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PubMed1991

[Truth at the bedside--also with cancer patients?].

The emotional discussion on a frank information strategy towards cancer patients 10 to 15 years ago has fortunately become more objective today, not the 'if', but the 'how' is now important; however, psychologic problems in the confrontation with the terminally ill are still recognized, mainly in groups of physicians lacking personal contact with dying and death during postgraduate training and later practise. Improvement of primary information and of further adapted communication with cancer patients cannot be solved alone by a larger number of experienced oncologists, since these represent in most instances only the second or third medical authority approaching the patient with neoplastic disease. Therefore, more supporting and less prejudiced patient contacts should be provided by first-line medical care, i.e. the family physician or surgeon. However, a truthful information strategy is a personal challenge for the physician. It demands an individual preoccupation of the therapist with the basic questions regarding his own life and its impermanence. Critical peer-reviewed training (i.e. in discussion and Balint groups) can teach a balanced dimension for a difficult patient interview (information, emotional involvement, patient-oriented behaviour). Deviations from adapted behaviour such as over-identification can thus be recognized and prevented. Since coping with disease does not develop in a linear fashion from initial resistance and negation of disease to mature acceptance in many patients, experienced therapists may always encounter sudden new problems regarding communication and information; therefore, the requirements for a therapist regarding tact, sensitivity and readiness to learn are high. This overview is written in this intent from an oncologists point of view in order to provide practical hints for daily encounters with cancer patients.

Adaptation, Psychological↗
PubMed1991

[Erysipelas: epidemiological, clinical and therapeutic data (111 cases)].

A retrospective study of 111 patients admitted to the Dermatology department of the Bichat hospital, Paris, between 1981 and 1988 for treatment of erysipelas revealed the following data: 1. Erysipelas was located on the lower limbs in 88.3 p. 100 of the cases and on the face in only 9.8 p. 100. 2. Facilitating and/or aggravating factors were: portal of entry in 75 p. 100 of the cases; impairment of venous and lymphatic circulations (41 p. 100); diabetes mellitus (13.5 p. 100); alcoholism and its socio-economic consequences (29 p. 100); unnecessary prescription of anti-inflammatory agents (11 p. 100). 3. Insufficient consideration was given to the clinical diagnosis: in 7.2 p. 100 of the patients erysipelas was diagnosed either after failure of heparin therapy or because phlebography was normal; some clinical features, notably bullae (30 p. 100) or purpura on the lower limbs (13 p. 100), confused the physicians. Delayed treatment was the main cause of local complications, such as abscess (4 cases) or focal cutaneous necrosis (4 cases). Erysipelas was recurrent in 23.5 p. 100 of the patients. 4. Bacteriological data in this series were insufficient to establish percentages of responsible organisms. However, penicillin G in mean doses of 12 million units per day administered intravenously for 5.5 days, then intramuscularly for 10 days was effective as first-line treatment in 80 p. 100 of the cases. Penicillin therapy may fail in patients with insulin-dependent diabetes or belated treatment with complications. No thromboembolic complication was observed (89 p. 100 of patients with lower limb erysipelas had received anticoagulants). There was only one death due to a severe underlying condition.

Administration, Oral↗
PubMed1991

Malignant neck lumps: a measured approach.

The options currently available for establishing the histological diagnosis of a neck mass are open biopsy or a measured approach involving head and neck examination, fine-needle aspiration biopsy (FNAB) and panendoscopy. We present the results of 10 patients initially managed by open biopsy and 22 who were subject to the alternative approach. All had a histological diagnosis of squamous carcinoma. Seven of the open biopsy patients developed problems related to the biopsy that later adversely affected their management. There were no such problems in the other group. Patients undergoing open biopsy required a mean of one further general anaesthetic and a mean inpatient stay of 7 days longer than the patients in the second group. FNAB in our hospital was shown to be reliable (91% accurate, 93% sensitive, 97% specific), especially for squamous malignancy (100% specific). The relative merits of the two methods are discussed. It is our belief that open biopsy should not be used as a first-line investigation of a neck mass.

Adult↗
PubMed1991

Intensive sequential chemotherapy with mitoxantrone and continuous infusion etoposide and cytarabine for previously treated acute myelogenous leukemia.

