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Medical Management (medical + management)
Kinds of Medical Management Selected AbstractsDirect Cost of Medical Management of Epilepsy among Adults in Italy: A Prospective Cost-of-Illness Study (EPICOS)EPILEPSIA, Issue 2 2004Ettore Beghi Summary: Purpose: To investigate the costs of epilepsy from a nationwide survey comparing adult patients included in different prognostic categories. Methods: A 12-month prospective observational study was conducted in 15 epilepsy centers from Northern, Central, and Southern Italy. The study population included a random sample of individuals aged 18 years and older with newly diagnosed (ND) epilepsy, seizure remission (R), occasional seizures (OS), active non,drug-resistant (NDR) seizures, drug-resistant (DR) seizures, or surgical candidates (SC). Estimates of the direct costs of care of epilepsy were based on the use of diagnostic examinations, laboratory tests, specialist consultations, hospital admissions, day-hospital days, and drugs, taking the Italian National Health Service perspective. Results: The sample included 631 patients (ND 62, R 158, OS 155, NDR 114, DR 128, and SC 14). The SC group had the highest total cost per patient (,3,619) followed by DR (,2,190), ND (,976), NDR (,894), OS (,830), and R (,561). For each epilepsy group, the main components of the total cost were drugs and hospital admissions. Drug costs increased from the R group to the DR group. The new antiepileptic drugs (AEDs) were the largest part of the cost of treatment. Conclusions: The costs of epilepsy in referral patients vary significantly according to the time course of the disease and the response to treatment. Hospital admissions and drugs are the major sources of expenditure. [source] Medical management of left-sided ulcerative colitis and ulcerative proctitis: Critical evaluation of therapeutic trialsINFLAMMATORY BOWEL DISEASES, Issue 10 2006Miguel Regueiro MD Abstract Background: The goal of this work was to critically evaluate the published studies on the treatment of ulcerative proctitis (UP) and left-sided ulcerative colitis (L-UC). The results of this review provided the content for the accompanying treatment guidelines, Clinical Guidelines for the Medical Management of Left-sided Ulcerative Colitis and Ulcerative Proctitis: Summary Statement. Methods: All English language articles published between 1995 and September 2005 were identified through a comprehensive literature search using OVID and PubMed. The quality of the data supporting or rejecting the use of specific therapies was categorized by a data quality grading scale. An "A+" grade was assigned to treatment supported by multiple high-quality randomized controlled trials with consistent results, whereas a "D" grade was given to therapy supported only by expert opinion. The therapeutic efficacy of a treatment was defined by its success in treating UP and L-UC compared with placebo. A medication was ranked as "excellent" if it was specifically studied for UP and L-UC and had consistently positive results compared with placebo or another agent. Quality and efficacy scores were agreed on by author consensus. Results: For the acute treatment of UP or L-UC, the rectally administered corticosteroids and mesalazine (5-ASA), either alone or in combination with oral 5-ASAs, are the most effective therapy: evidence quality, A+; efficacy, excellent. Only rectally administered 5-ASA received an A+/excellent rating for maintenance of remission. Infliximab received an A+ grade for induction and maintenance of remission but only a "good" rating because the studies were performed in all UC, not specifically UP or L-UC. Conclusions: This critical evaluation of treatment provides a "report card" on medications available for the management of patients with UP and L-UC. The guidelines should provide a useful reference and supplement for physicians treating UC patients. [source] Gender Differences in Alcohol Treatment: An Analysis of Outcome From the COMBINE StudyALCOHOLISM, Issue 10 2010Shelly F. Greenfield Background:, Relatively few studies have examined gender differences in the effectiveness of specific behavioral or pharmacologic treatment of alcohol dependence. The aim of this study is to assess whether there were gender differences in treatment outcomes for specific behavioral and medication treatments singly or in combination by conducting a secondary analysis of public access data from the national, multisite NIAAA-sponsored COMBINE study. Methods:, The COMBINE study investigated alcohol treatment among 8 groups of patients (378 women, 848 men) who received medical management (MM) with 16 weeks of placebo, naltrexone (100 mg/day), acamprosate (3 g/day), or their combination with or without a specialist-delivered combined behavioral intervention. We examined efficacy measures separately for men and women, followed by an overall analysis that included gender and its interaction with treatment condition in the analyses. These analyses were performed to confirm whether the findings reported in the parent trial were also relevant to women, and to more closely examine secondary outcome variables that were not analyzed previously for gender effects. Results:, Compared to men, women reported a later age of onset of alcohol dependence by approximately 3 years, were significantly less likely to have had previous alcohol treatment, and drank fewer drinks per drinking day. Otherwise, there were no baseline gender differences in drinking measures. Outcome analyses of 2 primary (percent days abstinent and time to first heavy drinking day) and 2 secondary (good clinical