Definite Improvement In Symptoms Research Articles

Opioid Prescription Method for Breathlessness Due to Non-Cancer Chronic Respiratory Diseases: A Systematic Review.

A previous pooled analysis demonstrated significant relief of breathlessness following opioid administration in patients with chronic obstructive pulmonary disease. However, in clinical practice, it is important to know the characteristics of patients responding to opioids, the best prescription methods, and the evaluation measures that can sufficiently reflect these effects. Thus, we performed a systematic review of systemic opioids for non-cancer chronic respiratory diseases. Fifteen randomized controlled studies (RCTs), four non-randomized studies, two observational studies, and five retrospective studies were included. Recent RCTs suggested that regular oral opioid use would decrease the worst breathlessness in patients with a modified Medical Research Council score ≥ 3 by a degree of 1.0 or less on a scale of 1–10. Ergometer or treadmill tests indicated mostly consistent significant acute effects of morphine or codeine. In two non-randomized studies, about 60% of patients responded to opioids and showed definite improvement in symptoms and quality of life. Furthermore, titration of opioids in these studies suggested that a major proportion of these responders had benefits after administration of approximately 10 mg/day of morphine. However, more studies are needed to clarify the prescription method to reduce withdrawal due to adverse effects, which would lead to significant improvements in overall well-being.

Therapeutic uses of Soft Contact Lenses

Soft contact lenses are widely used for correction of refractive errors and in diseases related to corneal surface irregularities. In this case series we have used soft contact lenses in treatment of patients having bullous keratopathy, corneal ulcer, dry eye, trichiasis and corneal perforation. Soft contact lenses were found to be superior than conventional method of treatment and they have revolutionized the management of corneal diseases. Visual improvement was found to be satisfactory in all cases along with definite improvement of symptoms in cases of corneal surface irregularities.

Application of diffusion tensor imaging in preoperation and postoperation patients of glioma with 3.0 Tesla MRI

To investigate the clinical usefulness of diffusion tensor imaging (DTI) in demonstrating between gliomas and surrounding fibers. 24 patients of glioma (WHO grade: grade I - II 16 cases; grade III - IV 8 cases) were examined using DTI and conventional contrast-enhanced MRI of 3.0 T MRI scanner (GE company, America). After the initial data acquisition introduced into workstation, image analysis was performed with the use of functool software. Mean diffusivity (MD) and fractional anisotropy (FA) values were measured in regions of solid tumor, surrounding edema and normal white matter of the high grade cerebral gliomas. Differences in these values among the tissues were assessed on the high grade cerebral gliomas. Anatomic relationship between intracranial tumors and surrounding fibers was analysed on fractional anisotropic (FA) map, color-coded directional map, three-dimensional white matter tractography. All patients' symptoms were evaluated preoperative and postoperative respectively. The DTI patterns altered by the tumor were categorized as follows: displacement, infiltration and destruction. The tractography showed that the main influence in 16 cases of grade I - II glioma on adjacent white matter tracts was displacement, but infiltration and destruction were also revealed. The patients have definite improvement in symptoms. The destruction and infiltration of fiber tracts could be seen in all edema regions around grade III - IV gliomas in 8 cases. The patients have not definite improvement in symptoms. Apparently significant differences of MD were found in solid tumor, surrounding edema, compared with normal white matter regions (P < 0.05). But there was no significant difference among solid tumor and surrounding edema region (P > 0.05). There were significant differences of FA between solid tumor, surrounding edema and normal white matter region (P < 0.05). The DTI offered the optimal visualization of white matter tracts. DTI plays an important role in demonstrating relationship between gliomas and neighboring fibers. MD and FA values could be used to distinguish normal white matter from solid tumor and surrounding edema region of high grade glioma. The application of DTI in preoperation plays an guidance role in making microsurgery plans and the evaluation of brain functional recovery in postoperation. DTI should be of great value in the microsurgical planning as well as estimation and reduction of potential postoperative neurological deficits for the cerebral gliomas resection.

