Continued Medical Treatment Research Articles

Extending the limits of extracorporeal membrane oxygenation: lung rest for a child with non-specific interstitial pneumonia

Veno-venous extracorporeal membrane oxygenation (ECMO) is an established therapy for the treatment of respiratory failure. Traditionally ECMO has been used to support patients with an acute, reversible disease process, with a predictable outcome. We report the successful use of veno-venous ECMO for an unusual indication. A 10-year old girl was admitted to intensive care with severe, hypoxic respiratory failure on the background of a 2-month history of worsening respiratory symptoms. She required high levels of conventional positive pressure ventilation, and high frequency oscillation. Lung biopsy confirmed a non-specific interstitial pneumonia, and the patient was commenced on immune suppressive therapy. Her clinical course was further complicated by pulmonary haemorrhage and severe air leak. On day 20 after admission the patient was placed on veno-venous ECMO for lung rest while awaiting a response to continued medical treatment. She required ECMO for 20 days, during which time sedation was reduced, and she was able to interact with those around her. The patient's ventilatory requirements after decannulation were minimal, and she subsequently made a steady clinical recovery. ECMO was safely and successfully used to provide a period of lung rest and time for medical therapy to take effect in a child with an unusual indication for support: a rare disease with an uncertain outcome on the background of prolonged mechanical ventilation.

How effective is surgery to cure seizures in drug-resistant temporal lobe epilepsy?

It is well recognized that two-thirds of patients with drug-resistant temporal lobe epilepsy will be free of disabling seizures with continued medical treatment after temporal resection. Seizure recurrence has been noted during a five-year follow-up in approximately one-third of these seizure-free patients mostly but not exclusively following planned complete discontinuation of antiepileptic drugs (AEDs). This leaves one-third of patients without disabling seizures and without AEDs several years after surgery. Despite improvements in seizure frequency or severity, seizures persist in another third of patients undergoing surgery. Although cure (five years without any seizures and off AEDs) is the ultimate aim of epilepsy surgery, the percentage of patients cured by surgery cannot be well defined at the moment. We need a long-term randomized controlled trial on AED discontinuation in seizure-free patients followed by long-term open extension to determine if only one in three adult patients with drug-resistant temporal lobe epilepsy is cured by surgical intervention.

Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy

ObjectivesThis study was designed to compare the long-term consequences of percutaneous transluminal coronary angioplasty (PTCA) and continued medical treatment. BackgroundThe long-term effects of percutaneous coronary intervention need evaluating, especially in comparison with an alternative policy of continued medical treatment. MethodsThe Second Randomized Intervention Treatment of Angina (RITA-2) is a randomized trial of PTCA versus conservative (medical) care in 1,018 patients considered suitable for either treatment option. Information on clinical events, interventions, and symptoms is available for a median seven years follow-up. ResultsDeath or myocardial infarction (MI) occurred in 73 (14.5%) PTCA patients and 63 (12.3%) medical patients (difference +2.2%, 95% confidence interval −2.0% to +6.4%, p = 0.21). There were 43 deaths in both groups, of which 41% were cardiac-related. Among patients assigned PTCA 12.7% subsequently had coronary artery bypass grafts, and 14.5% required additional non-randomized PTCA. Most of these re-interventions occurred within a year of randomization, and after two years the re-intervention rate was 2.3% per annum. In the medical group, 35.4% required myocardial revascularization: 15.0% in the first year and an annual rate of 3.6% after two years. An initial policy of PTCA was associated with improved anginal symptoms and exercise times. These treatment differences narrowed over time, mainly because of coronary interventions in medical patients with severe symptoms. ConclusionsIn RITA-2 an initial strategy of PTCA did not influence the risk of death or MI, but it improved angina and exercise tolerance. Patients considered suitable for PTCA or medical therapy can be safely managed with continued medical therapy, but percutaneous intervention is appropriate if symptoms are not controlled.