Intensive sequential chemotherapy with mitoxantrone, 12 mg/m2/d on days 1 through 3, etoposide, 200 mg/m2/d as a continuous infusion on days 8 through 10, and cytarabine, 500 mg/m2/d as a continuous infusion on days 1 through 3 and 8 through 10 was administered to 72 patients aged less than 60 years with previously treated acute myelogenous leukemia (AML). Forty patients had refractory AML (nonresponse to prior therapy, early first relapse, or multiple relapse) and 32 had late first relapse. Sixty-one percent of patients, with a 95% confidence interval (CI) ranging from 49% to 72%, achieved complete remission (CR), including 45% (CI: 30% to 62%) of refractory patients and 81% (CI: 64% to 93%) of late first relapse patients. Twenty-nine percent of patients (CI: 19% to 41%) did not respond to therapy and 10% (CI: 4% to 19%) died from therapy-related toxicity. Median duration of aplasia was 30 days. Nonhematologic WHO grade 3 or more toxicity included sepsis (57% of patients), vomiting (10%), mucositis (35%), diarrhea (7%), skin rash (6%), and hyperbilirubinemia (11%). Postinduction therapy was attempted in 36 of 44 CR patients: 16 of them received a second course of the same regimen, 7 received maintenance chemotherapy, 4 underwent autologous bone marrow transplantation (BMT), and 9 allogeneic BMT. At a median follow-up of 20 months, 23 of the 44 complete remitters have relapsed, 1 to 14 months after achievement of CR, including 19 of 31 patients not undergoing BMT. Median survival is 7 months with 16% (CI: 4% to 28%) projected survival at 47 months. Median disease-free survival is 6 months with 21% (CI: 3% to 39%) of CR patients projected to remain disease-free at 46 months. Twenty-six percent (CI: 13% to 43%) of the evaluable patients who did not receive transplantation had inversion of CR duration. Among patients younger than 50 years, there was no significant difference in disease-free survival between patients receiving postinduction chemotherapy and those receiving BMT. We conclude that this chemotherapy regimen is highly efficient and could be used as first-line therapy in young patients with AML.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1991

Fluconazole: a new antifungal agent.

The chemistry, activity, pharmacokinetics, clinical efficacy, adverse effects, drug interactions, and administration of fluconazole are reviewed. Fluconazole is a triazole antifungal agent labeled for use in the treatment of oropharyngeal and esophageal candidiasis and cryptococcal meningitis. Like the imidazoles, fluconazole inhibits the C-14 demethylation of lanosterol, but it has little or no effect on mammalian cytochrome P-450 enzymes. Fluconazole's activity in vitro does not reflect its effectiveness in vivo. Pharmacokinetic characteristics include water solubility and excellent bioavailability, low protein binding, extensive tissue distribution, and penetration into the cerebrospinal fluid. Fluconazole is eliminated primarily by the kidneys; dosage adjustments are necessary in patients with renal insufficiency. Studies have shown fluconazole to be effective in patients with cryptococcal meningitis and candidiasis, but the superiority of fluconazole over such agents as amphotericin B, ketoconazole, clotrimazole, and itraconazole remains to be proved. Fluconazole has shown varying degrees of success in the treatment of other systemic mycoses. The adverse effects of fluconazole are relatively infrequent and are primarily gastrointestinal. Tolbutamide, warfarin, rifampin, cyclosporine, and phenytoin interact with fluconazole. The drug is available in both oral and intravenous formulations. Fluconazole is a broad-spectrum antifungal drug that appears to be similar in efficacy to other antifungals in the treatment of some systemic mycoses. More studies must be completed before fluconazole can be recommended as a first-line antifungal therapy.

Animals↗
PubMed1991

[Obligatory surgery after endoscopic sphincterotomy for the treatment of stones in the common bile duct].

Endoscopic sphincterotomy is the treatment of choice for stones in the common bile duct in patients with a high operative risk. However, when this modality is insufficient or fails, these patients need to be operated. The authors have operated 14 patients under these conditions. In addition to the cholecystectomy performed in 9 patients who still retained their gallbladder, the common bile duct was cleared in 3 cases and drained by means of choledochoduodenal anastomoses in 10 cases. Three patients developed complications and one of them died. Endoscopy and surgery appear to be complementary in this indication. Sphincterotomy should be proposed as first-line treatment as, even in the case of incomplete disobstruction, it enables high-risk patients to be operated under better conditions.

Aged↗
PubMed1991

Current issues in the treatment of epilepsy.