Thromboendarterectomy in chronic thromboembolic pulmonary hypertension. Hemodynamics and right-heart function over the long term

To find out whether pulmonary thromboendarterectomy (PTE) can achieve lasting reduction of pulmonary vascular resistance in patients with pulmonary arterial hypertension due to chronic thromboembolism. 45 patients (25 women, 20 men; mean age 45 +/- 24 [19-67] years) were re-investigated a mean of 21 (13-32) months after successful PTE. Two patients had then been in New York Heart Association (NYHA) stage II, 26 in stage III, and 17 in stage IV. In addition to clinical examination and chest radiogram 36 patients had right heart catheterization, 28 pulmonary angiography and 44 echocardiography. Definite improvement of symptoms had occurred in all. 34 were now in NYHA stage I, nine in stage II, and two in stage III. The pulmonary vascular resistance was significantly lower than before and immediately after PTE (pre-PTE: 1052 +/- 472 dyn.s.cm-5; post-PTE: 293 +/- 175 dyn.s.cm-5; at follow-up: 187 +/- 92 dyn.s.cm-5; P < 0.001 for follow-up vs pre-PTE; P < 0.05 for follow-up vs post-PTE). Correspondingly, cardiac index had significantly increased (3.0 +/- 0.5 vs 2.0 +/- 0.7 l/min.m2; P < 0.001). Radiological and echocardiographic examinations showed a definite decrease in right ventricular dimensions and improvement in right ventricular function. In patients with pulmonary arterial hypertension due to chronic pulmonary thromboembolism PTE can achieve a reduction in pulmonary vascular resistance with lasting improvement in right heart function and clinical symptoms.

Transient subacute cerebellar ataxia in a patient with Lambert-Eaton myasthenic syndrome after intracranial aneurysm surgery

Several reports have presented patients with subacute cerebellar ataxia (CA) and Lambert-Eaton myasthenic syndrome (LEMS). Some clinical features of those patients have been described in the previous reports, manifestation of subacute CA prior to LEMS or a co-existence of both diseases, a high incidence of malignancy, and less efficacy of the treatment for subacute CA compared with that for LEMS. Cerebellar ataxia in some patients with LEMS has been suggested to be caused by antibodies to P/Q-type voltage-gated calcium channels (VGCCs). We report herein a patient with subacute CA and LEMS. Cerebellar ataxia appeared 15 months after the occurrence of LEMS, and the onset of CA was thought to be due to serum anti-P/Q-type VGCC antibodies. The clinical course of this patient was atypical, as follows: (1) LEMS preceded subacute CA, which developed after intracranial aneurysm surgery, (2) no malignancy was detected when both diseases co-existed, (3) symptoms of LEMS did not progress with the onset of CA, and (4) there was a definite improvement in symptoms of CA and 123I-IMP SPECT imaging findings after steroid administration. In addition, it is remarkable that LEMS became aggravated in electrophysiologic examinations, in contrast to subacute CA. We suggest that these atypical features of subacute CA and the changes in LEMS may be associated with a balance between the amount of serum anti-P/Q-type VGCC antibodies and the susceptibility of the cerebellum and presynaptic nerve terminals to the antibodies. More cases are needed to investigate the mechanisms involved. The subacute CA and LEMS in this patient have remained comparatively silent after the withdrawal of steroids, and we are continuing to observe her condition.

319 Rapid control system of calcium in presynaptic terminal of frog neuromuscular junction

Several reports have presented patients with subacute cerebellar ataxia (CA) and Lambert-Eaton myasthenic syndrome (LEMS). Some clinical features of those patients have been described in the previous reports, manifestation of subacute CA prior to LEMS or a co-existence of both diseases, a high incidence of malignancy, and less efficacy of the treatment for subacute CA compared with that for LEMS. Cerebellar ataxia in some patients with LEMS has been suggested to be caused by antibodies to P/Q-type voltage-gated calcium channels (VGCCs). We report herein a patient with subacute CA and LEMS. Cerebellar ataxia appeared 15 months after the occurrence of LEMS, and the onset of CA was thought to be due to serum anti-P/Q-type VGCC antibodies. The clinical course of this patient was atypical, as follows: (1) LEMS preceded subacute CA, which developed after intracranial aneurysm surgery, (2) no malignancy was detected when both diseases co-existed, (3) symptoms of LEMS did not progress with the onset of CA, and (4) there was a definite improvement in symptoms of CA and 123I-IMP SPECT imaging findings after steroid administration. In addition, it is remarkable that LEMS became aggravated in electrophysiologic examinations, in contrast to subacute CA. We suggest that these atypical features of subacute CA and the changes in LEMS may be associated with a balance between the amount of serum anti-P/Q-type VGCC antibodies and the susceptibility of the cerebellum and presynaptic nerve terminals to the antibodies. More cases are needed to investigate the mechanisms involved. The subacute CA and LEMS in this patient have remained comparatively silent after the withdrawal of steroids, and we are continuing to observe her condition.

