Discontinuation Of Medical Therapy Research Articles

Italian Association of Clinical Endocrinologists (AME) and International Chapter of Clinical Endocrinology (ICCE). Position statement for clinical practice: prolactin-secreting tumors.

Prolactinomas are the most frequent pituitary adenomas. Prolactinoma may occur in different clinical settings and always require an individually tailored approach. This is the reason why a panel of Italian neuroendocrine experts was charged with the task to provide indications for the diagnostic and therapeutic approaches that can be easily applied in different contexts. The document provides 15 recommendations for diagnosis and 54 recommendations for treatment, issued according to the GRADE system. The level of agreement among panel members was formally evaluated by RAND-UCLA methodology. In the last century, prolactinomas represented the paradigm of pituitary tumors for which the development of highly effective drugs obtained the best results, allowing to avoid neurosurgery in most cases. The impressive improvement of neurosurgical endoscopic techniques allows a far better definition of the tumoral tissue during surgery and the remission of endocrine symptoms in many patients with pituitary tumors. Consequently, this refinement of neurosurgery is changing the therapeutic strategy in prolactinomas, allowing the definitive cure of some patients with permanent discontinuation of medical therapy.

Rivaroxaban Versus Warfarin in Patients with Mechanical Heart Valves: Open-Label, Proof-of-Concept trial-The RIWA study.

To date, vitamin K antagonists are the only available oral anticoagulants in patients with mechanical heart valves. In this way, we developed a pilot trial with rivaroxaban. The RIWA study was a proof-of-concept, open-label, randomized clinical trial and was designed to assess the incidence of thromboembolic and bleeding events of the rivaroxaban-based strategy (15 mg twice daily) in comparison to dose-adjusted warfarin. Patients were randomly assigned in a 1:1 ratio and were followed prospectively for 90 days. A total of 72 patients were enrolled in the present study. Of these, 44 patients were randomized: 23 patients were allocated to the rivaroxaban group and 21 to the warfarin group. After 90 days of follow-up, the primary outcome occurred in one patient (4.3%) in the rivaroxaban group and three patients (14.3%) in the warfarin group (risk ratio [RR] 0.27; 95% confidence interval [CI] 0.02-2.85; P = 0.25). Minor bleeding (without discontinuation of medical therapy) occurred in six patients (26.1%) in the rivaroxaban group versus six patients (28.6%) in the warfarin group (RR 0.88; 95% CI 0.23-3.32; P = 0.85). One patient in the warfarin group died from myocardial infarction. No cases of hemorrhagic stroke, valve thrombosis, peripheral embolic events, or new intracardiac thrombus were related in both groups. In this pilot study, rivaroxaban 15mg twice daily had thromboembolic and bleeding events similar to warfarin in patients with mechanical heart valves. These data confirm the authors' proof-of-concept and suggest that a larger trial with a similar design is not unreasonable. CLINICALTRIAL. NCT03566303.