response and percent heavy drinking days) drinking measures yielded the same overall pattern in each gender as that observed in the parent COMBINE study report. That is, only the naltrexone by behavioral intervention interaction reached or approached significance in women as well as in men. There was a naltrexone main effect that was significant in both men and women in reduction in alcohol craving scores with naltrexone-treated subjects reporting lower craving than placebo-treated subjects. Conclusions:, This gender-focused analysis found that alcohol-dependent women responded to naltrexone with COMBINE's Medical Management, similar to the alcohol-dependent men, on a wide range of outcome measures. These results suggest that clinicians can feel comfortable prescribing naltrexone for alcohol dependence in both men and women. In this study, it is also notable that fewer women than men reported receiving any alcohol treatment prior to entry into the COMBINE study. Of note, women tend to go to primary health care more frequently than to specialty substance abuse programs for treatment, and so the benefit we confirm for women of the naltrexone and MM combination has practical implications for treating alcohol-dependent women. [source] Searching for Responders to Acamprosate and Naltrexone in Alcoholism Treatment: Rationale and Design of the Predict StudyALCOHOLISM, Issue 4 2009Karl Mann Background:, Alcoholism represents a major public health issue and treating alcohol dependent patients remains an imminent challenge. Evidence based psychotherapies and pharmacotherapies are available. However, when administered to heterogeneous populations of patients effect sizes are only modest. We present the rationale and design of a double-blind randomized trial comparing acamprosate, naltrexone, and placebo. Additionally we subtype patients on the basis of biological and psychometric measures and explore their treatment response to both acamprosate and naltrexone. According to our initial hypothesis, the "relief drinker/craver" is an endophenotype associated with glutamatergic dysfunction who responds to acamprosate. The "reward drinker/craver" is mainly associated with alterations in the dopaminergic and opioidergic system and responds to naltrexone. Methods:, The study is planned for 430 patients (2:2:1 for both drugs and placebo) over 12 weeks of medication. All receive manualized counselling to improve compliance (Medical Management) which is extended to 6 months. Subtyping is primarily done using the acoustic startle reflex, functional magnetic resonance imaging, positron emission tomography (in a subset of patients), and the Inventory of Drinking Situations. Relapsers will be re-randomized into a second study where additional psychotherapy (Cognitive Behavioral Intervention) is used in a stepped care approach. Genotyping and additional analyses such as health economy are being done as well. The study follows the assessment methods, treatments, and medications used in the U.S. based COMBINE study, which will allow for a direct comparison between this U.S. study trial and a study performed in Europe. [source] An Analysis of the Components of Pain, Function, and Health-Related Quality of Life in Patients with Failed Back Surgery Syndrome Treated with Spinal Cord Stimulation or Conventional Medical ManagementNEUROMODULATION, Issue 3 2010FRCA, Sam Eldabe MB Objectives:, Failed back surgery syndrome (FBSS) patients experience pain, functional disability, and reduced health-related quality of life (HRQoL) despite anatomically successful surgery. Examining sub-dimensions of health outcomes measures provides insight into patient well-being. Materials and Methods:, The international multicenter PROCESS trial collected detailed HRQoL (EuroQol-5D; Short-Form 36) and function (Oswestry Disability Index) information on 100 FBSS patients. Results:, At baseline, patients reported moderate-to-severe leg and back pain adversely affecting all dimensions of function and HRQoL. Compared with conventional medical management alone, patients also receiving spinal cord stimulation (SCS) reported superior pain relief, function, and HRQoL at six months on overall and most sub-component scores. The majority of these improvements with SCS were sustained at 24 months. Nonetheless, 36,40% of patients experienced ongoing marked disability (standing, lifting) and HRQoL problems (pain/discomfort). Conclusions:, Longer-term patient management and research must focus on these refractory FBSS patients with persisting poor function and HRQoL outcomes. [source] Determinants of Early Medical Management of Nausea and Vomiting of PregnancyBIRTH, Issue 1 2009Anaïs Lacasse BSc ABSTRACT: Background: Early medical management of nausea and vomiting during pregnancy is desirable but less than optimal. The aims of this study were to describe the management of nausea and vomiting during the first prenatal visit and to identify the determinants of 1) addressing the subject of nausea and vomiting during pregnancy with the health practitioner and 2) receiving an antiemetic prescription.Methods: A prospective study was conducted of 283 women who reported nausea and vomiting during the first trimester of pregnancy. Women were eligible if they were at least 18 years of age and , 16 weeks' gestation at the time of their first prenatal visit. Participants completed a questionnaire to determine their maternal characteristics, the presence of nausea and vomiting during pregnancy, and its management.Results: Of the 283 study participants, 79 percent reported that the condition was addressed during their first prenatal visit, 52 percent reported being asked