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PubMed1999

Beta-blockers for the treatment of hypertension in patients with diabetes: exploring the contraindication myth.

PURPOSE: To review the evidence supporting the "contraindications" (hypoglycemic unawareness, insulin resistance, and dyslipidemia) usually given as the reasons for not using beta blockers for treating hypertension in patients with diabetes mellitus. METHODS: A research synthesis based on MEDLINE (January 1966 through January 1999), hand searches of pertinent references and textbooks, and consultation with experts. RESULTS: There is little evidence to support the assertion that beta blockers should be routinely contraindicated in diabetes. Beta blockers have few clinically important effects on hypoglycemic awareness and recovery, insulin resistance and hyperglycemia, or lipid profiles. Moreover, when diabetics have been treated with beta blockers for hypertension or for the secondary prevention of myocardial infarction, they benefit as much, if not more, than nondiabetic patients. There may be circumstances (e.g., hypertensive patients with coronary disease) under which beta blockers are the drugs of first choice for diabetic patients. Recommendations to use agents other than beta blockers for the treatment of hypertension in diabetes are based on these agents' effectiveness against surrogate endpoints, and not their proven benefit in preventing important clinical endpoints. CONCLUSIONS: Except for patients with brittle glycemic control, manifest hypoglycemic unawareness, renal parenchymal disease, or documented intolerance, beta blockers should no longer be considered routinely contraindicated in the presence of diabetes.

Adrenergic beta-Antagonists↗
PubMed2000

Contraindications to vaccination in the Russian Federation.

Failure to achieve high levels of immunity among children contributed to the epidemic of diphtheria that occurred in the Russian Federation during the 1990s. A major factor in this failure was the extensive list of contraindications to vaccination that was in use throughout the countries of the former Soviet Union. In 1980, the Ministry of Health (MOH) of the Soviet Union adopted an extensive list of contraindications for use of the diphtheria-tetanus toxoids-pertussis (DTP) vaccine. In 1994, the MOH of the Russian Federation revised the list of contraindications to vaccination to be largely in accord with World Health Organization recommendations. Since then, age-appropriate vaccination coverage has increased markedly: In 1996, DTP3 coverage among children 12 months of age had increased to 87% from 60% in 1990.

Child, Preschool↗
PubMed2005

Possible contraindications and adverse reactions associated with the use of ocular nutritional supplements.

The role of oxidation in the development of age-related eye disease has prompted interest in the use of nutritional supplementation for prevention of onset and progression. Our aim is to highlight possible contraindications and adverse reactions of isolated or high dose ocular nutritional supplements. Web of Science and PubMed database searches were carried out, followed by a manual search of the bibliographies of retrieved articles. Vitamin A should be avoided in women who may become pregnant, in those with liver disease, and in people who drink heavily. Relationships have been found between vitamin A and reduced bone mineral density, and beta-carotene and increased risk of lung cancer in smoking males. Vitamin E and Ginkgo biloba have anticoagulant and anti-platelet effects respectively, and high doses are contraindicated in those being treated for vascular disorders. Those patients with contraindications or who are considered at risk of adverse reactions should be advised to seek specialist dietary advice via their medical practitioner.

Ascorbic Acid↗
PubMed1998

Perceived contraindications to thrombolytic treatment in acute myocardial infarction. A survey at a teaching hospital.