General principles of antiepileptic drug (AED) therapy are reviewed, current issues involving the use and monitoring of AEDs are examined, promising investigational agents are briefly reviewed, and situations that require potentially difficult decisions about long-term care are discussed. The initial treatment should be monotherapy with a first-line AED for the particular seizure disorder. The usual approach is to maximize seizure control and minimize the adverse effects of AED therapy. Current issues involving the pharmacokinetics, use, and monitoring of the conventional AEDs phenytoin, phenobarbital, primidone, carbamazepine, valproic acid, ethosuximide, benzodiazepines, and acetazolamide are discussed. AED therapy may have adverse effects on behavior and cognition. The risk of teratogenicity with well-monitored AED therapy is probably low, and severe hepatotoxicity is uncommon. Because carbamazepine, phenobarbital, phenytoin, and primidone all have enzyme induction properties, a number of clinically important interactions are possible. Issues related to discontinuing AED therapy, serum concentration monitoring, and generic interchange of AED products are addressed. Whether AEDs should be used to prevent recurrent febrile seizures, alcohol withdrawal seizures, or seizures in patients with head trauma or stroke must be considered. The treatment of seizure disorders is a complex process involving identification of the seizure disorder, selection and monitoring of an appropriate AED(s), and consideration of adverse effects and drug interactions. Whether therapy should be discontinued after a prolonged seizure-free period, compliance issues, and whether to treat certain conditions prophylactically also must be considered.

Anticonvulsants↗
PubMed1991

Alpha 2b interferon (IFN) by intraperitoneal administration via temporary catheter in ovarian cancer. Preliminary data.

Thirty-nine patients with epithelial ovarian cancer admitted to the Division of Medical Oncology of the Medical School II of Naples were given 159 courses of alpha 2b interferon (30 Mil./sqm IU) intraperitoneally from October 1986 to November 1989. IFN was generally administered every three weeks, but six patients received the drug weekly at the same dose, for an additional period. In 15 patients IFN was added to standard systemic chemotherapy as first line treatment; the remaining patients, all pretreated (22 with minimal and 2 with no residual disease), received an intraperitoneal multidrug treatment combining IFN, cisplatin and mitoxantrone. Peritoneal access was achieved through a temporarily implanted 18 gauge catheter and the drug was instilled in a large fluid volume (2,000 ml) to ensure wide spread and uniform distribution. IFN was well tolerated: only one patient had to discontinue treatment because of severe fatigue. No major complication related to catheter implantation or function occurred. 3/15 untreated and 11/20 pretreated patients, evaluable for response, achieved a pathological complete response (pCR). In view of IFN's lack of significant toxicity and the safety and tolerability of a temporary small gauge catheter for peritoneal access, intraperitoneal chemotherapy including IFN should be useful in ovarian cancer patients with minimal or absent disease after first-line systemic treatment.

Adult↗
PubMed1991

[Antibiotherapy of maternal-fetal infections].

The initial antibiotic therapy of neonatal infections must be aimed at Streptococcus B, E. coli and Listeria which are the most frequent responsible pathogens. It must be initiated promptly and be effective against a possible meningeal infection. The first-line therapy with amoxicillin, amikacin and cefotaxime, which in theory should cover all the micro-organisms involved, must be short and rapidly replaced by an antibiotic proved to be active against the isolated pathogen. If aminoglycosides are administered for a long time, serum level assays are recommended for optimal safety.

Anti-Bacterial Agents↗
PubMed1990

[The pathogenesis of arterial hypertension in diabetes mellitus and its role in nephropathy].

This paper synthesizes the pathogenic steps of arterial hypertension in diabetes mellitus: hyperosmolarity due to the hyperglycemia and increased sodic tubular reabsorption accounting for the expansion of the extracellular volume with hypervolemia; abnormalities of the ionic membrane pumps leading to abnormal intracellular calcium distribution, thereby inducing an increased vascular tone; atypical vasomotor reactivity to cathecolamines; modifications of the renin-angiotension-aldosterone system. The pathophysiological derangements by which hypertension could induce nephropathy are examined: the vasodilatation which can be detected from the onset of diabetes, may be a determinant in the transmission of systemic hypertension to the glomerular microcirculation with resulting enhancement of the hydrostatic transglomerular pressure gradient (i.c. the major factor producing glomerular injury), glomerular plasmatic flow and filtration rate. The nephron hyperfiltration increases the movement of plasmatic proteins across the glomerular capillary wall with subsequent mesangial hyperactivity and sclerosis. Antihypertensive treatment in diabetes follows general guidelines and it should be instituted even in the case of microhypertension being facilitated in this setting the appearance of microalbuminuria i.e. the starting point of nephropathy. Even if experimental studies are to favor ACE inhibitors as the first-line drugs for abating glomerular hypertension by mitigation of the direct effect of angiotensin II on the efferent arteriolar tone, clinical observations suggest that, regardless of type of treatment, the normalization of systemic arterial pressure, by reversing glomerular hypertension may be effective in preventing diabetic nephropathy.

