Oral Medical Therapy Research Articles

Surgical Results of Selective Median Neurotomy for Wrist and Finger Spasticity

This study aimed to evaluate the surgical outcomes of selective median neurotomy (SMN) for spastic wrist and fingers. We studied 22 patients with wrist and finger spasticity refractory to optimal oral medication and physical therapy. The authors evaluated spasticity of the wrist and finger muscles by comparing preoperative states with postoperative states using the modified Ashworth scale (MAS). We checked patients for changes in pain according to the visual analog scale (VAS) and degree of satisfaction based on the VAS. The preoperative mean MAS score was 3.27±0.46 (mean±SD), and mean MAS scores at 3, 6, and 12 months after surgery were 1.82±0.5, 1.73±0.7, and 1.77±0.81 (mean±SD), respectively. On the last follow-up visit, the mean MAS score measured 1.64±0.9 (mean±SD). Wrist and finger spasticity was significantly decreased at 3, 6, and 12 months after the operation (p<0.01). The preoperative mean pain VAS score was 5.85±1.07 (mean±SD), and the mean pain VAS score on the last follow-up visit after surgery was 2.28±1.8 (mean±SD). Compared with the preoperative mean pain VAS score, postoperative mean pain VAS score was decreased significantly (p<0.01). On the basis of a VAS ranging from 0 to 100, the mean degree of patient satisfaction was 64.09±15.93 (mean±SD, range 30-90). The authors propose SMN as a possible effective procedure in achieving useful, long-lasting tone and in gaining voluntary movements in spastic wrists and fingers with low morbidity rates.

E0454 The impact of therapy on 6-months health-related quality of life following acute coronary syndrome

BackgroundFew studies have focused on the change of health-related quality of life following acute coronary syndrome, to compare of oral medical therapy, percutaneous coronary intervention and coronary artery bypass grafting....

Treatment choice, duration, and cost in patients with interstitial cystitis and painful bladder syndrome.

Introduction and hypothesisIn order to better understand provider treatment patterns for interstitial cystitis (IC)/painful bladder syndrome, we sought to document the therapies utilized and their associated expenditures using a national dataset.MethodsA cohort was created by applying the ICD-9 diagnosis of IC (595.1) to INGENIX claims for the year 1999. Subjects were followed for 5 years, and patterns of care and related expenditures were evaluated.ResultsOf 553,910 adults insured in 1999, 89 subjects had a diagnosis of IC with 5-year follow-up data. All subjects were treated with oral medication(s), 26% received intravesical treatments, and 22% underwent hydrodistension. Total expenditures per subject were $2,808.ConclusionsThe majority of IC expenditures were attributable to oral medical therapy. Hydrodistension and intravesical instillations were utilized in less than 25% of patients. Hydrodistension was used more frequently among subjects with a new diagnosis; this may reflect its utilization as part of a diagnostic algorithm.

Patient perspectives in the development and use of long-acting antipsychotics in schizophrenia: focus on olanzapine long-acting injection

Schizophrenia is a chronic mental disorder generally treated with antipsychotic medication. However, non-adherence and partial adherence to antipsychotic medication treatment is common and long-acting injectable "depot" preparations of antipsychotic medications have been used as an alternative to oral medication therapy for patients for whom adherence is a clinically significant problem, as well as for the sake of convenience and in response to patient preference. Olanzapine long-acting injection (OLAI) is a new treatment option and has been approved by several regulatory agencies for the treatment of schizophrenia. OLAI is a crystalline salt formulation of olanzapine and pamoic acid. Efficacy was established in 2 double-blind randomized clinical trials of OLAI for the treatment of acute schizophrenia and for the maintenance of response. The therapeutic OLAI dosages are 150 mg q2 weeks, 210 mg q2 weeks, 300 mg q2 weeks or q4 weeks, and 405 mg q4 weeks, administered by deep intramuscular gluteal injection with a 19-gauge needle. Injection volume ranges from 1 to 2.7 mL. OLAI has essentially the same general tolerability as that of oral olanzapine; however with the depot there is the additional risk of a post-injection delirium sedation syndrome occurring at a rate of 0.07% of injections, requiring a risk management plan that includes observing the patient for 3 hours post injection.

