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PubMed1991

Management of malignant ventricular arrhythmias using antitachycardia devices.

Cardioverter defibrillators were implanted in 26 patients at Charleston Area Medical Center for management of cardiac arrest (7 patients), and drug refractory sustained ventricular tachycardia (19 patients). A variety of operative approaches and concomitant surgical procedures were utilized in the implantation of these devices. No operative deaths occurred. A superficial wound infection was the only operative complication. During the follow-up period (9.3 +/- 5 months), 11 of 26 patients (46 percent) had a defibrillator discharge and one death occurred (3 percent), which was due to heart failure. Patients with malignant ventricular arrhythmias may present with sustained monomorphic ventricular tachycardia with associated syncope, pre-syncope or without any associated symptoms. Unfortunately, cardiac arrest may be the initial presentation. The use of antitachycardia devices such as implantable cardioverter defibrillators and antitachycardia pacemakers has allowed physicians to more successfully treat patients with malignant ventricular arrhythmias. In a significant number of patients with these arrhythmias, such devices are now used as first-line therapy.

Adult↗

PubMed1991

Penicillinase-producing Neisseria gonorrhoeae in a subset of nonemergent patients: I. A trend in the Washington, DC area.

A significant increase in penicillinase-producing isolates of Neisseria gonorrhoeae has been detected and documented in the District of Columbia. Currently, the prevalence of beta-lactamase isolates is approaching 50%, with the greatest number of cases being detected in the 18- to 23-year-old age group, in both males and females. Indicators suggest that this trend, which was first noted in 1987, will become more pronounced in the future. Ceftriaxone is now the first-line drug of choice in treating suspected gonococcal infections.

Adolescent↗

PubMed1991

Droloxifene, a new antiestrogen, in advanced breast cancer. A double-blind dose-finding study. The Droloxifene 002 International Study Group.

To determine the optimal daily dose of the new antiestrogen droloxifene for the treatment of breast cancer, a multinational, multicenter, randomized, double-blind, phase II trial was initiated. Postmenopausal women with progressive advanced breast cancer (distant metastatic cancer, inoperable recurrent or primary tumor) with positive or unknown hormone receptor status (estrogen or progesterone) were entered in the study. Droloxifene was administered in a double-blind randomized design with daily doses of either 20, 40, or 100 mg once daily as first-line systemic therapy. None of the patients had received previous systemic antitumor therapy with the exception of adjuvant chemotherapy terminated at least one year before the patient's recruitment. Response was determined according to Union Internationale Contre le Cancer/World Health Organization criteria. Only patients with at least one measurable lesion were entered into the trial. The highest quality of data was achieved in two ways: source verification in the hospitals through monitors and peer review with subgroups of investigators determining the tumor response of each patient at adjudication meetings (evaluating parameters obtained from physical examination and reviewing X-rays and computer tomography scans). To date, 254 patients have been enrolled. Results from all these groups, without breaking the randomization code, based on 131 patients whose data have been verified are as follows: 10 complete responses (CR), 37 partial responses (PR), 47 no change, 29 progressive disease, 8 patients too early to evaluate. Thus, the overall response rate (CR + PR) was 38%. Droloxifene was well tolerated.

Antineoplastic Agents↗

PubMed1990

Attention-deficit hyperactivity disorder.

The epidemiology, etiology, pathogenesis, clinical presentation, diagnostic criteria, and clinical course of attention-deficit hyperactivity disorder (ADHD) are described and the role of pharmacotherapy in the management of this disorder is discussed. ADHD is a behavioral disorder of unknown etiology characterized by inattention, impulsiveness, and hyperactivity. The behavior, which may be manifest at home, at school, or in social situations, is generally worse in settings requiring sustained attention; as a result, academic underachievement is frequently an associated problem. Although the onset usually occurs before the age of four years, ADHD is most commonly diagnosed when the child enters school. It is up to six times more common in boys than in girls. Nearly one third of all children with ADHD continue to show symptoms of the disorder in adulthood. While many questions about the pathophysiology of ADHD remain unanswered and a cure has not yet been found, pharmacotherapy can effectively control the symptoms of the disorder in most patients. Three psychostimulant medications--dextroamphetamine sulfate, methylphenidate hydrochloride, and pemoline--are considered the drugs of first choice for management of the behavioral manifestations of ADHD. Dextroamphetamine and methylphenidate are equally effective in improving the symptoms of ADHD. Pemoline, a newer agent, may be tried in patients who cannot tolerate or do not respond to these two first-line agents. Common adverse effects associated with stimulant medications include anorexia, insomnia, stomach pain, and weight loss; these are generally transient and decrease with time. Imipramine hydrochloride and desipramine hydrochloride are less effective and may produce more serious adverse effects than the psychostimulants and are therefore considered second-line agents for the treatment of ADHD. Dextroamphetamine sulfate, methylphenidate hydrochloride, and pemoline have been shown to effectively control the behavioral symptoms of ADHD. For maximum impact, pharmacotherapy should be accompanied by behavioral, educational, and psychosocial intervention.

