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At least 199 records · Page 11Linked to original sources

PubMed1992

Influence of diuretics, calcium antagonists, and alpha-blockers on insulin sensitivity and glucose tolerance in hypertensive patients.

Treatment with thiazide diuretics causes impaired glucose tolerance, biochemical diabetes, and insulin resistance. The effect of diuretics on glucose tolerance is clearly dose-related. Spironolactone does not impair glucose tolerance, even at high dosage, but differences among other diuretics could be due to comparisons at doses that are not equal. Diuretic-induced changes in glucose metabolism are not conclusively related to altered potassium homeostasis, and impaired glucose tolerance occurs even when relatively low doses of thiazide are combined with potassium-sparing agents. The effects of diuretics on glucose homeostasis are in large part and probably entirely reversible. These disturbances of glucose metabolism have been detected only by detailed biochemical testing, and their clinical relevance is uncertain. In established diabetes, diuretics have a rapid and substantial adverse effect on metabolic control. In nondiabetic subjects, diuretics rarely cause or trigger a serious hyperosmolar nonketotic diabetic syndrome. Otherwise, it is not known whether the metabolic changes cause clinical diabetes or lead to microvascular complications in the long term. Evidence from large outcome trials suggests that biochemical diabetes, glucose intolerance, and insulin resistance do not increase the risk of coronary heart disease in treated hypertensive patients. Diuretics should be avoided in patients with diabetes unless their use is essential. Otherwise, a low dose of thiazide remains as excellent choice for first-line antihypertensive therapy. Dihydropyridine calcium antagonists, diltiazem, and verapamil appear to have no important effects on glucose homeostasis. There is very limited evidence that selective alpha-antagonists increase insulin sensitivity. The importance of metabolic differences between drug classes will be established only by comparative outcome trials with coronary events as the end point.

Adrenergic beta-Antagonists↗

PubMed1992

Antipyretic therapy in the febrile child.

General principles of thermoregulation, the pathophysiology of fever, controversies concerning the use of antipyretic therapy, and nonpharmacologic and pharmacologic treatments commonly used for antipyresis in the pediatric population are reviewed. Several arguments can be made for not ameliorating the febrile response. Fever is an important diagnostic and prognostic clinical sign that may have beneficial effects for the host. In addition, body temperatures of < or = 41 degrees C (105.8 degrees F) are relatively harmless. Reasons for treating fever include patient discomfort, the potential for adverse sequelae, the possibility of seizures, and the possibility that fever could affect the pharmacokinetic profiles of drugs. Nonpharmacologic treatment for fever includes environmental measures to enhance dissipation of body heat and sponging. Aspirin and acetaminophen are the agents used most frequently for antipyresis in pediatric patients. However, aspirin use in children with a viral illness has been associated with development of Reye's syndrome. As a result, its use in children has declined in the United States. Acetaminophen is relatively free of adverse effects and is considered first-line pharmacologic antipyresis therapy. Ibuprofen suspension should be considered as second-line antipyretic therapy. Combination therapy with acetaminophen and aspirin may be considered if the patient fails to respond to other nonpharmacologic and pharmacologic therapies; however, combination therapy may result in increased risk of drug toxicity, increased probability of adverse reactions, and increased risk of intoxication. Aspirin, acetaminophen, and ibuprofen are equally effective for antipyresis in pediatric patients. However, because acetaminophen is the safest medication, it is currently the therapy of choice.

Acetaminophen↗

PubMed1992

[Multidirectional instabilities and hyperlaxity of the shoulder].

Multidirectional instability is an unusual entity which is frequently missed in the context of unstable shoulder. The diagnosis of this condition may be difficult and is based on demonstration of basic anatomical lesions, usually acquired: capsular distension and damage to the inferior glenohumeral ligament responsible for the inferior component of the instability. Despite a suggestive clinical history, the positive diagnosis is based on a very detailed clinical and radiological examination, performed under general anaesthesia if necessary, in order to define the preferential direction of instability. Conventional and CT arthrography are of undeniable diagnostic and therapeutic value in the context of assessment. First-line treatment should be conservative. When surgery is indicated, it may consist of a combination of bone grafts and capsulorraphy, as described by C.S. Neer.

