Showing papers on "Symptomatic relief published in 2009"
TL;DR: Five strategies that have the potential to meet either the efficacy and/or the benefit‐to‐risk ratio of a cannabinoid receptor agonist are focused on.
Abstract: Medicines that activate cannabinoid CB(1) and CB(2) receptor are already in the clinic. These are Cesamet (nabilone), Marinol (dronabinol; Delta(9)-tetrahydrocannabinol) and Sativex (Delta(9)-tetrahydrocannabinol with cannabidiol). The first two of these medicines can be prescribed to reduce chemotherapy-induced nausea and vomiting. Marinol can also be prescribed to stimulate appetite, while Sativex is prescribed for the symptomatic relief of neuropathic pain in adults with multiple sclerosis and as an adjunctive analgesic treatment for adult patients with advanced cancer. One challenge now is to identify additional therapeutic targets for cannabinoid receptor agonists, and a number of potential clinical applications for such agonists are mentioned in this review. A second challenge is to develop strategies that will improve the efficacy and/or the benefit-to-risk ratio of a cannabinoid receptor agonist. This review focuses on five strategies that have the potential to meet either or both of these objectives. These are strategies that involve: (i) targeting cannabinoid receptors located outside the blood-brain barrier; (ii) targeting cannabinoid receptors expressed by a particular tissue; (iii) targeting up-regulated cannabinoid receptors; (iv) targeting cannabinoid CB(2) receptors; or (v) 'multi-targeting'. Preclinical data that justify additional research directed at evaluating the clinical importance of each of these strategies are also discussed.
407 citations
TL;DR: SSTs currently provide the most efficient treatment to achieve symptomatic relief and have recently been demonstrated to inhibit tumour growth.
Abstract: Summary
Background The discovery of somatostatin (SST) and the synthesis of a variety of analogues constituted a major therapeutic advance in the treatment of gastroenteropancreatic neuroendocrine (carcinoid) tumours (GEP-NETs). They currently provide the most efficient treatment to achieve symptomatic relief and have recently been demonstrated to inhibit tumour growth.
Aim To review 35 years of experience regarding the clinical application and efficacy of SST analogues.
Methods The PubMed database (1972–2009) was searched using somatostatin as a search term with combinations of terms including ‘treatment’; ‘neuroendocrine’; ‘carcinoid’; ‘tumor’; ‘octreotide’; ‘lanreotide’ and ‘pasireotide’.
Results In a review of 15 studies including 481 patients, the slow-release formulations Sandostatin LAR and Somatuline SR/Autogel achieved symptomatic relief in 74.2% (61.9–92.8%) and 67.5% (40.0–100%), biochemical response in 51.4% (31.5–100%) and 39.0% (17.9–58%), and tumour response in 69.8% (47.0–87.5%) and 64.4% (48.0–87.0%) respectively. Novel SST analogues like SOM230 (pasireotide) that exhibit pan SST receptor activity and analogues with high affinity to specific somatostatin receptor (sstr) subtypes may further advance the field, but efficacy studies are lacking.
Conclusion As more precise understanding of NET cell biology evolves and molecular biological tools advance, more accurate identification of individual tumours sstr profile will probably facilitate a more precise delineation of SST analogue treatment.
Aliment Pharmacol Ther 31, 169–188
360 citations
TL;DR: The PET and SPECT evidence implicating dopaminergic dysfunction, especially presynaptic dysregulation, as a mechanism for psychosis is reviewed and the role of dopamine in motivational salience is discussed, showing how psychosis could be viewed as a process of aberrant salience, and antipsychotics might provide symptomatic relief by blocking this aberant salience.
Abstract: Molecular imaging studies have generated important in vivo insights into the etiology of schizophrenia and treatment response. This article first reviews the PET and SPECT evidence implicating dopaminergic dysfunction, especially presynaptic dysregulation, as a mechanism for psychosis. Second, it summarises the neurochemical imaging studies of antipsychotic action, focussing on D2/3 receptors. These studies show that all currently licensed antipsychotic drugs block striatal D2/3 receptors in vivo- a site downstream of the likely principal dopaminergic pathophysiology in schizophrenia- and that D2/3 occupancy above a threshold is required for antipsychotic treatment response. However, adverse events, such as extra-pyramidal side-effects or hyperprolactinemia, become much more likely at higher occupancy levels, which indicates there is an optimal 'therapeutic window' for D2/3 occupancy, and questions the use of high doses of antipsychotic treatment in clinical practice and trials. Adequate D2/3 blockade by antipsychotic drugs is necessary but not always sufficient for antipsychotic response. Molecular imaging studies of clozapine, the one antipsychotic licensed for treatment resistant schizophrenia, have provided insights into the mechanisms underlying its unique efficacy. To link this pharmacology to the phenomenology of the illness, we discuss the role of dopamine in motivational salience and show how i) psychosis could be viewed as a process of aberrant salience, and ii) antipsychotics might provide symptomatic relief by blocking this aberrant salience. Finally, we discuss the implications of these PET and SPECT findings for new avenues of drug development.
223 citations
TL;DR: It appears that VP is associated with a statistically significant increased rate of procedure-related complications and cement extravasation (symptomatic and asymptomatic).
