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PubMedDate not supplied

Is impaired renal function a contraindication to the use of low-molecular-weight heparin?

BACKGROUND: Because of the risk of accumulation of anticoagulant effect, it has been suggested that patients with a creatinine clearance of 30 mL/min or less (< or =0.50 mL/s) should be excluded from treatment with low-molecular-weight (LMW) heparin, or have anti-factor Xa heparin level monitoring performed. OBJECTIVE: To assess the appropriateness of this recommendation. METHODS: We performed a systematic search of MEDLINE, EMBASE, and International Pharmaceutical Abstracts to identify prospective articles comparing differences in the pharmacokinetics of LMW heparins in nondialyzed patients with varying degrees of renal function. Reference lists of retrieved reports were checked for additional articles. RESULTS: Three single-dose pharmacokinetic trials and 2 multiple-dose deep vein thrombosis (treatment trials met our selection criteria. The 3 trials that could address our primary objective did not support the use of a 30-mL/min (0.50-mL/s) cutoff of creatinine clearance to select individuals at risk of accumulation when LMW heparin is used. Four of the 5 trials support the notion that anti-factor Xa activity of some LMW heparin preparations accumulates in patients with impaired creatinine clearance. Tinzaparin sodium, an LMW heparin with a higher-than-average molecular weight distribution, appears to be the exception, since it did not exhibit accumulation in patients with creatinine clearances as low as 20 mL/min (0.33 mL/s). CONCLUSIONS: The use of a 30-mL/min (0.50-mL/s) cutoff is not justified, on the basis of currently available evidence, to select individuals at increased risk of accumulation when LMW heparin is used. The pharmacokinetic response to impaired renal function may differ among LMW heparin preparations.

Adult↗
PubMed1997

Prior fungal infection is not a contraindication to bone marrow transplant in patients with acute leukemia.

PURPOSE: Our aim was to assess the feasibility of bone marrow transplantation (BMT) in patients with acute leukemia who have had prior documented invasive fungal infection within 5 months pretransplant treated aggressively with systemic amphoteric in B and, when applicable, surgical resection of the infected tissue. MATERIALS AND METHODS: We reviewed the charts of patients with acute leukemia at our institution who underwent BMT between August 1992 and April 1994 after being treated for a severe fungal infection. We evaluated criteria for diagnosis of fungal infection, timing of infection in relation to BMT, and antifungal treatment modalities. We determined peritransplant complications, evidence for recurrence of fungal infection during BMT, morbidity related to antifungal drug therapy, and overall outcome in each patient. RESULTS: Fungal infection developed in eight patients. Sites of involvement included lung, liver, spleen, and skin. All patients were treated with systemic amphotericin B. Some also underwent surgical resection of infected tissue following clinical control of infection. All patients underwent BMT. Seven of eight patients engrafted and survived BMT. One patient died of recurrent pulmonary mucormycosis. Three patients are alive and free of leukemia and fungal disease. Four patients died of noninfectious causes and had no evidence of fungal disease at the time of death. CONCLUSIONS: Aggressive therapy of prior fungal infection followed by ongoing anti-fungal prophylaxis in acute leukemia patients may allow BMT without reactivation of the fungus. Reports of larger series of such patients as well as studies of the efficacy of chemoprophylaxis of fungal infections are needed.

Adolescent↗
PubMed2001

Masked left ventricular restriction in elderly patients with atrial septal defects: a contraindication for closure?

The impact of an atrial septal defect in the elderly with reduced diastolic elasticity of the left ventricle is unclear. We studied the hemodynamic changes during balloon occlusion of atrial septal defects in patients over 60 years of age. In 18 patients (61-78 years old; median, 70), the left atrial pressure and the mitral valve inflow was measured during complete balloon occlusion of the defect and after deflation of the balloon. In seven patients, the left atrial pressure and the E/A ratio of the mitral valve inflow increased markedly (P = 0.02). Mean atrial pressures reached values of 27 mm Hg and the v-wave peak values of 55 mm Hg. Two patients received a transcatheter device closure and developed congestive heart failure. In the elderly, an atrial septal defect can have a decompressive impact on the left ventricle. Therefore, caution appears to be warranted if atrial septal closure is planned.

Aged↗
PubMed2004

Indication and contraindication for hepatic resection for liver tumors without fine-needle biopsy: validation and extension of an Eastern approach in a Western community hospital.