Continued symptomatic improvement three to five years after transmyocardial revascularization with co2laser: A late clinical follow-up of the norwegian randomized trial with transmyocardial revascularization

ObjectivesThe goals of this study were to assess late clinical outcome and left ventricular ejection fraction (LVEF) after transmyocardial revascularization with CO2laser (TMR). BackgroundDuring the 1990s TMR emerged as a treatment option for patients with refractory angina not eligible for conventional revascularization. Few reports exist on clinical effects and LVEF >3 years after TMR. MethodsOne hundred patients with refractory angina not eligible for conventional revascularization were block-randomized 1:1 to receive continued medical treatment or medical treatment combined with TMR. The patients were evaluated at baseline and after 3, 12 and 43 (range: 32 to 60) months with end points to angina, hospitalizations due to acute myocardial infarctions or unstable angina, heart failure and LVEF. Mortality was registered and MOS 36 Short-Form Health Survey answered at baseline and after 3, 6 and 12 months. ResultsForty-three months after TMR, angina symptoms were still significantly improved, and unstable angina hospitalizations reduced by 55% (p < 0.001). Heart failure treatment (p < 0.01) increased, whereas the number of acute myocardial infarctions, LVEF and mortality was not affected. Quality of life was improved 3, 6 and 12 months after TMR. ConclusionsForty-three months after TMR, angina symptoms and hospitalizations due to unstable angina were significantly reduced, heart failure treatment increased and LVEF and mortality were seemingly unaffected.

Percutaneous transmyocardial laser revascularisation for severe angina: the PACIFIC randomised trial

Percutaneous transmyocardial laser revascularisation (PTMR) is a proposed catheter-based therapy for refractory angina pectoris when bypass surgery or angioplasty is not possible. We undertook a randomised trial to assess the safety and efficacy of this technique. 221 patients with reversible ischaemia of Canadian Cardiovascular Society angina class III (61%) or IV (39%) and incomplete response to other therapies were recruited from 13 centres. Patients were randomly assigned PTMR with a holmium:YAG laser plus continued medical treatment (n=110) or continued medical treatment only (n=111). The primary endpoint was the exercise tolerance at 12 months. Analyses were by intention to treat. 11 patients died and 19 withdrew; 92 PTMR-group and 99 medical-treatment-group patients completed the study. Exercise tolerance at 12 months had increased by a median of 89.0 s (IQR -15 to 183) with PTMR compared with 12.5 s (-67 to 125) with medical treatment only (p=0.008). On masked assessment, angina class was II or lower in 34.1% of PTMR patients compared with 13.0% of those medically treated. All indices of the Seattle angina questionnaire improved more with PTMR than with medical care only. By 12 months there had been eight deaths in the PTMR group and three in the medical treatment group, with similar survival in the two groups. PTMR was associated with increased exercise tolerance time, low morbidity, lower angina scores assessed by masked reviewers, and improved quality of life. Although there is controversy about the mechanism of action, and the contribution of the placebo effect cannot be quantified, this unmasked study suggests that this palliative procedure provides some clinical benefits in the defined population of patients.

Medical management of significant coronary angiographic stenoses: outcome of 60 patients observed for 433 patient years.

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. 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. 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. 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. Medical management of selected patients with significant coronary stenoses is safe and effective.

Is epilepsy surgery possible in countries with limited resources?

This study illustrates the outcome and cost-effectiveness of anterior temporal lobectomy (ATL) among patients with medically refractory temporal lobe epilepsy (TLE) treated in an epilepsy center in Kerala, South India. Patients for ATL were selected on the basis of a noninvasive protocol comprising clinical, interictal scalp electroencephalogram (EEG), magnetic resonance imaging, and ictal video-EEG data. The authors compared the outcome and direct cost of 119 patients (mean age, 25.6 years; mean duration of epilepsy before ATL, 16.1 years) who have completed at least 1 year follow-up after ATL with 71 refractory TLE patients (mean age, 27.1 years; mean duration of epilepsy, 15.4 years) who did not undergo ATL. Patients in the study who underwent ATL had a 70% likelihood of becoming seizure-free after ATL and a 30% chance of being completely off of antiepileptic drug treatment within 3 years after ATL. The out-of-pocket one-time payment for ATL (including presurgical evaluation) in this setup is Indian Rupees (INR) 47,000 (US$ 1,200). The total direct medical cost of caring for TLE patients aged 26 to 60 years would be INR 200,000 (US$ 5,000). Patients freed from seizures often can be better employed and achieve an improved quality of life. It is concluded that ATL for refractory TLE is a more cost-effective option than continued medical treatment. Epilepsy surgery is not only possible in a developing country but can also be undertaken in a cost-effective way.