Abstract: Study Design and Objective. This study performs a meta-analysis to compare complication rates from vertebroplasty (VP) and kyphoplasty (KP). Summary of Background Data. Recently, the development of VP and balloon KP has been shown to provide symptomatic relief and restoration of sagittal alignment of vertebral compression fractures refractory to medical therapy. Complications in treatment of vertebral compression fractures are rare, however can be potentially devastating. Fortunately, clinical sequelae are rare; however, severe clinical complications from cement extravasation have been reported. Methods. Using PubMed and Ovid, we performed a literature search for "kyphoplasty," "vertebroplasty," and "vertebral augmentation." This search was performed in December 2006. Case reports and reports not available in English were excluded. We categorized complications in 3 categories: (1) procedure-related complications, (2) medical complications, and (3) new vertebral fracture. Cement leakage, asymptomatic and symptomatic, and its locations were recorded. We performed a meta-analysis of complications of all studies. We then repeated the meta-analysis examining only prospective studies. We then used proportion analysis to determine statistical significance. We defined statistical significance as a P value less than 0.05. Results. We identified 121 reports of KP and/or VP that specifically addressed complications. Of these studies, 33 addressed KP and 82 addressed VP (6 reports addressed complications of both). There were 29 reports in which the data appeared to be collected prospectively. Of these, 9 addressed KP and 21 addressed VP. VP was found to have a significantly increased rate of procedure-related complications than KP in the analysis of all studies and only prospective studies. VP also appears to have a significantly higher rate of symptomatic and asymptomatic cement leakage than KP (P < 0.05). The incidence of medical complications was significantly higher in the KP procedure; however, this difference was not observed when analyzing only prospective studies. The incidence of new fracture was significantly higher in the VP procedure; however, this was not observed when analyzing only prospective studies. Conclusion. VP and KP are 2 minimally invasive procedures that have been shown to be effective in the treatment of symptomatic vertebral compression fractures. Although the incidence of adverse events for both VP and KP are low, it appears that VP is associated with a statistically significant increased rate of procedure-related complications and cement extravasation (symptomatic and asymptomatic). Future prospective studies with large patient enrollment will be needed to further validate the finding of this meta-analysis.
200 citations
TL;DR: The murine hindlimb ischemia preparation is a model of PAD, and is useful for testing new therapies, and provides for a simpler model of ischemic tissue.
Abstract: In the United States, peripheral arterial disease (PAD) affects about 10 million individuals, and is also prevalent worldwide. Medical therapies for symptomatic relief are limited. Surgical or endovascular interventions are useful for some individuals, but long-term results are often disappointing. As a result, there is a need for developing new therapies to treat PAD. The murine hindlimb ischemia preparation is a model of PAD, and is useful for testing new therapies. When compared to other models of tissue ischemia such as coronary or cerebral artery ligation, femoral artery ligation provides for a simpler model of ischemic tissue. Other advantages of this model are the ease of access to the femoral artery and low mortality rate. In this video, we demonstrate the methodology for the murine model of unilateral hindimb ischemia. The specific materials and procedures for creating and evaluating the model will be described, including the assessment of limb perfusion by laser Doppler imaging. This protocol can also be utilized for the transplantation and non-invasive tracking of cells, which is demonstrated by Huang et al.
195 citations
TL;DR: Chronic administration of curcumin significantly improved memory retention in both tasks, attenuated oxidative damage, acetylcholinesterase activity and aluminium concentration in aluminium treated rats (P<0.05) and has neuroprotective effects against aluminium-induced cognitive dysfunction and oxidative damage.
175 citations
TL;DR: The neurobiological and neuroinflammatory pathways of AD is discussed, different molecular targets and potential therapeutic agents, including curcumin, for the treatment of AD are evaluated, and turmeric, which is a yellow colored polyphenol compound present in Turmeric, showed anti-inflammatory properties.
144 citations
TL;DR: Percutaneous radiofrequency ablation, which involves the use of thermal coagulation to induce necrosis in the lesion, is a minimally invasive alternative to surgical treatment of osteoid osteoma.
Abstract: Osteoid osteoma is a small, benign but painful lesion with specific clinical and imaging characteristics. Computed tomography is the imaging modality of choice for visualization of the nidus and for treatment planning. Complete surgical excision of the nidus is curative, providing symptomatic relief, and is the traditionally preferred treatment. However, surgery has disadvantages, including the difficulty of locating the lesion intraoperatively, the need for prolonged hospitalization, and the possibility of postoperative complications ranging from an unsatisfactory cosmetic result to a fracture. Percutaneous radiofrequency (RF) ablation, which involves the use of thermal coagulation to induce necrosis in the lesion, is a minimally invasive alternative to surgical treatment of osteoid osteoma. With reported success rates approaching 90%, RF ablation should be considered among the primary options available for treating this condition.
130 citations
TL;DR: The lack of cyst recurrence after concomitant fusion supports the need to investigate the value of fusion of the involved motion segment in the treatment of symptomatic synovial cysts of the spine.
111 citations
TL;DR: An important predictor of long-term outcome after pericardiectomy is the etiology of the pericardial disease, which is worse than with idiopathic CP, but significantly better than with post-radiation CP.
