Initial Therapy (initial + therapy)

Distribution by Scientific Domains
Distribution within Medical Sciences

Selected Abstracts

Diuretics Should Continue to Be One of the Preferred Initial Therapies in the Management of Hypertension

Robert A. Phillips MD, Section Editor
First page of article [source]

Costs of Managing Helicobacter pylori -Infected Ulcer Patients After Initial Therapy

HELICOBACTER, Issue 3 2002
Xavier Calvet md
No abstract is available for this article. [source]

Fixed-Dosed Combinations Are Not Indicated as Initial Therapy: A Debate

Barry L. Carter PharmD
First page of article [source]

Response to Letter to the Editor: ,Costs of Managing Helicobacter pylori -Infected Ulcer Patients After Initial Therapy'

HELICOBACTER, Issue 3 2002
Linda Rabeneck md
No abstract is available for this article. [source]

Hypoadrenocorticism in a cat

J. Stonehewer
Primary hypoadrenocorticism was diagnosed in an eight-year-old neutered male cat. The predominant presenting complaint was dysphagia. Other historical signs included lethargy, weight loss, polydipsia, polyuria, muscle weakness and occasional vomiting. The signs had waxed and waned over the two months before presentation and had improved when the cat was treated with enrofloxacin and prednisolone by the referring veterinarian. On referral, dehydration, depression and poor bodily condition were found on physical examination. Results of initial laboratory tests revealed mild anaemia, hyperkalaemia, hyponatraemia, hypochloraemia and elevations in serum creatinine and creatine kinase. The diagnosis of primary adrenocortical insufficiency was established on the basis of results of an adrenocorticotropic hormone (ACTH) stimulation test and endogenous plasma ACTH determination. Initial therapy for hypoadrenocorticism included intravenous administration of 0,9 per cent saline and dexamethasone, and oral fludrocortisone acetate. Within one week the cat was clinically normal and two years later was still alive and well on fludrocortisone acetate treatment only. [source]

Use of rotation thromboelastometry (ROTEM®) to achieve successful treatment of polytrauma with fibrinogen concentrate and prothrombin complex concentrate

ANAESTHESIA, Issue 2 2010
H. Schöchl
Summary Goal-directed coagulation therapy is essential in the management of trauma patients with severe bleeding. Due to the complex nature of coagulation disorders in trauma, a quick and reliable diagnostic tool is essential. We report a severely injured multiple trauma patient who received haemostatic therapy with coagulation factor concentrates, guided by rotational thromboelastometry (ROTEM®). Initial therapy consisted of fibrinogen concentrate (Haemocomplettan® P), as maximum clot firmness in the ROTEM analyses was low, whereas clotting time was normal. Later on, prothrombin complex concentrate was given to optimise thrombin generation. This approach enabled extended emergency hemihepatectomy to be performed without using fresh frozen plasma. As the EXTEM maximum clot firmness showed good clot quality, no platelets were transfused despite low platelet counts. This case shows the potential success of treatment using both fibrinogen concentrate and prothrombin complex concentrate, not only in restoring haemostasis but also in minimising requirement for transfusion of allogeneic blood products. [source]

Classification, presentation, and initial treatment of Wegener's granulomatosis in childhood

David A. Cabral
Objective To compare the criteria for Wegener's granulomatosis (WG) of the American College of Rheumatology (ACR) with those of the European League Against Rheumatism/Pediatric Rheumatology European Society (EULAR/PRES) in a cohort of children with WG and other antineutrophil cytoplasmic antibody (ANCA),associated vasculitides (AAVs), and to describe the interval to diagnosis, presenting features, and initial treatment for WG. Methods Eligible patients had been diagnosed by site rheumatologists (termed the "MD diagnosis") since 2004. This diagnosis was used as a reference standard for sensitivity and specificity testing of the 2 WG classification criteria. Descriptive analyses were confined to ACR-classified WG patients. Results MD diagnoses of 117 patients (82 of whom were female) were WG (n = 76), microscopic polyangiitis (n = 17), ANCA-positive pauci-immune glomerulonephritis (n = 5), Churg-Strauss syndrome (n = 2), and unclassified vasculitis (n = 17). The sensitivities of the ACR and EULAR/PRES classification criteria for WG among the spectrum of AAVs were 68.4% and 73.6%, respectively, and the specificities were 68.3% and 73.2%, respectively. Two more children were identified as having WG by the EULAR/PRES criteria than by the ACR criteria. For the 65 ACR-classified WG patients, the median age at diagnosis was 14.2 years (range 4,17 years), and the median interval from symptom onset to diagnosis was 2.7 months (range 0,49 months). The most frequent presenting features by organ system were constitutional (89.2%), pulmonary (80.0%), ear, nose, and throat (80.0%), and renal (75.4%). Fifty-four patients (83.1%) commenced treatment with the combination of corticosteroids and cyclophosphamide, with widely varying regimens; the remainder received methotrexate alone (n = 1), corticosteroids alone (n = 4), or a combination (n = 6). Conclusion The EULAR/PRES criteria minimally improved diagnostic sensitivity and specificity for WG among a narrow spectrum of children with AAVs. Diagnostic delays may result from poor characterization of childhood WG. Initial therapy varied considerably among participating centers. [source]

The good initial response to therapy with a combination of traditional disease-modifying antirheumatic drugs is sustained over time: The eleven-year results of the Finnish rheumatoid arthritis combination therapy trial

