Complications in connection with venous port systems: prevention and therapy

OBJECTIVE: To assess the effects of graded intramedullary reaming and nailing on the healing pattern of segmental diaphyseal fractures using male Wistar rats. STUDY DESIGN: In male Wistar rats we produced two standardized, partial osteotomies with an eight-millimeter intermediary fragment in the femoral diaphysis. The osteotomies were subsequently manually broken. In Group A, intramedullary reaming was performed to 1.6 millimeters, and the fracture was stabilized with a 1.6-millimeter steel pin. In Group B, the femoral canal was reamed to 2.0 millimeters, and a hollow steel tube of 2.0 millimeters was installed. The rats were allowed free movement. After four, eight, and twelve weeks, eight rats in each group were sacrificed and callus formation, biomechanical properties, and bone blood flow were evaluated. RESULTS: The callus area was relatively constant with time in Group B, whereas a reduction was observed in Group A at twelve weeks. The biomechanical properties increased throughout the experimental period in both groups, and no significant differences between the groups were detected in bending moment, bending rigidity, or fracture energy. Total bone blood flow was substantially increased at four weeks in both groups and decreased throughout the experimental period. In addition, blood flow of the segmental fractured area was substantially increased after four weeks and decreased gradually thereafter. The increases in blood flow tended to be largest in the moderately reamed group. CONCLUSION: This study indicates that the degree of reaming does not significantly affect the healing pattern measured as restoration of mechanical characteristics.     

Infusional therapy with alkylating agents

Newborns with chronic problems needing continuous and special care even after discharge are not very frequent but represent a challenge for the caring team. The discharge program of the Neonatal Care ward of Trento hospital includes several steps: discharge meetings of teh neonatologist and the nurse responsible for the child, the head nurse, the psychologist and, when possible, the social worker; a training program for the parents; the coordination of communications and interventions of the home-care nurses and a detailed post-discharge planning. From 1995 a home-hospital program, as an alternative to the hospital admission was started. To describe how the team functions and stress the need of a close integration among the team members, the case of Ahmed is presented. This case faced the team with several challenges, because of the lack of parent's knowledge of the italian language and of the severity of the child's problems. Every care plan is developed building on newborn's needs and patients' resources. Data on the patients-problems dealt with from 1991 to 1995 and the interventions and resources needed are presented.     

Postoperative nausea and vomiting. A retrospective analysis in patients undergoing elective craniotomy

CONTEXT: Managed care and capitation have placed new responsibilities on primary care physicians, including formally acting as "gatekeepers" for specialty services and tests. Previous studies have not examined whether primary care physicians who provide services to patients under many coverage arrangements feel differently about caring for patients covered under capitation vs those covered through more traditional forms of insurance. An understanding of whether California primary care physicians feel that they deliver a different level of quality to capitated patients could help signal whether variations in care for patients with different coverage forms are evolving. OBJECTIVE: To evaluate whether primary care physicians in California capitated groups report different satisfaction levels with quality of care for patients in their overall practice than for patients covered by capitated contracts and to examine whether physicians' satisfaction with capitated care quality is influenced by the characteristics of the practice setting. DESIGN: Cross-sectional questionnaire. SETTING: A total of 89 California physician groups with capitated contracts. PARTICIPANTS: A total of 910 primary care physicians (80% response rate). MAIN OUTCOME MEASURE: Satisfaction with 4 aspects of quality of care provided to patients covered by capitated contracts vs patients overall. RESULTS: Physicians reported lower satisfaction with all 4 aspects of care for patients covered by capitated contracts than for patients in their overall practice: 71% were very or somewhat satisfied with relationships with capitated patients (compared with 88% for overall practice), 64% were very or somewhat satisfied with the quality of care they provided to capitated patients (compared with 88% for overall practice), 51% were very or somewhat satisfied with their ability to treat capitated patients according to their own best judgment (compared with 79% for overall practice), and 50% were very or somewhat satisfied with their ability to obtain specialty referrals (compared with 59% for overall practice) (P< or =.001 for all comparisons). Being in a medical group practice (vs an independent practice association) and having a larger percentage of capitated patients were independently associated by multivariate analysis with higher levels of satisfaction with capitated quality of care (P< or =.005). CONCLUSION: These California primary care physicians were less satisfied with the quality of care they deliver to patients covered by capitated contracts than with the quality of care they deliver to patients covered by other payment sources. However, those in medical group practices and with a higher percentage of capitated patients were more satisfied with capitated care. National expansion of capitation should be accompanied by efforts to ensure that the satisfaction of practicing physicians with the care they deliver does not decline.     

