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PubMed1990

[Diagnostic approach of pleural effusion in children. Report of 59 cases].

The retrospective analysis of 59 pediatric cases of pleural effusion showed that infectious agents account for 80% of cases. Thoracentesis proved to be the first-line diagnostic tool. Pleural biopsy was diagnostic in four tuberculous and two malignant pleural effusions. The literature data shows that pleural fluid total protein, lactate deshydrogenase, glucose, pH, white blood cell count and differential should be obtained in all patients. Because of the high incidence of infection, microbiologic studies are also indicated in children. These studies are of great value in distinguishing transudates from exsudates and in deciding on pleural drainage.

Adolescent↗

PubMed1990

Hairy cell leukemia. Current management.

The long-term outlook for patients with HCL has brightened over the last 5 years with the development of two highly effective systemic therapies, pentostatin and alpha-interferon. Pentostatin can induce complete responses in over 75 per cent of patients and may offer cure in this disease. Splenectomy continues to have a role as first-line therapy in selected patients in whom it may offer a median remission duration of over 5 years. Alpha-interferon is the treatment of choice for patients requiring initial systemic therapy and can be used intermittently to re-induce remission in patients with disease progression off therapy. Outside of clinical trials pentostatin should be utilized only in appropriately selected patients refractory to interferon therapy.

Bone Marrow↗

PubMed1990

Overview of medical therapy of peptic ulcer disease.

Medical management of peptic ulcer disease continues to evolve with the recent introduction of new H2-receptor antagonists, prostaglandin analogs, and a proton pump inhibitor, and clarification of the relationship between suppression of gastric acidity and ulcer healing. Nizatidine and roxatidine acetate, the new H2 blockers, are safe and effective but do not appear to have new properties of clinical importance. The modes of action of omeprazole and the prostaglandins have been clarified. Omeprazole is a prodrug that is protonated and secured in the secretary canaliculus of the parietal cell where the active derivative covalently binds sulfhydryl groups of H+/K(+)-ATPase, thereby irreversibly and profoundly blocking acid secretion. Prostaglandins bind a receptor on the basolateral membrane of the parietal cell, releasing a protein that inhibits cyclic AMP, the second messenger of histamine-stimulated acid secretion. The ulcer-healing properties of prostaglandins can be attributed largely if not entirely to their inhibition of acid secretion. Antacids, on the other hand, may heal ulcers by effects other than acid neutralization, as the low-dose regimens that heal ulcers only weakly neutralize acid. The way in which sucralfate and colloidal bismuth heal ulcers remains unclear; they may do so through multiple effects including, in the case of bismuth, eradication of C. pylori. H2-receptor antagonists continue as first-line treatment for acute DU and GU and the prevention of recurrence. The antacid and sucralfate regimens are less convenient but safe and effective. Misoprostol has a disadvantageous safety profile relative to available agents but is effective in preventing NSAID-induced gastric ulcers. The efficacy of omeprazole in acid-peptic disease is established but the way in which it should be used is still unclear because of long-term safety concerns.

Anti-Ulcer Agents↗

PubMed1990

[The xanthines: status in the therapeutic arsenal in 1990].

Methylxanthines are at present widely prescribed for obstructive airway-diseases. However, the exact therapeutic role of these drugs is not clear in 1990. In this short review, we discuss what we think to be a rational use of xanthines in asthma and in COPD patients: shortly speaking, we propose that the drugs are not first-line therapeutic tools and should be only prescribed in selected situations.

Asthma↗

PubMed1990

Use of metoclopramide, domperidone, and cisapride in the management of diabetic gastroparesis.