Vappu Rantalaiho
Objective To evaluate the evolution of functional and clinical outcomes over 11 years in patients with early rheumatoid arthritis (RA) initially treated with a combination of 3 disease-modifying antirheumatic drugs (DMARDs) or with a single DMARD. Methods A cohort of 199 patients with early active RA were initially randomized to receive treatment with a combination of methotrexate, sulfasalazine, and hydroxychloroquine with prednisolone or treatment with a single DMARD (initially, sulfasalazine) with or without prednisolone. After 2 years, the drug treatment strategy became unrestricted, but still targeted remission. At 11 years, function was assessed with the Health Assessment Questionnaire (HAQ), and clinical outcomes were assessed with the modified Minimal Disease Activity (MDA) measure and the American College of Rheumatology (ACR) criteria for remission. Results At 11 years, 138 patients were assessed (68 in the combination-DMARD group and 70 in the single-DMARD group). The mean ± SD HAQ scores were 0.34 ± 0.54 in the combination-DMARD group and 0.38 ± 0.58 in the single-DMARD group (P = 0.88). Modified MDA was achieved by 63% (95% confidence interval [95% CI] 51, 77) and by 43% (95% CI 32, 55) (P = 0.016) of the combination-DMARD group and the single-DMARD group, respectively, and ACR remission by 37% (95% CI 26, 49) and by 19% (95% CI 11, 29) (P = 0.017), respectively. Conclusion Initial therapy with a combination of DMARDs in early RA results in higher rates of patients achieving modified MDA and strict ACR remission even over the long term than initial single-DMARD therapy. Targeting remission with tight clinical controls results in good functional and clinical outcomes in most RA patients. [source]

Pediatric Crohn's disease activity at diagnosis, its influence on pediatrician's prescribing behavior, and clinical outcome 5 years later

Tamara Mesker MD
Abstract Background: No studies have been performed in which therapeutic regimens have been compared between mild and moderate-to-severe pediatric Crohn's disease (CD) at diagnosis. The aim was to analyze pediatric CD activity at diagnosis, its influence on pediatrician's prescribing behavior, and clinical outcome 5 years later. Methods: In a retrospective multicenter study we divided pediatric CD patients at diagnosis into mild or moderate-severe disease. We compared initial therapies, duration of first remission, number of exacerbations, height-for-age and weight-for-height evolvement, and cumulative duration of systemic steroid use in a 5-year follow-up period. Results: Forty-three children were included (25 with mild and 18 with moderate-severe disease). Aminosalicylate monotherapy was more frequently prescribed in the mild group (40% versus 17%; P < 0.01). The median duration of systemic steroid use was 18.3 months in the mild group and 10.4 months in the moderate-severe group (P = 0.09). Duration of first remission was 15.0 months in the mild group and 23.4 months in the moderate-severe group (P = 0.16). The mean number of exacerbations was 2.2 in the mild group and 1.8 in the moderate-severe group (P = 0.28). Conclusions: CD patients with mild disease were treated with aminosalicylate monotherapy more frequently. These patients, however, tend to have more exacerbations, shorter duration of first remission, and longer total duration of systemic steroid use. Our data support the concept that severity of disease at diagnosis does not reliably predict subsequent clinical course. This study suggests that there is no indication that children with mild CD should be treated differently compared to children with moderate-severe disease. (Inflamm Bowel Dis 2009) [source]

Selective dose escalation of chemoradiotherapy for locally advanced esophageal cancer

S. K. Seung
SUMMARY., This phase II study assessed the use of concurrent continuous infusion of 5-fluorouracil and weekly carboplatin plus paclitaxel with selective radiation dose escalation for patients with localized esophageal cancer. Patients with esophageal carcinoma were staged by thoracic and abdominal computed tomography, endoscopic ultrasound, and positron emission tomography scans. Patients received a continuous infusion of 5-fluorouracil 225 mg/m2 on days 1 to 38 and intravenous paclitaxel 45 mg/m2 and carboplatin AUC 2 on days 1, 8, 15, 22, 29, and 36. Radiotherapy was delivered in 1.8-Gy fractions, 5 d/wk for 5.5 weeks. Six to 8 weeks after initial therapy, patients without metastatic progression but with a positive biopsy, or less than partial response received a 9-Gy boost with the same concurrent chemotherapy. Twenty-four patients were enrolled: 18 patients were enrolled initially; 6 additional patients were enrolled following a protocol amendment designed to reduce the esophagitis by adding the radioprotectant amifostine. Median follow-up was 30 months. Twenty (83%) patients had adenocarcinomas of the lower esophagus/gastroesophageal junction. Seventeen patients (81%) attained at least a partial response. Six patients received boost treatment. At 4 years, overall survival was 28%, cause-specific survival was 38%, locoregional control was 61%, and distant metastasis-free survival was 52%. Radiation delays ranged from 0 to 62 days (median, 8 d), primarily owing to esophagitis. In total, 28% of patients developed esophageal strictures requiring dilatations. There were no differences in esophageal strictures, local control, or survival with the addition of amifostine. [source]

Relationship between weight, levodopa and dyskinesia: the significance of levodopa dose per kilogram body weight

J. C. Sharma
Purpose:, Levodopa dose per kilogram body weight is reported to be a significant factor for dyskinesia in Parkinson's disease. We have investigated this hypothesis in data from the studies comparing ropinirole versus levodopa as the initial therapy. Methods:, Data from the ropinirole versus levodopa studies 056 and REAL-PET in early Parkinson's disease were pooled and manipulated to calculate levodopa dose per kilogram body weight. Logistic regression analysis was performed to investigate significant variables for the development of dyskinesia. Only the patients on levodopa monotherapy or with ropinirole were analyzed. Results:, Analysis of levodopa therapy patients revealed that dyskinetic patients had received significantly higher absolute levodopa dose and levodopa dose per kilogram body weight. Logistic regression revealed that the most significant factor was the higher levodopa dose per kilogram body weight, P = 0.005, odds ratio 1.078, 95% CI 1.023,1.135; younger age was the second factor ,P = 0.026. Variables of gender, absolute levodopa dose, weight, disease duration and initial motor Unified Parkinson's disease rating score were not significant. Conclusion:, Higher levodopa dose per kilogram body weight is an independently significant factor for developing dyskinesia. This relationship should be considered in treatment of Parkinson's disease patients aiming to prevent and manage dyskinesia. [source]

Usefulness of 201TL SPECT/CT relative to 18F-FDG PET/CT in detecting recurrent skull base nasopharyngeal carcinoma

