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PubMed1992

[Grand mal epilepsy in childhood].

Generalized tonic-clonic seizures are the most common type of convulsive disorders in children. They are always a sign of an epileptogenic cerebral dysfunction and present either acutely, predominantly as a single event with detectable origin, or chronically, recurring as an epileptic syndrome. In view of the etiology and classification of convulsions it is important to differentiate between primarily and secondarily generalized seizures. This distinction is first of all based on an exact description of the very beginning and of the course of the seizures, on the EEG findings and on any connection between the seizures and a particular time of day. Primarily generalized tonic-clonic seizures with and without associated petit mal seizures are manifestations of an idiopathic epilepsy and are most probably genetically determined, secondarily generalized seizures on the other hand are often signs of a central nervous lesion or of another symptomatic form of epilepsy. Benign idiopathic partial seizures, however, take the from of secondarily generalized convulsions during the morning sleep. Prolonged tonic-clonic seizures of any origin require vigorous treatment with anticonvulsants, if necessary in an intensive care unit. Recurrent seizures are treated with long-term anticonvulsant medication. The first-line treatment is valproic acid or phenobarbitone (or if necessary, a bromide) in primarily generalized seizures and carbamazepine or phenytoin in secondarily generalized convulsions. The recommended duration of this therapy and the risk of recurrence of seizures vary widely with the underlying etiology and the type of epilepsy.

Anticonvulsants↗

PubMed1992

Imipenem-cilastatin.

Imipenem-cilastatin, with its broad spectrum of activity and relative safety, offers an excellent alternative for the treatment of many obstetric and gynecologic infections. In addition, the possibilities for intramuscular administration give clinicians additional treatment options. Because of the relatively high cost of imipenem-cilastatin, it should not be considered "first-line" therapy for most obstetric and gynecologic infections at present. Misuse and overuse of imipenem-cilastatin will result in the further development of resistant organisms, as has already been seen with many other antibiotics, and continued monitoring of susceptibility patterns is necessary.

Animals↗

PubMed1992

[The treatment of hemifacial spasm using botulinum toxin].

Hemifacial spasm is a disagreeable disturbance with involuntary unilateral twitching of the facial muscles. Its most common form is supposedly due to an irritation of the facial nerve at its proximal intracranial segment by vascular structures. Various forms of treatment including surgical procedures are employed, very often without satisfactory results but frequently involving the risk for severe complications. For a few years a new method has been using injection of botulinum toxin into the affected muscles, which in the majority of patients relieves the abnormal movements for about half a year; therefore, this very effective and secure procedure is recommended as first-line treatment of hemifacial spasm.

Adult↗

PubMed1992

[Asthma and sleep].

In asthmatics, nocturnal cough and dyspnea are much more common than generally known. Therefore, patients with asthma must be asked specifically whether they suffer from symptoms of asthma at night. Usually, nocturnal wheezing is a sign of a badly controlled asthma. Nocturnal bronchoconstriction appears to be an exaggeration of the normal circadian changes in airway calibre. The cause of this exaggeration is not well understood, and it's origin is presumably multifactorial. Careful treatment of nocturnal asthma is particularly important because many deaths due to asthma occur at night and because regular disturbance of sleep impairs performance during the day. Inhaled corticosteroids and beta 2 agonists, especially the new long-acting beta agonists, are first-line drugs for therapy.

Airway Resistance↗

PubMed1992

[Visceral leishmaniasis in HIV infection. A totally opportunistic infection].

Visceral leishmaniasis occurring in immunocompromised patients, and in particular during HIV infection, has been described in recent years and differs from the usual Mediterranean kala-azar as encountered in France. In order to define the clinical, diagnostic and therapeutic features of the HIV-Leishmania spp. co-infection, we report 8 new cases and compare them with data from the literature. The co-infection occurs at any stage of HIV infection, usually in drug addicts using intravenous injections. Clinical manifestations, such as fever, weight loss, liver and spleen enlargement and polyadenopathy, and laboratory findings (cytoponia, inflammatory syndrome) are generally present but not specific during the HIV infection course. Moreover, some gastrointestinal and pleuropulmonary forms of the co-infection are misleading. Leishmaniasis serology is negative in 50 percent of the patients. In most cases the diagnosis is provided by detection of the parasite in bone marrow samples. Culture must be systematic, and samplings must be repeated if they are negative. The first-line treatment consists of pentavalent antimony. Almost 80 percent of the patients respond to this treatment, but relapses occur in 50 percent of the cases. This high risk of relapse and the opportunistic behaviour of leishmaniasis justify a prophylaxis of relapses.

AIDS-Related Opportunistic Infections↗

PubMed1992

Antiepileptic drugs and their psychotropic effects.