OBJECTIVE: To examine the use of thrombolytic treatment in acute myocardial infarction when faced with perceived contraindications to treatment and to explore the justification for withholding treatment in such clinical situations. METHODS: Interview survey of all doctors responsible administering thrombolysis to patients with acute myocardial infarction at a teaching hospital in the UK from March to May 1997. RESULTS: 20 doctors were interviewed and asked whether they would give or withhold thrombolysis in a series of 19 clinical situations. These included patients presenting with both an acute myocardial infarction and one of the following associated conditions: a confirmed gastrointestinal haemorrhage, a suspected gastrointestinal haemorrhage, a peptic ulcer, an abdominal aortic aneurysm, a recent cerebrovascular accident, a known intracranial aneurysm, a known intracranial tumour, a recent dental extraction, recent surgery, severe hypertension, proliferative diabetic retinopathy, a history of bleeding diathesis, coma, recent cardiopulmonary resuscitation, pregnancy, menstruation, and a recent central venous puncture. In all but one of the clinical situations (definite current gastrointestinal haemorrhage) there was wide variation in response as to what constitutes a contraindication to thrombolytic treatment. Overall, a substantial proportion of doctors (35%-95%) would withhold treatment on account of any one of these clinical histories. CONCLUSION: Clinicians may be withholding thrombolysis in acute myocardial infarction on account of perceived contraindications for which there is little or no evidence of increased haemorrhagic risk. An effective treatment for acute myocardial infarction is probably being underused.

Contraindications↗
PubMed2001

Intravenous immune globulins in patients with Guillain-Barré syndrome and contraindications to plasma exchange: 3 days versus 6 days.

Plasma exchange is contraindicated in 10 to 20% of patients with Guillain-Barré syndrome (GBS). The optimal schedule for intravenous immune globulin (IVIg) therapy has not yet been established in these patients. The objective was to compare the efficacy and safety of two IVIg treatment durations in patients with GBS with contraindications for plasma exchange. In this randomised, double blind, multicentre phase II trial conducted in seven French centres, patients with GBS with severe haemostasis, unstable haemodynamics, or uncontrolled sepsis were randomly assigned to 0.4 g/kg/day IVIg for 3 or 6 days. The primary outcome measure was the time needed to regain the ability to walk with assistance. Thirty nine patients were included from March 1994 to May 1997, 21 in the 3 day group and 18 in the 6 day group. Time to walking with assistance was non-significantly shorter in the 6 day group (84 (23-121) v 131 days (51-210), p=0.08); the difference was significant in ventilated patients (86 days (13-151) in the 6 day group v 152 days (54-332) in the 3 day group; p=0.04). The prevalence and severity of IVIg related adverse effects were comparable between the two groups. In conclusion, in patients with GBS and contraindications for plasma exchange, especially those who need ventilatory assistance, IVIg (0.4 g/kg/day) may be more beneficial when given for 6 days rather than 3 days.

Aged↗
PubMedDate not supplied

Contraindications and safety of transbronchial lung biopsy via flexible bronchoscopy. A survey of pulmonologists and review of the literature.

BACKGROUND: Transbronchial lung biopsy (TBLB) via flexible bronchoscopy is a common procedure performed by pulmonologists. Limited scientific data exist concerning the risk of this procedure in patients with conditions that may adversely affect the rate of procedural complications. OBJECTIVES: To evaluate the current practice pattern and attitude of pulmonologists toward the performance of TBLB in the presence of high-risk conditions. METHODS: A survey was constructed and distributed at the American College of Chest Physicians annual meeting, held in Philadelphia, USA, in November of 2001. RESULTS: A total of 227 surveys were distributed with a return of 158 (69.6%). Anticoagulation medications are temporarily held prior to TBLB by the majority of our survey respondents (98.7% for intravenous heparin, 90.5% for warfarin, and 87.3% for low-molecular-weight heparin). Medications with effect on platelet function are held by fewer pulmonologists. There is a wide variation in the pulmonologists' perception of the risk of performing TBLB when certain medical conditions coexist: pulmonary hypertension [absolute contraindication (AC), 28.7%; relative contraindication (RC) 58.6%], superior vena cava syndrome (AC 19.6%, RC 51%), mechanical ventilation (AC 17.8%, RC 58.6%) and lung cavity/abscess (AC 7%, RC 44.9%). A significant percentage of pulmonologists (55%) do not regard an elevated serum creatinine at any level as AC to TBLB. Thirty-eight percent of the survey participants administer desmopressin prior to TBLB in uremic patients to prevent excessive bleeding. CONCLUSIONS: Prior to performing bronchoscopic TBLB, the majority of pulmonologists temporarily holds anticoagulation medications. However, there is a lack of agreement in relation to perceived contraindications and safety of TBLB.