Ruoh-Fang Yen MD
Abstract Background This study was designed to compare 201Tl single photon emission computed tomography (SPECT)/CT with 18-fluoro-2-deoxyglucose (18F-FDG) PET/CT in diagnosing recurrent skull base nasopharyngeal carcinoma (NPC). Methods Twenty-seven patients were recruited. Both 201Tl SPECT/CT and 18F-FDG PET/CT for each patient were performed at least 4 months later after initial therapy. Results The sensitivity and specificity for 201Tl SPECT/CT were 66.7% and 100%, and those for 18F-FDG PET/CT were 86.7% and 75.0%. Lesion/background ratios were obtained for the 10 lesions that were both SPECT and PET true positive. For the 8 patients with recurrences in nasopharyngeal regions, PET lesion/background ratios were all higher than SPECT lesion/background ratios. For the 2 patients with intracranial metastases, SPECT lesion/background ratios were higher than PET lesion/background ratios. Conclusion 201Tl SPECT/CT is as effective as 18F-FDG PET/CT in detecting recurrent NPC. For intracranial recurrence, 201Tl SPECT, because of its high intracranial lesion/background ratio, is probably better than 18F-FDG PET. © 2009 Wiley Periodicals, Inc. Head Neck, 2009 [source]

A Report Card to Grade Helicobacter pylori Therapy

HELICOBACTER, Issue 4 2007
David Y. Graham
Helicobacter pylori causes a serious bacterial infectious disease, and the expectations of therapy should reflect this fact. Increasing antibiotic resistance, especially to clarithromycin, has significantly undermined the effectiveness of legacy triple therapy consisting of a proton pump inhibitor, clarithromycin, and amoxicillin. Current cure rates are consistently below 80% intention-to-treat, the accepted threshold separating acceptable from unacceptable treatment results. Grading clinical studies into effectiveness categories using prespecified criteria would allow clinicians to objectively identify and compare regimens. We offer a therapy report card similar to that used to grade the performance of school children. The intention-to-treat cure rate categories are: F or unacceptable ( 80%), D or poor (81,84%), C or fair (85,89%), B or good (90,95%), and A or excellent (95,100%). The category of "excellent" is based on the cure rates expected with other prevalent bacterial infectious diseases. We propose that only therapies that score "excellent" (grade = A) should be prescribed. Regimens scoring as B or "good" can be used if "excellent" results are not obtainable. In most regions legacy triple therapy should be abandoned as unacceptable. Quadruple therapy and sequential therapy are reasonable alternatives for initial therapy. [source]

A Community-Based Study of Helicobacter pylori Therapy Using the Strategy of Test, Treat, Retest, and Re-treat Initial Treatment Failures

HELICOBACTER, Issue 5 2006
Yi-Chia Lee
Abstract Background:, Although eradication of Helicobacter pylori infection can decrease the risk of gastric cancer, the optimal regimen for treating the general population remains unclear. We report the eradication rate (intention-to-treat and per protocol) of a community-based H. pylori therapy using the strategy of test, treat, retest, and re-treat initial treatment failures. Materials and methods:, In 2004, a total of 2658 residents were recruited for 13C-urea breath testing. Participants with positive results for infection received a standard 7-day triple therapy (esomeprazole 40 mg once daily, amoxicillin 1 g twice daily, and clarithromycin 500 mg twice daily), and a 10-day re-treatment (esomeprazole 40 mg once daily, amoxicillin 1 g twice daily, and levofloxacin 500 mg once daily) if the follow-up tests remained positive. Both H. pylori status and side-effects were assessed 6 weeks after treatment. Results:, Among 886 valid reporters, eradication rates with initial therapy were 86.9% (95% confidence interval [CI]: 84.7,89.1%) and 88.7% (95%CI: 86.5,90.9%) by intention-to-treat and per protocol analysis, respectively. Re-treatment eradicated infection in 91.4% (95%CI: 86,96.8%) of 105 nonresponders. Adequate compliance was achieved in 798 (90.1%) of 886 subjects receiving the initial treatment and in all 105 re-treated subjects. Mild side-effects occurred in 24% of subjects. Overall intention-to-treat and per protocol eradication rates were 97.7% (95%CI: 96.7,98.7%) and 98.8% (95%CI: 98.5,99.3%), respectively, which were only affected by poor compliance (odds ratio, 3.3; 95%CI, 1.99,5.48; p < .0001). Conclusions:, A comprehensive plan using drugs in which the resistance rate is low in a population combined with the strategy of test, treat, retest, and re-treat of needed can result in virtual eradication of H. pylori from a population. This provides a model for planning country- or region-wide eradication programs. [source]

An Educational Intervention to Improve Antimicrobial Use in a Hospital-Based Long-Term Care Facility

(See Editorial Comments by Dr. Lona Mody on pp 130, 1302)
OBJECTIVES: To improve antimicrobial use in patients receiving long-term care (LTC). DESIGN: Prospective, quasi-experimental before,after assessment of the effects of physician education and guideline implementation. SETTING: Public LTC and acute care hospital. PARTICIPANTS: Twenty salaried internists who provided most of the medical care to LTC patients. INTERVENTION: National guidelines, hospital resistance data, and physician feedback were incorporated into a series of four teaching sessions presented over 18 months and into booklets detailing institutional guidelines on the optimal management of common LTC infection syndromes. MEASUREMENTS: One hundred randomly selected LTC patients treated with antimicrobials were reviewed before these interventions were implemented and 100 after, and measures of the quality of care were compared. The effect of the interventions on antimicrobial days and starts were also assessed using interrupted time series analysis. RESULTS: Charted clinical abnormalities met guideline diagnostic criteria (62% vs 38%, P=.006), and initial therapy agreed with guideline recommendations (39% vs 11%, P<.001), more often in the post- than in the preintervention cohort. Mean census-adjusted monthly LTC antimicrobial days fell 29.7%, and antimicrobial starts fell 25.9% during the intervention period; both decreases were sustained during the 2-year postintervention period. CONCLUSION: The teaching and guideline intervention improved the quality and reduced the quantity of antimicrobial use in LTC patients. [source]