Humans↗

PubMedDate not supplied

Malaria prophylaxis: taking aim at constantly moving targets.

The prevention of malaria infections is one of the most important functions that any clinician can perform for those traveling to tropical geographic regions where malaria risks are present. The prophylaxis question has become complicated by continued emergence of chloroquine-resistant strains of Plasmodium falciparum, the recent appearance of Plasmodium vivax resistance, and the availability of a wide choice of antimalarial pharmaceuticals. Chemoprophylaxis may produce different toxicities among various patient populations. With increasing numbers of women who travel during their professional lives, there are potential implications for using chemoprophylaxis during pregnancy. Children are unable to tolerate certain antimalarials because of toxicities unique for them. In some instances, the safest and most palatable formulations for children are not even available in the United States and must be purchased in Canada or elsewhere. Reliance upon chemoprophylaxis alone has proven to be increasingly futile. With the introduction of new repellent formulations and nontoxic insecticides for use on clothing or bed netting, there are non-pharmacologic adjunctive measures which can now be considered first-line for the prevention of malaria infections.

Amodiaquine↗

PubMed1992

[Results of trabeculectomy in congenital glaucoma].

Congenital glaucoma has a very serious prognosis. It represents the first cause of blindness in Tunisian children. Trabeculectomy introduced by Cairns in 1968, was initially proposed as second-line treatment in congenital glaucoma surgery. It has now become more frequently used as first-line treatment in this indication. We have already used this technique directly in 35 children suffering from congenital glaucoma with a total of 54 eyes. Forty four eyes underwent a single operation, ten eyes underwent two to four trabeculectomies. Then study of these cases with a mean follow up of 24 months shows an overall success rate of 64% after one trabeculectomy, with or without additional medical treatment. The study of tonometric diagrams shows that the successful results obtained after 3 months persisted in the long term. Trabeculectomy gives better results in congenital glaucoma with intraocular pressure greater than 40 mmHg. Repeated operations are sometimes necessary. In these cases, postoperative subconjunctival 5 fluorouracil (SFU) did not improve the surgical outcome.

Child↗

PubMed1992

[Endoscopic treatment of vesico-ureteral reflux after reimplantation of the ureter (transplants excluded)].

O'Donnell's technique was used to treat 9 refluxing ureteric units after surgical reimplantation of the ureter in 8 patients (mean age: 45 years) between May 1986 and January 1991. The reimplantation was performed according to Cohen's technique in 5 cases (including ureteric remodelling in one case), Leadbetter's technique in 2 cases (including ureteric remodelling in one case), the Campos Freire technique in 1 case and a direct reimplantation in 1 case (with Boari). The reflux was grade II for 1 ureter, grade III for 54 ureters, grade IV for 2 ureters and grade V for 1 ureter. A single injection was performed in 5 patients and multiple injections were required in 3 patients. An associated bladder neck incision was performed in 2 male patients. No complications were observed. Correction of reflux was obtained for 8 ureteric units, i.e. 87% success with a mean follow-up of 28 months. The failure corresponded to the case of grade V reflux in a megaureter reimplanted with remodelling. The authors recommend that endoscopic treatment of reflux be performed as first-line treatment for reflux of reimplanted ureters because of the simplicity and efficacy of this technique.

Adult↗

PubMed1992

[Usefulness of converting enzyme inhibitors in the diagnosis of arterial hypertension].

