Medical Treatment In Patients Research Articles

Myocardial viability for decision-making concerning revascularization in patients with left ventricular dysfunction and coronary artery disease: A meta-analysis of non-randomized and randomized studies

BackgroundMyocardial viability tests have been proposed as a key factor in the decision-making process concerning coronary revascularization procedures in patients with left ventricular dysfunction and coronary artery disease (LVD–CAD). MethodsWe performed a systematic review and meta-analysis of studies that compared medical treatment with revascularization in patients with viable and non-viable myocardium and recorded mortality as outcome. ResultsThirty-two non-randomized (4328 patients) and 4 randomized (1079 patients) studies were analyzed. In non-randomized studies, revascularization provided a significant mortality benefit compared with medical treatment (p<0.05). Since the heterogeneity was significant (p<0.05) a viability subgroup analysis was performed, showing that revascularization provided a significant mortality benefit compared with medical treatment in patients with viable myocardium (p<0.05) but not in patients without (p=0.34). There was a significant subgroup effect (p<0.05) related to the intensity of the effect, but not to the direction. In randomized studies, revascularization did not provide a significant mortality benefit compared with medical treatment in either patients with viable myocardium or those without (p=0.21). There was no significant subgroup effect (p=0.72). Neither non-randomized nor randomized studies demonstrated any significant difference in outcomes between patients with and without viable myocardium. ConclusionsThe available data are inconclusive regarding the usefulness of myocardial viability tests for the decision-making process concerning revascularization in LVD–CAD patients.Patients with viable myocardium appear to benefit from revascularization, but similar benefits were observed in patients without viable myocardium. Moreover, a neutral or adverse effect of revascularization cannot be excluded in either group of patients.

Long-term results of medical treatment in patients with a severe attack of ulcerative colitis

To assess the long-term result of medical treatment in patients with a severe attack (SA) of ulcerative colitis (UC). The course of UC was analyzed in 56 patients who were accessible by telephone contact and consecutively recruited for a year after therapy for a SA of UC. All the patients were stated to have a SA of UC according to the Truelove-Witts' criteria; they received therapy with intravenous glucocorticosteroids (GCS) (prednisolone 2 mg/kg) along with anti-recurrence therapy with mesalasine (5-ASA) or azathioprine (AZA). Ten (17.9%) GCS-resistant patients were given infliximab (INF) (5 mg/ kg), followed by its maintenance infusions. Anti-recurrence therapy using 5-ASA, AZA, and INF was performed in 33 (58.9%), 13 (23.2%), and 10 (17.9%) patients, respectively. During one year, 14 (25%) patients continued to be in clinical remission on maintenance therapy or to have attacks stopped without using GCS, immunosuppressive agents, or INF (a satisfactory response group). Colectomy was carried out in 23 (41.1%) patients; due to recurrent UC when decreasing the dose of GCS, 5 (8.9%) patients continued to take the latter during a year. A GCS cycle was repeated in 3 patients who had received AZA (the basic therapy was not corrected) and 11 patients who had taken 5-ASA. The prognostic factors for a long-term result of medical therapy included the choice of AZA as an anti-recurrent drug (57.1 and 11.9% in the satisfactory and poor treatment outcome groups, respectively; p = 0.004) and patient age (34.4 and 42.8 years, respectively; p = 0.0357). During 1 year after a SA of UC, indications for colectomy and repeated GCS use occurred in 41 and 34% of the patients, respectively. The long-term efficiency of medical therapy for a SA of UC declines with advancing age. The use of AZA as an anti-recurrence agent after termination of GCS intake increases the probability of long-term clinical response.

Update on medical treatment of patients with eisenmenger syndrome.

Eisenmenger syndrome (ES) is the most advanced form of pulmonary arterial hypertension (PAH) associated with congenital heart defects. ES greatly affects functional capacity, quality of life, and survival of patients. Clinical management of patients with ES has been dramatically changed and developed in a new therapeutic era of PAH, approximately a century after the first ES case described by Dr. Eisenmenger. Targeted drugs for PAH improve functional capacity and quality of life of patients with ES. In addition, these drugs may also provide a benefit for patients' survival. To achieve further development in medical treatment of patients with ES, they will need to be individualized according to functional classes, underlying cardiac defects, and underlying systemic diseases.