Achieving Goal Blood Pressure in Patients With Type 2 Diabetes: Conventional Versus Fixed-Dose Combination Approaches

George L. Bakris MD
Data from the Third National Health and Nutrition Examination Survey (NHANES III) demonstrate that only 11% of people with diabetes who are treated for high blood pressure achieve the blood pressure goal of <130/85 mm Hg recommended in the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). The current study tests the hypothesis that initial therapy with a fixed-dose combination will achieve the recommended blood pressure goal in patients with type 2 diabetes faster than conventional monotherapy. This randomized, double-blind, placebo-controlled study had as a primary end point achievement of blood pressure <130/85 mm Hg. Participants (N=214) with hypertension and type 2 diabetes received either amlodipine/benazepril 5/10 mg (combination) or enalapril 10 mg (conventional) once daily for 4 weeks, titrated to 5/20 mg/day or 20 mg/day, respectively at this time, if target blood pressure was not achieved. Hydrochlorothiazide (HCTZ) 12.5 mg/day was added for the final 4 weeks, if target blood pressure was still not reached. Time from baseline to achieve blood pressure <130/85 mm Hg was shorter in the combination group (5.3±3.1 weeks combination vs. 6.4±3.8 weeks conventional; p=0.001). At 3 months, more participants in the combination group achieved treatment goal (63% combination vs. 37% conventional; p=0.002). Data analysis at 3 months comparing blood pressure control rates between the fixed-dose combination group (with out HCTZ) to the conventional group (receiving HCTZ) showed an even greater disparity in blood pressure goal achievement (87% combination without HCTZ vs. 37% conventional group with HCTZ; p=0.0001). We conclude that initial therapy with a fixed-dose combination may be more efficacious than conventional monotherapy approaches for achieving blood pressure goals in the diabetic patient. A fixed-dose combination approach appears as safe as the current conventional approaches. [source]

Impaired healing response of periodontal furcation defects following flap debridement surgery in smokers

A controlled clinical trial
Abstract Objectives: The purpose of the present parallel-design, controlled clinical trial was to evaluate the treatment outcome of periodontal furcation defects following flap debridement surgery (FDS) procedure in cigarette smokers compared to non-smokers. Materials and Methods: After initial therapy, 31 systemically healthy subjects with moderate to advanced periodontitis, who presented at least one Class I or II molar furcation defect, were selected. Nineteen patients (mean age: 40.3 years, 15 males) were smokers (,10 cigarettes/day) and 12 patients (mean age: 44.8 years, 3 males) were non-smokers. Full-mouth plaque score (FMPS) and full-mouth bleeding score (FMBS), probing pocket depth (PPD), vertical clinical attachment level (v-CAL), and horizontal clinical attachment level (h-CAL) were assessed immediately before and 6 months following surgery. Results: Overall, statistically significant v-CAL gain was observed in smokers (1.0 ± 1.3 mm) and non-smokers (1.3±1.1 mm), the difference between groups being statistically significant (p=0.0003). In proximal furcation defects, v-CAL gain amounted to 2.3±0.7 mm in non-smokers as compared to 1.0±1.1 mm in smokers (p=0.0013). At 6 months postsurgery, non-smokers presented a greater h-CAL gain (1.3±1.1 mm) than smokers (0.6±1.0 mm), with a statistically significant difference between groups (p=0.0089). This trend was confirmed in both facial/lingual (1.4±1.0 versus 0.8±0.8 mm) and proximal furcation defects (1.2±1.3 versus 0.5±1.2 mm). The proportion of Class II furcations showing improvement to postsurgery Class I was 27.6% in smokers and 38.5% in non-smokers. After 6 months, 3.4% of presurgery Class I furcation defects in smokers showed complete closure, as compared to 27.8% in non-smokers. Conclusions: The results of the present study indicated that (1) FDS produced clinically and statistically significant PPD reduction, v-CAL gain, and h-CAL gain in Class I/II molar furcation defects, and (2) cigarette smokers exhibited a less favorable healing outcome following surgery in terms of both v-CAL and h-CAL gain. Zusammenfassung Ziele: Der Zweck der vorliegenden kontrollierten klinischen Studie mit einem parallelen Design war die Überprüfung des Behandlungsergebnisses bei parodontalen Furkationsdefekten nach Wurzelreinigung und ,glättung bei Lappenoperationen (FDS) bei Zigarettenrauchern und Nichtrauchern. Material und Methoden: Nach der initialen Therapie wurden 31 systemisch gesunde Personen mit moderater bis schwerer Parodontitis, die mindestens einen Klasse I oder Klasse II Furkationsdefekt aufwiesen, ausgesucht. 19 Patienten (mittleres Alter 40,3 Jahre, 15 Männer) waren Raucher (,10 Zigaretten/Tag), 12 Patienten (mittleres Alter 44,8 Jahre, 3 Männer) waren Nichtraucher. Der Plaqueindex (FMPS) und die Provokationsblutung (FMBS) im gesamten Mund, die Sondierungstiefen (PPD), die vertikalen klinischen Befestigungsniveaus (v-CAL) und die horizontalen klinischen Befestigungsniveaus (h-CAL) wurden unmittelbar vor und 6 Monate nach der Operation erhoben. Ergebnisse: Insgesamt wurde ein statistisch signifikanter v-CAL Gewinn bei Rauchern (1,0±1,3 mm) und Nichtrauchern (1,3±1,1 mm) beobachtet, die Differenz wischen den Gruppen war statistisch signifikant (p=0,0003). Bei den approximalen Furkationsdefekten betrug der v-CAL Gewinn bei Nichtrauchern 2,3±0,7 mm verglichen zu den Rauchern mit 1,0±1,1 mm (p=0,0013). 6 Monate post operationem zeigten die Nichtraucher einen größeren h-CAL Gewinn (1,3±1,1 mm) verglichen mit den Rauchern (0,6±1,0 mm) mit einer statistischen Signifikanz zwischen den Gruppen (p=0,0089). Dieser Trend wurde sowohl bei den fazialen/lingualen Defekten (1,4±1,0 mm vs. 0,8±0,8 mm) und bei den approximalen Furkationsdefekten (1,2 v 1,3 mm vs. 0,5±1,2 mm) bestätigt. Das Verhältnis von Klasse II Furkationen, die post operationem eine Verbesserung zu Klasse I Furkationsdefekten zeigten, war bei Rauchern 27,6 % und 38,5 % bei Nichtrauchern. Nach 6 Monaten zeigten 3,4 % der Klasse I Furkationsdefekte bei Rauchern einen kompletten Verschluss verglichen mit 27,8 % bei Nichtrauchern. Zusammenfassung: Die Ergebnisse der vorliegenden Studie zeigten, dass 1) FDS eine klinische und statistisch signifikante PPD Reduktion, einen v-CAL Gewinn und h-CAL Gewinn bei Klasse I/II Molaren Furkationsdefekten erbringt; 2) Zigarettenraucher weniger gute Heilungsergebnisse nach Operationen sowohl bei v-CAL als auch bei h-CAL zeigten. Résumé Objectifs: cette étude clinique contrôlée en parallèle se proposait d'évaluer l'issue du trai-tement des lésions des furcations par un lam-beau de débridement (FDS) chez des fumeurs de cigarette par rapport à des non-fumeurs. Matériel et méthodes: Après un traitement initial, 31 sujets en bonne santé atteints de parodontite modérée à avancée et présentant au moins une lésion inter-radiculaire de classe I ou II sur une molaire, furent sélectionnés. 19 patients (d'âge moyen: 40.3 ans, 15 hommes) étaient fumeurs (,10 cigarettes/jour), 12 patients (d'âge moyen: 44.8 ans, 3 hommes) étaient non-fumeurs. Le score de plaque de toute la bouche (FMPS) et le score de saignement (FMBS), la profondeur de poche au sondage (PPD), le niveau clinique d'attache vertical (v-CAL), et horizontal (h-CAL) furent estimés immédiatement avant et 6 mois après la chirurgie. Résultats: D'une façon générale, un gain de v-CAL statistiquement significatif gain était observé chez les fumeurs (1.0±1.3 mm) et chez les non-fumeurs (1.3±1.1 mm), la différence entre les groupes étant statistiquement significative (p=0.0003). Pour les lésions des furcations proximales, le gain de v-CAL atteignait 2.3±0.7 mm chez les non-fumeurs et seulement 1.0±1.1 mm chez les fumeurs (p=0.0013). 6 mois après la chirurgie, les non-fumeurs présentaient un gain de h-CAL gain plus important (1.3±1.1 mm) que les fumeurs(0.6±1.0 mm), avec une différence statistiquement significative entre les groupes (p=0.0089). Cette tendance était confirmée à la fois sur les lésions des furcations vestibulo-linguales (1.4±1.0 mm vs 0.8±0.8 mm) et proximales (1.2±1.3 mm vs 0.5±1.2 mm). La proportion de furcations de Classe II s'améliorant après chirurgie en Classe I était de 27.6% chez les fumeurs et 38.5% chez les non-fumeurs. Après 6 mois, 3.4% des furcations initialement de Classe I étaient complètement fermées contre 27.8% chez les non-fumeurs. Conclusions: Les résultats de cette étude indiquent que: 1) FDS produit une réduction cliniquement et statistiquement significative de PPD, un gain de v-CAL et de h-CAL gain sur les lésions de furcations molaires de Classe I/II; 2) Les fumeurs de cigarette ont une cicatrisation moins favorable après chirurgie en terme de gain de v-CAL et de h-CAL. [source]