In situ anterior vaginal wall sling for treatment of stress urinary incontinence: extended application and further experience.

Our aim was to evaluate the efficacy of utilizing in situ anterior vaginal wall sling in the treatment of stress urinary incontinence (SUI). The study included 11 women with a median age of 50 years (range, 36 to 60 years) who were operated on during the period of November 2005 to August 2006. They were diagnosed with SUI and were operated on using placard-shaped in situ anterior vaginal wall sling technique. Nine patients underwent surgical treatment for the first time, while 2 patients had postoperative recurrent SUI. In all of the patients, urethral hypermobility with or without cystocele was observed. The mean follow-up period was 22.5 months (range, 17 to 28 months). Ten patients (90.9%) were considered cured and 1 (9.1%) started leakage of urine after 1 month during the postoperative period. One patient (9.1%) had urinary retention. Three patients (27.3%) had evidence of wound infection which was treated by appropriate oral medical therapy. In situ anterior vaginal wall sling technique is accredited with a good success rate and low incidence of complications. It is easy to learn and cost-effective, making it a suitable technique for SUI. Longer follow-up and larger number of patients are needed before final conclusion could be drawn.

Double-J Stenting Compared with One Night Externalized Ureteral Catheter Placement in Tubeless Percutaneous Nephrolithotomy

We prospectively analyzed the outcome of tubeless percutaneous nephrolithotomies (PCNLs) using two different stenting techniques (i.e., externalized ureteral catheter compared with Double-J placement) without strict exclusion or inclusion criteria. Forty-six patients who were undergoing tubeless PCNL were randomized to two groups: Group 1 (tubeless PCNL with externalized ureteral catheter) and group 2 (tubeless PCNL with Double-J placement). The only exclusion criterion was presence of significant residual stones. The two groups were comparable with regard to age, sex, stone laterality, stone burden, and number of previous open renal surgeries. Factors evaluated included operative time, stent-related symptoms, analgesic requirement, postoperative pain, postoperative morbidity, hospital stay, blood loss, and success rates. The mean operative times, mean number of accesses, percentage of supracostal accesses, mean visual analog scale scores, analgesic requirements, mean decreases in hemoglobin level, blood transfusion rates, success rates, and mean hospital stays were not statistically significant in both groups. The only statistically significant difference between groups was the postoperative stent-related symptoms. In group 2, 52.1% experienced some sort of stent-related symptoms. In most of the patients, these symptoms were not severe; however, in two of them (16.6 %), oral medication therapy with anticholinergics was needed. None of the patients in group 1 had stent-related symptoms and needed medication (P < 0.01). Tubeless PCNL with externalized ureteral catheter is as feasible as Double-J stenting. Moreover, stent-related discomforts because of the presence of a Double-J stent and the need for postoperative cystoscopy to remove the Double-J stent can be avoided with an externalized ureteral catheter.

Self-Monitoring of Blood Glucose Among Adults With Diabetes—United States, 1997-2006