Rapid control system of calcium in presynaptic terminal of frog neuromuscular junction

Several reports have presented patients with subacute cerebellar ataxia (CA) and Lambert-Eaton myasthenic syndrome (LEMS). Some clinical features of those patients have been described in the previous reports, manifestation of subacute CA prior to LEMS or a co-existence of both diseases, a high incidence of malignancy, and less efficacy of the treatment for subacute CA compared with that for LEMS. Cerebellar ataxia in some patients with LEMS has been suggested to be caused by antibodies to P/Q-type voltage-gated calcium channels (VGCCs). We report herein a patient with subacute CA and LEMS. Cerebellar ataxia appeared 15 months after the occurrence of LEMS, and the onset of CA was thought to be due to serum anti-P/Q-type VGCC antibodies. The clinical course of this patient was atypical, as follows: (1) LEMS preceded subacute CA, which developed after intracranial aneurysm surgery, (2) no malignancy was detected when both diseases co-existed, (3) symptoms of LEMS did not progress with the onset of CA, and (4) there was a definite improvement in symptoms of CA and 123I-IMP SPECT imaging findings after steroid administration. In addition, it is remarkable that LEMS became aggravated in electrophysiologic examinations, in contrast to subacute CA. We suggest that these atypical features of subacute CA and the changes in LEMS may be associated with a balance between the amount of serum anti-P/Q-type VGCC antibodies and the susceptibility of the cerebellum and presynaptic nerve terminals to the antibodies. More cases are needed to investigate the mechanisms involved. The subacute CA and LEMS in this patient have remained comparatively silent after the withdrawal of steroids, and we are continuing to observe her condition.

Use of the CO2-laser micropoint micromanipulator for the treatment of laryngomalacia.

Between September 1989 and June 1994, 21 children (17 boys, 4 girls) with moderate to severe symptoms due to laryngomalacia underwent endoscopic surgery using the CO2-laser micropoint manipulator (shot-by-shot, 0.1 s, super-pulse, 2-3 W power; 280 microns beam; 400 mm working distance). Mean age of the children was 5 months (range, 1-11 months). The procedure was performed under high-frequency jet ventilation and consisted in the resection and/or vaporization of the aryepiglottic folds. This tissue removal could be extended to the laryngeal mucosa of the arytenoids and the lateral edge of the epiglottis. Results of surgery were excellent with normalization (8 patients) or, at worst, a very definite improvement of symptoms (4 patients). Furthermore, no complications occurred due to the technique used. These results have convinced us that the CO2-laser micropoint manipulator technique, with the "super-pulse" shooting mode and high-frequency jet ventilation, is by far superior to microsurgery with cold instruments when endoscopic treatment of laryngomalacia is indicated.

Therapeutic Possibilities of 131I-Mibg in Metastatic Carcinoid Tumors - Preliminary Report

The poor results of traditional therapy in advanced carcinoid tumors and the well-proven uptake of 131I-MIBG shown by some of these tumors induced us to attempt a radiometabolic approach. We selected for the treatment 5 patients (3 men and 2 women) who showed progression of disease, a fairly good uptake of 131I-MIBG with severe related symptoms, and a poor response to traditional therapy. A cumulative radioactivity of 5.5-29.6 GBq was given. Acute side effects after 131I-MIBG administration or late radiation-induced damages were not observed. Symptoms increased during the first 2-4 weeks in 2 patients: in one of these relief was achieved with drugs. Results concerning objective remission of the disease were unsatisfactory. In contrast, definite improvement of symptoms was shown in 2 of 5 patients, resulting in a better quality of life.

Serial studies of 100 patients with chronic airway obstruction in London and Chicago.

One hundred patients with chronic airway obstruction, 50 in Chicago and 50 in London, were studied by standardized techniques in 1961. The results of the initial studies, previously reported, showed that the patients in the two cities were similar; using clinical and physiological criteria based on pathological studies, the patients were divided into three types—emphysematous type A, bronchial type B, and an indeterminate type X. The patients were studied again in succeeding years, 1962-65. During this time 26 died, 19 due to their respiratory disease; these 19 patients were initially more breathless, had a higher incidence of cor pulmonale, and had more severe airway obstruction and higher carbon dioxide pressures than the remainder. Type B patients (mortality 36%) had a worse prognosis than either type A (15%) or type X (12%). Of the measurements made, high carbon dioxide pressures were most closely related (p<0·001) to mortality. During the period of follow-up about one-third of the patients who did not die became more short of breath and developed more severe airway obstruction and carbon dioxide retention: about 10% showed definite improvement in symptoms and pulmonary function. The F.E.V.1·0 declined on average by 46 ml./year, 4·8% of the initial value; V.C. declined by 120 ml./year, 4·0% of the initial value; mixed venous Pco2 increased 1 mm. Hg/year. The changes that occurred during this time confirmed the previously reported similarity between the patients attending the two clinics. Although the incidence of bronchitic exacerbations was similar in the two cities, such illnesses in the London patients led to more frequent and more prolonged incapacity.