Bronchoscopy↗
PubMed2002

Mandibular advancement devices: rate of contraindications in 100 consecutive obstructive sleep apnea patients.

Mandibular advancement devices (MAD) should be contraindicated (Clark GT, Sleep Med Rev 1998;2:163-174) if there are: (1) insufficient teeth to support the device, (2) periodontal problems inducing tooth mobility, (3) active temporomandibular joint (TMJ) disorder, and (4) limited maximum protrusive distance (< 6 mm). The aim of the present study was to evaluate the proportion of the obstructive sleep apnea population that exhibits any contraindication (CI) to MAD. For this study there were 100 unselected adult patients consecutively diagnosed by polysomnography in a tertiary sleep laboratory. Clinical and radiologic evaluation of the dental, periodontal, and TMJ status of these 100 patients were performed by two expert maxillofacial surgeons, blind to each other, permitting the identification of MAD CIs. The two maxillofacial surgeons agreed on MAD absolute CIs in 96 of the 100 patients. CIs were identified in 34% of the patients. The nature of the CIs systematically referred to an insufficient number of remaining teeth (mean number of teeth lost: 7.8 +/- 6.1 with 31 patients having had more than 10 teeth removed). The tooth avulsions were significantly higher in contraindicated compared with noncontraindicated patients (16 +/- 8 versus 4 +/- 3, p < 0.00001). Periodontal abnormalities coexisted with dental CI in approximately half of the patients. A TMJ disorder was considered as significant enough to lead to CI in two patients. Dental and periodontal care was needed in 16 patients before the use of MAD could be considered. Conclusions were that primary CIs were present in 34% of 100 consecutive patients, mainly owing to dental problems. Moreover, another subgroup of patients (16%) required close supervision and follow-up to avoid impairment of preexisting TMJ and dental problems. Such a high rate of CI should be considered when the overall efficacy of oral appliances is compared with other treatments, such as surgery or nasal continuous positive airway pressure.

Adult↗
PubMed2002

Gadodiamide as an alternative contrast agent during angioplasty in patients with contraindications to iodinated media.

PURPOSE: To evaluate gadodiamide as an alternative contrast agent for peripheral and renal angioplasty in patients with contraindications to iodinated contrast media. METHODS: Seventeen patients (10 men; mean age 74 years, range 68-83) with contraindication to iodinated contrast media were given gadodiamide as the contrast agent during peripheral and renal intra-arterial digital subtraction angiography (DSA) and subsequent percutaneous interventions (balloon angioplasty, stent placement). RESULTS: The mean volume of gadodiamide used was 136 +/- 46 mL (range 60-200). No serious side effects were observed, especially no change in renal or thyroid function; no exanthema or other allergic reactions were noted. In patients without renal artery intervention, serum creatinine at discharge remained unchanged (2.57 +/- 1.43 mg/dL to 2.40 +/- 1.28 mg/dL, p=NS). In patients undergoing angioplasty/stenting of renal artery stenoses, serum creatinine decreased significantly from 3.53 +/- 1.75 mg/dL to 2.36 +/- 1.15 mg/dL (p<0.01). All but 1 intervention was successful. Using a simple scoring system, 2 judges blinded to the contrast agent graded the quality of the peripheral DSAs as "good," whereas renal DSA images were only "sufficient." CONCLUSIONS: For patients with contraindications to iodinated materials, gadodiamide may be a suitable alternative for renal or peripheral DSA followed by angioplasty.

Aged↗
PubMed2005

A trial of automated decision support alerts for contraindicated medications using computerized physician order entry.