Attention Deficit Disorder with Hyperactivity↗

PubMed1990

Medical management of unstable angina. What have we learned from the randomized trials?

Because of the absence of a generally accepted definition of unstable angina, the clinical context of drug trials for this condition has varied from trial to trial. Early- versus late-entry trials must be distinguished, and the possibility of a modification of effect caused by the nature of drug therapy already given when the patient became unstable or by concomitant treatment in addition to experimental treatment must be taken into account. These factors cannot be overlooked when the results from a limited number of reported trials are pooled together. The largest early-entry trial with a beta-blocker and a calcium antagonist was the Holland Interuniversity Nifedipine/metoprolol Trial (HINT), which enrolled patients with suspected unstable angina diagnosed at coronary care unit admission. HINT results showed that unstable angina cannot be reliably differentiated from evolving myocardial infarction (MI) in this particular context and that there are few early MIs that could have been prevented. In patients who were not already taking a beta-blocker, metoprolol reduced the incidence of acute MI or recurrent ischemia, and there was no benefit of nifedipine. On the other hand, the addition of nifedipine was effective in patients whose conditions became unstable despite maintenance treatment with a beta-blocker. Thus, previous beta-blockade modified the effect of the calcium antagonist studied. Based on evidence from HINT and other trials, it is concluded that beta-blockers should be used as the first-line treatment in patients with unstable angina and that a calcium antagonist should be added when patients remain unstable despite beta-blockade.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic beta-Antagonists↗

PubMed1990

Cardiac contractility and conduction: a comparison of antihypertensives.

The four classes of first-line antihypertensive agents recommended in the 1988 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure are reviewed here. Particular consideration is given to the effects of these agents on heart rate, atrioventricular nodal conduction, and myocardial contractility in patients with other cardiovascular diseases. Diuretics and angiotensin-converting enzyme inhibitors have no significant direct effects on cardiac function. beta-Blockers inhibit catecholamine stimulation of the heart and may be particularly beneficial in treating patients with a history of myocardial infarction. Calcium channel blockers reduce blood pressure by dilating arterial resistance vessels. They are structurally heterogeneous and highly selective in their sites of action. As a consequence, cardiac effects can be minimized by selecting a calcium channel blocker with more potent peripheral vasodilatory effects. A new calcium channel blocker, isradipine, currently undergoing clinical trials, is highly selective for arterial smooth muscle and appears to be a safe and effective antihypertensive agent.

Adrenergic beta-Antagonists↗

PubMed1990

Serial peritoneal macrophage function studies in CAPD patients with peritonitis.

Continuous ambulatory peritoneal dialysis, peritoneal macrophage, IL-1, IFN-r, TNF, phagocytosis. Peritoneal macrophages (PM) perform first-line defense activity against peritonitis, the most important complication in CAPD therapy. Our longitudinal study compared the PM function in 14 patients in a low peritonitis occurrence group (LPOG) and 6 in a high peritonitis occurrence group (HPOG) before and during peritonitis; all started CAPD therapy after January 1988. The results show that at the onset of peritonitis, PM function including bactericidal killing (BA) activity, phagocytosis index (PI), H2O2 release, interleukin-1 (IL-1) and tumor necrosis factor (TNF) secretion can increase rapidly in the LPOG. However, this was absent in the HPOG. Both groups had a decrease of PM immunological function in the initial 7 to 10 days after onset of peritonitis, then PM functions began to return toward their pre-peritonitis state. However, in the HPOG, the recovery of PM function was very slow, resulting in significantly lower PM functions. In vitro, when normal PM were put into peritonitis dialysate, IL-1, TNF production and PI, BA activity of PM were decreased. This suppressor activity was absent in the peritonitis-free dialysate. These results suggest a suppressor factor(s) in the HPOG peritoneal dialysate may decrease the function of PM rather than cause easy peritonitis development.

Bacterial Infections↗

PubMed1990

Oral treatment of CAPD-peritonitis with ciprofloxacin.