Clinical manifestations and survival of hepatocellular carcinoma patients with peritoneal metastasis

Chien-Chu Lin
Abstract Background and Aim:, Peritoneal metastasis is an uncommon manifestation of hepatocellular carcinoma (HCC). The aim of the present paper was to investigate the characteristics and survival of HCC patients with peritoneal metastases. Methods:, From January 1985 to December 2004, we retrospectively reviewed the records of 53 Taiwanese HCC patients with peritoneal metastases. Results:, Peritoneal metastases were detected at the time of HCC diagnosis (synchronously) in 10 patients and after the initial therapy for the primary tumors (metachronously) in 43 patients. The mean time for development of the metachronous peritoneal metastases was similar whether the primary cancer was treated with surgery (24 months) or transarterial chemoembolization (22.2 months). The single patient whose primary cancer was treated with supportive care alone developed peritoneal metastasis only 7.5 months after detection of the primary cancer. Surgical resection of the peritoneal metastases was possible in two-thirds of the 43 metachronous patients. The median survival for those who received surgery for these metastases was 12.5 months vs. 2.1 months for those without surgery (P = 0.0013). However, there was no difference in survival if patients were stratified to Child-Pugh grade. Conclusions:, Peritoneal metastases of HCC are rare and can occur synchronously or metachronously. Though increased long-term survival was found in patients who had surgical removal of peritoneal metastases, the main determinant of better survival is Child-Pugh grade. [source]

Healthcare-associated candidemia,A distinct entity?,

Joyti Gulia MD
Abstract BACKGROUND: The concept of health care-associated infection (HCAI) was developed to address the fact that select patients now present to the hospital with infections due to traditionally nosocomial pathogens. Although epidemiologic studies document the clear existence of health care-associated pneumonia, little is known about fungal pathogens and their role in HCAIs. OBJECTIVE: To describe the epidemiology of health care-associated bloodstream infections (BSIs) due to candida species and to compare patients with HCA candidemia to nosocomial candidemia. DESIGN: Retrospective case series. SETTING: Academic, tertiary care hospital. MEASUREMENTS: We measured the proportion of cases of candidal BSI classified as health care-associated along with the microbiology of these infections. We compared health care-associated and nosocomial cases of candidemia with respect to demographics, severity of illness, and fluconazole susceptibility. RESULTS: We noted 233 cases of candidal BSI over a 3-year period. Nearly one-quarter represented an HCAI that presented to the hospital, as opposed to a nosocomial process. Although patients with HCA candidemia were similar to subjects with nosocomial infection in terms of underlying comorbidities and severity of illness, those with HCA yeast BSI were more likely to be immunosuppressed and to have their infection caused by a fluconazole-resistant organism. C. glabrata was seen more often in patients presenting to the hospital with an HCA case of candidemia. CONCLUSIONS: Clinicians must recognize the potential for candida species to cause HCA infections and to be present at time of hospital presentation. Physicians need to consider this and the distribution of species of yeast causing BSI in their institution when considering initial therapy for patients with a suspected BSI. Journal of Hospital Medicine 2010;5:298,301. © 2010 Society of Hospital Medicine. [source]