BACKGROUND: Automated clinical decision support has shown promise in reducing medication errors; however, clinicians often do not comply with alerts. Because renal insufficiency is a common source of medication errors, the authors studied a trial of alerts designed to reduce inpatient administration of medications contraindicated due to renal insufficiency. METHODS: A minimum safe creatinine clearance was established for each inpatient formulary medication. Alerts recommending cancellation appeared when a medication order was initiated for a patient whose estimated creatinine clearance was less than the minimum safe creatinine clearance for the medication. Administration of medications in patients with creatinine clearances less than the medication's minimum safe clearance were studied for 14 months after, and four months before, alert implementation. In addition, the impact of patient age, gender, degree of renal dysfunction, time of day, and duration of housestaff training on the likelihood of housestaff compliance with the alerts was examined. RESULTS: The likelihood of a patient receiving at least one dose of contraindicated drug after the order was initiated decreased from 89% to 47% (p < 0.0001) after alert implementation. Analysis of the alerts seen by housestaff showed that alert compliance was higher in male patients (57% vs. 38%, p = 0.02), increased with the duration of housestaff training (p = 0.04), and increased in patients with worsening renal function (p = 0.007). CONCLUSION: Alerts were effective in decreasing the ordering and administration of drugs contraindicated due to renal insufficiency. Compliance with the alerts was higher in male patients, increased with the duration of housestaff training, and increased in patients with more severe renal dysfunction.

Contraindications↗
PubMed2002

Bariatric surgery in a patient with possible psychiatric contraindications.

Grade III obesity (BMI > 39.9 kg/m2) is considered a chronic disease where clinical and diet therapy show poor results, with high rates of relapse. The most consistent results are those obtained through surgical procedures. Several authors discuss the contraindications for the performance of anti-obesity operations. Psychiatric disorders are often considered contraindications to these operations, especially affective disorders, psychotic disorders and personality disorders. The authors report the case of a 37-year-old patient, with obesity history since the age of 12, and anorexiant abuse (amphetamine-derived substances) during 20 years, binge-eating episodes, purgative compensatory behaviors and recurrent depressive symptoms. She was submitted to anti-obesity surgery in August 2000 (BMI 40.2). The outcome is reported and a discussion of the possible psychiatric contraindications for the anti-obesity surgeries is proposed.

Adult↗
PubMedDate not supplied

[Drugs contraindicated in children: a study of drug prescriptions in ambulatory medicine in the south of France (Aude Department)].

AIMS: The aim of this study was to describe prescriptions of drugs contra-indicated in children according to the summary product characteristics (SPC) of the drugs. METHODS: An exhaustive cross-sectional study based on the data used by the French Health Insurance in the Aude Department (France) during 2001 was carried out to identify all instances where children under the age of 15 years were prescribed a drug that stated in its SPC that its use in this age group was contraindicated. RESULTS: The prescription of drugs stated as being contraindicated in children under the age of 15 years involved 4316 children. The incidence rate was 116 per 1000 child-years. It was patently obvious for two classes of drugs: nasal decongestants (21.0% of prescriptions) and non-steroidal anti-inflammatory drugs (16.9%). These prescriptions were made by 610 physicians, of which 70% were general practitioners, 8% dentists and 3% paediatricians. CONCLUSION: This study shows a high incidence of children receiving contraindicated drugs in Aude department in France. This work highlights the need for, first, the widespread dissemination of information on the good use of drugs in children and, secondly, specific clinical trials performed in children.

Adolescent↗
PubMed2001

Confounding by contraindication in a nationwide cohort study of risk for death in patients taking ibopamine.