Abstract: The diagnosis of constrictive pericarditis (CP) continues to be a challenge in the modern era. Understanding the pathophysiology and integrating the results of invasive and non-invasive techniques are important in the differential diagnosis of CP and e.g. restrictive cardiomyopathy. New echocardiographic techniques such as tissue Doppler imaging (TDI) and 2D-speckle tracking, dual-source CT (computed tomographic imaging) and especially tagged cine-MRI (magnetic resonance imaging) with the analysis of phase contrast angiography sequences are promising novel approaches. Pericardiectomy in experienced centers with complete decortication (if technically feasible) is the treatment of choice for CP and it results in symptomatic relief in most patients. However, some patients may not benefit from pericardiectomy and this may be due to myocardial compliance abnormalities, myocardial atrophy after prolonged constriction, residual constriction or other myocardial processes. An important predictor of long-term outcome after pericardiectomy is the etiology of the pericardial disease. The overall mortality in the current literature is nearly 5-6%. Survival with post-surgical CP is worse than with idiopathic CP, but significantly better than with post-radiation CP.
106 citations
TL;DR: Oestrogen given systemically or locally in all dosage regimens is effective, but topical vaginal application alone is preferred if systemic treatment is not needed and treatment is long term and may be required for many years.
TL;DR: The National Institutes of Health has redefined prostatitis into four distinct entities, and the focus of therapy is symptomatic relief, which provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin.
Abstract: The National Institutes of Health (NIH) has redefined prostatitis into four distinct entities. Category I is acute bacterial prostatitis. It is an acute prostatic infection with a uropathogen, often with systemic symptoms of fever, chills and hypotension. The treatment hinges on antimicrobials and drainage of the bladder because the inflamed prostate may block urinary flow. Category II prostatitis is called chronic bacterial prostatitis. It is characterized by recurrent episodes of documented urinary tract infections with the same uropathogen and causes pelvic pain, urinary symptoms and ejaculatory pain. It is diagnosed by means of localization cultures that are 90% accurate in localizing the source of recurrent infections within the lower urinary tract. Asymptomatic inflammatory prostatitis comprises NIH category IV. This entity is, by definition, asymptomatic and is often diagnosed incidentally during the evaluation of infertility or prostate cancer. The clinical significance of category IV prostatitis is unknown and it is often left untreated. Category III prostatitis is called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). It is characterized by pelvic pain for more than 3 of the previous 6 months, urinary symptoms and painful ejaculation, without documented urinary tract infections from uropathogens. The syndrome can be devastating, affecting 10-15% of the male population, and results in nearly 2 million outpatient visits each year. The aetiology of CP/CPPS is poorly understood, but may be the result of an infectious or inflammatory initiator that results in neurological injury and eventually results in pelvic floor dysfunction in the form of increased pelvic muscle tone. The diagnosis relies on separating this entity from chronic bacterial prostatitis. If there is no history of documented urinary tract infections with a urinary tract pathogen, then cultures should be taken when patients are symptomatic. Prostatic localization cultures, called the Meares-Stamey 4 glass test, would identify the prostate as the source for a urinary tract infection in chronic bacterial prostatitis. If there is no infection, then the patient is likely to have CP/CPPS. For healthcare providers, the focus of therapy is symptomatic relief. The first therapeutic measure is often a 4- to 6-week course of a fluoroquinolone, which provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin. Second-line pharmacotherapy involves anti-inflammatory agents for pain symptoms and alpha-adrenergic receptor antagonists (alpha-blockers) for urinary symptoms. Potentially more effective is pelvic floor training/biofeedback, but randomized controlled trials are needed to confirm this. Third-line agents include 5alpha-reductase inhibitors, glycosaminoglycans, quercetin, cernilton (CN-009) and saw palmetto. For treatment refractory patients, surgical interventions can be offered. Transurethral microwave therapy to ablate prostatic tissue has shown some promise. The treatment algorithm provided in this review involves a 4- to 6-week course of antibacterials, which may be repeated if the initial course provides relief. Pain and urinary symptoms can be ameliorated with anti-inflammatories and alpha-blockers. If the relief is not significant, then patients should be referred for biofeedback. Minimally invasive surgical options should be reserved for treatment-refractory patients.
TL;DR: The levels of evidence adopted by the Centre for Evidence-Based Medicine in Oxford were used to assess the studies for all reported outcomes that were meaningful to clinicians making decisions about treatment, including the impact of clinical symptoms, pH study profile, and esophageal appearance at endoscopy.