Tropisetron or ondansetron compared with placebo for prevention of postoperative nausea and vomiting

In a prospective, randomized, double-blind, placebo-controlled, multicentre study, the efficacy of prophylactic tropisetron (2 mg) or ondansetron (4 mg) for the prevention of post-operative nausea and vomiting after abdominal or non-abdominal surgery with general balanced anaesthesia was studied in 842 ASA I-III patients. In patients undergoing abdominal surgery, ondansetron and tropisetron reduced the frequency of emetic episodes compared with the placebo (29%, 30% vs. 42% respectively). In men, neither tropisetron nor ondansetron had an effect different from the placebo, whereas in women both drugs led to lower rates of emetic episodes and nausea. In comparison with abdominal surgery, fewer patients in the non-abdominal surgery subgroup had emetic episodes (42% vs. 23% in the placebo group). However, neither tropisetron nor ondansetron was significantly different from the placebo in this patient subgroup. In conclusion, for patients at increased risk of post-operative nausea and vomiting, a prophylactic therapy at the lowest effective dose with tropisetron or ondansetron may be useful.     

Interaction of alpha-interferon with chemotherapeutic agents: effects on cytotoxic drug metabolism and multiple drug resistance

Sj?gren's syndrome (SS) is an autoimmune exocrinopathy that primarily affects the salivary glands but can also involve almost any other part of the gut. The most distressing manifestation of SS is xerostomia secondary to destruction of the salivary glands. The lack of saliva also leads to difficulty with chewing and initial swallowing and an increased frequency of dental caries. Another major problem is dysphagia due to the lack of saliva as well as esophageal dysmotility and/or esophageal webs. Chronic atrophic gastritis probably accounts for the epigastric pain, nausea, and other dyspeptic symptoms seen in SS. Sj?gren's syndrome is also one of the most frequent extrahepatic diseases associated with primary biliary cirrhosis, suggesting that this entity may be a secondary form of SS. The degree to which SS affects the small and large bowel is unclear, whereas pancreatic involvement appears to lead to only subclinical exocrine insufficiency.     

Postoperative adhesion prevention with low-dose aspirin: effect through the selective inhibition of thromboxane production

The aim of the present study was to evaluate the efficacy of low-dose versus high-dose aspirin in the prevention of postoperative adhesion formation. Forty New Zealand White rabbits were randomized into three groups: low-dose aspirin (1.7 mg/kg per day for 5 days starting on the day of surgery), high-dose aspirin (28.0 mg/kg per day), and controls. The rabbits underwent a standardized surgical injury on the ovary, uterine horn and abdominal wall on one side at laparotomy. On postoperative day 21, a second-look laparotomy was performed for the evaluation of postoperative adhesions. In five animals in each group, peritoneal fluid samples were collected at initial surgery, then through an additional 2 cm incision performed on postoperative day 3, and at second-look laparotomy. The peritoneal concentrations of thromboxane B2 and 6-keto-prostaglandin F1alpha (the stable hydrolysis product of prostacyclin) were measured by radioimmunoassay. At second-look laparotomy, the adhesion formation rate was 46% in the low-dose aspirin group, 77% in the high-dose group, and 100% in the control group. The adhesion score in the low-dose group was significantly lower (P < 0.01) than in the high-dose and control groups. Peritoneal thromboxane decreased significantly during treatment in both low-dose and high-dose aspirin groups, whereas prostacyclin decreased only in the high-dose group. Postoperative adhesion reduction observed in this study with low-dose aspirin treatment could be due to the selective inhibition of thromboxane over prostacyclin production.     