about the intensity and severity of their symptoms, and 22 percent reported being questioned about the extent to which it disrupted their daily tasks. Health practitioners prescribed an antiemetic for 27 percent of women and recommended a nonpharmacological method for 14 percent. Multivariate models showed that the severity of the nausea and vomiting, previous use of an antiemetic, and smoking before pregnancy were significantly associated with an increased likelihood of addressing the subject of nausea and vomiting during pregnancy. Variables associated with an increased likelihood of women receiving an antiemetic prescription included nausea and vomiting severity, excessive salivation, previous antiemetic use, and work status.Conclusions: Health practitioners can improve their management of nausea and vomiting during pregnancy based on the available guidelines for treatment and they should address important factors such as symptom severity and work status at the first prenatal visit to assess women's need for antiemetic treatment. (BIRTH 36:1 March 2009) [source] Medical Management of the Surgical Patient.BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 1 20074th Edn. No abstract is available for this article. [source] Medical management of left-sided ulcerative colitis and ulcerative proctitis: Critical evaluation of therapeutic trialsINFLAMMATORY BOWEL DISEASES, Issue 10 2006Miguel Regueiro MD Abstract Background: The goal of this work was to critically evaluate the published studies on the treatment of ulcerative proctitis (UP) and left-sided ulcerative colitis (L-UC). The results of this review provided the content for the accompanying treatment guidelines, Clinical Guidelines for the Medical Management of Left-sided Ulcerative Colitis and Ulcerative Proctitis: Summary Statement. Methods: All English language articles published between 1995 and September 2005 were identified through a comprehensive literature search using OVID and PubMed. The quality of the data supporting or rejecting the use of specific therapies was categorized by a data quality grading scale. An "A+" grade was assigned to treatment supported by multiple high-quality randomized controlled trials with consistent results, whereas a "D" grade was given to therapy supported only by expert opinion. The therapeutic efficacy of a treatment was defined by its success in treating UP and L-UC compared with placebo. A medication was ranked as "excellent" if it was specifically studied for UP and L-UC and had consistently positive results compared with placebo or another agent. Quality and efficacy scores were agreed on by author consensus. Results: For the acute treatment of UP or L-UC, the rectally administered corticosteroids and mesalazine (5-ASA), either alone or in combination with oral 5-ASAs, are the most effective therapy: evidence quality, A+; efficacy, excellent. Only rectally administered 5-ASA received an A+/excellent rating for maintenance of remission. Infliximab received an A+ grade for induction and maintenance of remission but only a "good" rating because the studies were performed in all UC, not specifically UP or L-UC. Conclusions: This critical evaluation of treatment provides a "report card" on medications available for the management of patients with UP and L-UC. The guidelines should provide a useful reference and supplement for physicians treating UC patients. [source] Medical management of fulminant colitisINFLAMMATORY BOWEL DISEASES, Issue 2 2002Dr. Robert Modigliani First page of article [source] Medical management of patients with aneurysmal subarachnoid haemorrhageINTERNATIONAL JOURNAL OF STROKE, Issue 3 2008Gabriel J. E. Rinkel Abstract Treating patients with aneurysmal subarachnoid haemorrhage is taking care of acutely ill patients, and should be performed in centres where a multidisciplinary team is available 24 hours a day 7 days a week, and where enough patients are managed to maintain and improve standards of care. There is no medical management that improves outcome by reducing the risk of rebleeding, therefore occlusion of the aneurysm, nowadays preferably by means of coiling, remains an important goal in treating patients with aneurysms. Because the poor outcome after subarachnoid haemorrhage is caused to a large extent by complications other than rebleeding, proper medical management to prevent and treat these complications is therefore essential. On basis of the available evidence, oral (not intravenous) nimodipine should be standard care in patients with subarachnoid haemorrhage. It is rational to refrain from treating hypertension unless cardiac failure develops and to aim for normovolaemia, even in case of hyponatraemia. There is no evidence for prophylactic hypervolaemia, and the strategy of hypervolaemia and hypertension in patients with secondary cerebral ischaemia is based on case reports and uncontrolled observational series of patients. Magnesium sulphate and statins are promising therapies, and large trials on effectiveness in improving clinical outcome are underway. There is no evidence for prophylactic use of anti epileptic drugs, and routine use of corticosteroids should be avoided. [source] Evaluating the Cost-Effectiveness of Fall Prevention Programs that Reduce Fall-Related Hip Fractures in Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2010Kevin D. Frick PhD OBJECTIVES: To model the incremental cost-utility of seven interventions reported as effective for preventing falls in older adults. DESIGN: Mathematical epidemiological model populated by data based on direct clinical experience and a critical review of the literature. SETTING: Model represents