Abstract: Gastro-esophageal reflux (GER) is a common phenomenon, characterized by the regurgitation of the gastric contents into the esophagus. Gastro-esophageal reflux disease (GERD) is the term applied when GER is associated with sequelae or faltering growth. The main aims of treatment are to alleviate symptoms, promote normal growth, and prevent complications. Medical treatments for children include (i) altering the viscosity of the feeds with alginates; (ii) altering the gastric pH with antacids, histamine H2 receptor antagonists, and proton pump inhibitors; and (iii) altering the motility of the gut with prokinetics, such as metoclopramide and domperidone. Our aim was to systematically review the evidence base for the medical treatment of gastro-oesophageal reflux in children. We searched PubMed, AdisOnline, MEDLINE, and EMBASE, and then manually searched reviews from the past 5 years using the key words ‘gastro-esophageal’ (or ‘gastroesophageal’), ‘reflux’, ‘esophagitis’, and ‘child$’ (or ‘infant’) and ‘drug$’ or ‘therapy’. Articles included were in English and had an abstract. We used the levels of evidence adopted by the Centre for Evidence-Based Medicine in Oxford to assess the studies for all reported outcomes that were meaningful to clinicians making decisions about treatment. This included the impact of clinical symptoms, pH study profile, and esophageal appearance at endoscopy. Five hundred and eight articles were reviewed, of which 56 papers were original, relevant clinical trials. These were assessed further. Many of the studies considered had significant methodological flaws, although based on available evidence the following statements can be made. For infant GERD, ranitidine and omeprazole and probably lansoprazole are safe and effective medications, which promote symptomatic relief, and endoscopic and histological healing of esophagitis. Gaviscon® Infant sachets are safe and can improve symptoms of reflux. There is less evidence to support the use of domperidone or metoclopramide. More evidence is needed before other anti-reflux medications can be recommended. For older children, acid suppression is the mainstay of treatment. The largest evidence base supports the early use of H2 receptor antagonists or proton pump inhibitors.
TL;DR: The majority of authors of this document recommended that for all people traveling from low‐risk to high‐risk regions, one of the three antibacterial drugs should be transported with them for self‐treatment of diarrhea that occurs, given in respective order of development for TD therapy: a fluoroquinolone (ciprofloxacin or levofloxac in), rifaximin, or azithromycin.
Abstract: The most frequent illness among people traveling from industrialized regions to developing countries is travelers’ diarrhea (TD). For all people entering areas known to pose a high risk for TD, medication should be included in the travel kit on trips, which can be taken for self‐therapy of resultant diarrheal illness. Drugs aimed at relief of symptoms, particularly loperamide, are the preferred standard treatment of TD by some professionals in Europe. Travel medicine experts in the United States and many in Europe feel that an antimicrobial agent that cures while shortening the duration of illness represents the mainstay of therapy. Loperamide combined with an appropriate antimicrobial agent will provide the most rapid relief of TD. In the following document, the authors used an evidence base when available to determine the strength and quality of evidence and when data were lacking, the panel of experts provided consensus opinion.
Drugs used for symptomatic relief, including bismuth subsalicylate (BSS) and loperamide, decrease the number of unformed stools passed during a bout of TD but may not speed up illness recovery. The majority of authors of this document recommended that for all people traveling from low‐risk to high‐risk regions, one of the three antibacterial drugs should be transported with them for self‐treatment of diarrhea that occurs, given in respective order of development for TD therapy: a fluoroquinolone (ciprofloxacin or levofloxacin), rifaximin, or azithromycin. Azithromycin is preferred for treatment when diarrhea is complicated by dysentery (passage of grossly bloody stools) or by high fever and for use in children with TD. A number of experts would recommend additionally including loperamide in the travel kit for adults with TD as this may accelerate relief of the illness when used with an antimicrobial agent. An uncertain proportion of Europeans feel that it is sufficient to include loperamide alone …
TL;DR: It is demonstrated that acute administration of the selective alpha(7) nAChR partial agonist SSR180711 dose-dependently reversed the behavioral impairment induced by PCP, and the first to demonstrate prevention of the deleterious effects induced by repeated PCP treatment.
TL;DR: Evidence supporting the hypothesis that worsened outcomes are associated with antimotility therapy of CDI is lacking and further study of the role of antimOTility agents in providing symptomatic relief and reducing environmental contamination with infectious stool may be warranted.
Abstract: Antimotility agent use for the treatment of Clostridium difficile infection (CDI) is discouraged. We reviewed the literature and unpublished postmarketing surveillance reports regarding antimotility treatment of CDI. Twenty reports met inclusion criteria, describing 55 patients with CDI who were exposed to antimotility agents. All studies were case reports or series, with the exception of 1 retrospective review. Nineteen patients (35%) improved, with clinical resolution. Nine patients (16%) died, and 27 patients (49%) had unknown outcomes. Seventeen patients (31%) with CDI developed colonic dilation; 5 of these patients with severe CDI died. However, all patients who experienced complications or died were given antimotility agents alone initially, without an appropriate antibiotic. Twenty-three patients who received metronidazole or vancomycin coadministered with the antimotility agent experienced no complications. Evidence supporting the hypothesis that worsened outcomes are associated with antimotility therapy of CDI is lacking. Further study of the role of antimotility agents in providing symptomatic relief and reducing environmental contamination with infectious stool may be warranted.
TL;DR: Intraprostatic BT seems to be a promising approach to the treatment of BPH, which is safe, effective, well-tolerated, and not related to the patient's willingness to complete treatment.
TL;DR: In considering neuroplasticity as a target for the treatment of psychiatric disorders, this review builds on exciting new findings in the areas of anxiety disorders, mood disorders, and schizophrenia.
TL;DR: Corticosteroids provide symptomatic relief of pain in sore throat, in addition to antibiotic therapy, mainly in participants with severe or exudative sore throat.