The Treatment of Pulmonary Emphysema and of Diffuse Pulmonary Fibrosis with Nebulized Bronchodilators and Intermittent Positive Pressure Breathing

Twenty-two patients with chronic pulmonary emphysema were treated for two weeks with oxygen administered by intermittent positive pressure breathing (IPPB) four times daily for 20-minute periods. A bronchodilator was not used. The IPPB treatment without bronchodilators was considered unsatisfactory. Forty-three patients received the combined treatment of isuprel aerosol and oxygen by IPPB at some time during the period they were studied. Twenty patients received the combined treatment without previous regular use of nebulized bronchodilator and 70 per cent reported definite improvement in symptoms, including decreased dyspnea, cough and volume of sputum (when present). Twenty-three patients were treated during an initial period with oxygen and isuprel aerosol without IPPB. Eighteen of these reported symptomatic improvement, an incidence similar to that obtained with the combined bronchodilator and IPPB treatment. The incidence of improvement was similar to that of other reports, in which the combined treatment was used without control studies to determine the separate effects of the features of the combined treatment. Twenty-two of the 23 patients treated with bronchodilators alone then received IPPB in combination with the bronchodilator. Three patients became worse during treatment and two were hospitalized; 15 reported continued improvement. Four of these patients preferred aerosol without IPPB, six preferred the IPPB and bronchodilator combination, feeling that it “opened them up more” and five had no preference. Persistent objective improvement in vital capacity, maximal breathing capacity, nitrogen washout index or arterial oxygen saturation was unusual. Only four of the 42 patients, who at some time during the study received the combined treatment, had persistent improvement in vital capacity and maximal breathing capacity. Three of these patients were 25, 30 and 36 years old respectively and the fourth was 60 years of age. Many patients who had previously used aerosol bronchodilators were found to be using them inefficiently. When they were instructed in the correct use of a nebulizer and when they followed a systematic program similar to that used with IPPB in combination with aerosol bronchodilators, the incidence of symptomatic improvement was similar to that of patients using the combined treatment during short-term treatment. The lack of persistent change in the results obtained by various tests for pulmonary function suggests that none of these therapeutic methods alter the basic pulmonary lesion. The occasional improvement in arterial oxygen saturation, the decrease in cough and volume of sputum and the improved sense of well being suggest an improvement in the bronchial hygiene brought about by the use of aerosol bronchodilators. The only inherent feature of IPPB that we have observed is the assurance of a relatively large tidal volume during aerosol therapy. In alert, ambulatory patients a satisfactory tidal volume can be maintained without mechanical assistance. Five patients with pulmonary fibrosis of uncertain etiology, but with minimal evidence of bronchospasm or other obstructive features, did not improve with use of the combined treatment. Further controlled studies are needed to demonstrate (1) the relative therapeutic effects of long-term bronchodilator treatment with and with-out IPPB, and (2) whether or not the intrapulmonary distribution of gases and aerosols with IPPB differs from that of similar breathing patterns achieved solely by the respiratory muscles.

The Indications for and Effects of Irradiation of the Pituitary Gland

A Convenient basis for discussion is afforded by Denis Williams' (1940) classification in Cade's Malignant Disease and its Treatment by Radium. Williams points out that tumours of the gland itself are almost invariably simple adenomata, and tumours of the hypophyseal duct are usually slowly growing neoplasms of congenital origin. Adenomata. 1. Chromophobe. 2. Eosinophil. 3. Mixed. 4. Basophil. Adenocarcinomata. Craniopharyngiomata (Adamantinomata). Papillary cysts. Carcinomata. Frankly at first sight, they appear a depressing collection for the radiation therapist. I feel that in dealing with them our clinical colleagues are inclined to ask from us at once too much and too little. Too much because a large number of these tumours are resistant to radiation or only slightly sensitive, and the delivery of a large dose of radiation of the order of 3000 to 4000 röntgens or even more at the pituitary gland is not a procedure to be undertaken lightly either by the patient or the radiologist. It demands careful and tedious planning and technique which call for an assurance that definite improvement of symptoms will result. On the other hand the services of the radiation therapist are too little in demand for certain symptoms which I believe to be due to excessive hormonal secretion by the gland, and where much smaller doses can often afford striking relief. At the outset I would like to make it clear that radiation therapy in endocrinology should only be undertaken by a closely collaborating team of whom the radiologist is one member.