The pathophysiology, diagnosis, and treatment of diabetic gastroparesis are reviewed, and the mechanisms of action, pharmacokinetics, clinical efficacy, adverse effects, and dosage of metoclopramide, domperidone, and cisapride are described. Diabetic gastroparesis is a state of delayed gastric emptying that reportedly affects 20-30% of diabetic patients. Symptoms include nausea, early satiety, postprandial bloating and fullness, and vomiting. Diabetic gastroparesis has been managed most successfully with drugs that stimulate gastric emptying. Of the three agents studied--metoclopramide, domperidone, and cisapride--only metoclopramide is commercially available in the United States. The clinical efficacy of metoclopramide, domperidone, and cisapride has been well documented in several placebo-controlled trials. Metoclopramide effectively decreases mean gastric emptying time, although tolerance to this stimulation of gastric emptying may develop with long-term therapy. However, symptomatic relief persists with long-term therapy because of metoclopramide's antiemetic properties. Domperidone, which has also been shown to stimulate gastric motility and to possess antiemetic properties, improves symptoms in patients suffering from diabetic gastroparesis. Cisapride appears to have continued beneficial effects on gastric motility with long-term therapy. All three agents have favorable adverse-effect profiles. Although metoclopramide is currently the first-line agent for the management of gastroparesis, domperidone and cisapride both possess properties that may make them useful alternatives in patients who are unresponsive to or cannot tolerate metoclopramide therapy.

Cisapride↗

PubMed1990

Oat bran supplementation for elevated serum cholesterol.

The National Heart, Lung, and Blood Institute (NHLBI) has recommended intensive dietary treatment as first-line therapy for patients with high cholesterol levels. The NHLBI has also encouraged research into the effectiveness and safety of alternative diets and further study of human behavior as it relates to adherence to diets. Based on these recommendations and previous studies suggesting a hypocholesterolemic effect of oat bran dietary supplementation, 16 family practice outpatients with elevated cholesterol levels were enrolled in a 12 week study designed to assess the practicality and effectiveness of adding four oat bran muffins per day to the diet. Subjects were randomized into immediate intervention and delayed intervention groups. The combined group had a significant decrease in total cholesterol of 7.9 percent (p less than .03) and in LDL-cholesterol of 10.1 percent (p less than .03) but there was no significant difference with respect to lipid changes between the immediate group and the delay group when the delay group was serving as a control for the immediate group. The results taken in conjunction with evidence in the literature indicate that the simple addition of oat bran muffins to the diet of certain family practice outpatients is well tolerated and probably effective in lowering serum total and low density lipoprotein cholesterol.

Edible Grain↗

PubMed1990

Syphilis: test procedures and therapeutic strategies.

The diagnosis of syphilis is dependent mainly on serological tests. In primary syphilis there is a seronegative period when the diagnosis is dependent on demonstration of Treponema pallidum in lesional exudate. The most widely used screening tests for syphilis are the VDRL and the rapid plasma reagin (RPR) and for confirmation the fluorescent treponemal antibody (FTA) and the treponema pallidum hemagglutination (TPHA) tests. The nonvenereal treponematoses have the same serological response as in syphilis. For the diagnosis of neurosyphilis, the cerebrospinal fluid (CSF) parameters available are insufficient. The albumin quotient for estimation of the blood-brain barrier function is recommended as well as the IgG index, which is a measure of intrathecal immunoglobulin production. Treponemal antibodies in CSF have high sensitivity for neurosyphilis, although the specificity is low. Although penicillin has been used as first-line therapy in syphilis for more than 40 years, T pallidum has not shown any signs of decreased sensitivity. T pallidum is still one of the most penicillin-sensitive microorganisms known. The standard treatment is depot preparations (benzathine penicillin and procaine penicillin) giving a continuous low penicillinaemia. Treatment failures in early syphilis have been exceedingly rare, although in neurosyphilis there have been several reports indicating that low-dose therapy is insufficient. With recommended treatment regimens, treponemicidal levels of penicillin in CSF are not achieved. Failure of therapy and rapid progression to neurosyphilis has recently been reported in patients coinfected with human immunodeficiency virus (HIV). It has been proposed that neurosyphilis and patients coinfected with syphilis and HIV should be treated with high intravenous doses of benzylpenicillin.