Blood-glucose control is critical for managing diabetes and preventing diabetes-related complications such as cardiovascular disease, retinopathy, nephropathy, and neuropathy. In addition to recommending that patients with diabetes have a glycated hemoglobin (HbA1c) measurement at least two times a year, the American Diabetes Association recommends self-monitoring of blood glucose (SMBG) as an integral part of diabetes management for patients who are treated with insulin and as a useful component for achieving glycemic goals for patients who use oral medications or medical nutrition therapy. One of the Healthy People 2010 national objectives is to increase to 61% the proportion of persons with diabetes who perform SMBG at least once a day (objective 5-17). To estimate the rates of SMBG and to track the progress of states during 1997-2006, CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) for that period. This report summarizes the findings of that analysis, which indicated that the proportion of adults with diabetes who check their blood glucose at least once a day increased at the national level, and 25 of the 38 states examined had statistically significant rate increases from 1997 to 2006. In 2006, the daily SMBG rate was 63.4% among all adults with diabetes and 86.7% among those treated with insulin. Collaborations to ensure adequate health insurance coverage, diabetes education and counseling to encourage more intensive medical care and self-management practices, and continued surveillance measures to track changes in SMBG rates are needed to improve and monitor SMBG trends.

Cervical Dystonia

Cervical dystonia, which is the most common form of focal dystonia, presents with sustained neck spasms, abnormal head posture, head tremor, and pain. One of the interesting and unique features of cervical dystonia is the geste antagoniste. There is not a well-described pathophysiology for cervical dystonia, but several hypotheses report involvement at the central and peripheral level. Treatment options include: oral medical therapy, botulinum toxin injection, and surgery. Oral medical therapy has limited efficacy in control of the symptoms of cervical dystonia. Two types of botulinum toxin, types A and B, are being used for treatment of cervical dystonia, with equivalent benefit. Surgery is an option when other treatments fail or become ineffective. The surgical procedures are brain lesioning, brain stimulation, and peripheral surgical intervention. Several trials are currently ongoing in the United States and Europe to evaluate the efficacy of deep brain surgery in cervical dystonia.

A cost-utility analysis of hysterectomy, endometrial resection and ablation and medical therapy for menorrhagia

Four types of treatment [hysterectomy, endometrial resection/ablation, levonorgestrel-releasing intrauterine system (LNG-IUS) and oral medical therapy] are available for management of menorrhagia. The objective of this study was to compare the cost and quality-adjusted life-years (QALYs) gained by these four treatment alternatives. A Markov model was designed to simulate the healthcare resource utilization and QALYs of the four treatment alternatives for patients presenting with menorrhagia over 5 years. Clinical inputs were estimated from literature, and the cost analysis was conducted from the perspective of healthcare provider in Hong Kong. The base-case analysis showed that the hysterectomy group was the most effective (4.725 QALYs) alternative with the highest cost (USD6878, 1USD=7.8HKD). The incremental cost per additional QALY (ICER) gained by hysterectomy was USD23 500. The probability of extra surgery in the endometrial resection/ablation was an influential factor. Probabalistic sensitivity analysis of 10,000 simulations of the Monte Carlo model showed that the hysterectomy group gained higher number of QALYs than the LNG-IUS, oral medical treatment and endometrial resection/ablation groups, 99, 99 and 98% of the time, and it was more costly than the other three groups over 85% of the time. Hysterectomy appears to be cost effective, with ICER less than USD50,000, for management of menorrhagia.

Partial segmental thrombosis of corpus cavernosum: Case report and review of world literature

Partial segmental priapism is an unusual clinical condition characterized by thrombosis within the proximal corpora cavernosa. Previous management strategies have included open exploration, surgical shunts, corporal injection, irrigation, and oral medication therapy. We report a case of a 37-year-old man treated conservatively with full restoration of erectile function.

Phenol block for cervical dystonia: effects and side effects

Takeuchi N, Chuma T, Mano Y. Phenol block for cervical dystonia: effects and side effects. Arch Phys Med Rehabil 2004;85:1117-20. Objective To report on the effectiveness and side effects of 2% phenol block in patients with cervical dystonia (CD). Design Case series. Setting A rehabilitation department at a university medical center in Japan. Participants Sixteen patients (11 men, 5 women; mean age ± standard deviation, 43.4±11.2y) with CD. The cause of the CD was unknown, and all cases were refractory to the oral medication and rehabilitation therapy. Intervention Two percent phenol blocks guided by electromyography. Main outcome measures A blind analysis by neurologists of the Tsui score before and after 2 weeks of treatment with phenol block. Side effects were evaluated by another neurologist and patient report. Results There was significant ( P=.0002) improvement in neck movement and position, based on a reduced Tsui score, after the phenol block. However, 4 patients had a complication of sensory disturbance of the transverse cutaneous nerve of the neck area. The sensory disturbances decreased gradually and disappeared within 3 months, whereas the effects of the phenol block continued. Conclusions Phenol block can reduce the impact of CD that is refractory to therapy.