population level interventions. PARTICIPANTS: No human subjects were involved in the study. MEASUREMENS: The last Cochrane database review and meta-analyses of randomized controlled trials categorized effective fall-prevention interventions into seven groups: medical management (withdrawal) of psychotropics, group tai chi, vitamin D supplementation, muscle and balance exercises, home modifications, multifactorial individualized programs for all elderly people, and multifactorial individualized treatments for high-risk frail elderly people. Fall-related hip fracture incidence was obtained from the literature. Salary figures for health professionals were based on Bureau of Labor Statistics data. Using an integrated healthcare system perspective, healthcare costs were estimated based on practice and studies on falls in older adults. Base case incremental cost utility ratios were calculated, and probabilistic sensitivity analyses were conducted. RESULTS: Medical management of psychotropics and group tai chi were the least-costly, most-effective options, but they were also the least studied. Excluding these interventions, the least-expensive, most-effective options are vitamin D supplementation and home modifications. Vitamin D supplementation costs less than home modifications, but home modifications cost only $14,794/quality-adjusted life year (QALY) gained more than vitamin D. In probabilistic sensitivity analyses excluding management of psychotropics and tai chi, home modification is most likely to have the highest economic benefit when QALYs are valued at $50,000 or $100,000. CONCLUSION: Of single interventions studied, management of psychotropics and tai chi reduces costs the most. Of more-studied interventions, home modifications provide the best value. These results must be interpreted in the context of the multifactorial nature of falls. [source] Medical management of thyroid cancer: a risk adapted approachJOURNAL OF SURGICAL ONCOLOGY, Issue 8 2008R. Michael Tuttle MD Abstract Risk adapted treatment recommendations are dependent on accurate predictions of the risk of recurrence, risk of death, and likely sites of recurrence. When combined with response to therapy assessments and secondary risk stratification during follow-up, this risk adapted approach will allow the clinician to tailor the aggressiveness of therapy and follow up to the risk of recurrence and death in individual patients. J. Surg. Oncol. 2008;97:712,716. © 2008 Wiley-Liss, Inc. [source] Medical management of early fetal demise using sublingual misoprostolBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 4 2002Prabhath T. Wagaarachchi The aim of this study was to determine the efficacy of mifepristone in combination with sublingual misoprostol for the medical management of early fetal demise. Fifty-six consecutive women were studied prospectively. The mean (SD) gestation at diagnosis was 9.6 weeks (1.84). Four women had complete miscarriage with mifepristone alone. The overall success rate was 83.9% and the median induction,miscarriage interval was 8.19 hours (range 0.83 to 37.50 hours). Of those women who had a successful outcome, 91.5% were satisfied with the regimen. Sublingual misoprostol in combination with mifepristone is an effective and safe alternative to vaginal or oral misoprostol in the management of early fetal demise. [source] Medical management of bowel obstructionBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 10 2000J. R. Hardy No abstract is available for this article. [source] Prophylactic Implantation of Cardioverter Defibrillators in Idiopathic Nonischemic Cardiomyopathy for the Primary Prevention of Death: A Narrative ReviewCLINICAL CARDIOLOGY, Issue 5 2010Cihan Cevik MD, FESC Implantable cardioverter defibrillator (ICD) therapy reduces sudden cardiac death rates and reduces mortality in patients with ischemic heart disease and low ejection fractions. One-third of the deaths in patients with nonischemic cardiomyopathy are sudden. However, the efficacy of ICDs in the primary prevention of death in these patients is less clear. The most common cause of mortality in patients treated with ICDs is heart failure progression. ICD shocks can cause direct myocardial injury, fibrosis, inflammation, and adverse psychological outcomes, and these changes may contribute to the ventricular dysfunction in patients who already have a significantly depressed ejection fraction. We have reviewed the published randomized controlled trials and meta-analysis of prophylactic ICD therapy in the primary prevention of death in patients with nonischemic cardiomyopathy. The individual randomized controlled trials do not report a statistically significant reduction of mortality unless the ICD treatment is added to cardiac resynchronization therapy, but the meta-analysis did show a significant mortality reduction and favored ICD therapy in these patients. Medical management of many study participants was suboptimal, at least based on current guidelines. The patients with non-ischemic cardiomyopathy have good outcomes with medical therapy, and ICD therapy in this relatively low-risk population needs better selection criteria. Copyright © 2010 Wiley Periodicals, Inc. [source] Medical management of significant coronary angiographic stenoses: Outcome of 60 patients observed for 433 patient yearsCLINICAL CARDIOLOGY, Issue 8 2000Charles L. Baird Jr. M.D. Abstract Background: Percutaneous transluminal coronary angioplasty (PTCA) has become routine in the management of patients with stable angina pectoris and significant coronary stenoses, while medical management of such patients has declined. Hypothesis: The purpose of