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PubMed1989

[Implantation of endoprostheses in aortocoronary bypass. Preliminary experience at the Thoraxcenter of Rotterdam].

An intraluminal stent was implanted in 5 patients after dilatation of an aorto-coronary venous graft. In the first 4 patients the procedure was motivated by restenosis after angioplasty. In the 5th patient the stent was implanted as a first-line measure in a case of dilated venous bypass stenosis. Stent implantation carries a risk of thrombosis and requires effective anticoagulation. Thus, one of our patients had to be reoperated upon for prosthetic thrombosis facilitated by the withdrawal of anticoagulants owing to a gastrointestinal haemorrhage. After a 3-month follow-up, the results seem to be encouraging in spite of a case of restenosis located at the proximal end of the tutor. However, more time will be needed to determine precisely the effectiveness of stents in the prevention of restenosis after venous graft dilatation.

Aged↗

PubMed1989

Percutaneous transluminal angioplasty of failing arteriovenous dialysis fistulae.

Percutaneous transluminal angioplasty (PTA), a method combining diagnostic and therapeutic procedures, was studied prospectively in 40 patients with clinically failing a-v fistulae. Forty-seven procedures were performed in 40 patients with a variety of a-v fistulae (26 Cimino, five saphenous loops, five goretex grafts, and four upper-arm fistulae). In 43 cases the procedure was initially successful. The mean time of fistula patency after first PTA was 10.06 +/- 2.10 months. Primary failures were due either to technical inability to pass the stenosis (two patients) or to vessel perforation during the attempt (two patients). Surgical intervention had to follow both perforations. Restenosis at the dilatation site occurred in six patients, and in one a new stenosis at a different site occurred; the mean time of fistula patency in these patients was 5.8 months. Our results suggest that PTA is a highly effective therapy for the majority of cases of shunt stenosis. The success rate of the method is excellent and the complication rate low. The combination of this interventional approach with the mandatory angiographic procedure if stenosis of a fistula is suspected makes PTA a favourable first-line treatment and appears to save a considerable number of surgical interventions.

Adult↗

PubMed1989

[Treatment of achalasia by pneumatic dilatation].

Between 1979 and 1988, 60 patients with achalasia were treated by pneumatic dilatation under general anaesthesia, using the Rider-Moeller apparatus. The diagnosis rested on clinical, radiological, manometric and endoscopic criteria. These 60 patients underwent a total of 99 dilatations: 63.3 per cent were dilated once and 37.7 per cent were dilated several times. Forty seven of the 60 patients were followed up for more than 12 months (mean: 44 months): 2 of them (4.2 per cent) had to be operated upon, while 45 (95.7 per cent) are asymptomatic. Immediate complications were perforation in one case and cardial fissure in another; both were treated medically and cured. There was no oesophagitis or peptic stenosis, and no patient died. These results are compared with those found in the literature. The authors underline the simplicity, safety and effectiveness of pneumatic dilatation and suggest that it should be used as first-line treatment of achalasia, surgery being performed only when dilatation fails.

Adolescent↗

PubMed1989

Therapeutic focus. Minocycline in the treatment of acne.

Minocycline has an established place in the oral therapy of acne. Prolonged courses of therapy have an acceptable safety profile. Where therapy with oxytetracycline has failed, minocycline is still likely to prove effective. The twice-daily dosage and ease of absorption from the gastrointestinal tract offer significant advantages over other tetracyclines. The simpler minocycline regime and early onset of clinical improvement are likely to result in better patient compliance, and hence optimise therapeutic response. There is therefore justification for the use of minocycline as first-line oral therapy, but, whether as a first- or second-line therapy, minocycline is a valuable drug in the treatment of this very distressing disorder. The earlier effective therapy is used in a patient with acne, the less physical and psychological scarring will remain thereafter.

Acne Vulgaris↗

PubMed1989

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↗

PubMed1989

Ifosfamide in small cell lung cancer.

Ifosfamide, an analogue of cyclophosphamide, has been proven to be of value in numerous malignancies, including testicular cancer, sarcoma, and lymphoma. Furthermore, ifosfamide is more suitable for combination chemotherapy than its parent compound because it causes less myelosuppression than cyclophosphamide. There have been only a few studies evaluating single-agent ifosfamide in small cell lung cancer (SCLC). In patients who have had little or no prior chemotherapy, ifosfamide appears as active as any single agent. Combination chemotherapy regimens employing cisplatin (or carboplatin) plus etoposide plus ifosfamide are currently under way on both sides of the Atlantic. A Hoosier Oncology Group (HOG) study will evaluate this three-drug regimen v cisplatin plus etoposide, and this protocol will establish or refute the value of ifosfamide as first-line therapy in extensive SCLC.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1989

[Recent trends of chemotherapy in small cell lung cancer: a slow but steady progress].