Adherence to oral therapy for type 2 diabetes: opportunities for enhancing glycemic control.

Although diet and exercise are important parts of type 2 diabetes treatment, most patients require pharmacological intervention with multiple agents to maintain adequate glycemic control. This article addresses the numerous patient-related, disease-related, and demographic variables affecting medication adherence in this patient population. Extensive review of scientific literature, clinical practice guidelines, and Internet sources. Studies have demonstrated that treatments including multiple medications or frequent dosing had a negative impact on adherence. Practitioners have used several approaches in an effort to improve adherence to oral antidiabetic medical therapy, including increased communication between health care providers and patients, implementation of multidisciplinary programs, and use of treatment regimens with easier dosing (i.e., reduced number of drugs or doses taken per day). Options for type 2 diabetes treatments that combine effective medications into a simpler oral-dosage form may motivate and improve patient adherence. Ultimately, simplifying dosing may lead to better glycemic control, thereby reducing the risks associated with long-term consequences of the disease.

DEFibrillators In Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE)

The DEFibrillators In Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) was a multi-center, randomized, investigator-initiated trial. Patients enrolled in the trial had non-ischemic cardiomyopathy (LVEF <or=35%), a history of symptomatic heart failure and spontaneous arrhythmia (>10 PVCs/hr or non-sustained ventricular tachycardia defined as 3 to 15 beats at a rate of >120 bpm) on Holter monitor or telemetry within the past 6 months. All patients received standard oral medical therapy for heart failure including angiotensin converting enzyme inhibitors and beta-blockers. Patients were randomized to implantable cardioverter defibrillator (ICD) versus no ICD. Patients were followed for 2 to 3 years. The primary endpoint was total mortality. Quality of life and pharmacoeconomics analysis was also performed. A registry tracked patients who met basic inclusion criteria but were not randomized. We estimated an annual total mortality of 15% at 2 years in the treatment arm that did not receive an ICD. The ICD was expected to reduce mortality by 50%. Approximately 229 patients were required in each treatment group. Forty-five centers were included in this trial that was designed to last an estimated 4 years. Enrollment was projected to occur over 2 1/2 years with a post enrollment follow-up of 1 1/2 years.

Oral therapy for Peyronie's disease.

Peyronie's disease (PD) remains a therapeutic dilemma for the urologist. Despite a myriad of medical therapies proposed for PD there have been limited advances in oral medical treatment. Several new approaches are presented which hold promise of success, although a definitive medical therapy for PD has yet to be established. Since early stage disease is reputed to respond better than well-established plaques, an early trial of inexpensive, safe and well-tolerated oral therapy is often initially recommended. This review discusses the historical aspects as well as contemporary oral medical therapy for PD. With advances in the molecular biology of inflammation and wound healing, the management and understanding of this frustrating disease will no doubt improve.