Personalized antiplatelet therapy with P2Y12 receptor inhibitors: benefits and pitfalls.

Antiplatelet therapy with P2Y12 receptor inhibitors has become the cornerstone of medical treatment in patients with acute coronary syndrome, after percutaneous coronary intervention and in secondary prevention of atherothrombotic events. Clopidogrel used to be the most broadly prescribed P2Y12 receptor inhibitor with undisputable benefits especially in combination with aspirin, but a considerable number of clopidogrel-treated patients experience adverse thrombotic events in whom insufficient P2Y12-inhibition and a consequential high on-treatment platelet reactivity is a common finding. This clinically relevant limitation of clopidogrel has driven the increased use of new antiplatelet agents. Prasugrel (a third generation thienopyridine) and ticagrelor (a cyclopentyl-triazolo-pyrimidine) feature more potent and predictable P2Y12-inhibition compared to clopidogrel, which translates into improved ischemic outcomes. However, excessive platelet inhibition and consequential low on-treatment platelet reactivity comes at the price of increased risk of major bleeding. The majority of randomized clinical trials failed to demonstrate improved clinical outcomes with platelet function testing and tailored antiplatelet therapy, but results of all recent trials of potent antiplatelets and prolonged antiplatelet durations point towards a need for individualized antiplatelet approach in order to decrease thrombotic events without increasing bleeding. This review focuses on potential strategies for personalizing antiplatelet treatment.

Safety and Efficacy Analyses of Angioplasty and Stenting for Severe Intracranial Arterial Stenosis: A Single-Center Retrospective Study in China.

BackgroundThe value of percutaneous transluminal angioplasty and stenting (PTAS) in the context of aggressive medical treatment for severe intracranial artery stenosis (ICAS) is under debate. This study compared the effects of PTAS and aggressive medical treatment in patients with severe ICAS and transient ischemic attack or stroke.Material/MethodsA retrospective cohort study was performed. Patients with severe ICAS were assigned to a PTAS group or aggressive medical treatment group, according to the angiographic features of the stenotic lesions. The primary outcome was defined as stroke or death within 30 days or cerebral ischemia occurring ipsilaterally to the qualifying artery beyond 30 days.ResultsWe included 220 patients: 48 in the PTAS group and 172 in the medical group. The median follow-up was 32 months. PTAS was not associated with an increased incidence of the primary outcomes (10/42 vs. 39/172, p=0.96) or increased risks of the secondary outcomes of stroke, cardiovascular events, major bleeding, or mortality. The results of log-rank tests did not support a significant difference in event-free survival as a primary outcome between the 2 groups (chi-square=0.07, p=0.79). Moreover, although not significantly greater, the mean survival of patients in the PTAS group appeared to be better than that among patients in the medical group, as indicated by the curve for cumulative survival.ConclusionsA suitable PTAS procedure is safe for patients with severe ICAS, and no significant differences in incidence of recurrent stroke or death were found between PTAS and aggressive medication treatment.

The adverse influence of spina bifida occulta on the medical treatment outcome of primary monosymptomatic nocturnal enuresis.

Previous reports have suggested that the incidence of spina bifida occulta (SBO) in patients with primary monosymptomatic nocturnal enuresis (PMNE) is higher than the general population. The purpose of this study was to investigate the effect of spina bifida occulta on the medical treatment outcome of PMNE. Between January 2008 and December 2011, a total of 223 children (151 boys and 72 girls, aged 6-16 years; mean age: 10.1 ± 3.04 years) with PMNE were reviewed retrospectively. All of the children underwent physical examination, urine analysis, urinary tract ultrasonography and kidney ureter bladder (KUB) scout film. All patients were initially treated with a timed voiding program and were given desmopressin acetate when necessary. Spina bifida occulta was detected in 75 children (33.6%). Spina bifida occulta affected L4 in 2 children, L5 in 6 children, L4-L5 in 3 children, S1 in 52 children, S2 in 7 children and S1-S2 in 2 children. Treatment was successful in 79% of the children without SBO, and in only 48% of the children with SBO. Medical treatment success rates differed significantly between the study groups. The presence of spina bifida occulta significantly affects the response to medical treatment in patients with PMNE. Thus, verifying spina bifida occulta status in PMNE can facilitate prognostic predictions about the response to medical treatment.