The author reviewed some distinct findings concerning chemotherapy of small cell lung cancer (SCLC) which had appeared recently in the articles of journals and proceedings. Of new drugs, teniposide and carboplatin have a significant activity against SCLC, however, the usefulness of these drugs must be determined in the comparative fashion with their mother compounds. Cisplatin plus etoposide (PVP), which was demonstrated to have a distinct activity in previously treated SCLC and to be not fully cross-resistant to CAV, has recently been incorporated into the first-line treatment. PVP has been evaluated as either induction chemotherapy or consolidation therapy, as alternating chemotherapy with CAV and as a chemotherapy regimen in the combined modality treatment with chest irradiation. The data obtained provide results comparable or rather superior to those achieved with CAV or other conventional regimens when used as induction chemotherapy, and provide some encouraging results when used as consolidation chemotherapy and in combination with chest irradiation. Four trials have been conducted to test the usefulness of CAV-PVP alternation, however, the results is still controversial. Recently, two institutions reported the results of pilot study of an intensive weekly chemotherapy. Although the complete response rate of the weekly regimens appears superior to that of conventional regimens, the survival benefit is still obscure because of an inadequate follow-up time. The pace of therapeutic advances in SCLC has slowed and appears to reach a plateau, however, recent articles indicate a slow but steady progress in the treatment of SCLC.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1989

Drug therapy for juvenile arthritis.

Juvenile arthritis includes a variety of rheumatic disorders with varied articular and extraarticular manifestations. The heterogeneity of JA cannot be overemphasized in a rational approach to therapy. Fortunately, most children with JA improve significantly with first-line treatment, especially those with pauciarticular disease. Only a small number of these patients go on to require second-line treatment, usually because of the evolution of their condition into the polyarticular type. Patients with polyarticular, RF-positive disease and patients with early-onset polyarthritis in association with systemic-onset disease both have poor prognoses in terms of ultimate joint function, and should receive second-line treatment early in their therapy. Injectable gold is the drug of choice for the former patients, if an initial trial of NSAIDs has failed. Patients with polyarticular onset, RF-negative disease generally have a better prognosis than other patients with polyarticular involvement. One may wait considerably longer before introducing a second-line agent for these patients. An antimalarial agent may be a reasonable choice for these patients, especially those with limited polyarticular involvement (5 to 10 active joints). This latter principle may also be applied to patients who evolve from pauciarticular to polyarticular involvement. In all such cases, penicillamine is almost never used as first choice. If the patient is a young child, the difficulty with injecting gold and the hazards of antimalarial agents may limit the use of these treatments. In situations such as this, auranofin or sulfasalazine may be the drug of choice. Cytotoxic/antimetabolic therapy should be reserved for those children who have continued active disease despite full courses of two SAARDs, or for those who have been unable to take SAARDs because of their side effects. Corticosteroid therapy should be used only when specifically indicated, and every attempt should be made to wean the patient from it as soon as feasible. The aim of therapy is to ensure that patients enter their remission in the best condition possible. For this to be assured, a sensible approach to drug therapy is mandatory.

Adolescent↗

PubMed1989

[Combination of anti-angina drugs].

Within the last decade it became obvious that the treatment of angina pectoris alone is not sufficient. Modern goals include the optimization of anti-ischemic treatment ("silent myocardial ischemia") without compromising quality of life, as well as the reduction of fatal and non-fatal cardiac events. The failure of nitrates to continuously protect from myocardial ischemia ("nitrate tolerance") requires a modification of the current step-care recommendations for medical treatment. Numerous combinations of nitrates, betablockers and calcium channel blockers compensate for each other regarding their effects on heart rate, contractility, peripheral resistance and coronary blood flow. Recommendations for combination therapy decisively depend on the choice of the first-line drug. Only nitrates reduce myocardial preload by venodilation and substitute for EDRF-deficiency. After headaches disappear, nitrates do not affect quality of life and they are cheap. The nitrate-induced acceleration of heart rate should be compensated by the addition of beta-blockers or heart rate-decreasing calcium channel blockers. Therefore, the combination of nitrates with heart-rate-increasing calcium channel blockers, such as nifedipine, should be avoided. Many studies have proven the superiority of different double and triple therapies, as compared to their single components. A few reports, however, did not confirm this increase of anti-ischemic efficacy with combination therapy. The improvement of prognosis is proven for beta blockers without ISA in subgroups of patients with acute or post myocardial infarction and can be assumed for nitrates as well. With regard to prognosis, calcium channel blockers were inferior to nitrates and beta blockers. The combination of nitrates with a non-ISA betablocker should be preferred in post myocardial infarction patients with ventricular arrhythmias, whereas the combination of nitrates with a heart rate decreasing calcium channel blocker should be preferred in patients with COPD, severe peripheral arterial disease or severe diabetes. The combination of nitrates with a heart-rate-increasing calcium channel blocker should be considered in patients with sinus bradycardia, first degree AV-block, or proven coronary spasm. In patients with congestive heart failure, betablockers and calcium channel blockers should be avoided. To optimize medical treatment of ischemic heart disease, intermittent high dosage ISDN plus a beta blocker without ISA or ISDN plus a calcium channel blocker like verapamil are recommended. Frequently, however, the patient decides by himself, based on unacceptable side effects.