ASPERGILLUS FUMIGATUS EMPYEMA IN AN IMMUNOCOMPROMISED PATIENT WITH RHEUMATOID ARTHRITIS

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Fungal empyema is a rare entity (less than 1 percent of all cases) with Candida spp. being the most common etiological agents and only a few cases due to Aspergillus spp (1). CASE PRESENTATION: A 74-year-old male with history of rheumatoid arthritis on maintenance prednisone and methotrexate presented with progressive exertional shortness of breath and productive cough for 3 months. Chest X-ray showed a large left pleural collection with air-fluid level and thick wall. Computed tomography (CT) of the chest showed a large pleural loculation with an air fluid level surrounded by thickened wall, consolidation of the left lower lobe, and scattered tree-in-bud opacities bilaterally. A small right pleural effusion with multiple benign appearing pulmonary nodules was also noted. Video-assisted thoracoscopic surgery (VATS) with decortication was done. Pleural biopsy showed a dense mat of branching, septated fungal hyphae involving necrotic pleura. Pleural fluid cultures grew Aspergillus fumigatus. IV liposomal amphotericin was started, caused hypotension, was changed to IV voriconazole which led to acute liver injury and was eventually treated with micafungin. Repeat cultures from thoracostomy drainage grew Streptococcus viridans and Neisseria flava. They were suspected to have seeded from a bronchopleural fistula and IV piperacillin-tazobactam was given for coverage. The hospital course was complicated by left sided pneumothorax post-VATS requiring reinsertion of chest tube, atrial fibrillation with rapid ventricular rate, dysphagia and right sided pleural effusion requiring diagnostic thoracentesis (exudative fluid with negative culture). Patient requested discontinuation of medical therapy and transition to comfort measures due to his extended hospital stay. He was eventually transferred to hospice. DISCUSSION: Among the Aspergillus empyema cases, A. fumigatus is isolated most often, though other spp., such as A. flavus and A. terreus, have also been implicated (2). Fifty percent of such cases are polymicrobial. Risk factors include immunocompromised state and conditions predisposing to bronchopleural fistula (tuberculosis, sarcoidosis, cavitary pneumonia, thoracic surgery, pneumonectomy and lung transplantation). Diagnosis is made from pleural fluid culture or pleural biopsy stains showing characteristic hyphae. Pleural fluid is generally turbid with high protein, low glucose, increased neutrophils and galactomannan. Treatment is combined surgical (drainage of the pleural cavity, necrotic tissue resection and closure of bronchopleural fistula) and prolonged systemic antifungal therapy with triazoles (first line) or echinocandins (salvage therapy for treatment failure or tolerability concerns) (3). CONCLUSIONS: Aspergillus empyema is a rare but highly morbid entity that should be considered in immunocompromised hosts and requires surgical and prolonged medical management. Reference #1: Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC. Fungal empyema thoracis: an emerging clinical entity. Chest. 2000;117(6):1672. Reference #2: Albelda SM, Gefter WB, Epstein DM, Miller WT. Bronchopleural fistula complicating invasive pulmonary aspergillosis. Am Rev Respir Dis. 1982 Jul;126(1):163-5 Reference #3: Bonatti H, Lass-Floerl C, Angerer K, Singh N, Lechner M, Stelzmueller I, Singh R, Schmid T, Geltner C. Successful Management of Post pneumonectomy Aspergillus pleural empyema by combined surgical and antifungal treatment with voriconazole and caspofungin. Mycoses. 2010 Sept; 53(5) 448-54 DISCLOSURES: No relevant relationships by Amit Rout, source=Web Response No relevant relationships by Adrian Sarzynski, source=Web Response No relevant relationships by Sahib Singh, source=Web Response

SAT-465 Somatostatin Receptor Ligand as Initial Therapy in a Patient with Pituitary Microadenoma and Acromegaly: Temporary Remission and Recurrence

BACKGROUND: Transsphenoidal surgery is recommended as initial therapy for microadenomas causing acromegaly. Primary medical therapy with somatostatin analogues has shown to cause a reduction in the size of microadenomas and secretion of growth hormone. Normalization of IGF-1 levels with somatostatin receptor ligand does not occur in most patients treated with primary therapy. We present a case of acromegaly with microadenoma treated with somatostatin analogue showing complete resolution on MRI within 1 year of treatment. We show that after one year of treatment discontinuation, reappearance of microadenoma to original presentation and elevation of IGF-1 was noted. CLINICAL CASE: A 43-year woman presented with headaches, frontal bossing, jaw enlargement and galactorrhea. Initial tests revealed high prolactin 31.6 ng/ml (1.2- 29.9 ng/ml), elevated IGF-1 level of 233 ng/ml (68 – 225 ng/mL) and abnormal growth hormone suppression testing. Brain MRI showed a 4 mm microadenoma within the left side of the pituitary gland. She was referred for neurosurgery, which she declined. Subsequently, medical therapy was started with Cabergoline, resulting in normalization of prolactin14.2 ng/ml (1.2- 29.9 ng/ml). Somatostatin receptor ligand was initiated with lanreotide 90 mg monthly. After 1 year of treatment patient showed clinical improvement, normalized IGF-1 level 67ng/ml (68 – 225 ng/mL) and markedly reduced size of the microadenoma on brain MRI. Patient stopped the medication due to financial difficulties and within one year had a recurrence of symptoms including high IGF-1 of 331ng/ml (68 – 225 ng/mL) and reappearance of the microadenoma on brain MRI. CONCLUSION: Acromegaly is a rare and challenging disease to treat. Somatostatin receptor ligands are not recommended as primary therapy for microadenoma causing acromegaly, despite often needed as adjuvant treatment post-surgery. Medical therapy has been described for patients who do not undergo surgery but is generally not curative. Although we present great improvement in our patient with somatostatin treatment as primary therapy, remission was short lived, and patient will need surgical resection to achieve cure from her disease. Radiological recurrence after discontinuation of medical therapy has not been reported. Using somatostatin receptor ligands as initial therapy for cure of acromegaly offers benefit as demonstrated in our case, but long term remission needs to be evaluated over a longer treatment period. References Ramírez, C., Vargas, G., González, B., Grossman, A., Rábago, J., Sosa, E., Mercado, M. (2012, 1). Discontinuation of octreotide LAR after long term, successful treatment of patients with acromegaly: is it worth trying? European journal of endocrinology, 166(1), 21-26. doi:10.1530/EJE-11-0738