61. Natural history and outcome of 200 outpatients with classical trigeminal neuralgia treated with carbamazepine or oxcarbazepine in a tertiary centre for neuropathic pain

Carbamazepine (CBZ) and oxcarbazepine (OXC) are the first-choice medical treatments in patients with trigeminal neuralgia (TN). The aim of this retrospective study was to analyze the natural history of classical TN in a large cohort of patients, focusing on drug responsiveness, side effects, and changes in pain characteristics during the course of disease. We selected the last 100 consecutive patients with typical TN treated with CBZ and the last 100 with OXC. All had MRI scans and a complete neurophysiological study of trigeminal reflexes. The initial number of responders was 98% with CBZ and 94% with OXC. In a mean period of 8.6 months, 26% of responders to CBZ incurred in undesired effects leading to interruption of treatment or a dosage reduction to an unsatisfactory level. In a mean period of 13 months, the same occurred to 18% of responders to OXC. We found that the worsening of pain with time and the development of late resistance occurred in a small minority of patients. CBZ and OXC were efficacious in a large majority of patients, but the side effects caused withdrawal from treatment in an important percentage of patients, suggesting the opportunity to develop a drug better tolerated.

Artificial nutrition in gastrointestinal diseases

The association between nutrition and intestinal function is based on facts. The main function of the gut is to digest and absorb nutrients in order to maintain life. Consequently, chronic gastrointestinal diseases commonly result in malnutrition and increased morbidity and mortality. Chronic malnutrition impairs digestive and absorptive function. Parenteral and enteral nutritions are effective therapeutic modalities in several diseases. In cases of gastrointestinal malfunctions, nutrition has a direct therapeutic role. The benefit of nutrition therapy is similar to medical treatment in patients with pancreatitis, Crohn disease, hepatic failure, and in those with gastrointestinal fistulas. Nutrition has both supportive and therapeutic roles in the management of chronic gastrointestinal diseases. With the development of modern techniques of nutritional support, the morbidity and mortality associated with chronic gastrointestinal diseases can be reduced.

S37 Vascular Endothelial Cell Growth Factor-a (vegf-a) Signalling And Neovascularisation Of Pulmonary Endarterectomy Material In Chronic Thromboembolic Pulmonary Hypertension (cteph)

Background Despite recent advances in the medical treatment of patients with CTEPH, relatively little is understood surrounding the underlying pathological mechanisms. Many patients have a historical documented venous thromboembolic event (VTE) and consequently, failed resolution of an acute VTE has been proposed as a key initiating factor in the subsequent development of CTEPH. Here we investigated VEGF-A levels, a key regulator of angiogenesis, in CTEPH patients prior to and following pulmonary endarterectomy (PEA) surgery to remove the thromboembolic material. We also examined the surgically excised PEA material and measured neovessel density in distal regions of the specimens. Methods and results Serum VEGF-A levels were measured by Luminex array in paired serum samples from n = 44 patients at baseline (before PEA surgery) and following PEA surgery. Following PEA surgery, serum VEGF-A levels were significantly reduced compared to baseline measurements (159.5 ± 174.8 vs. 194.4 ± 198.2, p = 0.0182). Distal regions of excised PEA material were cross sectioned and processed for histopathological examination. Neovessel density was calculated by counting the absolute number of vascular channels present within a cross-sectional area and normalised to tissue area using Image J. We also measured the time between documented VTE and subsequent PEA surgery (VTE-PEA time) in patients with a documented VTE (n = 40/44 [90%] patients), and identified an inverse correlation between neovessel density and VTE–PEA time. Conclusions Extensive angiogenesis was evident in distal PEA material from patients with CTEPH. VEGF-A is known to be a key regulator of angiogenesis and serum levels were significantly reduced following PEA surgery. Interestingly, a significant inverse correlation between neovessel density and VTE-PEA time was observed indicating that in the early stages following VTE, extensive angiogenesis is evident within the thromboembolus. Taken together these data provide further evidence that angiogenesis is an important mechanism in the attempted resolution of a VTE.

