Rapid marked response of severe hyperemesis gravidarum to oral erythromycin

A recent report has noted an association between Helicobacter pylori and hyperemesis gravidarum. We present two cases in which first-trimester patients with severe hyperemesis gravidarum requiring intravenous fluid replacement were placed on oral erythromycin therapy for other nonrelated conditions. Surprisingly, marked rapid improvement of the hyperemesis gravidarum was observed with complete resolution of all symptomatology. Both these patients tested seropositive for Helicobacter pylori. These unexpected, marked therapeutic responses are consistent with the recently reported association between hyperemesis gravidarum and Helicobacter pylori and possibly suggest a new therapeutic modality for similar patients.     

Psychiatric aspects of hyperemesis gravidarum

In this paper, we calculate a base line of statistical data on the frequency of sexual activity at various ages of Taiwanese women. A cross-sectional study using questionnaires administered during personal interviews was conducted on more than seventeen thousand women who attended family planning clinics in the Taipei metropolitan area in 1991 and 1992. Of the women surveyed, 2.8 per cent were sexually inactive in the previous month, 83.67 per cent had intercourse one to nine times in the previous month, and 13.56 per cent had intercourse ten times or more. The mean frequency of sexual activity was 6.8 times a month. Age-specific mean coital frequencies for the age groups of less than 25 years, of 25-34 years, and of 35-44 years were 10.3, 7.3, and 6.6 times per month, respectively. Increased sexual frequency was associated with the following factors: young age, unmarried, lower educational level, fewer years of marriage and being on the pill. When logistic regression was used to control for confounding variables, we found that a woman's age is the most significant factor in predicting her sexual frequency.     

Unsuspected thyrotoxicosis and hyperemesis gravidarum in Asian women

This report describes three women with hyperemesis gravidarum caused by previously undiagnosed thyrotoxicosis. All three women were eight weeks pregnant and only one woman had typical features of thyrotoxicosis. Hyperemesis could not be controlled by anti-emetics. The patients were successfully treated with antithyroid drugs. Anti-thyroid treatment does not need to be continued once resolution of symptoms and thyrotoxicosis have occurred.     

Treatment of hyperemesis gravidarum by electrostimulation of the vestibular apparatus

26 patients hospitalized with Hyperemesis Gravidarum were treated with electrical stimulation of the vestibular system, as the symptoms of Hyperemesis Gravidarum resemble the symptoms of motion sickness, where the electrical stimulation has been used successfully. The patients were treated for one hour daily, two hours before the standard infusion therapy. 89% reported a decrease in vomiting and nausea during the first application, 85% a lasting improvement. Theoretical considerations concerning the mechanism of the effect are discussed.     

Saturated fat intake and the risk of severe hyperemesis gravidarum

We conducted a case-control study to investigate the effect of prepregnancy diet, particularly dietary fats, on the risk of severe hyperemesis gravidarum. Cases were 44 women previously hospitalized at Brigham and Women's Hospital, Boston, MA, for severe hyperemesis gravidarum who delivered a singleton liveborn between January 1, 1993, and December 31, 1995. Controls were 87 women who delivered a singleton liveborn at Brigham and Women's Hospital during the same period and who experienced less than 20 hours of nausea and fewer than three episodes of vomiting over the duration of their pregnancies. Odds ratios were derived from unconditional logistic regression models using data collected via self-administered food frequency questionnaires. Our results indicate that prepregnancy, high daily intake of total fat increases the risk of severe hyperemesis gravidarum (odds ratio = 2.9 for each 25 gm per day increase; 95% confidence interval = 1.4-6.0). This association is driven primarily by saturated fat intake [odds ratio = 5.4 for each 15 gm per day increase (equivalent to one quarter-pound cheeseburger); 95% confidence interval = 2.0-14.8]. We observed no independent effect of total energy intake.     

Nasoenteral tube feeding in hyperemesis gravidarum. An alternative to parenteral nutrition

A severe form of hyperemesis gravidarum involving maternal weight loss greater than 5% of the prepregnant weight occurs in up to 0.1-0.2% of all pregnancies and may lead to retarded foetal growth. Treatment consists of hospitalisation, antiemetics and correction of fluid and electrolyte deficiencies. If severe vomiting and weight loss continues, the mother must receive supplementary nutrition, usually parenteral. Nasoenteral tube feeding is a well documented method of nutrition for other patients. A gastroscopically placed nasojejunal tube as part of the treatment of hyperemesis gravidarum has not been reviewed before. Seven women with severe hyperemesis gravidarum were treated with nasojejunal tube feeding. The tube was positioned gastroscopically. Enteral feeding continued for up to 41 days, leading to reasonable weight gain. The tube was tolerated well by most patients and no serious adverse effects were seen. Nasoenteral nutrition ought to be considered as an alternative to parenteral nutrition for treatment of hyperemesis gravidarum.     