Angiotensin-converting enzyme (ACE) inhibitors are now widely used as first-line treatment of essential hypertension. Their effectiveness is potentiated by a low-salt diet and, above all, by the simultaneous prescription of diuretics. When secondary hypertension is suspected, ACE inhibitors are a good pharmacological tool to study the renin-angiotensin system. Since activation of this system is the main mechanism responsible for renovascular hypertension, ACE inhibitors are very useful for diagnosis. Conversely, blood pressure is not influenced by ACE inhibitors in primary hyperaldosteronism because of the low plasma renin and angiotensin II levels. Pheochromocytoma activates the renin-angiotensin system, and ACE inhibitors combined with beta-blockers enable the hypertension to be controlled prior to surgical treatment of the tumour. Finally, ACE inhibitors can be used to explore the renin-angiotensin system in the experimental model of renovascular hypertension and therefore contribute to our knowledge of the complex pathophysiology of this most frequent type of secondary hypertension.

Adrenal Gland Neoplasms↗

PubMed1992

[Rhabdomyosarcoma of the prostate. Diagnostic course and current therapy. Report of a case of a 17-year-old boy].

The authors report a case of rhabdomyosarcoma in a 17 year old boy which recurred after combination chemotherapy and radical prostatectomy, followed by death of the patient due to haematological complications of second-line chemotherapy. The diagnosis of these rhabdomyosarcomas is facilitated by the various immunohistochemical stains now available. Chemotherapy is undeniably effective and, combined with surgery and radiotherapy, ensures a 5-year survival of 47% to 93% depending on the stage. The first-line chemotherapy avoids the need for radiotherapy in the early stages and allows less mutilating surgical procedures, while maintaining the survival rate.

Adolescent↗

PubMed1992

[Value (and limitations) of the RAST fx5 in pediatric allergological practice].

RAST f x 5 (CAP-system, Pharmacia), an in vitro assay testing a mixture of 6 food antigens, was systematically applied to 400 children and adolescents with respiratory pathologies possibly of allergic origin. The clinical aspects of the 293 test-negative patients were compared with those of the 107 positive cases. Furthermore, 84 positive sera were also evaluated against each of the 6 antigens regrouped in the f x 5. In this population with allergic respiratory diseases, the most frequently positive tests reacted with antigens of plant origins: wheat, peanut and soybean. From an economic point of view, first-line use of f x 5 markedly reduced the cost of a systematic study of food allergens, whose clinical justification remains to be demonstrated.

Adolescent↗

PubMed1992

Teniposide (VM-26) and carboplatin as initial therapy for small cell lung cancer.

Forty-four patients with previously untreated histologically proven small cell lung cancer (SCLC) were treated with a combination of teniposide 60 mg/m2 intravenously (IV) on days 1 through 5 and carboplatin 400 mg/m2 IV on day 1 every 28 days for six courses. Patients with limited disease (LD) subsequently received prophylactic cranial and thoracic radiotherapy. Of the 44 patients, 40 were evaluable for response: 31 (78%) achieved an objective response; 9 of 18 patients (50%) with LD had a complete response (CR), with a partial response (PR) plus CR rate of 78%. Two of 22 patients (9%) with extensive disease achieved a CR, with a combined PR and CR rate of 77%. Median duration of response for all evaluable patients was 253 days (36 weeks). Median duration of survival for LD patients was 368 days (52 weeks). Survival of LD patients was 86% at 6 months, 52% at 12 months, and 26% at 18 months. Median duration of survival for all patients in the study was 275 days, with a survival of 79% at 6 months, 36% at 1 year, and 12% at 18 months. Myelosuppression was the main toxicity, with World Health Organization (WHO) grade 3 or 4 infection occurring in 38% of patients. However, no patient died of sepsis or hemorrhage. Treatment was otherwise well tolerated, with no neurotoxicity or nephrotoxicity documented. The high activity of this drug combination justifies its use as first-line treatment of previously untreated SCLC.

Adult↗

PubMed1992

Screening for cervical cancer: is there a place for incorporating tests for the human papillomavirus?