It's Funny Here. Is It There?

Last month’s column focused on theories of humor – the motivations behind humor – and the therapeutic use of humor and laughter as an adjuvant to medical treatment for patients with a variety of illnesses (Flaskerud, 2014). The theoretical motivations for humor described in the last column included several based on psychology – the expression of negative emotions, such as aggression and superiority; a coping mechanism for tension release; a means to resolve incongruity; a benign violation of various norms; and reverse engineering, an evolutionary development to correct errors in perception, based on neuroscience. The positive aspects of humor and the therapeutic use of laughter were explored also (Flaskerud, 2014). Several reports have demonstrated that laughter appears to improve mood, lessen anxiety, reduce psychological measures of stress, and reduce perception of pain (Christie & Moore, 2005). There are also physiological factors involved. Laughter can lead to changes in heart rate, skin temperature, blood pressure, pulmonary ventilation, skeletal muscle activity, and brain activity, which may improve overall wellbeing. Additionally, laughter may improve immune function by blocking the production of stress hormones, such as cortisol, and by increasing the release of immune-enhancers, such as beta-endorphin (Cancer Treatment Centers of America, 2013; Christie & Moore, 2005). Two other aspects of humor will be addressed here, as they apply to cultural differences and the use of humor. The first is: Are there other theoretical explanations of humor that do not rely on Western psychology and neuroscience? And second: Are humor and laughter used therapeutically in other cultures? It should be noted that humor and laughter are considered human traits: only humans have humor and we communicate it

Withdrawal and withholding of medical treatment for patients lacking capacity who are in a critical condition--reflections on the judgment of the Supreme Court in Aintree University Hospitals NHS Foundation Trust v James.

Consideration of recent judgment of the Supreme Court in leading case concerning the withdrawal and withholding of medical treatment for a patient lacking capacity who was in a critical condition.

PO-0249 Medical Treatment Of Hydatid Cysts: About 6 Cases

Background and aims Hydatidosis is a common parasitic disease which is still endemic in Tunisia. Treatment is usually surgical. Medical treatment is rarely recommended. The aim of our study is to evaluate follow-up and response to medical treatment in patients affected by hydatid cystis (HC). Methods We conducted a retrospective study about all cases of HC treated by albendazole in paediatrics department of Hedi Chaker University Hospital in Sfax over a period of 10 years (2004–2013). Results We report 6 cases of HC treated medically. Ages ranged between 2 and 8 years. Diagnosis was based on laboratory and imaging studies. Hydatid cystis had multiple localizations in all of cases: multiple hepatic HC (1 case), bilateral pulmonary HC (1 case), hepatic and pulmonary HC (1 case), hepatic and splenic HC, hepatic, splenic and renal HC and hepatic, pulmonary, cardiac and pancreatic HC. All patients were treated with Albendazole (10 mg/kg/day during 6 to 24 months). Surgical treatment was associated in 4 cases. The outcome was favourable in all cases. Conclusions Surgery remains the ideal treatment for hydatid cysts. However, medical treatment with albendazole can be efficient and can, in some circumstances, replace surgery especially in case of multiple locations.