Outcome of Novasure Endometrial Ablation in Women with Heavy Menstrual Bleeding with or without Dysmenorrhoea, Including Those with Uterine Cavity Length More Than 6.5 cm

Heavy Menstrual Bleeding (HMB) is a common health problem and may be associated with iron deficiency anaemia affecting the quality of life of many women. Problems of HMB can be more complicated when it is associated with dysmenorrhea. Traditionally, medical management of HMB has been the first line therapy. Unfortunately, many options can be associated with hormonal side effects or lack of efficacy, leading to discontinuation of medical therapy and requirement of surgical interventions.

Diagnosis, therapeutic response assessment, and detection of disease recurrence in cardiac sarcoidosis: Integral role of cardiac PET

Sarcoidosis is a systemic disease and recognition of cardiac involvement remains challenging. We report a case and illustrate the integral role of cardiac PET perfusion-metabolic imaging in evaluating various stages of cardiac sarcoidosis. A 61-year-old African-American male presented with a 6-month history of progressive exertional dyspnea, cough, palpitations, and atypical chest pain. Physical exam was consistent with acute heart failure and his baseline EKG showed sinus rhythm with frequent premature ventricular contractions. Chest x-ray showed bilateral hilar adenopathy and telemetry monitoring was significant for multiple runs of nonsustained ventricular tachycardia. Echocardiography showed ejection fraction of 30% with global biventricular hypokinesis. Patient underwent coronary angiogram revealing minimal coronary atherosclerosis. A gadolinium-enhanced cardiac MRI was obtained (Figure 1), and a diagnosis of pulmonary and cardiac sarcoidosis was made following which a dual chamber defibrillator was implanted. Prednisone 20 mg daily and methotrexate 12.5 mg weekly was planned. However, given that treatment response and disease progression assessment could not be achieved with serial cardiac MRI (ICD placed), a baseline rest Rubidium 82/F-18 flourodeoxyglucose (Rb-82/18-FDG) cardiac PET was obtained prior to treatment to be used to then assess treatment response with serial scans as indicated showing pattern consistent with active cardiac sarcoidosis (Figure 2). Treatment was initiated and methotrexate titrated up to 15 mg weekly. He was seen in the clinic five months after medical therapy was initiated. Subjectively reported minimal to no symptoms. A repeat cardiac PET was done (Figure 3) using same protocol to assess response to therapy showed marked improvement. His dose of prednisone was decreased to 10 mg daily and then discontinued. Few months later, amiodarone and methotrexate were discontinued due to early development of interstitial lung disease. Seven months after discontinuation of medical therapy, he developed recurrent heart failure symptoms. Echocardiogram EF was 30%-35%. Repeat cardiac PET was done (Figure 4) showing recurrence of active cardiac sarcoidosis. He was reinitiated on prednisone at 50 mg but refused to take it due to weight gain and did not return for follow-up appointments. This case highlights the role of cardiac PET not only in situations where MRI cannot be used but also following treatment response and disease reactivation which is challenging to assess with cardiac MRI. The emerging importance of cardiac PET in cardiac sarcoidosis is now acknowledged in the recent consensus documents and nuclear societies recommendations 1,2 as an indicator of cardiac sarcoidosis in contrast to prior older imaging criteria for CS which included on SPECT or MRI abnormalities. 3 Whole body imaging to evaluate sarcoid activity in other extra cardiac organs apart from the heart and quantitation of standardized uptake values (SUVmax) to enhance diagnosis of disease activity and response to therapy were not available in our study but are key methods to better evaluate and assess sarcoidosis as shown in recent studies. 4

