 days and 3 years apart, respectively. Postoperatively, 1 cat had persistent inspiratory noise because of minimal enlargement of the rima glottidis and 2 cats required a temporary tracheostomy for management of laryngeal swelling. Three cats developed aspiration pneumonia and died 4, 7, and 150 days after surgery; all 3 had bilateral (simultaneous or staged) procedures. Of the 7 remaining cats, 4 were alive at follow-up and 3 had died of causes unrelated to arytenoid lateralization. The calculated mean survival time for all 10 cats was 406 days (median, 150 days; range, 4–1825 days).
Conclusions— Arytenoid lateralization was effective at enlarging the rima glottidis and reducing signs of airway obstruction in most cats.
Clinical Relevance— Unilateral arytenoid lateralization is a feasible option for the surgical management of cats with marked clinical signs; however, bilateral procedures should be avoided or at least performed with considerable caution because of the apparent risk for aspiration pneumonia.  相似文献   

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