Clinical Case of the Korean Medical Treatment for the Patient with Anterior Interosseous Nerve Syndrome

The purpose of this study is to suggest a possibility of the Korean medical treatment in patient with anterior interoseous nerve entrapment syndrome. The patient treated with acupunture, herbal medicine and Needle-embedding Therapy from April 19th to May 15th. We measured Visual Analotgue Scale(VAS), and Observed the change in body tempreture using Digital Infrared Thermal Imaging(DITI). After received Korean medical treatment, the patient showed improvement in muscle strength, sensation, VAS, temperature differential. Therefore we can consider Korean medical treatment before operation in interosseous nerve syndrome.

Cost Effectiveness of Percutaneous Closure Versus Medical Therapy for Cryptogenic Stroke in Patients With a Patent Foramen Ovale

In patients with patent foramen ovales (PFOs) and cryptogenic stroke, observational studies have demonstrated reductions in recurrent neurologic events with transcatheter PFO closure compared with medical therapy. Randomized controlled trials and meta-analyses have shown a trend toward benefit with device closure. The cost-effectiveness of PFO closure has not been described. Therefore, a detailed cost analysis was performed using pooled weighted outcome and complication rates from published randomized controlled trials, Medicare cost tables, and wholesale medication prices. Incremental cost per life-year gained and per quality-adjusted life-year (QALY) gained by PFO closure was calculated. The commonly accepted cost-effectiveness threshold of <$50,000/quality-adjusted life-year gained was used. At 2.6 years (the mean duration of randomized controlled trial follow-up), PFO closure was more costly ($16,213, 95% confidence interval [CI] $15,753 to $16,749) per patient, with a cost of $103,607 (95% CI $5,826 to $2,544,750) per life-year gained. The expenditure to prevent 1 combined end point (transient ischemic attack, stroke, and death) at 2.6 years was $1.09 million (95% CI $1.04 million to $1.20 million). Modeling the costs of medical treatment prospectively, PFO closure reached cost-effectiveness (<$50,000/quality-adjusted life-year gained) at 2.6 years (95% CI 1.5 to 44.2). At 30.2 years (95% CI 28.2 to 36.2), the per patient mean cost of medical therapy exceeded that of PFO closure. In conclusion, PFO closure is associated with higher expenditures related to procedural costs; however, this increase may be offset over time by reduced event rates and costs of long-term medical treatment in patients who undergo transcatheter PFO closure. In younger patients typical of cryptogenic stroke, PFO closure may be cost effective in the long term.

Laparoscopic bariatric surgery for the treatment of severe hypertriglyceridemia

It is well established that severe hypertriglyceridemia can lead to pancreatitis. At present, medical treatment for patients with severe hypertriglyceridemia and repeat pancreatitis attacks is not adequate. The aim of this study was to assess the effectiveness of laparoscopic bariatric surgery in these patients. A review of 20 morbidly obese patients with severe hypertriglyceridemia (a triglyceride level of >1000mg/dL) who received laparoscopic bariatric surgery was performed. The study population comprised 14 males and six females, with an average age of 35.0 years (range 24-52 years), and the mean body mass index was 38.2kg/m(2) (range 25-53kg/m(2)). The preoperative mean plasma triglyceride level was 1782.7mg/dL (range 1043-3884mg/dL). Four patients had a history of hypertriglyceridemic pancreatitis and 13 patients had associated diabetes. Of the 20 patients, 17 (85%) received gastric bypass, whereas three (15%) received restrictive-type surgery. Laparoscopic access was used in all of the patients. Hypertriglyceridemia in morbidly obese patients was more commonly associated with male sex and a poorly controlled diabetic state. The mean weight reduction was 25.5% 1 year after surgery, with a marked improvement in diabetes management. As early as 1 month following surgery, the plasma mean triglyceride levels had decreased to 254mg/dL (range 153-519mg/dL), and this was further reduced to mean levels of 192mg/dL (range 73-385mg/dL) 1 year after surgery. One patient developed acute pancreatitis during the perioperative period, but none of the patients suffered an episode of pancreatitis in the follow-up period (from 6 months to 13 years). Bariatric surgery can be successfully used as a metabolic surgery in severe hypertriglyceridemia patients at risk of acute pancreatitis. However, control of triglyceride levels prior to bariatric surgery is indicated.