Bridging the gap between evidence and practice in acute decompensated heart failure management

FACP, Franklin A. Michota Jr MD
Abstract Registry data indicate a gap between evidence-based guidelines and current management of patients with acute decompensated heart failure (ADHF). Bridging this gap is crucial given the frequency and cost of hospitalization for this disorder. Patients with ADHF require rapid assessment to determine appropriate treatment location and initial therapy. Patients with impending respiratory failure or cardiogenic shock should be managed in an intensive care setting, patients with congestion that is expected to require prolonged intravenous therapy should be admitted to the hospital, and patients with congestion that is likely to respond within 12,24 hours can be managed in an observation unit. Clinical status should guide selection of initial therapy. Initially, therapeutic response should be assessed every couple of hours. Once effective acute therapy has been established, it is important to implement strategies to improve long-term outcomes. These strategies include ensuring that care complies with established core performance measures, providing patient education in a manner suited to ensure comprehension and retention, and arranging for appropriate outpatient follow-up, ideally in a comprehensive heart failure disease management program. The purpose of this review is (1) to examine evidence-based guidelines for the treatment of ADHF, (2) to present a practical algorithm for patient assessment and treatment derived from these guidelines and personal experience, and (3) to discuss systems to enhance the ultimate transition of patient care from the inpatient to outpatient setting. Journal of Hospital Medicine 2008;3(Suppl 6):S7,S15. ©2008 Society of Hospital Medicine. [source]

Hospitalized patients with acute decompensated heart failure: Recognition, risk stratification, and treatment review

Alpesh Amin MD
Abstract Acute decompensated heart failure (ADHF) has emerged as a major healthcare problem. It causes approximately 3% of all hospitalizations in the United States, with the direct medical cost of these hospitalizations estimated at $18.8 billion per year. Early recognition, risk stratification, and evidence-based treatment are crucial in reducing the morbidity, mortality, and costs associated with this disorder. Classic signs and symptoms of ADHF, such as rales, dyspnea, and peripheral edema, may be absent at hospital presentation and, even when present, are not specific to this disorder. As a result, serum B,type natriuretic peptide level is now used to rapidly and accurately detect ADHF. Multivariate analyses have identified renal dysfunction, hypotension, advanced age, hyponatremia, and comorbidities as significant and independent mortality risk factors. Based on these factors, mortality risk can be stratified from very low to very high using published algorithms that have been validated in independent populations. Evidence-based guidelines for the treatment of ADHF are available from both the European Society of Cardiology and the Heart Failure Society of America. In general, an intravenous loop diuretic, either alone or in combination with a vasodilator, is recommended as initial therapy in patients with volume overload, depending on the patient's clinical status. Use of inotropic agents should be limited to the small subset of patients with low-output syndrome and significant hypotension. In any event, frequent monitoring of clinical response is essential, with subsequent therapy determined by this response. Finally, focused patient education during hospitalization may help reduce readmissions for ADHF. Journal of Hospital Medicine 2008;3(Suppl 6):S16,S24. © 2008 Society of Hospital Medicine. [source]

Analysis of risk factors for recurrence and effective adjuvant therapy in patients with endometrial cancer

Tomoko Goto
Objective: The aim of this study was to explore risk factors for recurrence and effective adjuvant therapy in endometrial cancer. Methods: Between 1985 and 1999, 170 patients with uterine endometrial cancer received initial therapy at the National Defense Medical College Hospital. We retrospectively analyzed risk factors including; histopathological features, operative procedures, adjuvant therapies and surgical staging. Results: Although the prognosis in stage I and II patients was fairly good, recurrences were observed in patients with stage Ib or worse. Vagina walls were the frequent site of recurrence. About a half of relapses which occurred within seven months after surgery were observed during adjuvant chemotherapy. Multivariate analysis revealed that myometrial invasion (P = 0.0231) was the only risk factor for recurrence. Although the prognosis in stage III and IV patients was generally poor, serosal invasion in stage III disease seemed to be an im-portant risk factor. With regard to adjuvant therapy in stage I,III patients who could receive optimal cytoreductive surgery; the risk of recurrence was significantly (P = 0.0127) lower in patients receiving radiation therapy than in those receiving chemotherapy including platinum agents. Conclusion: The data suggested that in stage I,III patients with optimal cytoreductive surgery, myometrial invasion is an independent risk factor for recurrence and radiation therapy is more effective than chemotherapy as adjuvant therapy. [source]

A multiplex immunoassay demonstrates reductions in gingival crevicular fluid cytokines following initial periodontal therapy