Abstract: Objective To evaluate whether systemic corticosteroids improve symptoms of sore throat in adults and children. Design Systematic review and meta-analysis. Data sources Cochrane Central, Medline, Embase, Database of Reviews of Effectiveness (DARE), NHS Health Economics Database, and bibliographies. Outcome measures Percentage of patients with complete resolution at 24 and 48 hours, mean time to onset of pain relief, mean time to complete resolution of symptoms, days missed from work or school, recurrence, and adverse events. Results We included eight trials, consisting of 743 patients in total (369 children, 374 adults). 348 (47%) had exudative sore throat, and 330 (44%) were positive for group A β-haemolytic streptococcus. In addition to antibiotics and analgesia, corticosteroids significantly increased the likelihood of complete resolution of pain at 24 hours (four trials) by more than three times (relative risk 3.2, 95% confidence interval 2.0 to 5.1), and at 48 hours (three trials) to a lesser extent (1.7, 1.3 to 2.1). Corticosteroids (six trials) reduced mean time to onset of pain relief by more than 6 hours (95% confidence interval 3.4 to 9.3, P Conclusions Corticosteroids provide symptomatic relief of pain in sore throat, in addition to antibiotic therapy, mainly in participants with severe or exudative sore throat.
TL;DR: The purpose of this article is to provide an update and analyze current management, treatment options, and outcomes of treatment for elbow arthritis.
Abstract: The purpose of this article is to provide an update and analyze current management, treatment options, and outcomes of elbow arthritis This article focuses on studies that have been published in the past 5 years Nonoperative management may provide symptomatic relief in the early stages of the disease process for most patients Surgical treatment is guided by disease etiology and severity, patient age, and functional demands Arthroscopic or open synovectomy, debridement arthroplasty, and interposition arthroplasty are generally recommended for the young and active patient population, whereas for low-demand and elderly patients with end-stage painful arthritis, total elbow arthroplasty is considered a more suitable surgical option Advances in arthroscopic techniques and implant design have led to substantial improvements in treatment of elbow arthritis
TL;DR: All cognitive tests were limited in their ability to discriminate between AD and VaD, suggesting that they should be used cautiously and only in conjunction with other information (imaging, medical history) when diagnosing patients.
Abstract: Differentiating between Alzheimer's disease (AD) and vascular dementia (VaD) remains difficult but important if existing pharmacological treatments are to provide symptomatic relief in the case of AD or to alter disease progression in the case of VaD. Cognitive assessments play an important role in aiding diagnosis, despite a lack of clear evidence defining the cognitive abilities and tests that best distinguish between the two types of dementia. The current study therefore completed a meta-analysis of research comparing the cognitive abilities of persons diagnosed with AD and VaD. A comprehensive search was undertaken of the PubMed and PsychInfo databases, with 81 studies being eligible for inclusion. Weighted Cohen's d effect sizes, percentage overlap statistics, fail-safe Ns, and confidence intervals were calculated for all cognitive tests. Of the tests that were examined by more than one study, there was one test of perception and one test of verbal memory that showed large and significant group differences. There were an additional 12 tests that may prove useful. However, all cognitive tests were limited in their ability to discriminate between AD and VaD, suggesting that they should be used cautiously and only in conjunction with other information (imaging, medical history) when diagnosing patients.
Journal Article•
TL;DR: The treatment of plaque psoriasis with TNF-alpha antagonists is still a relatively recent addition to the pharmacologic armamentarium available to clinicians, and the collection of long-term data is small but growing as results from newer studies emerge.
Abstract: Introduction Psoriasis is one of several systemic diseases that presents chiefly with cutaneous symptoms and has the potential to negatively impact patients' overall health and quality of life. Physicians who treat patients with psoriasis must be cognizant of the chronic, lifelong character of the disease and of the potential for multisystem pathology. According to the National Institutes of Health (NIH), between 5.8 and 7.5 million persons in the U.S.--approximately 2.2% of the population--have psoriasis; worldwide, it affects an estimated 125 million people. The annual cost of treating psoriasis may exceed $3 billion annually. Immunologic mechanisms are now accepted as the pathophysiologic basis for the development of psoriatic disease. Treatment strategies--which include topical treatment, phototherapy, methtrexate, cyclosporine and acitretin--also encompass several biologic agents that target immune mediators associated with the condition. Discussion Patients with mild disease may obtain symptomatic relief with topical agents and targeted phototherapy. Patients with moderate-to-severe disease are likely to benefit from systemic therapy. Shortcomings of the traditional agents, particularly their adverse event profiles, have motivated research and development of biologic agents. Currently three anti-TNF agents--etanercept, infliximab and adalimumab--are FDA-approved for treatment of psoriasis. Differences exist among study designs and, therefore, in interpretation of data; however, the improvements observed in the psoriasis study populations participating in clinical trials are dramatic. Long-term clinical data continue to accumulate and demonstrate sustained benefits with anti-TNF agents. Safety data also continue to be collected over the long-term; key safety considerations are infection, cytopenia, demyelinating disease, lupus-like syndromes, congestive heart failure and malignancies. Combination therapy should also be considered when managing psoriasis for such reasons as augmenting an inadequate response to monotherapy or improving tolerability. Combination therapy with an anti-TNF agent and phototherapy has shown considerably higher rates of response compared with either intervention alone. Objective The objective of this paper is to critically examine the anti-TNF studies to assess the efficacy and safety of the agents in patients with psoriasis and determine applicability of the data in clinical practice. In light of the chronic nature of this disease, the emphasis will be on the longest-term data available. Conclusion The treatment of plaque psoriasis with TNF-alpha antagonists is still a relatively recent addition to the pharmacologic armamentarium available to clinicians. The collection of long-term data is, therefore, small but growing as results from newer studies emerge. From the data reviewed here, the clinician can attempt to arrive at a satisfactory assessment of the benefits and risks of treatment with these agents.