Well organized screening programmes for cervical cancer, based on exfoliative cervical cytology, are known to be effective at reducing the incidence of invasive cervical cancer and mortality from the disease. HPV testing should not replace cervical cytology as the first-line approach in screening for cervical cancer, as HPV testing is not sufficiently reliable and some cancers are not associated with HPV infection. Even though there are many unanswered questions about the validity of HPV tests, it is timely to consider whether HPV testing might improve the management of the substantial number of women whose smears are neither clearly normal nor abnormal, but are described as atypical, suspicious or mildly dyskaryotic. The efficacy and costs of incorporating HPV testing into a cervical cancer screening programme need to be evaluated in controlled trials.

Female↗

PubMed1976

Clindamycin: an evaluation of its role in dental patients.

A review of the etiology of orofacial infections, of the pharmacology and spectrum of clindamycin and its associated complications, and a treatment plan for orofacial infections have been presented. On the basis of the data presented, it would seem that except for proved B fragilis infections, clindamycin is not a first-line drug for infections of the orofacial region. There are, however, indications for its use that have been presented. The serious complications associated with its use have also been presented. A high index of suspicion must be maintained regarding the development of these complications if clindaymcin is to be used.

Bacterial Infections↗

PubMed1992

Sumatriptan: a new drug for vascular headache.

The role of serotonin in the pathogenesis of migraine is discussed, and the chemistry, pharmacology, pharmacokinetics, efficacy, adverse effects, and dosage and administration of sumatriptan are reviewed. Sumatriptan, which is structurally related to the neurotransmitter serotonin, is a serotonin type-1-like-receptor agonist that has a selective but heterogeneous effect on the carotid arterial system. Sumatriptan has a rapid onset of action and a large volume of distribution. Its subcutaneous bioavailability approaches 100%, and its mean terminal half-life is two hours. Studies have shown that both subcutaneous sumatriptan and oral sumatriptan are superior to placebo in relieving migraine and cluster headaches. Studies comparing oral sumatriptan with either ergotamine tartrate plus caffeine (Cafergot) or aspirin plus metoclopramide indicated that sumatriptan relieved headache more quickly and effectively; however, the dosages of these other agents may have been suboptimal. Sumatriptan is generally well tolerated by patients, and most dose-related effects are mild and transient. The most common adverse effect is pain at the injection site. No drug interactions have been identified so far. Subcutaneous sumatriptan 6 mg and oral sumatriptan 100 mg seem to offer the best benefit-to-risk ratio, although dosage and administration information is limited. Subcutaneous and oral sumatriptan are effective in aborting moderate to severe migraine and cluster headaches and their associated symtpoms. However, more studies are necessary to compare sumatriptan's efficacy with that of other treatments before it can be recommended as first-line therapy for migraine.

Cluster Headache↗

PubMed1992

Ifosfamide-based chemotherapy for patients with resistant germ cell tumors: the Memorial Sloan-Kettering Cancer Center experience.

Sixty-six patients with germ cell tumors (GCTs) refractory to cisplatin plus etoposide/vinblastine-based therapy were treated with cisplatin, ifosfamide, and either etoposide (VIP) (50 patients) or vinblastine (VeIP) (16 patients). Sixty-two patients were evaluable for response. Twenty-one patients (34%) achieved a complete response (CR), 18 with chemotherapy alone and an additional three following surgical resection of viable tumor. Six of these patients have relapsed, and 15 (24%) remain in CR at a median follow-up of 13 months (range, 3+ to 41+ months). Three patients who achieved an incomplete response or relapsed from CR are disease free following additional salvage therapy; one patient underwent resection of a solitary metastasis and two received high-dose chemotherapy with autologous bone marrow rescue. Ifosfamide adds efficacy to cisplatin plus etoposide or vinblastine-based salvage therapy. Ifosfamide/cisplatin-based combinations should be considered in the first-line salvage treatment of germ cell tumors. The modest proportion of patients who achieve a durable CR following salvage therapy with VIP/VeIP emphasizes the need for early identification of treatment failure and more effective salvage therapy.