Antibodies, Bacterial↗

PubMed1990

CEPP(B): an effective and well-tolerated regimen in poor-risk, aggressive non-Hodgkin's lymphoma.

Eighty-three patients with intermediate- or high-grade non-Hodgkin's lymphoma were treated with CEPP(B) (cyclophosphamide, etoposide [VP-16], procarbazine, and prednisone with or without bleomycin) chemotherapy at Stanford University Medical Center (Stanford, CA) from January 1982 through June 1989. Sixty-nine received CEPP(B) as second-line or subsequent therapy after relapse from previous combination chemotherapy, and 14 patients received CEPP(B) as first-line therapy. Of 75 patients evaluable for response, 30 patients (40%) achieved a complete response (CR) and 24 patients (32%) achieved a partial response (PR), providing an overall response rate of 72%. Complete responses were recorded on 21 of 61 (34%) patients with recurrent disease and 9 of the 14 patients who received CEPP(B) as first line therapy (64%). Myelosuppression was the major side effect of treatment, resulting in eight neutropenic-febrile episodes from a total of 253 courses. A single fatal toxic event occurred on a patient who developed adult respiratory distress syndrome. Overall, CEPP(B) was well-tolerated and proved to be effective palliative therapy for patients with non-Hodgkin's lymphoma after relapse. As such, CEPP(B) may be considered for cytoreduction before ablative therapy and bone marrow transplantation. CEPP(B) may also be considered for initial therapy in selected patients who cannot tolerate doxorubicin-containing regimens.

Adult↗

PubMed1990

Tourette syndrome: recent advances.

Clinical and genetic studies have allowed the limits of Tourette syndrome to be broadened. There is now strong evidence that chronic motor tics and Tourette syndrome are different manifestations of an autosomal dominant gene with high penetrance. A genetic link with obsessive-compulsive disorder also appears to have been established. Up to 10% of cases of Tourette syndrome may be nongenetic phenocopies, however. There is also an association between Tourette syndrome and attention deficit hyperactivity disorder. This complicates therapy, as psychostimulant drugs may precipitate or exacerbate tics in some individuals. A high proportion of patients with Tourette syndrome also has neuropsychological deficits and learning disabilities. The pathophysiology is incompletely understood. The best supported hypothesis is that there is dopamine receptor supersensitivity, although there are strong suggestions of abnormalities in serotonin metabolism. The possibility of abnormalities in neuropeptide systems is being explored. Treatment of tics relies primarily on neuroleptics with dopamine receptor blocking activity. Clonidine may be useful in some patients, especially those with behavior problems. Obsessive-compulsive symptoms can be treated using appropriate pharmacologic agents. The treatment of attention deficit disorder in patients with tics should begin with behavioral strategies. Clonidine can be tried as the first-line drug, and psychostimulants should be used only if necessary and with great caution. In rare instances it may be necessary to combine a psychostimulant and a neuroleptic.

Child↗

PubMed1990

[Treatment using an endo-urologic approach of stenoses following uretero-intestinal anastomosis].

Twenty-one strictures following uretero-digestive anastomoses were treated by percutaneous transrenal dilatation. In 20 cases, an Olbert type angioplasty balloon on a guidewire was used. Rigid coaxial dilators were used in one patient after failure of the preceding technique and an electroincision was performed prior to dilatation in the remaining case. Overall, percutaneous transrenal dilatation was successful in nine patients, whereas ten dilatations failed and two patients are undergoing continued modeling with a mean follow-up of 16 months (range 1-42 months). Success rates by type of anastomosis were as follows: Bricker 5/12; Coffey 1/4; enterocystoplasty 2/4 and ureteroileovesical anastomosis 1/1. The date of development of the stricture, duration of modeling, and caliber of the indwelling catheter were apparently without influence on results. Because morbidity is low with percutaneous transrenal dilatation, this technique is advocated as first-line treatment, with surgery being reserved to failures.

