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PubMedDate not supplied

Cerebral hemorrhagic complications of thrombolytic therapy.

Thrombolytic therapy is well established in the management of a select group of atherothrombotic and thromboembolic diseases at the expense of definite but increased risk of intracranial hemorrhage. The incidence of intracranial hemorrhage is higher (6.4% to 20%) in the thrombolytic treatment of acute ischemic stroke, whereas the cerebral hemorrhagic complications of thrombolytic treatment in acute myocardial infarction, acute pulmonary embolism, deep venous thrombosis, and arterial and graft occlusion is less than 2%. Although systemic fibrinolysis after thrombolysis is responsible for hemorrhagic complications, many factors are implicated in predisposition to cerebral hemorrhagic complications such as old age, untreated or chronic hypertension, history of cardiac disease, hyperglycemia, patients with small body mass, previous stroke, longer therapeutic treatment window, increasing neurological deficit or severity of neurological deficit, higher thrombolytic dose and computed tomography findings of mass effect, edema, or extended infarct sign involving more than one third of the territory of the middle cerebral artery. Although the knowledge of different factors associated with intracranial hemorrhage is important, it is the judicious use and strict adherence of appropriate clinical protocols in different clinical settings of thrombolytic treatment and avoidance of the contra-indications that will minimize the rate of hemorrhagic complication to achieve good clinical outcome and desired benefit.

Animals↗

PubMed2003

Use of primidone in low doses (250 mg/day) versus high doses (750 mg/day) in the management of essential tremor. Double-blind comparative study with one-year follow-up.

Essential tremor is the most common involuntary movement; we studied 113 affected subjects (54 men, 59 women) with an average age of 63.9 years and average duration of 9.05 years. These patients participated in a double-blind study with a 1-year follow-up to compare treatment efficiency using primidone dosages of 250 mg/day (G 250, 56 patients) versus 750 mg/day (G 750, 57 patients). The study was designed with an 80% power and 95% confidence level. The statistical analysis used was an ANOVA (with Bonferroni multiple comparison test corrections); a value of p<0.004 was accepted as significant. To compare other values, a chi-square test was used; p<0.05 was considered significant. To evaluate the efficacy of the drug, clinical protocol employed the 'clinical evaluation scale for tremor'. All of the patients were evaluated a total of 13 times, once prior to the introduction of primidone and the other 12 evaluations following the initiation of the treatment. Eighty-seven patients completed the study: 15 patients abandoned the study due to undesirable side effects, five due to negative response, and six who were lost to follow-up. The percentage of patients who didn't complete the study was significantly higher in the group that received 750 mg/day of primidone (p<0.04) and more frequent as well in this same group, due to undesirable side effects (p<0.03). The patients of both G250 and G750 showed a significant improvement in each of the controls compared to the basal value (p<0.0001). No significant differences (p<0.06) were found when the averages of the evaluations of each group were compared. These responses were maintained during the entire treatment period. Low doses of primidone (250 mg/day) were equally or more effective than high doses (750 mg/day) in the control of essential tremor; this response was maintained for 12 months and furthermore, demonstrated fewer undesirable effects.

Administration, Oral↗

PubMed2006

Evidence for early oral feeding of patients after elective open colorectal surgery: a literature review.

AIM: To review research on early oral feeding following elective, open colorectal surgery. BACKGROUND: Fasting following gastrointestinal surgery is a traditional surgical practice, based on fears of causing postoperative complications if oral intake begins before bowel function returns, but fasting following elective surgery is questionable as a best practice. METHODS: Searches in Journals@Ovid CINAHL, MEDLINE, PubMed, Web of Science and The Cochrane Library for primary studies, published during 1995-2004, used the keywords: 'surgery', 'postoperative', 'elective, 'colorectal', 'bowel, 'colon', 'oral', 'enteral', 'feeding', 'early', 'traditional'. Studies of adults undergoing elective, open colorectal surgery who were allowed fluids and food before bowel function returned (early feeding) were included. Outcomes of interest were safety, tolerability, duration of gastrointestinal ileus and length of hospital stay. Critical appraisal of randomized and controlled studies was undertaken following inclusion. RESULTS: Fifteen studies comprising 1352 patients were reviewed. All studies concluded early feeding was safe, based on complications rates. Total complications were 12.5% (range 0-25%) for 935 early feeding patients, with no increased risk of anastomotic leak, aspiration pneumonia, or bowel obstruction. For all studies an average of 86% patients (range 73-100%) tolerated early feeding. Studies demonstrating faster resolution of postoperative ileus or shorter hospitalization were associated with multimodal perioperative care, including early mobilization, epidural analgesia and comprehensive patient education. Appraisal of five randomized trials revealed no blinding and inadequate randomization. CONCLUSIONS: This review supports early oral feeding after elective, open colorectal surgery and challenges the traditional practice of fasting patients until return of bowel function. Early feeding was safe, well-tolerated and easy to implement. Reduced length of ileus and shorter hospitalization may occur with multimodal protocols. RELEVANCE TO CLINICAL PRACTICE: Nurses can highlight this new evidence for other health professionals, advocate development of clinical protocols featuring early feeding and participate in multi-disciplinary, multi-method research regarding benefits of early feeding.

Aged↗

PubMedDate not supplied

The Memphis diabetes continuing care program.

Since 1963 a network of nurse-operated, physician-backed decentralized clinics has provided continuing care for more than 5000 diabetic patients referred from the medical center clinics. Protocols that provide therapy goals and management details are used by the nurses and nutritionists in this network. To reduce fragmentation of care, intercurrent illnesses as well as other chronic diseases are treated using protocols in these clinics or in the home. This study examines certain outcome data in a subset of 556 diabetic patients under continuing care over a 7-yr period in this network, with comparisons being made to care before referral. Blood glucose is maintained at comparable levels in both decentralized and hospital clinics. Blood pressure levels in hypertensive patients are maintained in a satisfactory range. Total hospitalization rates are reduced by 47%. For ketoacidosis and amputation, hospitalization is decreased by 69% compared with the experience before referral. The maintenance care costs are decreased substantially compared with costs before referral due to the less expensive ambulatory services and the reduced need for hospitalization. The data support the concept that decentralization is an effective means of providing continuing care to patients with diabetes mellitus.

Ambulatory Care↗

PubMedDate not supplied