the present study was to evaluate the outcome of 60 patients at the Virginia Heart Institute with stable angina pectoris, observed between 1976 and 1997, who had documented evidence of severe angiographic disease but were elected to be monitored and managed in an outpatient pharmacologic rehabilitation program. Methods: Sixty patients with significant stenoses by coronary angiography (21 with single-vessel, 26 with double-vessel, and 13 with triple-vessel) without impaired ventricular function, exercise-induced ischemia or hypotension, limited exercise performance, malignant arrhythmias, or drug intolerance were enrolled in a program of pharmacologic rehabilitation and observed for an average of 7.2 years. Results: Among the 60 patients, there were 6 deaths at a mean interval of 8.3 years. Two deaths were in patients ineligible for revascularization. Another patient who died had refused revascularization after new-onset left ventricular dysfunction, and another died intraoperatively during abdominal aortic aneurysm repair. Two patients died while exercising. Thirteen patients underwent follow-up catheterization for worsening angina; 11 of 13 showed progression, predominantly from new lesions. Four of 11 were referred for revascularization; 7 of 11 continued medical treatment; 49 patients were stable on medical therapy throughout the period of observation. Conclusion: Medical management of selected patients with significant coronary stenoses is safe and effective. [source] Prognostic impact of psychoactive substances use during hospitalization for intentional drug overdoseACTA PSYCHIATRICA SCANDINAVICA, Issue 2 2005M. Tournier Objective:, To assess whether current use of psychoactive substance(s) is a prognostic factor during hospitalization for intentional drug overdose (IDO). Method:, Current intoxication with psychoactive substance(s) [cannabis, opiate, buprenorphine, amphetamine/ecstasy, cocaine, lysergic acid diethylamide (LSD)] was identified using toxicological urinalysis in 671 patients with IDO. An IDO was a priori defined as serious if associated with one of the following events: death, hospitalization in intensive care unit longer than 48 h, respiratory support, use of vasopressive drugs, cardiac massage or dialysis. Results:, Subjects positive for toxicological assays were twice as likely to present with serious IDO (OR = 1.9, 95% CI: 1.3,2.8, P = 0.001), independently from a large range of confounding factors. The risk of serious IDO was especially marked in subjects using LSD, buprenorphine or opiates. Conclusion:, Systematic investigation of substance use could be important to adapt medical management of subjects with IDO in general hospital, but also in primary care and psychiatric settings. [source] Bariatric surgery vs. advanced practice medical management in the treatment of type 2 diabetes mellitus: rationale and design of the Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently trial (STAMPEDE)DIABETES OBESITY & METABOLISM, Issue 5 2010Sangeeta R. Kashyap Obesity and Type 2 diabetes mellitus (T2DM) are closely interrelated, and are two of the most common chronic, debilitating diseases worldwide. Surgical approaches to weight loss (bariatric surgery) result in marked improvement of T2DM, however randomized trials directly comparing the efficacy of surgical and medical approaches are lacking. The Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial was designed to evaluate the efficacy of two bariatric surgery procedures involving gastric restriction only (laparascopic sleeve gastrectomy) and gastric bypass (Roux-en-Y) to advanced medical therapy in patients with T2DM with modest obesity with BMI of 27,42 kg/m2. This single site, prospective, randomized controlled trial will enroll 150 subjects who will be followed. The primary end point will be the rate of biochemical resolution of T2DM at 1 year as measured by HbA1c < 6%. The safety and adverse event rates will also be compared between the three arms of the study. [source] The Role of Vigabatrin in Childhood Seizure Disorders: Results from a Clinical AuditEPILEPSIA, Issue 1 2001Asuri N. Prasad Summary: ,Purpose: The emergence of visual field defects attributed to vigabatrin (VGB) treatment and intramyelinic edema in animal experiments has raised concerns about its future role in the treatment of childhood seizures. Methods: We evaluated our experience with this antiepileptic agent with retrospective analysis of database and chart audit. Results: Of 73 patients, 43 girls and 33 boys were treated with VGB over a 7-year period. The mean age of patients at the introduction of VGB was 87 months (range, 5,257 months). In 12 of 73 cases, VGB was used as monotherapy; in 61 of 73 cases, it was used as an add-on drug. Seizure types included secondarily generalized seizures (21), mixed seizures (21), partial seizures (18), and generalized seizures (13). Seizure etiology was idiopathic/cryptogenic in 22 patients, symptomatic in 50, and undetermined in a single patient. The mean duration of therapy was 16 months (median, 10 months; range, 1,144 months). VGB was effective in 30 (seven seizure free, 23 with >90% reduction in seizures), partially effective in four (50,90% reduction in seizures), and ineffective in 38 (<50% reduction in seizures). Nearly 50% of patients with infantile spasms responded to VGB. All patients underwent ophthalmic evaluation; two (16%) of 12 patients who could undergo static threshold perimetry were demonstrated to have the characteristic visual field constriction. Conclusions: VGB is effective in producing a significant reduction in seizure frequency in nearly half the patients with childhood