Peritonitis is still a major problem in CAPD. The synthetic chemotherapeutic quinolone ciprofloxacin offers new possibilities for oral treatment of this complication. The efficacy of ciprofloxacin as first-line antibiotic was investigated in five consecutive peritonitis episodes of five patients. The dosage was deduced from a pilot study and consisted of an intra-peritoneal loading dose during the first 24 hours. Simultaneously ciprofloxacin was given orally and thereafter only the oral medication was continued. The causative microorganisms in the 5 episodes were (MIC90 in brackets): nonfermentative Gram negative rod, group IVc-2 (0.6 micrograms/ml), S. aureus (0.25 micrograms ml), Strep. faecalis (0.4 micrograms/ml), S. aureus + S. epidermidis (both 0.25 micrograms/ml) and S. aureus (0.13 micrograms/ml). The clinical course was uncomplicated and all episodes were cured with ciprofloxacin monotherapy. In 4 patients all dialysate concentrations exceeded 2.3 micrograms/ml (mean 5.8 micrograms/ml). In one patient dialysate concentrations varied between 2.2 and 7.5 micrograms/ml during the first 24 hrs and between 0.4 and 1.2 micrograms/ml thereafter. Despite these low dialysate concentrations, the episode caused by S. aureus (MIC90 0.25 micrograms/ml) was cured uneventfully. We conclude that ciprofloxacin may be useful for the treatment of CAPD peritonitis. Large interindividual differences in dialysate concentrations should be taken into account.

Administration, Oral↗

PubMed1991

Cost savings in a hospital clinical laboratory with a pay-for-performance incentive program for supervisors.

A pay-for-performance incentive program for clinical laboratory supervisors was developed and implemented at Brigham and Women's Hospital (Boston, Mass). It provides monetary rewards to personnel who directly produce cost savings in their area of responsibility. This reward system is new to the hospital laboratory but is commonly used in industry. Substantial true cost savings over and above previously established stringent budgets were achieved, 11% of which was returned to first-line supervisors in the form of a bonus. The program expanded the scope of professionalism for supervisors to include fiscal management.

Cost Control↗

PubMed1991

Redesigning management roles. The executive challenge.

The revolutionary changes that have occurred in healthcare during the past decade challenge nurse executives to analyze and redesign managerial roles. To confront future change and developments in nursing and management practice, the role of the first-line nurse manager must take on new dimensions to facilitate quality outcomes in patient care and empowerment of nurses at all levels of practice. The author presents a model of job redesign for nurse managers with emphasis on the motivational approach. Role outcomes for nurse managers are also detailed.

Feedback↗

PubMed1991

The role of calcium channel blockers in the treatment of essential hypertension.

Calcium channel blockers, originally developed for the treatment of angina and supraventricular arrhythmias, have been shown to lower elevated blood pressure effectively in hypertensive patients. Verapamil, nifedipine, and diltiazem represent prototype compounds for unique chemical classes with differing pharmacologic properties. These drugs lower elevated blood pressure with efficacy comparable with other commonly used antihypertensives. Combination therapy with other agents usually results in an additive response. Side effects are usually mild and reversible and usually are an extension of the drug's pharmacologic effects. Moreover, adverse metabolic effects on lipid, glucose, or potassium levels are not common. Because of the excellent antihypertensive effects of calcium channel blockers and their potential importance in a variety of other disease states, these agents should be routinely considered for use as a first-line antihypertensive agent in appropriately selected patients with hypertension of any severity as part of a comprehensive plan to minimize cardiovascular risk.

Animals↗

PubMed1991

Intraperitoneal cisplatin-based chemotherapy for ovarian carcinoma.

Ovarian carcinoma demonstrates a steep dose-response curve for cisplatin, but even very small levels of acquired resistance at the cellular level are sufficient to block the efficacy of intravenous (IV) cisplatin. The intraperitoneal (IP) route of administration produces a 12-fold to 15-fold greater exposure for the peritoneal cavity, and concurrent use of IV thiosulfate permits the safe IP injection of 200 mg/m2 cisplatin. In this study, two phase II trials of an IP regimen containing cisplatin 200 mg/m2 and etoposide 350 mg/m2 with IV thiosulfate were conducted; the first trial enrolled patients with residual disease less than 2 cm who had failed primary cisplatin-based IV chemotherapy and the second trial newly diagnosed ovarian carcinoma patients irrespective of the size of residual disease after primary surgery. As salvage therapy, the IP cisplatin/etoposide regimen produced a median survival of 26 months from the start of IP therapy and 51 months from diagnosis. As first-line therapy, the median survival has not yet been reached; projected survival is 68% at 27 months. In both studies the major toxicity was myelosuppression; the use of concurrent thiosulfate almost completely eliminated serious nephrotoxicity and neurotoxicity. The size of the largest tumor mass was an important determinant of efficacy in both settings. The results of these trials are consistent with the hypothesis that increased drug delivery will result in higher response rates and improved survival. Data are sufficiently encouraging to mandate phase III randomized trials of this program.

Antineoplastic Combined Chemotherapy Protocols↗

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↗

PubMed1979

Bretylium tosylate: a review.