Reattachment therapy: Intervention with the very young physically abused child.

Describes the role of disruption of the parent–infant attachment in the etiology of child abuse in very young children. A treatment model is presented, using the case of a 4-yr-old female victim of child abuse to illustrate the treatment's 2 overlapping phases. First, a substitute bond between the therapist and child is established in order to ameliorate developmental lesions spurred by the abuse and to restore normal growth processes. The child's behavior and appearance are then shaped to make him/her a more attractive attachment object, thereby stimulating reattachment with the original caretaker and inhibiting aggression by the parent. (24 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Case report: Avoidance conditioning therapy of an infant with chronic ruminative vomiting.

Reports the treatment of a 9-mo-old infant whose life was seriously endangered by persistent vomiting and chronic rumination. An aversive conditioning paradigm, employing electric shock, significantly reduced the frequency of this maladaptive response pattern in a few, brief treatment sessions. EMG records were used in assessing response characteristics of the emesis, and in determining the shock contingencies used in therapy. Cessation of vomiting and rumination was accompanied by weight gains, increased activity level, and general responsiveness to people. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Antihypertensive therapy in stroke: acute therapy, primary and secondary prevention

Arterial hypertension represents the single most important treatable risk factor for stroke, therefore antihypertensive treatment is crucial. Observational studies have shown that in the acute phase of an ischemic stroke blood pressure is elevated during the first few days and helps to restore cerebral perfusion, activates collateral arterial supply and enhances the treatment goal of minimizing infarct size. Especially for acute ischemic strokes with stable deficits drug treatment of hypertension therefore is recommended only at systolic pressures of > or = 220 mm Hg or with diastolic pressures of > or = 120 mm Hg except when heart, lung or renal failure are also present. In primary prevention of stroke there is a large potential for hypertension treatment which reduces the relative risk by 42%. Especially elderly people with moderate hypertension should be treated. One vascular event per year can be avoided in 100 patient treatment years. Only scarce data exist on secondary prevention of stroke which show that hypertension treatment has a major importance for the modification of risk factors.     

A meta-analysis of nausea and vomiting following maintenance of anaesthesia with propofol or inhalational agents

Methamphetamine (m-AMPH) administration injures both striatal dopaminergic terminals and certain nonmonoaminergic cortical neurons. Fluoro-Jade histochemistry was used to label cortical cells injured by m-AMPH in order to identify factors that contribute to the cortical cell body damage. Rats given four injections of m-AMPH (4 mg/kg) at 2-h intervals showed hyperthermia (mean = 40.0 +/- 0.10 degrees C) and increased behavioral activation relative to animals given saline (SAL). Three days later, m-AMPH-treated animals showed indices of injury to striatal DA terminals (depletion of tyrosine hydroxylase immunoreactivity) and parietal cortical cell bodies (appearance of Fluoro-Jade stained cells). Pretreatment with a dopamine (DA) D1, D2, or N-methyl-D-aspartate (NMDA) receptor antagonist, or administration of m-AMPH in a 4 degrees C environment, prevented or attenuated m-AMPH-induced hyperthermia, behavioral activation, and injury to striatal DA terminals and parietal cortical cell bodies. Animals pretreated with a DA transport inhibitor prior to m-AMPH showed hyperthermia, behavioral activation, and parietal cortical cell body injury, but they did not show striatal DA terminal injury. Pretreatment with a 5HT transport inhibitor failed to prevent m-AMPH-induced damage to striatal DA terminals or parietal cortical cell bodies. Animals given four injections of SAL in a 37 degrees C environment became hyperthermic, but showed no injury to striatal DA terminals or cortical cell bodies. The ability of the DA transport inhibitor to block m-AMPH-induced striatal DA damage, but not cortical injury, and the inability of hyperthermia alone to cause the cortical cell body injury suggests that m-AMPH-induced behavioral activation and hyperthermia may both be necessary for the subsequent parietal cortical cell body damage.     