Urethral Lift for Benign Prostatic Hyperplasia: A Comprehensive Review of the Literature

Current treatments for benign prostatic hyperplasia (BPH) include watchful waiting, medical therapy, and interventional procedures. The post-surgical complication profile and the early discontinuation of medical therapy are significant drawbacks of the established approach and stimulate the search for less-invasive approaches. Our aim is to provide a comprehensive review all available literature on prostatic urethral lift (PUL), presenting an overview of safety, indications, surgical technique and results of the procedure, and to evaluate the potential role it could play in the treatment of BPH. A comprehensive search was conduct on PubMed and Scopus database to identify original articles in English dealing with PUL without any limit to publication date. Keywords used were prostatic urethral lift, urethral lifting, Urolift, benign prostatic hyperplasia and minimally invasive therapy. The PUL seems to offer a better IPSS improvement when compared to medical therapy, but the result is inferior when compared to surgical therapy. Published studies report an absence of degradation of erectile or ejaculatory function after treatment, which appears a noteworthy benefit of PUL. Additional advantages of the PUL are a better complication profile in comparison to other surgical therapies and the use of a local anesthesia, sometimes without postoperative catheterization. The PUL, a novel, minimally invasive treatment option for men affected by BPH, presents a promising potential although it is clear that PUL is not a substitute for traditional ablative surgical approach, as this procedure requires a scrupulous selection of the patient.

Extreme Clinical Variability of Dilated Cardiomyopathy in Two Siblings With Alström Syndrome

Alström syndrome (ALMS) is a rare autosomal recessive disorder caused by mutations in the ALMS1 gene. We report two brothers, 3 and 4 years of age and diagnosed with ALMS, who initially presented in infancy with severe dilated cardiomyopathy during febrile respiratory infection. The disease course in the two siblings was marked by significant intrafamilial variability. Although cardiomyopathy in the older sibling has mainly resolved thus allowing for the discontinuation of medical therapy, heart function in the younger sibling continues to deteriorate despite maximal drug support with furosemide, carvedilol, captopril, and aldospirone. Genetic analysis revealed homozygous mutations, c.8008C>T (R2670X), in ALMS1 resulting in premature protein truncation. This report further emphasizes the exceptional intrafamilial variability of ALMS, mainly during the natural course of cardiac disease.

Vertebral Coccidioidomycosis: Presentation and Multidisciplinary Management

BackgroundVertebral involvement is a severe complication of infection caused by Coccidioides species. MethodsWe conducted a retrospective review of patients diagnosed with vertebral coccidioidomycosis at an academic medical center between 1996 and 2009. ResultsWe identified 39 cases of vertebral coccidioidomycosis. Thirty-four patients (79%) were male, and 23 patients (61%) were black. Black patients were overrepresented in comparison with all other patients by a 50-fold odds ratio (95% confidence interval, 26-95). Only 8 patients (20%) were immunocompromised, including 7 who had received systemic steroids. The number of infected vertebrae ranged from 1 to 24; 8 patients (21%) had epidural involvement. All patients received a triazole as part of medical therapy, and 20 patients also received amphotericin B, typically early in the course. Twenty-six patients (67%) required surgery, 18 of whom also required hardware placement. The most common indication for surgery was pain, but 7 patients had neurologic compromise. No patients developed recurrent or refractory infection at the site of surgical debridement, but 6 patients experienced disease relapse after stopping antifungal therapy. ConclusionVertebral infection caused by Coccidioides species requires a multispecialty approach that always includes medical therapy and frequently requires surgical intervention for debridement or stabilization. A favorable outcome can usually be achieved, but discontinuation of medical therapy is associated with a high risk of relapse, which can occur years later.