D. H. Thunell
Thunell DH, Tymkiw KD, Johnson GK, Joly S, Burnell KK, Cavanaugh JE, Brogden KA, Guthmiller JM. A multiplex immunoassay demonstrates reductions in gingival crevicular fluid cytokines following initial periodontal therapy. J Periodont Res 2009; doi: 10.1111/j.1600-0765.2009.01204.x. © 2009 John Wiley & Sons A/S Background and Objective:, Cytokines and chemokines play an important role in the pathogenesis of periodontal diseases. The objective of this study was to quantitatively assess the effect of initial periodontal therapy on gingival crevicular fluid levels of a comprehensive panel of cytokines and chemokines, including several less extensively studied mediators. Material and Methods:, Clinical examinations were performed and gingival crevicular fluid samples obtained from six subjects with generalized severe chronic periodontitis prior to initial periodontal therapy and at re-evaluation (6,8 weeks). Four diseased and two healthy sites were sampled in each subject. Twenty-two gingival crevicular fluid mediators were examined using a multiplex antibody capture and detection platform. Statistical analyses were performed by fitting mixed effects linear models to log-transformed gingival crevicular fluid values. Results:, Gingival crevicular fluid interleukin (IL)-1, and IL-1, were the only cytokines to differ in initially diseased vs. initially healthy sites. Following initial therapy, 13 of the 16 detectable cytokines and chemokines decreased significantly in diseased sites, including IL-1,, IL-1,, IL-2, IL-3, IL-6, IL-7, IL-8, IL-12 (p40), CCL5/regulated on activation, normally T cell expressed and secreted (RANTES), eotaxin, macrophage chemotactic protein-1, macrophage inflammatory protein-1, and interferon-,. At healthy sites, only three of the 16 mediators were significantly altered following therapy. Conclusion:, This is the first study, to our knowledge, to evaluate such an extensive panel of gingival crevicular fluid mediators within the same sample prior to and following initial therapy. The results confirm that periodontal therapy effectively reduces pro-inflammatory cytokines and chemokines, including less well-described mediators that may be important in initiation and progression of periodontitis. The multiplex assay will prove useful for future gingival crevicular fluid studies. [source]

Gingival crevicular fluid and plasma levels of neuropeptide Substance-P in periodontal health, disease and after nonsurgical therapy

A. R. Pradeep
Background and Objective:, The level of Substance-P in gingival crevicular fluid has been found to correlate with clinical measures of periodontal disease. The present study was designed to assess the relationship between clinical parameters and levels of Substance-P in the gingival crevicular fluid from inflamed gingiva, periodontitis sites and after treatment of periodontitis sites, and to correlate them to the Substance-P levels of plasma. Material and Methods:, Thirty, age- and gender-matched subjects were divided into three groups (healthy, gingivitis and chronic periodontitis) based on modified gingival index scores and clinical attachment loss. A fourth group consisted of 10 subjects from the periodontitis group, 6,8 wk after initial therapy. Plasma and gingival crevicular fluid samples were collected and quantified for Substance-P using an enzyme immunoassay. Results:, The mean concentration of Substance-P, both in gingival crevicular fluid and plasma, was observed to be highest in the periodontitis group (45.13 pg/mL in gingival crevicular fluid and 67.8 pg/mL in plasma) and lowest in the healthy group (6.07 pg/mL in gingival crevicular fluid and below the detection level in plasma). The mean Substance-P concentration in the gingivitis group (11.42 pg/mL in gingival crevicular fluid and 38.8 pg/mL in plasma) and in the after-treatment group (7.58 pg/mL in gingival crevicular fluid and 39.7 pg/mL in plasma) lay between the highest and lowest values. In all groups the gingival crevicular fluid levels showed a statistically significant positive correlation with that of plasma and clinical attachment loss. Conclusion:, Substance-P levels were highest in the gingival crevicular fluid from sites with periodontal destruction; however, periodontal treatment resulted in the reduction of Substance-P levels. Gingival crevicular fluid and plasma Substance-P levels showed a positive correlation in all of the groups. [source]

The quality of oral anticoagulant therapy and recurrent venous thrombotic events in the Leiden Thrombophilia Study

Summary.,Background:,The International Normalized Ratio (INR) target range is a relatively narrow range in which the efficacy of oral anticoagulant treatment, i.e. prevention of extension and recurrence of thrombosis, is balanced with the risk of hemorrhagic complications. Over the years, different INR target ranges have been implemented for individual indications, depending on their thrombotic potential. In most of the studies defining these INR targets, the treatment of the patients was aimed at a certain INR range, but in the analysis no account was taken of the time that the patients spent within this range in reality. Methods:,The Leiden Thrombophilia Study (LETS) is a population-based case-control study on risk factors for venous thrombosis, in which many genetic and acquired factors have been investigated. Our aim was to investigate the effect of the quality of the oral anticoagulant therapy for the initial venous thrombosis and its relationship with recurrence of thrombosis. Quality of anticoagulation was defined as the time spent at various INR levels during treatment, and we focused on the effect of sustained intensities above a certain INR in preventing recurrences later on. Results:,Two hundred and sixty-six patients with a total follow-up of 2495 patient-years were studied. The mean duration of the initial anticoagulant therapy was 194.5 days (range 48,4671). During follow-up, 58 recurrences were diagnosed (cumulative recurrence rate of 21.8% over 9 years). The mean INR during initial therapy was 2.90, with 90.3% [95% confidence interval (CI) 88.4,92.3%] of the time being spent above an INR of 2.0, and 39.1% (95% CI 35.5,42.7%) above an INR of 3.0. Patients who spent more time below the target range, or who had a shorter duration of anticoagulation, did not experience a higher risk of recurrence after the initial period of anticoagulation had passed. Conclusion:,Provided that oral anticoagulant treatment is adequately managed, according to international guidelines, recurrent thrombosis cannot be ascribed to variation in the primary treatment. Further attempts to reduce the risk of recurrence should therefore be aimed at identifying other explanatory factors, and subsequently fine-tuning the target ranges. [source]

Small-volume resuscitation: from experimental evidence to clinical routine.