Role of adjunctive medical therapy with nifedipine and deflazacort after extracorporeal shock wave lithotripsy of ureteral stones

Objectives. To increase the success rate of the first treatment of ureteral stones through extracorporeal shock wave lithotripsy (ESWL), we tested the efficacy of a medical therapy with nifedipine and deflazacort administered to patients who had undergone ESWL for ureteral stones. Methods. This prospective study lasted from October 1998 to September 2000 and involved 80 patients. All the patients underwent ESWL with Sonolith 4000+. The patients were randomly divided into two groups: 40 patients (group 1) received an “adjunctive” treatment with oral medical therapy (nifedipine and deflazacort); the other 40 patients (group 2) were used as the control group. Results. Complete fragment expulsion occurred in 30 (75%) of the 40 patients of group 1 and in 20 (50%) of the 40 patients of group 2 at the endpoint. A statistically significant difference was observed in the stone-free rate ( P = 0.02). Concerning the symptomatic therapy, the average diclofenac use was 37.5 mg per patient in group 1 and 86.25 mg per patient in group 2 ( P = 0.02). Conclusions. The results of this study have shown the role that adjunctive medical therapy with nifedipine and deflazacort given after an ESWL procedure can play in increasing the success rate of ureteral stone treatment. Furthermore, these results would suggest that adjunctive medical therapy can reduce total analgesic consumption after the ESWL procedure.

Cost of treatment for onychomycosis. Data from a 9-month observational study.

To estimate component and total costs of treatment and to examine differences in cost and cost effectiveness between oral antifungal medication and local therapy for patients with toenail onychomycosis. Prospective, observational study of patients with onychomycosis who visited dermatologists and podiatrists in the US. Physicians provided data on clinical management, disease severity, nail improvement and resource utilisation. Patients completed questionnaires on resource utilisation and symptoms at base-line, 4 and 9 months. To estimate costs, reported utilisation was multiplied by unit costs expressed in 1997 US dollars ($US) and derived in 2 ways: first, using Medicare fees; and second, using standard physician fees. After adjustment for key demographic and clinical variables, participants receiving oral medication had higher total costs based on standard fees ($US794 vs $US575) and medication costs ($US564 vs $US109), lower procedure costs ($US0 vs $US122) and physician visit costs ($US200 vs $US330), and greater clinical effectiveness as measured by global improvement rating (86 vs 35%) and Toenail Symptom Index (94 vs 49%). For participants receiving oral medication, 90% of total costs were incurred during the first 4 months of follow-up, whereas for those receiving local therapy, costs were more evenly distributed throughout the study period. Incremental cost-effectiveness analysis showed $US304 to $US491 per additional case improved with oral medication over a 9-month timeframe. Extrapolation of these results using 2 time-points (months 4 and 9) suggested that cost equivalence would be reached 17 to 21 months following the initiation of treatment. During 9 months of follow-up in patients with toenail onychomycosis, the use of oral antifungal medication resulted in superior patient outcomes, but at higher total cost compared with local therapy.

Successful weaning from milrinone of a patient with severe congestive heart failure using carvedilol.

Congestive heart failure is a major and growing health care concern worldwide, and mortality in patients with severe heart failure is high. Few options are available to patients with New York Heart Association class IV heart failure refractory to oral medical therapy. Over the last 15-20 years milrinone, a phosphodiesterase-III inhibitor, has been used occasionally to treat patients with acute heart failure and as a bridge to heart transplantation and, more recently, has been used intermittently or continuously on an outpatient basis. We report a patient with severe, chronic congestive heart failure, whom we treated successfully with continuous milrinone infusions as an outpatient. We were able to wean him of the milrinone after successful up-titration of carvedilol. Nine months after discontinuation of milrinone the patient remains stable in New York Heart Association class I on high dose carvedilol. Research is required to validate the possibility that patients with severe heart failure may be successfully weaned from milrinone using carvedilol and achieve significant improvement of their functional status and quality of life. This may prove to be an effective strategy for the treatment of selected patients with severe, chronic congestive heart failure. (c)2001 by CHF, Inc.