Advances in child behavior therapy: Applications and implications.

Research in child behavior therapy has made important advances in treating a variety of childhood disorders. Treatment applications are highlighted to sample areas where accomplishments have been achieved, including the treatment of fear and avoidance behavior, social behaviors, habit disorders, academic performance, conduct problems and delinquency, autism and childhood schizophrenia, and mental retardation. Also, advances have been made in training parents, teachers, and peers to interact more effectively with children in such a way as to promote prosocial and adaptive behavior. Although marked gains have been made in developing treatment techniques and in training those responsible for the care, education, and training of children, a great deal of research remains to be completed. Nevertheless, a modest technology of behavior change has emerged. On the basis of contemporary findings alone, much more could be done for the welfare of children if the techniques could be disseminated and applied to adult–child interaction more widely than in the context of clinical treatment. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Update on drug interactions with azole antifungal agents

OBJECTIVE: To review and update the incidence, mechanism, and clinical relevance of drug interactions with itraconazole, ketoconazole, and fluconazole. DATA SOURCES: Literature was identified by MEDLINE search (from January 1990 to May 1997) using the name of each antifungal and the term "interaction" as MeSH headings. Abstracts were identified by literature citation and by review of Interscience Conference on Antimicrobial Agents and Chemotherapy from 1995 to 1996. STUDY SELECTION: Randomized, controlled, double-blind studies were emphasized; however, uncontrolled studies and case reports were also included. In vitro data were selected from literature review and citations. DATA EXTRACTION: Data were evaluated with respect to study design, clinical relevance, magnitude of interaction, and recommendations provided. DATA SYNTHESIS: The incidence of fungal infections and consequent azole antifungal usage continues to increase. By virtue of their antifungal mechanism (i.e., inhibition of cytochrome P450 fungal enzyme systems), azoles have been investigated and implicated in several drug interactions. The magnitude of interactions can vary from trivial to potentially fatal, and also vary with specific azole and interactant. CONCLUSIONS: The azole antifungal agents represent a commonly used class of agents with a broad range of potential interactions. Recent data have increased our understanding of drug--drug interactions with azoles. Pharmacists are in a unique position to identify these interactions and to intervene to decrease their morbidity and improve patient care.     

Drug-metabolism research challenges in the new millennium: individual variability in drug therapy and drug safety

One of the most challenging research areas in pharmacology in the new millennium is to understand why individuals respond differently to drug therapy and to what extent that individual variability in disposition is responsible for the observed differences in therapeutic efficacy and adverse reactions. To answer these complex questions, drug-metabolism research will rely on multidisciplinary approaches more than ever to investigate the many components involved in drug metabolism and disposition. Major research challenges include the following: (1) the genetic variation of drug targets (receptors, enzymes, etc.), drug transporters (multispecific organic anion transporter, P-glycoprotein, alpha-1-acid glycoprotein, etc.), and drug-metabolizing enzymes (cytochrome P450s and other enzymes); (2) the structure and function of all genetic variants of drug receptors, transporters, and metabolizing enzymes; (3) the induction, repression, and inhibition of all components involved in drug disposition; (4) the development of noninvasive in vivo methods to determine the physiological significance of various components in the handling of specific therapeutic agents in humans; (5) the mechanism of idiosyncratic adverse drug reactions; and (6) the pharmacokinetic and pharmacodynamic relationships to explain the individual differences in therapeutic efficacy and drug safety. Thus successful drug-metabolism research in the new millennium must integrate receptor biology, enzymology, recombinant DNA technology, biochemical toxicology, and drug disposition into study design and conduct balanced in vitro and in vivo experiments to allow a full understanding of the mechanisms of individual variability in drug therapy and drug safety.