seizures, including refractory epilepsy. Despite emerging concerns regarding visual side effects, this drug retains an important role in the medical management of childhood epilepsy. [source] Viral meningoencephalitis: a review of diagnostic methods and guidelines for managementEUROPEAN JOURNAL OF NEUROLOGY, Issue 8 2010I. Steiner Background:, Viral encephalitis is a medical emergency. The prognosis depends mainly on the pathogen and host immunologic state. Correct immediate diagnosis and introduction of symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury. Methods:, We searched the literature from 1966 to 2009. Recommendations were reached by consensus. Where there was lack of evidence but consensus was clear, we have stated our opinion as good practice points. Recommendations:, Diagnosis should be based on medical history and examination followed by CSF analysis for protein and glucose levels, cellular analysis, and identification of the pathogen by polymerase chain reaction amplification (recommendation level A) and serology (level B). Neuroimaging, preferably by MRI, is essential (level B). Lumbar puncture can follow neuroimaging when immediately available, but if this cannot be performed immediately, LP should be delayed only under unusual circumstances. Brain biopsy should be reserved only for unusual and diagnostically difficult cases. Patients must be hospitalized with easy access to intensive care units. Specific, evidence-based, antiviral therapy, acyclovir, is available for herpes encephalitis (level A) and may also be effective for varicella-zoster virus encephalitis. Ganciclovir and foscarnet can be given to treat cytomegalovirus encephalitis, and pleconaril for enterovirus encephalitis (IV class evidence). Corticosteroids as an adjunct treatment for acute viral encephalitis are not generally considered to be effective, and their use is controversial, but this important issue is currently being evaluated in a large clinical trial. Surgical decompression is indicated for impending uncal herniation or increased intracranial pressure refractory to medical management. [source] Viral encephalitis: a review of diagnostic methods and guidelines for managementEUROPEAN JOURNAL OF NEUROLOGY, Issue 5 2005I. Steiner Viral encephalitis is a medical emergency. The spectrum of brain involvement and the prognosis are dependent mainly on the specific pathogen and the immunological state of the host. Although specific therapy is limited to only several viral agents, correct immediate diagnosis and introduction of symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury in survivors. We searched MEDLINE (National Library of Medicine) for relevant literature from 1966 to May 2004. Review articles and book chapters were also included. Recommendations are based on this literature based on our judgment of the relevance of the references to the subject. Recommendations were reached by consensus. Where there was lack of evidence but consensus was clear we have stated our opinion as good practice points. Diagnosis should be based on medical history, examination followed by analysis of cerebrospinal fluid for protein and glucose contents, cellular analysis and identification of the pathogen by polymerase chain reaction (PCR) amplification (recommendation level A) and serology (recommendation level B). Neuroimaging, preferably by magnetic resonance imaging, is an essential aspect of evaluation (recommendation level B). Lumbar puncture can follow neuroimaging when immediately available, but if this cannot be obtained at the shortest span of time it should be delayed only in the presence of strict contraindications. Brain biopsy should be reserved only for unusual and diagnostically difficult cases. All encephalitis cases must be hospitalized with an access to intensive care units. Supportive therapy is an important basis of management. Specific, evidence-based, anti-viral therapy, acyclovir, is available for herpes encephalitis (recommendation level A). Acyclovir might also be effective for varicella-zoster virus encephalitis, gancyclovir and foscarnet for cytomegalovirus encephalitis and pleconaril for enterovirus encephalitis (IV class of evidence). Corticosteroids as an adjunct treatment for acute viral encephalitis are not generally considered to be effective and their use is controversial. Surgical decompression is indicated for impending uncal herniation or increased intracranial pressure refractory to medical management. [source] Estimating haplotype relative risks in complex disease from unphased SNPs data in families using a likelihood adjusted for ascertainmentGENETIC EPIDEMIOLOGY, Issue 8 2006J. Carayol Abstract The understanding of complex diseases and insights to improve their medical management may be achieved through the deduction of how specific haplotypes may play a joint effect to change relative risk information. In this paper we describe an ascertainment adjusted likelihood-based method to estimate haplotype relative risks using pooled family data coming from association and/or linkage studies that were used to identify specific haplotypes. Haplotype-based analysis tends to require a large amount of parameters to capture all the information that leads to efficiency problems. An adaptation of the Stochastic Expectation Maximization algorithm is used for haplotypes inference from genotypic data and to reduce the number of nuisance parameters for risk estimation. Using different simulations, we show that this method provides unbiased relative risk estimates even in case of departure from Hardy-Weinberg equilibrium. Genet. Epidemiol. 