Transmyocardial revascularization with CO2 laser in patients with refractory angina pectoris: Clinical results from The Norwegian Randomized Trial

OBJECTIVESThe purpose of the study was to evaluate clinical effects, exercise performance and effect on maximal oxygen consumption (MVO2) of transmyocardial revascularization with CO2-laser (TMR) in patients with refractory angina pectoris.BACKGROUNDTransmyocardial laser revascularization is a new method to treat patients with refractory angina pectoris not eligible for conventional revascularization. Few randomized studies comparing TMR with conventional treatment have been published.METHODSOne hundred patients with refractory angina not eligible for conventional revascularization were block-randomized in a 1:1 ratio to receive continued optimal medical treatment (MT) or TMR in addition to MT. The patients were evaluated at baseline and at three and 12 months with end points to symptoms, exercise capacity and MVO2.RESULTSTransmyocardial laser revascularization resulted in significant relief in angina symptoms after three and 12 months compared to baseline. Time to chest pain during exercise increased from baseline by 78 s after three months (p = NS) and 66 s (p < 0.01) after 12 months in the TMR group, whereas total exercise time and MVO2 were unchanged. No significant changes were observed in the MT group. Perioperative mortality was 4%. One year mortality was 12% in the TMR group and 8% in the MT group (p = NS.)CONCLUSIONSTransmyocardial laser revascularization was performed with low perioperative mortality and caused significant symptomatic improvement, but no improvement in exercise capacity.

Quality of life after coronary angioplasty or continued medical treatment for angina: three-year follow-up in the RITA-2 trial

OBJECTIVESWe sought to evaluate the impact of percutaneous transluminal coronary angioplasty (PTCA) and medical treatment on self-perceived quality of life among patients with angina.BACKGROUNDThe second Randomized Intervention Treatment of Angina trial (RITA-2) implemented initial policies of PTCA or continued medical treatment in patients with angina, allowing assessment of long-term health consequences.METHODSA total of 1,018 patients were randomly assigned (504 to PTCA and 514 to medical treatment). The short form 36 (SF-36) self-administered quality-of-life questionnaire was completed at randomization and three months, one year and three years later. To date, 98% of patients reached one year and 67% reached three years.RESULTSThe PTCA group had significantly greater improvements in physical functioning, vitality and general health at both three months and one year, but not at three years. These quality-of-life scores were strongly related to breathlessness, angina grade and treadmill exercise time both at baseline and at one year. The treatment differences in quality of life are explained by the PTCA group’s improvements in breathlessness, angina and exercise time. The attenuation of treatment difference at three years is partly attributed to 27% of medically treated patients receiving nonrandomized interventions in the interim. For both groups, there were also improvements in ratings of physical role functioning, emotional role functioning, social functioning, pain and mental health, but for these the superiority of PTCA over medical treatment was less pronounced. After one year, 33% and 22% of the PTCA and medical groups, respectively, rated their health much better.CONCLUSIONSCoronary angioplasty substantially improves patient-perceived quality of life, especially physical functioning and vitality, as compared with continued medical treatment. These differences are attributed to alleviation of cardiac symptoms (specifically, breathlessness and angina), but must be balanced against the small procedure-related risks of PTCA.

Factors affecting the therapeutic choice in patients with multivessel coronary artery disease. The Studio Lombardo Angiografia Multivasali (SLAM) Study Group.

OBJECTIVE: To assess how clinical and angiographic findings are related to the decision to carry out coronary angioplasty (PTCA) or coronary bypass grafting in patients with multivessel coronary artery disease....

Cost-effectiveness of lumbar discectomy.

Cost-effectiveness analysis is useful when attempting to determine whether the benefits of an intervention are worth is costs. It can help clinicians to consider more explicitly all potential costs and outcomes of a given treatment, and it can assist policy makers in determining how best to allocate limited health-care resources to maximize the health of a population. This article describes the research methods used to estimate cost-effectiveness, and then examines existing reports on the cost-effectiveness of lumbar disc surgery. Results of previously published studies were inconsistent, indicating that estimates of discectomy's cost-effectiveness are highly dependent on how one measures and values the improvement in quality of life resulting from the procedure. If only long-term outcomes are considered, the procedure appears no more effective than continued medical treatment. But discectomy seems effective when its short-term benefits are considered. In either case, costs for the procedure are moderate. The authors conclude that for carefully selected patients with herniated lumbar discs, short-term quality of life is improved substantially with surgical versus medical treatment. When this benefit is considered, discectomy appears to be a cost-effective intervention, although this conclusion applies only to carefully selected patients with clearly defined indications for surgery. For patients without these indications and for patients in whom the immediate relief of sciatica is less important, discectomy's cost-effectiveness will be less favorable.