Adrenergic beta-Antagonists↗

PubMed1989

Dosage cost analysis in glaucoma management.

After the diagnosis of chronic open-angle glaucoma has been made, and the indications vs. contraindications of each of the potential first-line topical medications have been weighed, what medical therapy should be initiated if the most cost effective form of management is desired? We surveyed 40 pharmacies in four cities and found no statistical difference between the mean annual cost of therapy with timolol maleate (Timoptic), betaxolol (Betoptic), and pilocarpine. Statistically, both dipivefrin (Propine) and levobunolol (Betagan) were found to be more expensive. We also discovered that there are large variations in medication prices between various pharmacies. In order to enhance compliance, optometrists may want to know the pharmacies in their communities that offer antiglaucoma medications at reasonable prices.

Analysis of Variance↗

PubMed1989

[The diagnostic value of radionuclide inferior veno-cavagraphy in Budd-Chiari syndrome].

To evaluate the diagnostic value of radionuclide inferior veno-cavagraphy (RIVC) for Budd-Chiari Syndrome, RIVC using Tc99m was performed on 106 patients with massive ascites. A positive RIVC result was defined as having at least two of the three following criteria: (1) a delay of more than 4 seconds in visualizing the heart; (2) sharply truncated inferior vena cava with marked hang-up of isotope activity; and (3) extensive collateral circulation. Of the 106 patients, 18 were RIVC positive and were later confirmed by operation or contrast venography to have Budd-Chiari Syndrome with IVC obstruction. Of the remaining 88 RIVC negative patients, 3 were shown by operation, computerized tomography and cardiac echo, respectively, to be Budd-Chiari Syndrome with IVC obstruction. Thus, the diagnostic sensitivity and specificity of RIVC for this syndrome was 85.7% and 100% respectively. If RIVC is combined with hepatic scintigraphy, it will help to elucidate the anatomic and functional change of IVC, as well as, liver parenchymal disease, such as liver cirrhosis, hepatic tumor or hepatic vein obstruction. RIVC is a simple safe, accurate, noninvasive and reproducible procedure. This study confirms the high diagnostic specificity and sensitivity of RIVC. We therefore recommend RIVC as the first-line study for IVC patency. Contrast venography may be used as a confirmatory study in preparation for surgical intervention.

Adolescent↗

PubMedDate not supplied

[Treatment of status epilepticus with intravenous lidocaine (Xylocaine)].

A case history of a 19-year old epileptic woman with diffuse encephalopathy of unknown aetiology and frequent attacks of status, epilepticus, whose last episode of the status epilepticus was successfully treated with intravenous lidocaine, after several first-line antiepileptic drugs failed to control, it, is presented. Although highly effective in treating refractory status epilepticus this treatment received little attention in clinical practice. We observed no un desired side effects of such treatment. The authors shortly reviewed current knowledge about several widely used treatment protocols. Some specific pharmacokinetic and pharmacodynamic properties of lidocaine during convulsions were also mentioned. A warning was drawn to toxic fide effects of lidocaine which were precipitated by increasing brain-blood pH gradient during convulsions, which in high doses included seizures caused by lidocaine per se. The effects of high dose lidocaine on the latencies and the amplitudes of the BAER and possible ways for mechanism of drug action were also reviewed.

Adult↗

PubMed1989

The effects of transsphenoidal surgery on endocrine function and visual fields in patients with functionless pituitary tumours.