Pourquoi un traitement local des métastases ?

The local treatment of metastases is based on the natural history of the cancer and its modifications following medical treatment. Local treatment of metastases may be a component of the global treatment of the disease. Local treatment of metastases often is entertained for symptomatic relief. There is a theoretical analogy between surgery, the gold standard of local treatment, and more recent interventional radiology procedures. Local treatment may sometimes lead to discontinuation of medical therapy, either permanently or temporarily, and may at times provide prolonged complete response. The purpose of this article is to further the understanding of the place of local treatment in patients with metastatic solid tumors.

Pathophysiology of Dynamic Left Ventricular Outflow Tract Obstruction in a Critically Ill Patient

Left ventricular outflow tract obstruction is not a rare problem in the intensive care units and can precipitate hemodynamic shock unresponsive to catecholamine therapy. The use of echocardiographic examination is extremely important in recognizing this phenomenon and its underlying conditions, finally identifying the most appropriate therapeutic strategy. The simple correction of one or more of these factors can dramatically change patients clinical outcome. We report the clinical case of a 72-year-old man who developed hemodynamic shock in the intensive care unit. Hypovolemia, catecholamine infusion, and mechanical ventilation induced geometric modification of the left ventricle causing a systolic anterior motion of the mitral anterior leaflet and a severe subaortic gradient. Simple restoration of fluids and discontinuation of medical therapy dramatically changed the outcome of the patient. A review of the medical literature has been carried out to deeply investigate pathophysiology of left ventricular outflow tract obstruction in critically ill patients.

Regression of Normalized Left Ventricular Systolic Function After Discontinuation of Treatment in Patients With Dilated Cardiomyopathy

Regression of Normalized Left Ventricular Systolic Function After Discontinuation of Treatment in Patients With Dilated Cardiomyopathy

Diagnosis and treatment of prolactinomas

Prolactinomas account for approximately 40% of all pituitary adenomas. Hyperprolactinemia causes hypogonadism, infertility and galactorrhea. Macroprolactinomas may cause signs of local expansion, such as headache, visual field defects and paresis of oculomotor nerves during suprasellar and parasellar extensions. Compression of healthy pituitary tissue together with the blockade of the flow of hypothalamic released hormones to the pituitary by macroprolactinomas results in the development of hypopituitarism. The aim of treatment is restoration of hypogonadism and fertility in the microprolactinoma patients, as well as tumor shrinkage in macroprolactinoma patients. Primary therapy for prolactinomas is pharmacological treatment with dopamine agonists (DAs). However, surgical or radiation treatment is recommended for prolactinoma patients resistant or intolerant to DAs. In patients with long-term normoprolactinemia and significant tumor shrinkage, a trial of tapering and discontinuation of medical therapy is possible. After discontinuation of DAs, a long-term follow-up is necessary. In cases of recurrence displaying hyperprolactinemia and tumor enlargement, treatment must be resumed.