2006. © 2006 Wiley-Liss, Inc. [source] Haemate® P von Willebrand factor/factor VIII concentrate: 25 years of clinical experienceHAEMOPHILIA, Issue 2008W. SCHRAMM Summary., Although von Willebrand disease (VWD) has a very long history, our understanding and treatment of the bleeding disorder has only evolved during the past 50 years or so. It was not until the 1920s that VWD was first recognized as a disease separate from that of classical haemophilia. It then took another 30 years before the first effective treatment was developed. Since then, the medical management of VWD has evolved considerably, but not without its ups and downs. One of the key milestones in the evolution of the treatment of VWD was the development of Haemate® P/Humate-P® (CSL Behring) , the first virus-inactivated factor VIII plasma product. For 25 years, this concentrate has demonstrated excellent clinical efficacy and safety for patients with VWD and for those with haemophilia. This article provides an historical overview of the early landmark efforts to ensure a safe plasma-derived replacement product and outlines the clinical evolution in the use of Haemate® P. [source] Post-Dural Puncture Headache: Part II , Prevention, Management, and PrognosisHEADACHE, Issue 9 2010David Bezov MD Post-dural puncture headache (PDPH) is a frequent complication of lumbar puncture, performed for diagnostic or therapeutic purposes or accidentally, as a complication of epidural anesthesia. As PDPH can be disabling, clinicians who perform these procedures should be familiar with strategies for preventing this disorder. Since the best preventative measures sometimes fail, clinicians should also be familiar with the therapeutic approaches for PDPH. Herein, we review the procedure-related risk factors for PDPH, the prognosis of PDPH and the studies of PDPH treatment. We divide the therapeutic approach to PDPH into 4 stages: conservative management, aggressive medical management, conventional invasive treatments, and the very rarely employed less conventional invasive treatments and provide management algorithm to facilitate treatment. [source] Inflammatory bowel disease patients who leave hospital against medical advice: Predictors and temporal trendsINFLAMMATORY BOWEL DISEASES, Issue 6 2009Gilaad G. Kaplan MD Abstract Background: Leaving hospital against medical advice (AMA) may have consequences with respect to health-related outcomes; however, inflammatory bowel disease (IBD) patients have been inadequately studied. Thus, we determined the prevalence of self-discharge, assessed predictors of AMA status, and evaluated time trends. Methods: We analyzed the 1995,2005 Nationwide Inpatient Sample (NIS) to identify 93,678 discharges with a primary diagnosis of IBD admitted to the hospital emergently and did not undergo surgery. We described the proportion of IBD patients who left AMA. Predictors of AMA status were evaluated using a multivariate logistic regression model and temporal trend analyses were performed with Poisson regression models. Results: Between 1995 and 2005, 1.31% of IBD patients left hospitals AMA. Crohn's disease (CD) patients were more likely to leave AMA (adjusted odds ratio [aOR], 1.53; 95% confidence intervals [CI]: 1.30,1.79). Characteristics associated with leaving AMA included: ages 18,34 (aOR, 7.77, 95% CI: 4.34,13.89); male (aOR, 1.75; 95% CI: 1.55,1.99); Medicaid (aOR, 4.55; 95% CI: 3.81,5.43) compared to private insurance; African Americans (aOR, 1.34; 95% CI: 1.09,1.64) compared to white; substance abuse (aOR, 2.75; 95% CI: 2.14,3.54); and psychosis (aOR, 1.55; 95% CI: 1.13,2.14). The incidence rates of self-discharge for CD patients were stable (P > 0.05) between 1995 and 1999, while they significantly (P < 0.0001) increased after 1999. In contrast, AMA rates for UC patients remained stable during the study period. Conclusions: Approximately 1 in 76 IBD patients admitted emergently for medical management leave the hospital AMA. These were primarily disenfranchised patients who may lack adequate outpatient follow-up. (Inflamm Bowel Dis 2009) [source] Lymphoma risk in inflammatory bowel disease: Is it the disease or its treatment?INFLAMMATORY BOWEL DISEASES, Issue 10 2007Jennifer L. Jones MD Abstract With the increasingly widespread use of immunosuppressive and biologic agents for the treatment of Crohn's disease and ulcerative colitis come concerns about potential long-term consequences of such therapies. Disentangling the potential confounding effects of the underlying disease, its extent, severity, duration, and behavior, and concomitant medical therapy has proven to be exceedingly difficult. Unlike the case in rheumatoid arthritis, the overwhelming preponderance of population-based evidence suggests that a diagnosis of inflammatory bowel disease (IBD) is not associated with an increased relative risk of lymphoma. However, well-designed studies that evaluate the potential modifying effect of IBD severity have yet to be performed. Although the results from hospital- and population-based studies have conflicted, the results of a recent meta-analysis suggest that patients receiving purine analogs for the treatment of IBD have a lymphoma risk ,4-fold higher than expected. Analyses of lymphoma risk in patients receiving biologic agents directed against tumor necrosis factor-alpha are confounded by concomitant use of immunosuppressive agents in most of these patients. Nevertheless, there may be a small but real risk of lymphoma associated with these therapies. Although the relative risk of lymphoma may be elevated in association with some of the medical therapies used in the treatment of IBD, this absolute risk is low. Weighing the potential risk of