Twenty-eight patients with functionless pituitary tumours have been treated by transsphenoidal surgery over the last 28 months. Mean age at presentation was 55 years. Tumor size was graded according to the extent of suprasellar extension on CT headscan from above the interclinoid line: four were small, 15 medium and nine large. Before surgery in 25 per cent of patients visual acuity and visual fields were normal. In the immediate postoperative period, 24 per cent of the patients with visual defects before surgery had normal vision, and in 38 per cent of the others it was improved. Six months after surgery, there had been further improvement; 43 per cent had normal vision and 48 per cent showed an overall improvement. In no patient did vision deteriorate following surgery. In the patients who presented with visual symptoms of one year or less, there was no correlation between the length of symptoms and the extent of visual recovery after surgery. Average age of the patients with full visual recovery was 47 +/- 4 years (mean +/- SEM); average age of the patients with only partial visual recovery was 63 +/- 3 years. Prolactin levels before surgery were elevated in 77 per cent of patients and fell significantly after operation, remaining elevated in 28 per cent of patients six months later. Fifty per cent of patients were treated with long-term hormone replacement therapy. Transsphenoidal surgery led to improved vision in the majority of patients, the results being comparable with those obtained with transfrontal surgery. Surgical complications were few, and long-term morbidity low. We suggest that the first-line treatment for patients with functionless pituitary tumours should be transsphenoidal surgery, even when large suprasellar extensions are present.

Adenoma↗

PubMed1989

ERCP in the assessment of patients with post-cholecystectomy syndrome: benefits and limitations.

The aim of our study was to assess the diagnostic accuracy yielded by endoscopic retrograde cholangio-pancreatography (ERCP) in a group of 41 patients presenting with persistent or recurrent abdominal pain and/or cholestasis following cholecystectomy. Each patient had previously undergone, without success, a different combination of non-invasive tests. Cannulation with adequate opacification of at least one duct was achieved in all patients. Aetiologically diagnostic findings obtained with ERCP were as follows: normal 36.8%, choledocholithiasis 34%, benign biliary stenosis 9.8%, chronic pancreatitis 4.9%, pancreatic carcinoma 2.4%, ampullary carcinoma 2.4%, cholangiocarcinoma 2.4%, miscellaneous 7.3%. ERCP gave a final diagnosis in 26 patients (63%) and in all the cases presenting with cholestasis. ERCP plays a first-line role in the diagnostic assessment of patients with the post-cholecystectomy syndrome. However, there is still a considerable part of this population in whom ERCP does not contribute to a diagnosis.

Abdominal Pain↗

PubMed1989

[Lidocaine levels in the plasma following peripheral or central venous administration during cardiopulmonary resuscitation. Results of an experimental animal study].

A review of the literature indicates that the intravenous bolus dose of lidocaine should be reduced in all conditions where cardiac output is diminished. During external cardiac compression the cardiac output is only approximately 20-40% of the normal resting value. Various routes of drug administration are currently used during CPR. The routine use of a central venous line is not recommended as a first-line procedure for resuscitation. This route of administration is favored by some authors, however, because it is presumed to result in a more rapid onset of drug action and higher peak concentrations of the drugs used. The aim of this study was to determine the aortic plasma concentration of lidocaine after central venous as compared to peripheral venous administration under the conditions of external cardiac compression. Twelve pigs were allocated to two groups of 6 animals each using random numbers. Ventricular fibrillation was induced by applying an alternating current via two needle electrodes placed subcutaneously. Cardiac arrest was allowed to continue for a period of 1 min before mechanical measures were applied. Cardiac massage was carried out using a pneumatic piston device set to a compression rate of 80/min. Sixty seconds after mechanical CPR had been initiated, a bolus of 1.5 mg/kg lidocaine was given to 6 animals via a central venous line. The remaining 6 animals were treated with the same dose given into a vein of the earlobe. The 2% lidocaine solution was diluted to 20 ml with physiological saline in all animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMedDate not supplied

[Radiotherapy instead of second-line chemotherapy in patients with Hodgkin's disease in partial remission after treatment with cytostatics].

Radiotherapy was given to 32 patients with Hodgkin's disease (clinical stage IIA-IIIA) in whom chemotherapy given as the first treatment produced partial remission or minimal regression with disappearance of all systemic symptoms (27 cases) or recurrence developed after earlier treatment with cytostatic agents (5 cases). For a more accurate determination of the extent of lesions before radiotherapy in 24 cases laparotomy was done with splenectomy. Radiotherapy given in place of a second course of chemotherapy led in 24 cases (75%) to complete remission lasting from 8 to 62 months, mean 23.2 months. Twenty-one patients are still in continuing remission. These results point to the usefulness of considering the possibility of using radiation energy for the treatment of patients with advanced Hodgkin's disease (phase IIP-IIIP) in whom cytostatic drugs given as a first-line therapy failed to produce complete remission after 4-6 treatment courses, but caused some regression of symptoms with disappearance of systemic signs.

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↗