WE-D-351-01: Atlas-Based Functional Radiosurgery: Early Results

Purpose: Functional disorders of the brain, such as dystonia and neuropathic pain, may exhibit poor response to medical therapy. The Globus Pallidus pars interna (GPi) and the medial-thalamus are potential targets for surgical or stimulation interventions in these two pathologies, respectively. Radiosurgery is an attractive non-invasive technique to treat dystonia or pain through a radio-induced lesion to create the internal pallidotomy (IP) and medial thalamotomy (MT), respectively, but does not provide the possibility of confirming the target location through microelectrode recording. Computer-aided atlas-based target identification may provide a tool to maximize the anatomic detection of the target. The aim of this work is to show the feasibility of atlas-based functional radiosurgery and evaluate the early results. Method and Materials: The coordinates of GPi, centro-median (CMN) and medio-dorsal (MD) nuclei were identified in the Talairach-Tournoux atlas and transformed to the corresponding regions of the Montreal Neurological Institute (MNI) electronic atlas. Binary masks describing the target nuclei were created. The MNI electronic atlas was deformed onto the patient T1-MRI by applying an affine transformation followed by a local nonrigid registration. The obtained deformation field was then applied to the target masks, which were superimposed on patient T2-MRIs. The radiosurgical targets were thus identified on the patient T2-MRI registered on the treatment CT. Results: Two patients affected by dystonia and neuropathic pain were treated through IP and MT (120 Gy prescribed at 65% and at 77%, respectively) delivered by the CyberKnife. Six month after the treatment, T2- and contrast-enhanced-T1-MRIs showed edematous regions around the targets, whose correct lesion placements were confirmed through DW-MRIs. Complete resolution of dystonia and pain was obtained within 6 months with consequent discontinuation of medical therapy so far required. Conclusion: This work shows that atlas-based target reconstruction is a valid tool to maximize target detection during functional radiosurgery.

Gonadotropin-releasing hormone agonist treatment for endometriosis of the rectovaginal septum

Objective: This study was undertaken to evaluate the effectiveness of a 6-month course of gonadotropin-releasing hormone agonist treatment for patients with symptomatic endometriosis of the rectovaginal septum. Study Design: Fifteen patients with rectovaginal endometriosis and moderate to severe pain symptoms were the subjects of the study. None of these patients had either clinical or objective evidence of ovarian endometriosis, nor was there evidence of any obstructive lesions of the intestine or ureters. All patients were given leuprolide acetate depot at 3.75 mg, 1 ampule intramuscularly every 28 days, and treatment had a planned duration of 6 months. Follow-up evaluations were set every 2 months during the treatment phase and every 3 months thereafter until the completion of 1 year after discontinuation of medical therapy. At each follow-up visit pain symptoms were recorded, and clinical exploration, transvaginal ultrasonography, and transrectal ultrasonography were performed. Results: Two patients stopped the treatment early after the second and fourth leuprolide doses; in both cases the reason was persistence of pain, and both requested a surgical solution. The other 13 patients showed a marked improvement with respect to pain during the 6-month treatment course but had early pain recurrence after drug suspension; 11 of them required further treatment within the first year of follow-up. The failure rate of gonadotropin-releasing hormone agonist therapy to produce 1-year pain relief after treatment discontinuation was 87% (13/15) on an intent-to-treat basis. The endometriotic lesions showed a slight but significant reduction in size during therapy but had returned to the original volume within 6 months after cessation of the gonadotropin-releasing hormone analog treatment. Conclusion: Our results suggest that gonadotropin-releasing hormone analogs should not be considered a real therapeutic alternative to surgical treatment for patients with symptomatic endometriosis of the rectovaginal septum, except possibly in a limited and unpredictable number of cases. (Am J Obstet Gynecol 2000;183:1462-7.)

Results of short-and long-term medical treatment of gastroesophageal reflux disease (GERD).