lymphoma associated with select medical therapies against the risk of undertreating IBD will help physicians and patients to make more informed decisions pertaining to the medical management of IBD. (Inflamm Bowel Dis 2007) [source] Intercenter variation in initial management of children with Crohn's diseaseINFLAMMATORY BOWEL DISEASES, Issue 7 2007Michael D. Kappelman MD Abstract Background: Variation in care is a ubiquitous feature of medical practice and may lead to significant differences in health care costs, quality, and outcomes. We undertook this study to determine the extent of intercenter variation in the initial management of children newly diagnosed with Crohn's disease. Methods: We analyzed the utilization of 5 classes of medication (immunomodulators, prednisone, antibiotics, 5-aminosalicylates, and infliximab) among 311 children with newly diagnosed Crohn's disease followed at 10 North American pediatric gastroenterology centers. Multivariate logistic regression was used to compare the utilization rate of each class of medication at each of the 10 centers, adjusting for potential confounders including patient age, sex, race, disease severity, and anatomic location of disease. Results: Median utilization of each class of medication was: immunomodulators, 56% (range 29%,97%); prednisone, 78% (range 32%,88%); antibiotics, 29% (range 11%,68%); 5-aminosalicylates, 63.5% (range 18%,92%); and infliximab, 7.5% (range 3%,21%). Each of these treatments showed statistically significant intercenter variation in utilization (P < 0.001 for immunomodulators, prednisone, antibiotics, and 5-ASA; P = 0.02 for infliximab). After adjusting for the demographic and clinical factors listed above, intercenter variation remained significant; however, the low utilization of infliximab precluded multivariate analysis. Conclusions: Widespread intercenter variation in the medical management of newly diagnosed children with Crohn's disease was observed, even after adjusting for possible differences in case mix between institutions. This variation may lead to unintended differences in health care costs and outcomes. (Inflamm Bowel Dis 2007) [source] Un-promoted issues in inflammatory bowel disease: opportunities to optimize careINTERNAL MEDICINE JOURNAL, Issue 3 2010J. M. Andrews Abstract Inflammatory bowel diseases (IBD), comprising Crohn's disease (CD) and ulcerative colitis (UC), are chronic inflammatory disorders of the gut, which lead to significant morbidity and impaired quality of life (QoL) in sufferers, without generally affecting mortality. Despite CD and UC being chronic, life-long illnesses, most medical management is directed at acute flares of disease. Moreover, with more intensive medical therapy and the development of biological therapy, there is a risk that management will become even more narrowly focused on acute care, and be directed only at those with more severe disease, rather than encompassing all sufferers and addressing important non-acute issues. This imbalance of concentration of medical attention on ,high-end' care is in part driven by the need to perform and publish randomized clinical trials of newer therapies to obtain registration and licensing for these agents, which thus occupy a large proportion of the recent IBD treatment literature. This leads to less attention on relatively ,low-technology' issues including: (i) the psychosocial burden of chronic disease, QoL and specific psychological comorbidities; (ii) comorbidity with functional gastrointestinal disorders (FGIDs); (iii) maintenance therapy, monitoring and compliance; (iv) smoking (with regard to CD); (v) sexuality, fertility, family planning and pregnancy; and (vi) iron deficiency and anaemia. We propose these to be the ,Un-promoted Issues' in IBD and review the importance and treatment of each of these in the current management of IBD. [source] A case of uterine tumour resembling ovarian sex cord tumour responding to second-line, single agent anastrazoleINTERNAL MEDICINE JOURNAL, Issue 9 2009P. Blinman Abstract Uterine tumour resembling ovarian sex cord tumour (UTROSCT) are a histological variant of endometrial stromal sarcomas (ESS). There is no established medical management of metastatic UTROSCT or ESS, although there is evidence supporting the use of hormonal therapy. Given the success of aromatase inhibitors in breast cancer, their potential role in ESS and UTROSCT is of current interest. We report the first case of response to second-line, single agent anastrazole in a patient with metastatic UTROSCT. [source] Does early medical intervention have a role in the management of intracerebral haemorrhage?INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 4 2008A. Bhalla Summary Introduction:, An increasing amount of research is now being directed towards the medical treatment of patients who have suffered an intracerebral haemorrhage (ICH). Despite this, no routine drug treatment to date has been shown to be unequivocally effective in unselected patients. Treatments/Discussion:, Approaches to treatment are based upon our understanding of the pathophysiological sequelae following ICH. Strategies to reduce haematoma growth, subsequent oedema formation and perihaematoma ischaemia are key targets for further research. Whether these therapies become valuable tools for the future is as yet unclear. Until then, the mainstay of the medical management of ICH remains individualised care. Conclusions:, There is now a pressing need for large prospective randomised controlled trials to determine the effectiveness of pharmacological therapies for this condition. [source] | |||||||||||||||||||||||||||||||||||||||||||