Advantages, disadvantages of hypertonic solutions
Background: The concept of small-volume resuscitatioin (SVR) using hypertonic solutions encompasses the rapid infusion of a small dose (4 ml per kg body weight, i.e. approximately 250 ml in an adult patient) of 7.2,7.5% NaCl/colloid solution. Originally, SVR was aimed for initial therapy of severe hypovolemia and shock associated with trauma. Methods: The present review focusses on the findings concerning the working mechanisms responsible for the rapid onset of the circulatory effect, the impact of the colloid component on microcirculatory resuscitation, and describes the indications for its application in the preclinical scenario as well as perioperatively and in intensive care medicine. Results: With respect to the actual data base of clinical trials SVR seems to be superior to conventional volume therapy with regard to faster normalization of microvascular perfusion during shock phases and early resumption of organ function. Particularly patients with head trauma in association with systemic hypotension appear to benefit. Besides, potential indications for this concept include cardiac and cardiovascular surgery (attenuation of reperfusion injury during declamping phase) and burn injury. The review also describes disadvantaages and potential adverse effects of SVR: Conclusion: Small-volume resuscitation by means of hypertonic NaCl/colloid solutions stands for one of the most innovative concepts for primary resuscitation from trauma and shock established in the past decade. Today the spectrum of potential indications envolves not only prehospital trauma care, but also perioperative and intensive care therapy. [source]

Long-term results of single-agent thalidomide as initial therapy for asymptomatic (smoldering or indolent) myeloma,

Kristen Detweiler-Short
We report the long-term follow-up results of a phase II trial of thalidomide for early-stage multiple myeloma (MM). Patients were eligible if they had smoldering multiple myeloma (SMM) or indolent MM without the need for immediate therapy. Thalidomide was initiated at a dose of 200 mg/day and adjusted as tolerated. Disease progression was defined using modified American Society of Hematology/Food and Drug Administration consensus panel criteria for SMM. Thirty-one patients were enrolled; 29 (19 SMM and 10 indolent MM) were eligible. The median age was 61 years. Median follow-up of living patients was 10.2 years (range, 7.5-11.0 years). Ten patients (34%) had a partial response (PR) and nine had minimal response (MR) for an MR plus PR rate of 66%. The median time to progression (TTP) to symptomatic myeloma was 35 months. Median TTP was 61 months in those achieving PR, 39 months with MR, and 9 months among those failing to achieve either MR or PR, P = 0.005. Median overall survival from diagnosis was 86 months; median survival from onset of symptomatic myeloma was 49 months. Grade 3-4 nonhematologic adverse events were noted in 55% of patients. Randomized trials are needed to determine the role of early therapy in SMM. Am. J. Hematol., 2010. © 2010 Wiley-Liss, Inc. [source]

Long-Term Effects of Upgrading to Biventricular Pacing: Differences with Cardiac Resynchronization Therapy as Primary Indication

Background: Few studies have assessed the long-term effects of cardiac resynchronization therapy (CRT) in patients with advanced heart failure (HF) and previously right ventricular apical pacing (RVAP). Aims: To assess the clinical and hemodynamic impact of upgrading to biventricular pacing in patients with severe HF and permanent RVAP in comparison with patients who had CRT implantation as initial therapy. Methods and Results: Thirty-nine patients with RVAP, advanced HF (New York Heart Association [NYHA] III,IV), and severe depression of left ventricular ejection fraction (LVEF) were upgraded to biventricular pacing (group A). Mean duration of RVAP before upgrading was 41.8 ± 13.3 months. Clinical and echocardiographic results were compared to those obtained in a group of 43 patients with left bundle branch block and similar clinical characteristics undergoing "primary" CRT (group B). Mean follow-up was 35 ± 10 months in patients of group A and 38 ± 12 months in group B. NYHA class significantly improved in groups A and B. LVEF increased from 0.23 ± 0.07 to 0.36 ± 0.09 (P < 0.001) and from 0.26 ± 0.02 to 0.34 ± 0.10 (P < 0.001), respectively. Hospitalizations were reduced by 81% and 77% (P < 0.001). Similar improvements in echocardiographic signs of ventricular desynchronization were also observed. Conclusion: Patients upgraded to CRT exhibit long-term clinical and hemodynamic benefits that are similar to those observed in patients treated with CRT as initial strategy. (PACE 2010; 841,849) [source]

Determinants of the optimal first-line therapy for follicular lymphoma: A decision analysis,

Rebecca L. Olin
Combination immunochemotherapy is the most common approach for initial therapy of patients with advanced-stage follicular lymphoma, but no consensus exists as to the optimal selection or sequence of available regimens. We undertook this decision analysis to systematically evaluate the parameters affecting the choice of early therapy in patients with this disease. We designed a Markov model incorporating the three most commonly utilized regimens (RCVP, RCHOP, and RFlu) in combinations of first- and second-line therapies, with the endpoint of number of quality-adjusted life years (QALYs) until disease progression. Data sources included Phase II and Phase III trials and literature estimates of long-term toxicities and health state utilities. Meta-analytic methods were used to derive the values and ranges of regimen-related parameters. Based on our model, the strategy associated with the greatest number of expected quality-adjusted life years was treatment with RCHOP in first-line therapy followed by treatment with RFlu in second-line therapy (9.00 QALYs). Strategies containing RCVP either in first- or second-line therapy resulted in the lowest number of QALYs (range 6.24,7.71). Sensitivity analysis used to determine the relative contribution of each model parameter identified PFS after first-line therapy and not short-term QOL as the most important factor in prolonging overall quality-adjusted life years. Our results suggest that regimens associated with a longer PFS provide a greater number of total QALYs, despite their short-term toxicities. For patients without contraindications to any of these regimens, use of a more active regimen may maximize overall quality of life. Am. J. Hematol. 2010. © 2010 Wiley-Liss, Inc. [source]

Chronic granulomatous disease presenting with disseminated intracranial aspergillosis

Abdul Alsultan MD
Abstract We describe an 8-year-old boy who presented with multiple unresectable aspergillus brain abscesses as the initial presentation of X-linked chronic granulomatous disease (CGD). He failed initial therapy with amphotericin B, but was subsequently salvaged with voriconazole. CGD should be considered in the differential diagnosis for all children presenting with invasive fungal infections, particularly, those involving the central nervous system (CNS). Whereas, optimal pharmacologic therapy is still unknown for CNS aspergillosis, voriconazole may have an advantage due to its ability to cross the blood brain barrier and excellent oral absorption and bioavailability. © 2005 Wiley-Liss, Inc. [source]