Symptomatic esophageal reflux affects a large number of individuals. Many find relief by avoiding trigger substances such as coffee or sweets; in other cases, lifestyle modifications do not suffice and drug treatment is necessary for symptom control. An adequate classification of gastroesophageal reflux disease (GERD) is currently lacking; esophagitis can be graded according to Savary and Miller or the more recent metaplasia ulcer stricture erosions (MUSE) classification. The control of symptoms should be achieved in all patients: in addition, if esophagitis is present, the healing of erosions/ulcers as well as the prevention of further complications, such as strictures, hemorrhage, Barrett's esophagus or ulceration, must be accomplished. SHORT-TERM TREATMENT: In the case of rare symptoms, control might be achieved by lifestyle modifications and by antacids or mucosal protectants taken on demand. In the case of continuous symptoms or signs of esophagitis, effective inhibition of gastric acid secretion with proton pump inhibitors (PPIs) is necessary in many patients. After discontinuation of medical therapy, almost all patients with esophagitis will experience a relapse within 30 weeks. The regimen offering the highest rate of remission in these patients is the one that induced remission in the first place. Reduction of PPI dose or a switch to H2 receptor antagonists increases the rate of relapse. RISKS OF LONG-TERM TREATMENT: Long-term acid suppressive therapy, as with the use of PPIs, may lead to hypergastrinemia, a situation in which the endocrine cells of the stomach may proliferate. In the presence of Helicobacter pylori infection, PPIs are more efficient in healing esophagitis; however, the occurrence of gastric mucosal atrophy, a potentially pre-cancerous condition, has been described. To date, however, no case of gastric cancer or endocrine neoplasia associated with PPI treatment has been documented; gastric mucosal atrophy is more likely to result from H. pylori infection and gastric carcinoid formation needs a genetic predisposition, such as multiple endocrine neoplasia (MEN) type I. Most cases of GERD can be effectively treated by non-surgical measures; in patients presenting with warning symptoms or persistent heartburn, endoscopy of the upper gastrointestinal tract is mandatory. Long-term use of PPIs seems to be a safe and efficient treatment for GERD. For the prevention of relapse, similar doses are needed as for the induction of remission in reflux esophagitis.

Characteristics, management, and midterm outcome in infants with atrioventricular nodal reentry tachycardia

Atrioventricular nodal reentry is a commonly recognized mechanism of supraventricular tachycardia (SVT) in adults, but is only rarely documented in the first year of life. The aim of this study was to elucidate characteristics, management, and outcome in infants with atrioventricular nodal reentrant tachycardia (AVNRT). Electrophysiologic studies performed between January 1988 and June 1996 were reviewed. Fifteen infants with AVNRT at 58 ± 27 days (mean ± SEM) were identified. Five had AVNRT detected following palliation of structural cardiac anomalies, including 4 with critical obstructions to left ventricular outflow. Typical AVNRT (ventriculoatrial interval 49 ± 5 ms) was observed in 14 of 15 patients and atypical AVNRT (ventriculoatrial interval 191 ± 22 ms) in 4 of 15. All patients received long-term therapy, beginning with digoxin in 13. Eight had symptomatic recurrences on digoxin and 6 of these were given β blockers, with satisfactory control in 4. Three patients were controlled with class III agents, and 2 underwent slow pathway radiofrequency modification at ages 4.1 and 6.7 years, respectively. AVNRT was still inducible in 6 of 6 asymptomatic patients who underwent follow-up atrial stimulation studies after discontinuation of medical therapy. All 15 patients were alive with either absent or well-controlled AVNRT at age 45 ± 7 months. We conclude that the course and outcome of AVNRT diagnosed in the first year of life are generally benign, but that a minority of patients have symptoms persisting beyond infancy. Digoxin is of questionable benefit in long-term control. AVNRT often remains inducible in asymptomatic patients, although the significance of this finding remains to be determined by long-term follow-up.

Omeprazole, Hypergastrinemia, and Gastric Carcinoid Tumors

Editorials1 August 1994Omeprazole, Hypergastrinemia, and Gastric Carcinoid TumorsJames W. Freston, MD, PhDJames W. Freston, MD, PhDUniversity of Connecticut Health Center; Farmington, CT 06030Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-121-3-199408010-00012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The long-term management of reflux esophagitis is challenging because of the frequency of symptomatic relapses and the uncertain efficacy and safety of long-term treatment with acid-suppressing drugs. Reflux esophagitis recurs within 6 months in at least 80% of patients after discontinuation of medical therapy [1]. Thus, some patients, such as those described in this issue by Klinkenberg-Knol and colleagues [2], require continuous therapy with omeprazole. Despite its superior efficacy when compared with histamine-2-(H2) receptor antagonists in healing reflux esophagitis [3] and maintaining remissions [4], clinicians have generally been reluctant to treat patients chronically with omeprazole because of concerns about the ...