Antiepileptic drugs (AEDs) are still the main treatment for epilepsy. The first drugs such as the bromides, phenobarbital (PB), and related barbituates were all found to be anticonvulsant by chance. They also all carried to some extent the disadvantages of slowing thinking and motor behavior. Bromides are now seldom used and (PB) is only used when other drugs fail, although it is an important drug in the third world because of its low cost. Carbamazepine (CBZ), valproate (VPA), and phenytoin (PHT) are the current first-line AEDs. All of these drugs vary in the extent of their effect on mood. These drugs have also all been used in the treatment of psychiatric disorders. CBZ has been used mainly as a mood normalizer and has had some success in treating hypermanic episodes. VPA has been used successfully in the treatment of cyclical psychoses, whereas PHT, although it had a vogue in the 1940s for the treatment of psychosis, is little used as a psychological treatment now.

Affect↗

PubMed1992

Cisplatin-based combination chemotherapy with or without doxorubicin in advanced epithelial ovarian cancer: 8-year update of a randomized multicentric clinical trial. The Gruppo Oncologico Nord Ovest (GONO).

One hundred and twenty-five patients with advanced epithelial ovarian cancer (EOC) were postsurgically included in a multicentric clinical trial comparing the association of cisplatin (CDDP) (50 mg/m2 iv day1) + cyclophosphamide (CTX) (600 mg/m2 iv day 1) (PC regimen) versus the combination of PC + doxorubicin (ADM) (45 mg/m2 iv day 1) (PAC regimen), repeated every four weeks. After the sixth course of chemotherapy, patients without clinical evidence of disease or with surgically resectable residual disease (RD) underwent second-look laparotomy. Afterwards patients in surgical complete response (sCR) stopped chemotherapy, while partial responders or patients with stable disease received six more courses of the same regimen used as first-line treatment. Among the 67 patients with measurable RD, PAC regimen achieved a better clinical complete response (40.6% vs 20.0%); the difference approached statistical significance. In the 75 patients who underwent second-look laparotomy, PAC regimen induced a significantly higher sCR rate (62.2% vs 39.5%, p less than 0.05). The median survival (S) and progression free survival (PFS) were better in PAC arm, even if the differences were not statistically significant. Eight-year S and 8-year PFS were 32.7% and 24.7% respectively, for PAC arm, and 23.9% and 14.1%, respectively, for PC arm. These data seem to confirm the clinical advantage provided by the addition of ADM to PC regimen in the treatment of advanced EOC.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1992

[Low-grade non-Hodgkin's lymphomas. Study of 73 cases].

PURPOSE: To analyse the clinico-biologic features at diagnosis and the response to therapy and survival of a group of patients with low-grade non-Hodgkin's lymphoma (NHL). MATERIAL AND METHODS: The study comprises 73 NHL patients diagnosed between 1974 and 1989 in the Covadonga Hospital and classified as low-grade in accordance with the international Working Formulation. The first-line treatment regimens used were cyclophosphamide-vincristine-prednisone (CVP), chlorambucil-prednisone (CBL-PRED), radiotherapy, and other combinations. The statistical study was performed by comparative statistics (Student's tests, chi-square), univariate analysis (Cox Mantel method) and multivariate analysis (Cox proportional risks); the BMDP pack was used for the study. RESULTS: The median age of the group was 63 years. Stages III and IV were seen at first in 75% of the patients, and 22% of the series had extranodal involvement. CVP was used in 69% of the cases, 7.6 received CBL-PRED, 11% were given radiotherapy, and other combinations were given to 11% of the patients. As a whole, responses were seen in 46 cases (73%), of whom complete remission (CR) was achieved in 49% and partial remission (PR) or minor responses (MR) were attained in 24% of instances. The factors influencing upon CR were: stage (p less than 0.0005), B-symptoms (p 0.004), splenomegaly (p less than 0.801), platelet count and haemoglobin rate (p less than 0.01). The total survival at 10 years was 53%, and the disease-free survival for those attaining CR was 48%, with disease-free median of 81 months. The univariate analysis was influenced in a negative fashion by the following: peripheral blood lymphocyte count below 2 x 10(9)/L, B-symptoms (p less than 0.002), bulky tumoural mass (p less than 0.007), advanced stage (p less than 0.003) and, chiefly, response to treatment (p less than 0.0001). The 10-year survival of the patients achieving CR was 86%, that of both types of response (PR and MR) was 20%, and it was 0% for the failures. CONCLUSIONS: 1) Patients in low stages have high possibilities of curation with radiotherapy. 2) CVP for advanced stages provides moderate percentage of response, with CR rate lower than 50%. It is necessary to select those patients with unfavourable prognostic factors in order to use aggressive treatment to achieve CR. 3) Patients attaining CR have better prognosis in spite of the frequent relapses (63% at 10 years).