Hypnosis in Spain (1888–1905): From spectacle to medical treatment of mediumship

Towards the end of the nineteenth century, some Spanish physicians sought to legitimize hypnotherapy within medicine. At the same time, hypnotism was being popularized among the Spanish population through stage hypnosis shows. In order to extend the use of medical hypnotherapy, some physicians made efforts to demarcate the therapeutic use of hypnotic suggestion from its application for recreational purposes, as performed by stage hypnotists. However, in the eyes of some physicians, the first public session to legitimize hypnotherapy turned out to be a complete failure due to its similarities with a stage hypnosis performance. Apart from exploring this kind of hitherto little-known historical cases, we explore the role of spiritists in legitimizing medical hypnosis. At a time when Spanish citizens were still reluctant to accept hypnotherapy, the spiritists sponsored a charitable clinic where treatment using hypnosis was offered. We conclude that the clinic was effective in promoting the use of hypnotherapy, both among physicians as clinical practice, and as a medical treatment for patients from the less privileged classes of Spanish society.

Fracture mortality: associations with epidemiology and osteoporosis treatment.

The rates of incident osteoporotic fractures seem to be stabilizing; however, fragility fractures are still associated with considerable disability, costs and an increased risk of mortality, which is particularly the case for fractures of the hip and vertebra. Mortality is usually highest during the first year after fracture; however, a notably increased mortality risk might persist for several years after the event. In addition to its efficacy in the prevention of new and recurrent osteoporotic fractures, medical treatment has been associated with improved survival after osteoporotic fractures. Observational studies and randomized controlled clinical trials have reported increased survival in patients with a fracture who are treated with bisphosphonates. Rates of medical treatment in patients with osteoporosis remain low, and although the rationale for the putative increase in survival is unclear, this emerging evidence might help further justify the use of medical treatment after fracture. However, further work is needed before medical therapy for mortality prevention in patients with osteoporotic fractures is accepted.

Pharmacotherapy in the treatment of patients with borderline personality disorder: results of a survey among psychiatrists in private practices.

Pharmacotherapy still seems to play a major role in the treatment of patients suffering from borderline personality disorder (BPD). However, little is known about psychiatrists’ detailed perspective on indication and significance of medication. A total of 233 psychiatrists in the city of Munich and in Upper Bavaria were asked by questionnaire about their treatment habits in the medical treatment of patients with BPD. One hundred and forty-one psychiatrists answered the questionnaire (60.5%). In total, 94% of BPD patients were treated with psychotropic medication. Psychiatrists predominantly saw an indication to prescribe antidepressants (98%), followed by antipsychotics, mood stabilizers, and benzodiazepines. Citalopram/escitalopram and quetiapine were mentioned most frequently. The results are discussed in conjunction with the international guidelines for the treatment of BPD.

En la estenosis carotídea asintomática, salvo excepciones, el tratamiento médico es el más adecuado

Asymptomatic carotid stenosis (ACS) has a high prevalence and a small possibility of stroke. Its treatment involves the application of the so-called, intensive medical treatment (IMT) of the arteriosclerosis, and in selected cases, carotid surgery, either by endarterectomy (TEA) or a Stent (CAS). The current indications are based on old clinical trials in which the current medical treatment was not applied, and the only selection criterion relating to the lesion was the grade of stenosis. With the application of IMT, the stroke rate in patients with ACS is currently similar to that obtained in the surgical arm of the clinical trials, results that are better than in normal practice. If there is a sub-group of patients who could benefit from surgery, then they are those with an unstable plaque despite the IMT. For all this, we should be cautious when performing a surgical intervention in patients with ACS. Randomised clinical trials are needed to compare CAS, TEA, and the improved medical treatment in patients with ACS.

Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis

Objective To investigate whether revascularisation improves prognosis compared with medical treatment among patients with stable coronary artery disease.Design Bayesian network meta-analyses to combine direct within trial comparisons between treatments with...