The chemistry, pharmacology, pharmacokinetics, clinical uses, adverse effects, drug interactions and dosage of bretylium tosylate, a recently approved antiarrhythmic agent, are reviewed. Bretylium tosylate is used to treat life-threatening ventricular arrhythmias, principally ventricular fibrillation and ventricular tachycardia, that have not responded to treatment with first-line antiarrhythmic agents. The drug has a direct positive inotropic effect on the myocardium and blocking effect on postganglionic sympathetic nerve transmission. The drug is poorly absorbed orally, requiring either i.m. or i.v. administration. Drug excretion occurs primarily through the kidney, necessitating dosage modification in renal disease. Hypotension is the most commonly observed adverse reaction to bretylium tosylate. Rapid i.v. administration may cause severe nausea and vomiting, and i.m. injection at the same site may cause atrophy and necrosis of muscle tissue. Quinidine and procainamide may potentiate the hypotensive effects of bretylium. Bretylium will aggravate digitalis-induced arrhythmias. Bretylium's use in resistant ventricular tachyarrhythmias requires close clinical monitoring.

Arrhythmias, Cardiac↗

PubMed1979

[Current chemotherapy of pulmonary tuberculosis].

Tuberculosis has today lost much of its dread for mankind: in 1976, 1823 persons contracted tuberculosis and 182 died of pulmonary tuberculosis in Switzerland. In contrast, 1375 died of pneumonia, 1309 of non-specific airway disease and 2202 of bronchial cancer in the same year. The present data on morbidity and mortality in Switzerland resemble those of the other industrial European countries or the USA. The decrease in morbidity and mortality of pulmonary tuberculosis was caused-among other factors-by chemotherapy. Chemotherapy not only profoundly changed the infectivity of tuberculous patients and made ambulatory, domiciliary treatment possible, but cured pulmonary tuberculosis. The introduction of the bactericidal rifampicin led to the latest major landmark in the chemotherapy of tuberculosis in the past 20 years: namely, short-course chemotherapy. Together with the other first-line drugs (isoniazid, streptomycin, ethambutol), rifampicin shortened the duration of chemotherapy from 18--24 to 9--12 months. Short-course chemotherapy is today the therapy of choice for most patients with pulmonary tuberculosis.

BCG Vaccine↗

PubMed2026

[Tics and Tourette Syndrome].

Tics disorders and Tourette syndrome (TS) are neurodevelopmental conditions characterized by motor and/or vocal tics with onset in childhood. Their clinical presentation is heterogeneous and fluctuating over time, with exacerbations related to emotional, environmental, and medical factors. Diagnosis is clinical and based on medical history and neurological examination, following DSM-5-TR criteria, with ancillary testing rarely required. The prevalence of TS is estimated at 0.7%, while transient tic disorders affect up to 10% of children. The natural history is generally favorable, with symptom improvement during adolescence, although a subset of patients continues to experience tics into adulthood. Most individuals with TS present psychiatric comorbidities, particularly attention-deficit/hyperactivity disorder and obsessive-compulsive disorder, which significantly impact quality of life and should be prioritized in management decisions. Treatment is recommended only when tics cause functional impairment and follows a stepwise approach including psychoeducation, behavioral interventions, and individualized pharmacological therapy. Comprehensive behavioral intervention for tics is considered first-line treatment when available. Alpha-2 adrenergic agonists and dopamine antagonists are the most commonly used pharmacological options. Neuromodulation therapies are reserved for severe, refractory cases. These recommendations from the Ibero-American Academy of Pediatric Neurology summarize current evidence and provide a practical, updated framework for the diagnosis and management of tic disorders and Tourette syndrome in pediatric patients.

Humans↗

PubMed1978

Rheumatoid arthritis.

Management should help relieve symptoms, increase or maintain function, produce few side effects and keep the cost to a minimum. Aspirin remains the first-line drug; other nonsteroidal anti-inflammatory drugs may be useful when aspirin cannot be tolerated. Symptoms and signs of rheumatoid disease may be suppressed by corticosteroids, but only gold compounds, penicillamine and cytotoxic therapy have been shown to decrease disease activity and lessen permanent joint damage.

Adrenal Cortex Hormones↗

PubMed1976

Role of DTIC (NSC-45388) in the chemotherapy of sarcomas.

DTIC was one of the first of several new agents evaluated by the Southwest Oncology Group (SWOG) and the M.D. Anderson Hospital and Tumor Institute (MDAH) in the therapy of adult patients with metastatic sarcomas. It yielded an overall response rate of 17%. This is similar to that seen in a review of 138 patients who represent the total number reported in either published or unpublished data. The subsequent addition of DTIC to adriamycin in several studies carried out at the MDAH and in the SWOG has increased the complete and partial remission rate over that seen with adriamycin alone, and more importantly has increased remission duration and survival. DTIC is currently used in combination with adriamycin in the first-line therapy of patients with metastatic sarcomas and should be considered for patients who have relapsed on primary therapy not including DTIC.

Clinical Trials as Topic↗