Adult↗

PubMed1992

Treatment of limited-disease small cell lung cancer.

Refinements in the use of chemotherapy, both alone and in combination with chest irradiation, have prolonged the survival of patients with limited-disease small cell lung cancer in the last two decades. Based on reviews of trials of patients with both limited and extensive disease, these improvements appear to transcend adjustments made in the staging of limited disease. Alternation of chemotherapy regimens according to the Goldie-Coldman hypothesis has not proven advantageous in this setting. Etoposide combined with cisplatin has been effective as a salvage regimen for previously treated small cell lung cancer, and is particularly useful in first-line treatment approaches when given concurrently with chest irradiation. Although prophylactic cranial irradiation has reduced central nervous system recurrence in complete responders, its role remains controversial due to an unclear effect on survival and associated long-term toxicities. Our present understanding of the biology of limited-disease small cell lung cancer should lead to further refinements in treatment.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1992

The role of etoposide therapy in germ cell cancer.

In the last decade, etoposide has become a standard component of first-line combination chemotherapy in germ cell cancer. The replacement of vinblastine by etoposide in primary treatment came after the therapeutic efficacy of etoposide-containing regimens was determined to be equivalent or superior to vinblastine, with diminished short-term side effects. Subsequent investigations in the salvage setting have demonstrated that high-dose carboplatin and etoposide regimens coupled with autologous bone marrow transplantation can cure some patients with highly resistant disease, and that novel scheduling of etoposide using daily, oral, low-dose therapy can provide effective palliation in some patients. Although these therapeutic successes have been clouded by the demonstration of secondary acute leukemias in rare patients who have received high-dose etoposide, the challenge of the 1990s will be to capitalize on the clinical leads of dose and scheduling as well as to continue to document the long-term safety of these agents.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1992

[Indications for Clozapine].

Clozapine does not constitute a first-line treatment due to the occurrence of agranulocytosis. However, the benefit risk/ratio fully justifies its use in two situations: resistance to neuroleptics, intolerance to neuroleptics. There are no internationally recognized objective criteria to define resistance. The ones defined in the well-restricted methodological environment of a clinical trial are generally not applicable to daily practice. In particular, the accepted criteria do not always take into account the personal factors, the social and environmental context and rehabilitation programs. May et al. for example defined in 1988 the degree of response to therapy based on clinical improvement as well as social integration. It is widely recognized that if the severity of residual symptoms (grade 5 response) requires the hospitalization, treatment with clozapine is warranted. For partial responders to classical treatment (grade 4 response) who could benefit from clozapine, the risk ratio of clozapine needs to be further evaluated. The identification of predictive factors of response to therapy would allow a novel approach of this indication. According to certain authors, paranoid type responds best to therapy. However, the evidence collected to date needs to be confirmed. In particular, the effects of clozapine on predominantly negative symptoms require further investigations. In contrast to several european studies, intolerance to neuroleptics is rarely a reason for initiation of clozapine therapy. This would indicate that the appreciation of intolerance to neuroleptics notably varies from one country to the next. Intolerance criteria need to be further specified as well as the benefit risk/ratio.(ABSTRACT TRUNCATED AT 250 WORDS)

Clozapine↗

PubMed1977

Drug prescribing in rheumatoid arthritis in Otago.

The drug therapy prescribed for a group of 50 patients with rheumatoid arthritis in Otago prior to specialist referral was examined. Thirty-two patients were receiving some first-line anti-inflammatory drugs and six were receiving no therapy at the time of their first hospital clinic visit. Salicylates had been prescribed first in only 16 of the 50 patients while this drug had been withdrawn because of side effects in about one-third of the patients who had been treated with it prior to specialist referral. Seven patients had received phenylbutazone and six corticosteroids as the first treatment for their rheumatoid arthritis. About one-third of the patients were receiving more than one anti-inflammatory drug at the time of their initial clinic visit.

Adult↗