Diabetes Complications↗
PubMed1990

Metabolic considerations in hypertension.

The frequent concurrence of other cardiovascular risk factors in hypertensive patients, such as obesity and diabetes mellitus, suggests that overlapping genetic and environmental factors may contribute to the common metabolic and cardiovascular derangements observed in these populations. Hypertension and hyperglycemia accelerate atherosclerosis in diabetics, and play an important role in associated morbidity and mortality. Several abnormalities in blood pressure regulatory systems such as the renin-angiotensin system, the sympathetic nervous system, and sodium/volume control have been described in diabetes mellitus. Sodium retention and cardiovascular hyperreactivity appear to occur early in the course of diabetes mellitus, even at normal blood pressure levels and before onset of renal failure, and could set the stage for the development of hypertension. The relationship between obesity and hypertension is also well-established, and may reflect metabolic and cardiovascular adaptations in obese subjects which predispose to blood pressure elevations. Obese subjects display changes in sympathetic nervous system activity, sodium metabolism, and vascular hemodynamics. Sodium-sensitive blood pressure responses in the obese may be secondary to increased cardiac output or fluid volume, and are directly related to circulating insulin levels. Certain metabolic and vascular characteristics of obesity and diabetes mellitus are found in patients with essential hypertension. It has been suggested that insulin and insulin resistance may be the common link between these risk factors. Improved understanding of metabolic considerations in the treatment of obese and diabetic hypertensives should lead to more careful selection of medications that avoid metabolic complications. Although diuretics and beta-blockers may be useful in some patients, there are several reasons not to recommend their use as initial therapy in obese and diabetic hypertensives. On the other hand, calcium channel blockers and angiotensin converting enzyme inhibitors are highly effective, with minimal effects on metabolic parameters, and are well-suited as first-line therapy in the treatment of obese and diabetic hypertensives.

Antihypertensive Agents↗
PubMed1990

A microbiological study of failed penicillin therapy for gonococcal urethritis in Durban.

Seventy-five men presenting with persistent urethral discharge after penicillin therapy were investigated for sexually transmitted pathogens during July - September 1987. The major aetiological agent isolated was Neisseria gonorrhoeae (58 patients (77.3%]. Penicillinase-producing N. gonorrhoeae (PPNG) accounted for 58.6% of 58 isolates. Chlamydia trachomatis was detected in 10.7% of patients and Trichomonas vaginalis in 14.7% of patients. When there is a high prevalence of PPNG, the use of penicillin as a first-line agent for therapy should be discontinued in favour of an agent active against PPNG and non-PPNG strains. Furthermore, in view of the relatively high prevalence of T. vaginalis, patients returning with persistent urethral discharge should be investigated and treated for infection with this protozoan.

Adolescent↗
PubMed1990

Metabolic effects of ramipril treatment in hypertensive subjects with non-insulin-dependent diabetes mellitus.

The antihypertensive and metabolic effects of the new long-acting angiotensin converting enzyme (ACE) inhibitor, ramipril (Hoe 498), were assessed in 21 patients with non-insulin-dependent diabetes mellitus (NIDDM) over a 12-week treatment period. In an average dose of 5 mg given once daily, ramipril effectively reduced the elevated blood pressure. In 74% of the cases systolic and diastolic blood pressure was normalised during monotherapy. Mean blood glucose and glycosylated hemoglobin (HbAI) values showed a slight but significant (p less than 0.05) decrease at the end of the ramipril treatment period (glucose: 8.5 +/- 1.4 mmol/l vs 8.0 +/- 0.9 mmol/l; HbAI: 10.0 +/- 1.3% vs 9.7 +/- 1.1%). C-peptide levels did not change. Since there was also a small reduction of body weight during treatment, the observed hypoglycemic response could not be fully ascribed to ramipril. Also, a reduction in total cholesterol and an increase of HDL cholesterol could be documented during treatment with ramipril. The reduction in body weight could also be made partly responsible for this positive effect on lipid metabolism. No serious side effects were reported during the entire study period. Due to these beneficial effects, ramipril can be recommended as first-line drug in the management of hypertensive subjects with NIDDM.

Aged↗
PubMed1990

National surveillance of antimicrobial resistance in Neisseria gonorrhoeae. The Gonococcal Isolate Surveillance Project.