Intravenous methylprednisolone in treatment of traumatic optic neuropathy

Traumatic optic neuropathy is one of true ophthalmic emergencies and there is no proven form of treatment for traumatic optic neuropathy. Here we were presented with 30 cases of sudden visual loss following blunt eye trauma seen in Kaohsiung Medical College Hospital, Taiwan from April 1994 to March 1997. We analyze the treatment style, visual acuity, elapsed time since injury and orbit computed tomography retrospectively. Among them, 21 cases received intravenous methylprednisolone treatment, 2 cases received oral prednisolone, 2 cases underwent optic canal decompression in addition to intravenous methylprednisolone and 5 cases were carefully monitored without any kind of treatment. Thirteen of the 21 cases (62%) in intravenous methylprednisolone group got visual improvement. Patients with initial vision better than light perception benefitted more from treatment than did the patients who with no light perception in medical treatment group (85% VS 20%) (p < 0.05). Thirteen of the 30 cases (53.3%) had orbit fracture and 2 of the 30 cases (6.7%) had a fracture of the optic canal. These two cases also received optic canal decompression surgery in addition to intravenous steroid treatment but the prognosis was poor. In conclusion, intravenous methylprednisolone does offer help in traumatic optic neuropathy. Whether or not initial visual acuity was better than light perception was a key risk factor in the outcome. In this article, we also compare our results with other series in the literature and found that the value of different treatment in traumatic optic neuropathy still needs to be prospectively judged in the future.     

Pharmacokinetics of methylprednisolone and prednisolone after single and multiple oral administration

The pharmacokinetics of methylprednisolone and prednisolone were evaluated in 24 healthy men after oral administration of single and multiple doses for 3 days. For each drug, 6 different administration regimens with doses ranging from 1 to 80-mg of methylprednisolone and 1.25 to 100-mg of prednisolone, and administration intervals ranging from 3 to 24 hours for both were investigated. Plasma was assayed using a normal phase high-performance liquid chromatography (HPLC) method. Methylprednisolone showed linear pharmacokinetics with no apparent dose or time dependency. Prednisolone showed marked dose dependency with higher clearance and volume of distribution for higher doses. This can be explained by its saturable protein binding of plasma, because unbound clearance and unbound volume of distribution were not dose-dependent. After multiple administration, prednisolone showed significant time-dependent pharmacokinetics with increased unbound clearance and increased unbound volume of distribution. Due to the complicated pharmacokinetic properties of prednisolone, it is extremely difficult to determine the dose needed to obtain a desired target concentration. The pharmacokinetics of methylprednisolone are more predictable because methylprednisolone concentrations are proportional to dose, and no determination of plasma protein binding is needed.     

Combined oral positive inotropic and beta-blocker therapy for treatment of refractory class IV heart failure

OBJECTIVES: We sought to assess the effects of combined oral positive inotropic and beta-blocker therapy in patients with severe heart failure. BACKGROUND: Patients with severe, class IV heart failure who receive standard medical therapy exhibit a 1-year mortality rate >50%. Moreover, such patients generally do not tolerate beta-blockade, a promising new therapy for chronic heart failure. Positive inotropes, including phosphodiesterase inhibitors, are associated with increased mortality when administered over the long term in these patients. The addition of a beta-blocker to positive inotropic therapy might attenuate this adverse effect, although long-term oral inotropic therapy might serve as a bridge to beta-blockade. METHODS: Thirty patients with severe heart failure (left ventricular ejection fraction [LVEF] 17.2+/-1.2%, cardiac index 1.6+/-0.1 liter/min per m2) were treated with the combination of oral enoximone (a phosphodiesterase inhibitor) and oral metoprolol at two institutions. Enoximone was given at a dose of < or = 1 mg/kg body weight three times a day. After clinical stabilization, metoprolol was initiated at 6.25 mg twice a day and slowly titrated up to a target dose of 100 to 200 mg/day. RESULTS: Ninety-six percent of the patients tolerated enoximone, whereas 80% tolerated the addition of metoprolol. The mean duration of combination therapy was 9.4+/-1.8 months. The mean length of follow-up was 20.9+/-3.9 months. Of the 23 patients receiving the combination therapy, 48% were weaned off enoximone over the long term. The LVEF increased significantly, from 17.7+/-1.6% to 27.6+/-3.4% (p=0.01), whereas the New York Heart Association functional class improved from 4+/-0 to 2.8+/-0.1 (p=0.0001). The number of hospital admissions tended to decrease during therapy (p=0.06). The estimated probability of survival at 1 year was 81+/-9%. Heart transplantation was performed successfully in nine patients (30%). CONCLUSIONS: Combination therapy with a positive inotrope and a beta-blocker appears to be useful in the treatment of severe, class IV heart failure. It may be used as a palliative measure when transplantation is not an option or as a bridge to heart transplantation. Further study of this form of combined therapy is warranted.     