TL;DR: The findings support the use of PleurX catheters for palliative patients with malignant pleural effusions in the presence of trapped lung, which are not only easy to insert and discrete but they can be managed effectively by patients and community nurse practitioners and prevent repeated admissions to hospital in palliatives patients with compromised life expectancy.
Abstract: Malignant pleural effusions in the presence of trapped lung remain notoriously difficult to treat. Various methods exist ranging from minimally invasive procedures including repeated needle thoracocentesis to the need for a formal surgical procedure such as placement of a pleuroperitoneal shunt and even thoracotomy and decortication. Controversy exists as to what is the optimum treatment for this condition. Any planned treatment should balance the therapeutic benefit provided against convalesce for a disease with a limited life expectancy. Patients should not spend a significant proportion of their remaining life span recovering from palliative procedures. In a series of patients with malignant pleural effusion the medial survival time was 20 weeks, with 30 days and 1 year mortality rates of 12.8% and 83.6%, respectively. We describe our five-year experience with the use of indwelling PleurX catheters in patients with malignant pleural effusions in the presence of confirmed trapped lung on radiological or VATS investigation. Patient health related quality of life was investigated by telephone questionnaire. The parameters analysed were symptomatic relief, mobility and ease of management following insertion. One hundred and sixteen patients underwent PleurX catheter insertion by a single operator, 48 questionnaires were completed. Of the 48 cases analysed, improvement in all three quality of life indices was recorded following catheter insertion. Ease of mobility was recorded as moderately satisfied and very satisfied in 50% and 15% of patients, respectively. Symptomatic improvement was found to have been increased with 42% and 6% of patients responding to moderately satisfied and very satisfied, respectively. Ease of management was recorded as 'slightly satisfied' and moderately satisfied in 50% and 33% of patients, respectively, demonstrating a high satisfaction index in patients with chronic progressively debilitating malignancies. Complications were either transient or readily correctable. Pain was the predominant complication occurring in 35% of patients lasting <3 days. No patient required catheter removal for resolution of discomfort. Our findings support the use of PleurX catheters for palliative patients with malignant pleural effusions in the presence of trapped lung. The catheters are not only easy to insert and discrete but they can be managed effectively by patients and community nurse practitioners and prevent repeated admissions to hospital in palliative patients with compromised life expectancy.
01 Jul 2009
TL;DR: The effectiveness and safety of CHM in alleviating endometriosis-related pain and infertility is reviewed and a greater improvement, measured as the disappearance or shrinkage of adnexal masses, than with danazol is shown.
Abstract: Endometriosis is a disease characterized by the presence of tissue that is morphologically and biologically similar to normal endometrium in ectopic locations outside the uterine cavity. Hormonally stimulated cyclical bleeding from the endometriotic deposit appears to contribute to the induction of a local inflammatory reaction, fibrous adhesion, and, in the case of deep implants in the ovary, leads to the formation of an endometrioma or chocolate cyst. Endometriosis classically presents with severe dysmenorrhoea, pelvic pain, dyspareunia (pain on intercourse), menstrual irregularities, and infertility. Systemic symptoms may also occur such as fatigue, an increased incidence of allergies, and autoimmune diseases (Ballweg 2004). Definitive diagnosis is usually made through laparoscopic investigation although recent research suggests that non-invasive symptom evaluation may have a greater positive prediction value (Ling 1999; Winkel 2003). The precise prevalence of endometriosis is unclear but there is a broad consensus that between 5 to 15% of the female population will have signs and symptoms of the disease during their reproductive years (15 to 50) (Eskenazi 1997; Stenchever 2001; Zondervan 2001). Endometriosis is increasingly regarded as a complex, multi-factorial condition of uncertain aetiology where immunological (Ballweg 2004; Lebovic 2001; Sheng 1998), hormonal (Noble 1997), genetic (Bischoff 2004; Malinak 1980), environmental (Ballweg 2004; Ohtake 2003), and possibly even psychological factors (Low 1993, Strauss 1992) combine together to create a context for rogue endometrial cells to develop into a full blown disease.The treatment of endometriosis can be broadly divided into medical and surgical management. Medical treatment ranges from symptomatic control with non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics, through to treatments that aim to suppress the normal ovarian production of oestrogen by either hormonally simulating pregnancy (continuous oral contraceptives (COC) and progestins) or menopause (danazol and gonadotrophin-releasing hormone agonists (GnRH-a's). Surgical intervention can be either 'conservative', involving the removal of endometrial lesions or the severing of the nerve pathways responsible for the transmission of pelvic and uterine pain; or 'definitive', involving the removal of the uterus and ovaries. Danazol, Progestins, GnRH-a's and the COC have comparable short-term rates of success in alleviating the symptoms of endometriosis and in partially reducing the size of endometriosis related lesions (GISG 1996; Parazzini 2000, Prentice 2004; Moore 2004; Vercellini 1993,). Unfortunately the benefits are poorly sustained over time with studies frequently reporting a high level of returning symptoms at six months post treatment (Vercellini 1993) and even studies with more positive findings commonly demonstrate a return of symptoms in over a third of the women who took part two to three years after stopping treatment (Biberoglu 1981; Dmowski 1998). The short-term benefits of conventional medical treatment have to