The Gonococcal Isolate Surveillance Project is a national sentinel surveillance system to estimate levels and monitor trends of antimicrobial resistance in prospectively collected isolates of Neisseria gonorrhoeae. Of 6204 isolates evaluated from 21 clinic sites between September 1987 and December 1988, 21% met at least one of the surveillance criteria for resistance to penicillin, tetracycline, cefoxitin, or spectinomycin; 2.2% were penicillinase-producing N gonorrhoeae; 1.0% had high-level plasmid-mediated tetracycline resistance; and 16.8% of the isolates without plasmid-mediated resistance had chromosomally mediated resistance (defined as a minimum inhibitory concentration greater than or equal to 2 micrograms/mL) to penicillin, tetracycline, or cefoxitin. Three isolates were resistant to spectinomycin. All isolates were susceptible to ceftriaxone. Resistant isolates were identified from all participating centers. Patient demographic and behavioral characteristics were not predictive of infections caused by resistant organisms. These results demonstrate the wide distribution of antimicrobial-resistant N gonorrhoeae and support recent changes in Centers for Disease Control therapy recommendations for gonococcal infections that no longer recommend tetracycline and penicillin as first-line therapies.

Adolescent↗
PubMed1990

[Long-term results of percutaneous transluminal angioplasty of the iliac arteries].

A well-mastered technique will cause percutaneous transluminal angioplasty of iliac arteries to achieve long-term results comparable to those obtained surgically. In isolated iliac stenosis, a 95% good result rate is attained (81% cured, 14% improved). More complex cases of iliac stenosis yield 90% good results (72% cure), with a mean Doppler ankle/arm pressure index gain of 0.5 point in a series including 673 patients at 5 years follow-up. Only the presence of combined distal femoral lesions may cause the good result score to drop to 85%, including merely 35% cure. General complications are practically lacking and local complications are minimal, which incites one to propose this technique as a first-line treatment of iliac stenosis whenever distal blood circulation is maintained.

Angioplasty, Balloon↗
PubMed1990

A long-term study of atenolol and doxazosin in mild and moderate hypertension.

The efficacy and tolerability of doxazosin and atenolol in the management of mild and moderate hypertension were compared in a multicentre, parallel study, the first year of which was randomized and double-blind. Patients who completed this first year were invited to enter a two-year extension phase; the results after the first year are presented. A total of 228 patients entered the double-blind phase (118 received atenolol). A reduction in dose was required by 4% in each group; eight patients on doxazosin and 11 on atenolol were withdrawn due to adverse effects. Ninety-three of the 100 doxazosin patients and 88 of the 104 atenolol patients who completed the double-blind phase agreed to participate in the open extension study. At 24 months, the mean dose of doxazosin was 5.2 mg/day, and of atenolol 66.7 mg/day. From baseline levels of BP of 158/104 mmHg in the doxazosin group and 161/103 mmHg in the atenolol group, average reductions at 24 months were -16/-14 and -19/-15 mmHg respectively. Neither drug had a significant effect on total cholesterol levels. At all four points of measurement over the two years, doxazosin decreased blood triglyceride levels and increased high density lipoprotein (HDL) cholesterol and the HDL: total cholesterol ratio. Atenolol had the opposite effect on each of these lipid values with the differences between the treatment groups being significant. Doxazosin was well tolerated and was shown to be effective as monotherapy in mild and moderate hypertension. Its effect on blood lipids was potentially favourable, and it should therefore be regarded as an alternative first-line drug in hypertensive patients.

Adolescent↗
PubMed1990

"Poor prognosis" metastatic gestational trophoblastic disease: the prognostic significance of the scoring system in predicting chemotherapy failures.

Twenty-eight patients with "poor prognosis" metastatic gestational trophoblastic disease were treated during a 17-year period. The primary treatment was combination chemotherapy with methotrexate, actinomycin D, and chlorambucil (MAC). Patients who failed to respond to this regimen were treated secondarily with other combinations. Adjuvant surgery and radiotherapy were used in selected cases. The overall remission rate was 89% (25 of 28): 71% for first-line treatment with MAC (20 of 28) and 62% for second-line treatment (five of eight). The response rate to MAC correlated well with the patient's score (modified World Health Organization [WHO] scoring system--1983). Seventeen patients treated with MAC had scores less than 12, and all of them achieved remission. Of 11 patients having scores of 12 or more, only three achieved remission with MAC (27%). Of the eight who did not, five achieved remission with other combinations (62%) and three died. No patient died because of chemotherapy toxicity. The WHO scoring system is a good index to select high-risk patients who need primary chemotherapy more aggressive than MAC.

Adult↗