Double blind trial of pulse methylprednisolone versus conventional oral prednisolone in lupus nephritis

A double blinded clinical trial was conducted in which the efficacy and safety of pulse methylprednisolone (400 mg/day) was compared with oral prednisolone (50 mg/day), a control drug for a period of 3 months. One-hundred and two (102) patients were enrolled in the study, of which 91 patients were determined as eligible for analysis of efficacy. Patients on pulse methylprednisolone had more favorable response to therapy with regard to laboratory value changes from baseline such as CH50 and anti-DNA antibody titers. In terms of anti-DNA antibodies, a significant difference was detected at one week after treatment. With regard to time course changes in laboratory values, CH50 at one and two weeks after treatment showed a significantly higher elevation in the pulse methylprednisolone group than in the control group. There was no significant difference noted in incidence of adverse reactions between both treatment groups. No serious adverse reaction was encountered in the pulse methylprednisolone group. The physician's assessment of final global improvement significantly favored the pulse methylprednisolone-treated group. The above results suggest that the pulse therapy with methylprednisolone leads to more rapid onset of drug effect than the conventional oral prednisolone in the treatment of lupus nephritis.     

Serum erythropoietin and granulocyte-macrophage-colony stimulating factor levels with megadose methylprednisolone treatment

We described an anesthetic management of a patient with abdominal aortic aneurysm associated with dilated cardiomyopathy (DCM) focusing on preanesthetic evaluation of cardiovascular reserve and on intraoperative continuous circulatory monitoring with transesophageal echocardiography (TEE) and continuous cardiac output measurement (CCO). Based on echocardiographic and hemodynamic measurements after a 50 m-walk load, we predicted the allowable range of alteration of preload (LV diastolic dimension; Dd), myocardial performance (arterial blood pressure and ejection fraction) and of heart rate. During anesthesia and operation, we continuously monitored Dd, arterial blood pressure, heart rate and cardiac output, and maintained these variables within the allowable range. The changes in preload after clamping or unclamping of the aorta was promptly reflected by Dd as compared to pulmonary capillary wadge pressure. The CCO was also usuful in detecting abrupt changes in myocardial performance. In conclusion, we suggest preanesthetic stress test to be performed to evaluate cardiovascular reserve and to predict the allowable range of alteration of hemodynamic variables. Continuous monitoring of preload (Dd) by TEE and of myocardial performance by CCO is useful to detect early changes in these variables.     

Use of granisetron in patients refractory to previous treatment with antiemetics

Since a high tissue penetration of dirithromycin (D) has been assessed in early studies, the aims of this study were to determine D concentrations in bronchial mucosa and secretions in patients suffering from an acute exacerbation of chronic bronchitis (AECB), to compare intra-individual bronchial mucosa and secretion concentrations and to relate bronchial concentrations of D and clinical efficacy. The main inclusion criteria were comprised of (1) AECB, defined by the presence of an increase in dyspnea, sputum production and change in sputum purulence, and (2) clinical indication of fiberoptic bronchoscopy allowing performance of bronchial biopsies. All patients were treated with a 500-mg once-daily D dose for 5 days. Patients were randomly divided into three groups, according to sampling times (24, 48 and 72 h after the last dose). Tissue concentration analyses were performed by one blinded microbiologist (microbiological agar diffusion assay). The results showed: (1) 37 out of the 46 patients (80.4%) had a favorable response to treatment at the time of fiberoptic bronchoscopy (14 cured, 23 improved); (2) bronchial mucosa concentrations were high in all groups, and (3) mean values at 24, 48 and 72 h after the last dose were respectively 6.51 +/- 1.44, 6. 61 +/- 2.7, 5.67 +/- 1.02 mg.kg-1; no statistical difference was observed between the groups. In bronchial secretions collected simultaneously, concentrations were lower, i.e. 1.26 +/- 0.3, 0.61 +/- 0.12, 0.84 +/- 0.12. Significant associations were observed between bronchial mucosa and secretion concentrations (r = 0.71, p = 0.0001), and between clinical response and bronchial concentrations (p = 0.03, Kruskall-Wallis test). In conclusion, these results may confirm the clinical significance of tissue concentrations measured in bronchial tissues of patients with AECB.     

硼替佐米联合异环磷酰胺、甲泼尼龙、沙利度胺方案治疗多发性骨髓瘤

目的 观察硼替佐米联合异环磷酰胺、甲泼尼龙、沙利度胺(V-CMPT方案)治疗多发性骨髓瘤(MM)的临床疗效和患者不良反应.方法 回顾性分析应用V-CMPT方案进行治疗的24例初治和复发难治MM患者资料,3周为1个周期,治疗2个周期.应用骨髓细胞学检查、M蛋白鉴定以及其他血液学指标评价病情及疗效.结果 初治的9例患者中,完全缓解(CR)3例、部分缓解(PR)5例、轻微缓解(MR)1例;复发难治的15例患者中,CR2例、接近完全缓解(nCR)2例、PR 3例、MR 6例、无变化(NC)2例;两组间总缓解率(ORR)(P=0.511)及CR/nCR率(P=1.000)差异无统计学意义.总的CR/nCR率29.2%(7/24),ORR达到91.7%(22/24).2个周期V-CMPT化疗后,患者的血红蛋白、血清清蛋白及血清β2微球蛋白得到明显改善.不良反应包括胃肠道反应、血小板减少、周围神经病变等,经对症处理或间歇期停药多好转,不影响化疗的继续进行.结论 V-CMPT方案对初治和复发难治性MM临床疗效明显,能够明显改善血液学指标,药物耐受性良好.