be balanced against the unpleasant and sometimes dangerous side effects resulting from these therapies. COC has recently been associated with increased thromboembolic risks (Anderson 2004), is unsuitable for certain patient groups, such as women over the age of 35 who smoke or who have a history of cardiovascular disease, and is obviously inappropriate for women trying to conceive. Danazol is associated with androgenic changes such as acne and weight gain, menopausal symptoms such as flushing and fatigue. Recent concerns have highlighted its potential role in raising LDL cholesterol levels (Hughes 2004) and in contributing to ovarian cancer (Cottreau 2003). GnRH agonists tend to produce a more hypo-oestrogenic state than danazol with more severe menopausal side effects such as hot flushes, insomnia, reduced libido and vaginal dryness (Prentice 2004). Low oestrogen levels can also cause serious osteoporosis and the long term risks of add-back regimes using small amounts of progesterone and oestrogen have not yet been adequately assessed. Patients using progestin therapy reported a higher incidence of acne, fluid retention, bloating and spotting. In addition progestins are known to unfavourably reduce the level of high-density lipo-proteins in the blood that could potentially increase the risk of cardiovascular side effects such as thrombosis (Vasilakis 1999). The surgical management of endometriosis is also far from satisfactory. Two RCTs (Abbott 2004; Sutton 1994) and several observational studies (Abbott 2003; Fedele 2004; Wheeler 1983) demonstrate significant symptomatic relief from conservative laparoscopic surgery but in many cases these benefits were relatively short lived with up to 44% of women experiencing a return of symptoms after one year (Lapp 2000). Surgery is also associated with the potential for serious side effects with one study reporting 2 to 3% of cases had post operative bowel perforations with peritonitis (Koninckx 1996) and an anonymous survey of 1951 gynaecologists revealing a significant number of unreported complications that suggest that the incidence of complications is higher than is commonly stated (Feste 1999). In summary current treatments all have high rates of re-occurrence and their short-term benefits have to be balanced by concerns over immediate and longer term side effects. Chinese herbal medicine (CHM) is a system of medicine with an unbroken written tradition stretching back over two thousand years. Although endometriosis as a distinct entity did not exist in the classical tradition, the symptoms of dysmenorrhoea, dysuria, dyschezia, menorrhagia and so on, were systematically differentiated and apparently well treated (Wu 1997). A common pattern underlying these conditions is the presence of what is known as stagnation of Blood and Qi (vital energy) causing localised obstructions and leading to pain. This is interestingly similar to the modern bio-medical understanding of the central role that endometrial lesions play in the symptomatology of the disease. We have recently seen increasing integration of Western medicine and CHM in China and in the past 10 years the use of laparoscopic diagnosis has allowed some evaluation of the specific benefits of CHM in the treatment of endometriosis through a number of clinical trials. For example, one review article identified 13 randomised clinical trials on Chinese medicine for treatment of endometriosis from Chinese literature published between 1994 and 2000 (Xu 2004). In these trials, 1076 participants were involved, and Chinese herbal medicines were applied either alone or in combination with biomedical drugs. The suggested mechanism of Chinese medicine for endometriosis may involve regulation of endocrine and immune systems, improvement of blood circulation, and anti-inflammatory activity (Huang 2006; Xu 2004). At present no English language systematic review evaluating the results of these individual studies has been conducted. The available Chinese and English language literature on the subject will be reviewed in an attempt to establish whether Chinese herbal medicine has a valid role in the treatment of this common and disabling condition.
Journal Article•
TL;DR: Low frequency pulsed electromagnetic field (PEMF) not only alleviates the pain in the arthritis condition but it also affords chondroprotection, exerts antiinflammatory action and helps in bone remodeling and this could be developed as a viable alternative for arthritis therapy.
Abstract: Arthritis refers to more than 100 disorders of the musculoskeletal system The existing pharmacological interventions for arthritis offer only symptomatic relief and they are not definitive and curative Magnetic healing has been known from antiquity and it is evolved to the present times with the advent of electromagnetism The original basis for the trial of this form of therapy is the interaction between the biological systems with the natural magnetic fields Optimization of the physical window comprising the electromagnetic field generator and signal properties (frequency, intensity, duration, waveform) with the biological window, inclusive of the experimental model, age and stimulus has helped in achieving consistent beneficial results Low frequency pulsed electromagnetic field (PEMF) can provide noninvasive, safe and easy to apply method to treat pain, inflammation and dysfunctions associated with rheumatoid arthritis (RA) and osteoarthritis (OA) and PEMF has a long term record of safety This review focusses on the therapeutic application of PEMF in the treatment of these forms of arthritis The analysis of various studies (animal models of arthritis, cell culture systems and clinical trials) reporting the use of PEMF for arthritis cure has conclusively shown that PEMF not only alleviates the pain in the arthritis condition but it also affords chondroprotection, exerts antiinflammatory action and helps in bone remodeling and this could be developed as a viable alternative for arthritis therapy
TL;DR: Palliative oxygen for refractory dyspnoea is frequently prescribed, even when the criteria for long-term home oxygen are not met, and neither the underlying diagnosis causing breathlessness nor the demographic factors predicted responders at 1 week.