BACKGROUND: Outcomes may differ in treated and untreated patients because of a contraindication for treatment in the latter that is independently associated with the outcome of interest. OBJECTIVE: To evaluate the effects of confounding by contraindication on risk factors for death in patients taking ibopamine after its use was restricted in early September 1995. DESIGN: Retrospective cohort study. SETTING: The Netherlands. PATIENTS: 1146 patients with congestive heart failure who were prescribed ibopamine at least once and for whom medication history and medical data were available. MEASUREMENTS: Cardiovascular risk factors, clinical characteristics, and medication use. Each patient was assigned an index date (the date of death, or a random date for patients still alive at the end of the study). RESULTS: In univariate analyses comparing patients with an index date before and those with an index date after 8 September 1995, the relative risk for death associated with current use of ibopamine was 3.02 (95% CI, 2.12 to 4.30) compared with 0.71 (CI, 0.53 to 0.96), respectively. In multivariate analyses, the risk for death was 2.62 (CI, 1.76 to 3.90) and 0.93 (CI, 0.84 to 1.02), respectively. CONCLUSION: The marked inversion of the relative risk estimate can be considered a practical example of confounding by contraindication.

Aged↗
PubMedDate not supplied

Influence on survival after heart transplantation of contraindications seen in transplant recipients.

Fifty-seven patients underwent heart transplantation at our hospital between April 1986 and April 1991. In an attempt to assess the result of and the influence of contraindications seen in transplant recipients before transplantation on the outcome after transplantation, we have analyzed six of these "relative" contraindications: (1) age over 55 years (21% of patients); (2) pulmonary hypertension (pulmonary vascular resistance of more than 5 Wood units, and/or transpulmonary gradient of more than 12 mm Hg; 26% of patients); (3) renal failure (serum creatinine level of more than 2 mg/dl, and/or creatinine clearance of less than 35 ml/min; 11% of patients); (4) active infection (9% of patients); (5) diabetes mellitus (7% of patients); and (6) critical/unstable clinical condition before transplantation (25% of patients). An overall "risk score," obtained by adding one point for each contraindication, was also analyzed. Risk score was 0 (the "ideal" recipient) in 38% of patients, 1 in 25% of patients; 2 in 23% of patients; and 3 or more in 14% of patients. Actuarial survival was significantly lower for patients over 55 years of age (45% versus 68% at 18 months; p less than 0.05), for patients with elevated pulmonary vascular resistance (38% versus 72%; p less than 0.01), and for patients with kidney failure (16% versus 70%; p less than 0.01). On the contrary, survival at 18 months was not significantly different for patients with or without diabetes mellitus (50% versus 63%; not significant [NS]), active infection (60% versus 63%; NS), or critical/unstable condition (45% versus 69%; p less than 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed2005

The appropriate use of patellofemoral arthroplasty: an analysis of reported indications, contraindications, and failures.

UNLABELLED: Patellofemoral arthroplasty is going through a recent resurgence in interest with various new designs being introduced for general orthopaedic use. With this renewed enthusiasm for the procedure, it is important to understand the various indications and contraindications for using patellofemoral arthroplasty devices with the expectation that proper patient selection will improve outcome. Our purpose was to analyze the appropriate usage of these prostheses based on published historical results. A literature search was done to review the indications, contraindications, and factors contributing to the failure of these devices. We analyzed 12 studies reporting results of patellofemoral arthroplasty between 1979 and 2005. Commonly cited contraindications for using these devices have been tibiofemoral arthritis, uncorrected patellofemoral or tibiofemoral malalignment, and inflammatory arthritis. The highest failure rates were in patients with progression of osteoarthritis in other compartments or persistence of congenital or surgically uncorrected malalignment. In analyzing the reasons for failures in these reports together with issues already known to affect total knee arthroplasty surgery, we suggest an expanded list of outcome-altering factors to consider when choosing to do a patellofemoral arthroplasty. Finally, based on these observations and our own experience, suggestions on the best approach to the patient with patellofemoral arthritis are made to avoid less than optimal results if patellofemoral arthroplasty is considered. LEVEL OF EVIDENCE: Prognostic Study, Level II-3 (systematic review of Level-II studies. See the Guidelines for Authors for a complete description of levels of evidence.

Arthroplasty, Replacement, Knee↗
PubMed1996

[Contraindications of thrombolytic therapy in acute myocardial infarct].