Adult↗

PubMed1990

Phase II study of recombinant interferon alpha-C in patients with metastatic renal cell carcinoma.

Recombinant interferon alpha-C is a new strain of the alpha interferon family. It was given to 33 patients with measurable metastatic renal cell carcinoma of whom 31 were evaluable. Protocol consisted of 3 million U/d for 2 weeks, then 3 million U/m2 every other day until progression. No complete response was observed. Three patients (9.7%) had partial response for a mean duration of 5.6 months and eight patients (25.8%) were stabilized for a mean of 4.3 months. Responsive sites were mainly lung, bone, and kidney, while side effects were generally mild. better results were observed in previously nephrectomized patients who had not received chemotherapy or hormonotherapy for recurrent or metastatic disease (p less than 0.05), and also in patients with a brief disease-free interval and short delay from presenting symptoms of the primary tumor until interferon treatment (p less than 0.05). Median survival was significantly longer in responders than in progressors (p less than 0.05). We suggest that the efficacy of recombinant interferon alpha-C in a low-dose regime versus other types of interferon as first-line therapy for inoperable, metastatic, or locally recurrent renal cell carcinoma should be investigated in a prospective, controlled, randomized study.

Adult↗

PubMed1990

Treatment of fallopian tube carcinoma with cisplatin, doxorubicin, and cyclophosphamide.

Primary carcinoma of the fallopian tube is uncommon and is often treated using regimens active in ovarian carcinoma. Evidence is scant that such therapies benefit patients with fallopian tube carcinoma. Between December 1979 and July 1988, we treated 18 patients who had adenocarcinoma of the fallopian tube with the combination of cisplatin (50 mg/m2), doxorubicin (50 mg/m2), and cyclophosphamide (500 mg/m2) administered intravenously on 1 day every 28 days. Histologic confirmation of fallopian tube carcinoma was obtained before entry in the study. Three patients had stage I disease, five had stage II, nine had stage III, and one had stage IV. Sixteen patients received the combination therapy as first-line treatment after cytoreductive surgery, and two patients received it for recurrent carcinoma. Seven patients had clinically measurable disease at the start of therapy. Two of these patients had a complete clinical response, two had stable disease, and three had progressive disease. Eight of the 15 patients with stages II-IV disease underwent second-look laparotomy; four had a complete response to therapy and four had a partial response, making the overall response rate 53%. The toxicity of the regimen was moderate. The median survival was 81 months. Patients with stages II-IV disease had a median survival of 43.9 months and a progression-free survival of 22.5 months. This regimen appears to be active in fallopian tube carcinoma and can result in response rates comparable to those reported for epithelial ovarian cancer.

Adenocarcinoma↗

PubMed1990

Menorrhagia.

Excessive vaginal bleeding, or menorrhagia, is one of the most common presenting symptoms for gynecologic patients. Although this disorder has many possible etiologies, it is generally possible to approach its diagnosis and management in an orderly fashion. When evaluating the menorrhagic patient, it important to gear the work-up toward a differential diagnosis that includes pregnancy-related causes, hormonal problems, iatrogenic etiologies, mechanical intrauterine disorders, infections of the lower genital tract, and gynecologic cancers (PHIMIC). This differential approach can guide the types of historical data obtained from the patient, focus the physical examination, and alert the practitioner to the most appropriate laboratory and radiologic evaluation. Therapy can differ widely, depending on the cause of the bleeding. Most types of menorrhagia respond to medical therapy with oral contraceptives, oral synthetic estrogens or progestins, and long-acting intramuscular progestins or GnRH agonists. Surgical approaches, such as dilatation and curettage or hysterectomy, are less and less a first-line therapy; but innovative surgical techniques such as hysteroscopy and laparoscopic surgery are becoming increasingly important. With rapid, goal-directed diagnosis and specific therapy, the medical complications, anxiety, and discomfort suffered by the woman with menorrhagia can be alleviated quickly.