Adult↗

PubMed1992

[Sarcoma of the breast].

Sarcoma of the breast represents only 0.2-1% of all mammary malignancies. This study reports 5 such cases, including 2 osteosarcomas, 1 fibro-, 1 lipo-, and 1 malignant fibrous sarcoma. The treatment used was mastectomy in 3 cases with excision of axillary lymph nodes. The remaining 2 patients were treated by simple mastectomy whereby 1 of these received a immediate reconstruction with a prosthesis. 1 patient demonstrated local recurrence and died. The remaining 4 patients did not develop neither metastases nor local recurrence and are still alive after an observing period between 12 months up to 17 years. Today, first-line treatment is wide local excision or simple mastectomy. Excision of the axillary lymphatics, adjuvant radiotherapy, and chemotherapy have been disappointing in the treatment of breast sarcoma.

Adult↗

PubMed1992

[Percutaneous mitral commissurotomy].

Since it was introduced, in 1984, as an alternative to surgical commissurotomy, percutaneous balloon mitral commissurotomy has been performed in a large number of patients with mitral valve stenosis, significantly improving the valvular function with a final area of 2 square centimetres. The quality of the result obtained basically depends on valve anatomy. The incidence of complications is globally low, with a mortality of 0.5 to 3 percent, and severe mitral regurgitation in 5 percent of the cases. Left-to-right atrial shunts are detected by oxymetry in 20 percent of the patients, but they subsequently vanish in two-thirds of them. For the moment, only medium-term results are available: when the initial result is good functional improvement is the rule, and the incidence of restenosis is low. Conversely, when the result is insufficient or severe mitral regurgitation develops secondary surgery is usually necessary. Before deciding to perform percutaneous commissurotomy, the contre-indications of this method (left atrial thrombosis, moderate to severe mitral insufficiency) must be excluded. In view of the encouraging results obtained, percutaneous commissurotomy can be advocated as first-line treatment of soft valve mitral stenosis. In patients with calcified valve mitral stenosis, valve replacement remains the principal treatment, percutaneous commissurotomy being reserved for special cases.

Adult↗

PubMed1992

[Are all calcium antagonists alike?].

The group of calcium channel blockers includes drugs with marked structural differences and hence different fundamental pharmacodynamic and pharmacokinetic properties. The combination of these properties characterizes the different hemodynamic and electrophysiological effects of individual calcium antagonists as well as their profile of adverse effects. In treatment of essential hypertension the most important criteria for choosing one of the calcium antagonists are the rate of adverse effects, which is different between individual drugs of this class, and the possibility of once-daily administration to improve compliance. The effect on blood pressure in contrast is comparable for all calcium antagonists. In ischemic heart disease with markedly reduced left-ventricular function verapamil, diltiazem, but also nifedipine should be avoided as these drugs have important negative inotropic effects which may induce congestive heart failure and adversely affect prognosis. For monotherapy in this indication verapamil and diltiazem are drugs of first choice in patients with normal left-ventricular function, whereas second generation calcium antagonists of the dihydropyridine class can be given also in patients with reduced left-ventricular function and in combination with beta-blockers. Dihydropyridine derivatives with reflectory increase of sympathetic tone, such as nifedipine, should be administered in combination with beta-blockers only. Whereas calcium antagonists are first-line drugs for antihypertensive and anti-ischemic treatment, results in secondary prevention after myocardial infarction are rather disappointing when compared with established alternatives.

Calcium Channel Blockers↗

PubMed1992

Implementing shared governance: a false start.

A case study of the implementation of shared governance in a large teaching hospital in Western Canada has been presented. The project was placed in jeopardy due to two major contingencies: turnover in the chief nursing executive position, and a sudden reduction in the operating budget of the nursing division necessitating significant layoffs. Other factors that threatened the survival of shared governance included lack of systematic, long-range planning; the number and diversity of major changes introduced concurrently in the nursing division; and insufficient support systems to sustain organizational change. In particular, some senior and first-line managers could not adapt to or accept the radical philosophical change and so they were unable to empower their staff and to provide the necessary reinforcement needed to ensure the success of shared governance. This combination of these factors contributed to the loss of momentum in the implementation of shared governance. Lowered morale in the wake of layoffs, together with union grievances, and lack of clarity of the role to be played by union representatives in shared governance produced conflict and confrontation within the nursing division and between union and management. Despite the difficulties encountered, there remains optimism and commitment to the challenge of making shared governance succeed. As this article goes to press, remarkable strides have been made in addressing the described issues. A task force composed primarily of staff nurses has developed a "customized" model of governance that meets the needs of the hospital and deals with the identified flaws of the first implementation attempt. The organization is optimistic that by taking time to develop a solid foundation for the proposed change and tending carefully to the details of decision-making processes, an effective structure to support the professional role of the nursing staff will be a reality.