Effects of intravenous milrinone followed by titration of high-dose oral vasodilator therapy on clinical outcome and rehospitalization rates in patients with severe heart failure

This study evaluated the efficacy of intravenous milrinone in improving hemodynamics and facilitating the titration of high-dose oral vasodilator therapy to improve clinical status. Fourteen patients (mean age 52 ± 12 years) with severe heart failure and a left ventricular ejection fraction of 18 ± 6% underwent right-side heart catheterization and an intravenous milrinone infusion followed by titration of oral vasodilator and diuretic therapy. Milrinone significantly (p <0.05) improved right atrial pressure (12 ± 5 to 8 ± 5 mm Hg), pulmonary capillary wedge pressure (23 ± 7 to 15 ± 7 mm Hg), cardiac index (1.9 ± 0.4 to 3.4 ± 0.5 L/min/m 2), systemic vascular resistance (1,809 ± 526 to 891 ± 144 dynes/s/cm −5), and pulmonary vascular resistance (285 ± 151 to 163 ± 68 dynes/s/cm −5), which was maintained in 10 patients with titration of high-dose oral vasodilator therapy. Oral angiotensin-converting enzyme inhibitor and diuretic doses were increased 318% and 89%, respectively. Four patients also received hydralazine to optimize hemodynamics. New York Heart Association functional class improved from 3.8 ± 0.4 to 2.6 ± 0.6 following therapy. Ten patients who responded to therapy had fewer hospitalized days during the subsequent year compared with the year before treatment (4 ± 17 vs 17 ± 15), and no patient died. In contrast, the 3 patients who responded poorly to therapy tended to have more hospitalized days at 12 months compared with pretreatment (31 ± 11 vs 20 ± 18; NS); 1 patient died. We conclude that intravenous milrinone followed by optimization of oral medical therapy may be used as a therapeutic trial to identify patients in need of cardiac transplantation.

Placebo-controlled study of oral terbutaline and pseudoephedrine in management of prostaglandin E1-induced prolonged erections

Prolonged erections, priapism, secondary to pharmacologic stimulation are usually treated by drainage of the corporeal bodies and irrigation with a sympathomimetic. To study the efficacy of oral medical therapy in the treatment of priapism, 75 patients with pharmacologically induced (prostaglandin E 1) prolonged erections were randomized to receive terbutaline, pseudoephedrine, or placebo. Detumescence occurred in 36 percent, 28 percent, and 12 percent, respectively. Terbutaline was significantly better than placebo ( p < 0.05) in achieving detumescence. The results of this study suggest that oral terbutaline should be considered in the initial management of pharmacologically induced prolonged erections.

Extracorporeal Shock Wave Lithotripsy: An Update

Extracorporeal shock wave lithotripsy has revolutionized the treatment of urinary calculi. It should be considered the treatment of choice for renal stones smaller than 2 cm and for the majority of ureteral calculi, under which circumstances success rates approaching 80 to 90 per cent may be anticipated. Larger renal calculi or impacted ureteral stones probably should be managed by endoscopic techniques with or without adjunctive intracorporeal (ultrasonic or electrohydraulic) lithotripsy or laser fragmentation. Recent modifications in lithotripter design have been focused on the development of pain-free lithotripsy. Concomitant with a decrease in power, however, is an attendant decrease in the efficiency with which stones can be fragmented, resulting in an increase in the number of lithotripsy treatments required for adequate stone fragmentation. Additionally, sonography is assuming an increasing role in stone localization, and its use will require sonographic training on the part of the urologist. Biliary lithotripsy has been promising in preliminary European studies, with success rates approaching 90 per cent. It must be noted, however, that the U.S. experience has not been as impressive. Moreover, only 20 to 30 per cent of patients referred for biliary lithotripsy appear to be optimal candidates for this new technique. Adjunctive dissolution of gallstones with chronic oral medical therapy may be required after biliary lithotripsy, and long-term follow-up studies still need to be performed. Finally, the potential deleterious effects of extracorporeal shock wave lithotripsy must always be kept in mind. Although the majority of clinical and animal investigations have documented no significant long-term alterations in renal function, care must still be exercised when performing lithotripsy with the knowledge of the potential for long-term injurious effects on the functioning renal parenchyma.