Female↗

PubMed1990

Antibiotic therapy for common infections.

Several important points regarding the treatment of urinary tract infections should be made. Single-dose and short-course antibiotic therapy is appropriate only for women with acute bacterial cystitis due to E. coli. Studies comparing single-dose to full-course therapy have not been sufficiently designed to draw valid statistical conclusions, and only TMP/SMX is recommended at this time. Recurrent UTI in women is almost always due to reinfection, which is best managed by prophylactic antibiotics. Acute bronchitis and acute exacerbations of chronic bronchitis are often due to viral infections, and therefore antibiotic therapy is not always needed. In acute exacerbations of chronic bronchitis, the clearest success rates for antibiotic therapy have been in patients, who have all three of the following symptoms: increased dyspnea, increased sputum production, and sputum purulence. Mupirocin is an important addition to the agents used to treat bacterial skin infections due to streptococcal and staphylococcal strains. In impetigo, mupirocin has been demonstrated to be as effective or superior to oral erythromycin. In prostatitis, data on the fluoroquinolones appears impressive, but further comparative trials are needed. They may become first-line, empiric therapy. The newer oral antibiotics are not recommended as initial, empiric therapy in the outpatient management of common infections, with the possible exception of the treatment of prostatitis. These newer agents may be more important in the treatment of recurrent or resistant infections.

Anti-Bacterial Agents↗

PubMed1990

Management of elevated intracranial pressure.

The pathophysiology, clinical manifestations, monitoring techniques, and management of elevated intracranial pressure (ICP) are reviewed. The use of barbiturate coma to treat ICP is discussed in detail. Elevated ICP can be associated with severe head injuries and diseases of the central nervous system such as brain tumors and stroke. Symptoms of elevated ICP may be difficult to distinguish from symptoms of other disease states. ICP monitoring techniques such as the intraventricular catheter and the Camino fiber optic system are useful for determination of ICP elevations before any changes in vital signs or neurological status occur. Conventional treatment and control of ICP elevations includes general and physiologic management (cerebrospinal fluid removal, fluid restriction, controlled hyperventilation, sedation, and elevating the patient's head) and pharmacologic management. Osmotic diuretics, (e.g., urea, mannitol, glycerol) and loop diuretics (e.g., furosemide, ethacrynic acid) are first-line pharmacologic agents used to lower elevated ICP. Corticosteroids may be beneficial in some patients. Patients with elevated ICP refractory to conventional treatment may benefit from therapy with high-dose barbiturates. Pentobarbital has been used in the majority of the clinical studies. Pentobarbital serum concentrations should be determined every 24-48 hours when a patient is in a barbiturate coma because pentobarbital clearance increases with continued high-dose therapy. The treatment of elevated ICP requires aggressive therapy and intensive monitoring. In patients whose ICP is refractory to conventional therapies alone, survival rates have been improved by combining high-dose barbiturates with conventional therapies.

Adrenal Cortex Hormones↗

PubMedDate not supplied

[Percutaneous automated lumbar nucleotomy].

The results of percutaneous automated lumbar nucleotomy in the treatment of lumbar disc herniation were assessed in a series of 39 patients. The technique consists of mechanical decompression of the herniated intervertebral disc without total excision. Only one-space discs were treated by this method. Sciatica was the predominant clinical symptom in 30 cases, and lumbar pain in 9 cases. Good to very good results were obtained in 70% of patients with sciatica and in 55% of patients with lumbar pain. After 4 cases of nucleotomy performed after failure of nucleolysis were excluded, the proportion of very good results rose to 77% in sciatica. Conversely, it seems that a number of failed nucleotomies can be treated by nucleolysis. Nucleotomy is very well tolerated and deserves to be used as first-line treatment of single and radiologically well documented lumbar disc herniations.

Adult↗

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↗