Attitude of Health Personnel↗

PubMed1992

Treatment of refractory colorectal carcinomas with fluorouracil, folinic acid, and interferon alfa-2a.

Interferon has been shown to augment the cytotoxic effects of fluorouracil (5-FU) against colon cancer in vitro and possibly in vivo. Therefore a pilot study was initiated to evaluate the effects of the combination 5-FU/FA/interferon alfa (IFN-alpha) in colorectal adenocarcinomas refractory to first-line therapy with 5-FU/FA. Eleven patients with rectum cancer and four patients with colon cancer were treated according to the following schedule: 9 million units IFN-alpha subcutaneous three times a week; 500 mg/m2 5-FU via an intravenous bolus 1 hour after the initiation of a 2-hour infusion of 500 mg/m2 of FA, once a week. Of 15 patients, one had a minor response, one had a disease stabilization, and three had a mixed response. No complete or partial remissions were seen. Looking at the sensitivity of lung metastases (three of three), the regressions can be explained through the additive effect of IFN-alpha to 5-FU/FA. Although minimal side effects (World Health Organization classification) were observed, most patients experienced a reduction of well-being.

Adult↗

PubMed1992

Interleukin-2 followed by fluorouracil and folinic acid in refractory colorectal cancer--results of a clinical phase II study.

In a clinical phase II study, 23 patients with progressive metastatic colorectal cancer and failure after first-line chemotherapy with fluorouracil (5-FU) and folinic acid (FA) were treated with a 5-day continuous infusion of recombinant interleukin-2 (IL-2), 3 x 10(6) cetus U/m2/d, followed after a rest period of 2 days by 5-FU, 600 mg/m2/d, and FA, 300 mg/m2/d over an additional 3 days. After two to four treatment cycles, eight of 22 evaluable patients (36%) revealed antitumor responses, with three partial remissions and five minor responses or stable disease. Side effects consisted most frequently of fever, nausea and vomiting, an elevation of liver enzymes, hypotension, and skin toxicity, and required a 50% reduction of IL-2 dose in 17 of 71 treatment courses (24%). In four of the 23 patients (18%), treatment had to be stopped completely. These data indicate a significant antitumor activity of IL-2 combined with 5-FU/FA therapy in chemotherapy-resistant colorectal cancer. Hence, in spite of a substantial treatment-related toxicity, further studies are warranted to substantiate these findings and to elucidate the underlying mechanisms of the IL-2-5-FU/FA combination therapy.

Adult↗

PubMed1992

[Loop-diuretics anno 1992. Mechanisms of effect and current therapeutic principles].

Loop-diuretics inhibit the Na+/K+/2Cl(-) -cotransport system in the thick ascending loop of Henle, and are the most potent of the diuretic agents. They also increase production of prostaglandins and, when given intravenously, reduce pulmonary capillary pressure. The clinical effects, and side effects, of loop diuretics are reviewed. In Norway, use of thiazide diuretics has declined, but use of loop-diuretics has remained unchanged. Loop-diuretics are still first-line drugs in cases of heart failure. The author discusses treatment of patients resistant to conventional doses of diuretics, and the causes of the resistance. Since furosemide and bumetanide may have very different effects and side effects, both are needed as treatment alternatives.

Bumetanide↗

PubMed1992

[The treatment of early asthma].

Asthma is an inflammatory disease of the bronchial mucosa associated with pulmonary function disorders of varying degrees of severity. The early detection of eosinophil-related mucosal inflammation constitutes both a diagnostic challenge and the key to treatment that may markedly improve outcome. Corticosteroids for inhalation are the first-line anti-inflammatory agents.

Administration, Inhalation↗

PubMed1992

[Right atrial thrombosis and severe pulmonary embolism].

Two cases of severe pulmonary embolism associated with right atrial thrombosis are reported. In the first case, fibrinolytic therapy was administered and was thought to be a causative factor in the death of the patient due to massive pulmonary embolism. In the second case, the patient was referred for surgery and two enormous thrombi were extracted. Unfortunately, the outcome was fatal. These two cases were confronted with the results of the literature. They strongly suggest that echocardiography should be a first-line investigation in severe pulmonary embolism. The detection of right atrial thrombosis modifies the clinical strategy and orientates treatment towards surgical referral when the patient's condition allows it.

Adult↗

PubMedDate not supplied

Fetal biophysical profile scoring.

Assessment of real-time ultrasound fetal biophysical variables has a limited role in the management of selected high-risk pregnancies. Composite biophysical scores remain inadequately studied and are of unproven value as a first-line test.

Female↗