In 43 Swiss hospitals, 824 patients have been included in the ISIS-3 trial with suspected or proven myocardial infarction. Another 504 patients with proven myocardial infarction have been excluded for various reasons and have been registered in the study log-book (total 1328 patients). The usual clinical contraindications for thrombolysis are listed and discussed in this paper. 1/3 of those patients excluded from the trial had not received thrombolysis without clear contraindications (age, diabetes, anticoagulation, candidates for a pace-maker) and another 27% have had only relative contraindications (resuscitation, puncture, ulcer pain, hypertension). The new guidelines for thrombolytic therapy allowed more patients to benefit from this therapy.

Adult↗
PubMedDate not supplied

Complications and contraindications of thoracoscopy.

In many instances surgical intervention in the chest has been replaced by the minimally invasive thoracoscopic or VATS approach. With such a technique there are disadvantages, complications and contraindications that develop or exist. Disadvantages include the loss of tactile sensation and the cost of the procedural equipment. Absolute contraindications include a fused lung, markedly unstable patient, shock or cardiac arrest, and an individual unable to tolerate partial or complete unilateral collapse of the lung. Lesser contraindications include the patient with bleeding tendencies or under anticoagulant therapy. The few major complications we have seen include prolonged air leak, pulmonary atelectasis and respiratory failure, the "down" lung syndrome or retained secretions. Technical complications including inability to locate the lesion because of its small size, penetration of the lung or inadequate resection of a tumor with subsequent seeding of the tract through the pleural and chest wall have been reported. Major bleeding has not occurred in our institution. Mortality has been seen only in the preterminal malignancy patient.

Anesthesia, Local↗
PubMed2004

Benefits of soy germ isoflavones in postmenopausal women with contraindication for conventional hormone replacement therapy.

OBJECTIVE: To evaluate the effects of isoflavones on vasomotor symptoms and blood lipids in postmenopausal women with contraindication for conventional hormone replacement therapy (HRT). METHODS: This prospective, double-blind and placebo-controlled study included 50 postmenopausal women randomly divided into two groups: 25 women on soy germ isoflavones (60 mg per day, capsules) and 25 women on placebo. Inclusion criteria included: non-vegetarian, non-asian women whose last menstruation dated at least 12 months prior to the beginning of the study, with FSH > 40 mIU/ml, hot flushes and contraindication for HRT, not using tamoxifen or antibiotic and no disease of the gastrointestinal tract. For 6 months, the Kupperman menopausal index (KMI), the vaginal cytological maturation value (MV) and both hormonal and lipid profiles were assessed. The t-test and analysis of variance (ANOVA) were employed to compare the two groups. RESULTS: In both groups, a decreased KI rate was observed. However, isoflavone was significantly superior to placebo in reducing hot flushes (44% versus 10%, respectively) (P < 0.05). After 6 months, the isoflavone group showed increased estradiol levels with unchanged FSH, LH, and vaginal cytology, and a reduction of 11.8% in LDL and an increase of 27.3% in HDL (P < 0.05 ). In the placebo group, just a reduction in MV was observed after 6 months (P < 0.05 ). CONCLUSIONS: Soy germ isoflavone exerted favorable effects on vasomotor symptoms and lipid profile, showing itself to be an interesting alternative therapy for the postmenopausal women with contraindication for conventional HRT.

Brazil↗
PubMed1981

Interpretation of the contraindications to whooping cough vaccination.

The official recommendations on the contraindications to whooping cough immunisation are currently couched in general terms. The results of a simple inquiry made to directors of public health laboratories, general paediatriciains, paediatric neurologists, medical officers, general practitioners, and health visitors to see how they would interpret the contraindications in certain specific cases suggest that there is considerable uncertainty on how the contraindications should be interpreted. This is probably one factor responsible for the fall in the rate of whooping cough immunisation in the United Kingdom.

Allied Health Personnel↗