Fine-needle biopsy (FNB) is associated with problems, such as tumor seeding, which are not negligible. The aim of this study was to validate prospectively the accuracy of our diagnostic work-up without FNB, not just to address but also to rule out from a surgical program patients with focal liver lesions (FLLs). From September 2001 to July 2003, 89 patients were seen at an outpatient clinic for FLLs. Nine patients were excluded because of previous FNB and 18 were excluded because carrier of advanced disease. Sixty-two patients with 101 FLLs were included. Preoperative diagnoses were established by means of clinical histories, serum tumor marker levels, ultrasonography (US), and spiral computed tomography (CT). Other imaging modalities were carried out when it was considered necessary. Forty-eight patients underwent surgery, with histological confirmation of the preoperative diagnosis. The remaining 14 patients underwent a close follow-up. The preoperative diagnoses of 47 of the 48 patients who underwent surgery were confirmed (97.9%). All of the 14 patients ruled out for surgical treatment did not show FLL progression at 6-24 months of follow-up. Of the 9 patients who had FNB previously in other centers, 2 had a wrong histological diagnosis. In view of these results, a diagnostic work-up without FNB seems adequate either to include or to exclude patients with potentially resectable FLL from the surgical program and once more highlight the fact that the use of FNB should be drastically limited.

Adult↗
PubMed1989

Are inotropic agents contraindicated in congestive heart failure?

The myocardium in the patient with congestive heart failure is abnormal and probably unable to generate sufficient chemical energy to meet the heart's mechanical needs. Such a condition of "energy starvation" would have several important implications; among these is that inotropic stimulation, by increasing energy utilization, could accelerate the progressive death of myocardial cells that characterizes end-stage heart failure. An important goal of therapy in these patients, therefore, is to reduce cardiac energy expenditure. This can be accomplished by unloading the failing heart, which has already been shown to prolong survival in patients with severe congestive heart failure. Slowing the progressive death of myocardial cells may also be accomplished by the administration of negative, rather than positive, inotropic drugs.

Cardiotonic Agents↗
PubMed1996

Is severe renal osteodystrophy a contraindication for recombinant human growth hormone treatment?

Recent extension of the use of recombinant growth hormone (rhGH) to non-growth hormone-deficient patients necessitates close attention to possible complications in these patients, including effects on bone. Recent studies on the use of rhGH in children with chronic renal failure (CRF) provide some early data. No significant differences in radiographic osteodystrophy scores, serum calcium, phosphorus, or parathyroid hormone (PTH) levels were found between treated and untreated groups. Alkaline phosphatase increased transiently. The effect of renal osteodystrophy on growth response has not yet been reported. Animal models demonstrate that GH stimulates chondrocyte proliferation. Experimental data further suggest that GH can weaken the epiphyseal plate. Slipped capital femoral epiphysis has been reported in GH-deficient patients, before, during, and after GH therapy. In CRF patients treated with GH, slipped capital femoral epiphysis has also been reported. As renal osteodystrophy and hypocalcemia are risk factors for this condition, the relationship to GH therapy is unclear in these patients. Avascular necrosis, known to be associated with slipped capital femoral epiphysis and CRF, has also been reported in patients receiving GH, although the relationship to the therapy is unknown. Children with CRF treated with rhGH should be serially monitored for renal osteodystrophy, slipped capital femoral epiphysis, and avascular necrosis with serial radiographs and serum calcium, phosphorus, alkaline phosphatase, and PTH levels.

Child↗
PubMed1994

[Obstetric peridural anesthesia with sufentanil. Is it contraindicated?].

The advantages of the addition of low-dose sufentanil to local anaesthetics in epidural analgesia during labour (improvement of analgesia, reduction of total dose of local anaesthetic, reduction of rate of instrumental delivery outweigh) far the disadvantages (pruritus, sedation, potential maternal and neonatal respiratory depression). In over 8000 cases, the addition of incremental sufentanil (7.5 micrograms) up to 30 micrograms has not caused any negative effects on newborns, and hence, the addition of sufentanil is justified; it may even be indicated. Sufentanil has not yet been registered for epidural analgesia in Germany, in contrast to other countries. In considering whether this fact may prohibit its use, two aspects should be discussed: therapy and clinical experiments. The difference lies in the purpose rather than in the method of administration. Ethical and legal requirements for clinical tests are anchored in the declaration of Helsinki and the code of the medical profession. The legal background for therapy is represented in the proviso of the German Civil and Criminal Codes as well as the code of conduct on professional liability of the physician. Pain during labour is no absolute indication for the addition of sufentanil, but there are considerable arguments for its superiority in comparison to other standard procedures: the side effects and complications are very limited. Justification of this method is relatively easy in view of the fact that sufentanil has already been registered for peridural analgesia in obstetrics in many other countries. Last but not least, the patient must give informed consent before any procedure can be performed.

Adult↗