Relapses after withdrawal of proguanil treatment in tropical splenomegaly syndrome.

After the remission of symptoms and reduction in spleen size while on proguanil therapy four patients with the tropical splenomegaly syndrome defaulted from treatment. The withdrawal of proguanil caused a recrudescence of original symptoms, splenomegaly, and a return of the initially raised serum IgM. Complete return to normal values was again effected with proguanil therapy.The role of the spleen in the tropical splenomegaly syndrome in the production of the raised serum IgM is discussed. These patients should be educated as to the nature of their disease and the importance of continued medical treatment.

Chapter 2 - Healing of Initial Ulcers in Relation to Age and Race

Seven hundred and seventy-four patients were selected for this study, representing about 64% of the patients known to have gastric ulcers in the participating hospitals during this time. Of the 638 patients completing treatment, healing took place at least as rapidly as the protocol required in 76%, and the remainder failed these criteria. In 46.1%, healing was complete in 3 weeks; in 24.3%, it was complete in 6 weeks; and in an additional 5.5%, 12 weeks were required. Of the 154 patients whose ulcers did not heal as specified by the protocol, 111 patients were subjected to randomized decision for continued medical treatment or for surgery. The ulcers healed in 42% of cases randomized to medical treatment. Neither age nor race affected the location of the ulcers. Negro patients had fewer large ulcers, a lower healing rate, a higher rate of coexistent duodenal ulcer, and a higher recurrence rate.

Socio-Medical Studies on the Present Medical Care System

Investigations have been pursued on patients ranging from the time of onset of illness until their re-entry into society. The period of investigation covers 1962-1967. Total number of patients were 2, 000 who has been admitted by internists and surgeons in 21 hospitals in Kyoto, Osaka, Hyogo and Shiga Prefectures.Investigation procedures were, firstly personal interview covering onset of illness, admission and period under medical treatment, secondly personal communication after 1-3-6-12 months respectively following discharge. In addition, doctor of the hospitals were requested to inform their opinion on the following items:A. Timing of admissionsB. Patient's condition at dischargeC. Necessity of medical care after dischargeThe following conclusions can be drawn from the foregoing facts:(1) Each patient should be given the choice of Doctor and should follow this doctor's instructions regarding reference to specialists and treatment at proper time.(2) In order for patients to receive effective medical treatment the function of medical facilities should be differentiated and in addition these facilities should work in close co-operation with one another.(3) Regarding to post-discharge medical follow-up, it should be pointed out that prevention rather than treatment is the point which should be stressed. As prevention is closely related to their residential lives the medical facilities in the respective areas should be made responsible.(4) In order that patients enter into society adequately, care as well as socio-economic assistance are necessary after discharge. As for patients under continued medical treatment at home, social services should provide visting nurses as well as home helpers.

Restoration of gastroduodenal continuity.

The feasibility of reoperating to restore gastrointestinal continuity was studied in 30 patients who had suffered disabling complications after gastroenterostomy. The largest group consisted of 13 patients in whom the original operation was vagotomy and gastrojejunostomy. All of the 30 patients had symptoms so severe as to prevent them from carrying on gainful occupations, and in each case medical treatment had been given a thorough trial. The corrective operation consisted of closing the gastrojejunal stoma and frequently included end-to-end anastomosis for repair of the jejunum and end-to-end anastomosis between stomach and duodenum. Only one patient failed to obtain relief by the corrective operation; eight others were but partially relieved and required continued medical or dietary treatment. Twenty-one became free of symptoms, were relieved of the need for medication, and were able to return to work.

Leiomyoma of the stomach.

This case is reported because of the rarity of this condition and the radiological features conformed to the radiological characteristics described in the literature, subsequently confirmed by autopsy. G.S., a male aged 64, was referred for examination, because during the previous month he had been suffering from repeated attacks of melaena in spite of continued medical treatment and repeated blood transfusions. There had been a continued pyrexia and leucocytosis for the same period. In 1944 there had been a similar illness lasting about a month, and a barium meal examination (Fig. 1), carried out by Dr. F. F. C. Jagger, revealed a rounded filling defect containing a central spot of barium in the stomach. This appearance was confirmed by another barium meal examination three months later; but this time the central spot was not demonstrated.