Abstract: Palliativeoxygenfor refractorydyspnoea isfrequently prescribed, even when the criteria for long-term home oxygen (based on survival, rather than the symptomatic relief of breathlessness) are not met. Little is known about how palliative home oxygen affects symptomatic breathlessness. A 4 -year consecutive cohort from a regional community palliative care service in Western Australia was used to compare baseline breathlessness before oxygen therapy with dyspnoea sub-scales on the symptom assessment scores (SAS; 0–10) 1 and 2 weeks after the introduction of oxygen. Demographic and clinical characteristics of people who responded were included in a multi-variable logistic regression model. Of the study population (n = 5862), 21.1% (n = 1239) were prescribed oxygen of whom 413 had before and after data that could be included in this analysis. The mean breathlessness before home oxygen was 5.3 (SD 2.5; median 5; range 0–10). There were no significant differences overall at 1 or 2 weeks (P = 0.28) nor for any diagnostic sub-groups. One hundred and fifty people (of 413) had more than a 20% improvement in mean dyspnoea scores. In multi-factor analysis, neither the underlying diagnosis causing breathlessness nor the demographic factors predicted responders at 1 week. Oxygen prescribed on the basis of breathlessness alone across a large population predominantly with cancer does not improve breathlessness for the majority of people. Prospective randomised trials in people with cancer and non-cancer are needed to determine whether oxygen can reduce the progression of breathlessness compared to a control arm. Palliative Medicine (2009); 23 :3 09–316
TL;DR: There is insufficient evidence to demonstrate a clear overall benefit for topical steroids in CRS without polyps; however, their use appears safe and may show some symptomatic benefit.
Abstract: OBJECTIVE: To evaluate whether topical steroids provide symptomatic relief in patients with chronic rhinosinusitis without polyps.DATA SOURCES: MEDLINE, EMBASE, and Cochrane CENTRAL databases.REVIEW METHODS: Systematic review and meta-analysis was performed of the articles identified by two independent reviewers of all randomized controlled trials that had evaluated intranasal corticosteroids in patients with chronic rhinosinusitis (CRS) without polyps. The quality of included studies was evaluated, and results synthesized using standard random-effects meta-analytical methods.RESULTS: Of 424 potential studies, only nine randomized trials involving 657 patients in total were eligible. Quality of design and reporting was suboptimal, with only one trial adhering to accepted standards for reporting. Five trials combined outcome measures and reported on overall response of CRS without polyps to topical steroids. The summary estimate for overall response to treatment showed no significant benefit and substantia...
TL;DR: The role of M1 agonists as a potential disease-modifying therapy for Alzheimer's disease and in attenuating Abeta and tau pathology in different animal models is discussed.
Abstract: Cholinergic deficit is a cardinal feature of Alzheimer's disease, and cholinesterase inhibitors represent one of the most prominent means of mitigating this dysfunction. Cholinesterase inhibitors provide mild symptomatic relief, although they lose their efficacy over time most likely because they are not disease-modifying agents. An alternative strategy for restoring cholinergic function and attenuating the cognitive decline involves acting on the receptors on which acetylcholine acts. Stimulation of muscarinic acetylcholine receptors and in particular the M1 subtype has been shown to have a beneficial effect in restoring cognition in patients with Alzheimer's disease and in attenuating Abeta and tau pathology in different animal models. In this review, we discuss the role of M1 agonists as a potential disease-modifying therapy for Alzheimer's disease.
TL;DR: Nine patients with diuretic-resistant edema, secondary to congestive heart failure, liver cirrhosis, or nephrotic syndrome, were treated with ultrafiltration using high water flux dialyzers, which yielded immediate symptomatic relief and potential for restoration of an edema-free state.
Abstract: Nine patients with diuretic-resistant edema, secondary to congestive heart failure, liver cirrhosis, or nephrotic syndrome, were treated with ultrafiltration using high water flux dialyzers. Access to the blood stream was obtained by femoral vein catheterization. As much as 8.3 kg of fluid were removed in 3--4 hours with only transient decline in blood pressure. The procedure was well tolerated and yielded immediate symptomatic relief. The potential for restoration of an edema-free state in patients with diuretic-resistant edema suggests that further experience with this technique is justified.
TL;DR: Dyspnea is described as one of the most frightening and distressing symptoms, and patient self-report is the only reliable measure, and sedation is an effective, ethical option.
Abstract: Unfortunately, dyspnea is a common symptom in supportive care and the source of much suffering. As we understand more about the pathophysiology of dyspnea, we can better assess it, reverse its root causes when possible, and symptomatically treat it when reversal is not possible. This chapter focuses predominantly on the symptomatic relief of dyspnea. Because all interventions have benefits and burdens, any particular intervention must be assessed in the context of a patient’s goals of care. Although invasive and pharmacologic interventions can be useful in many patients, because dyspnea is a subjective phenomenon, psychosocial/spiritual support is needed in all patients.