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PubMed2001

Dietary treatment for familial hypercholesterolaemia.

BACKGROUND: Familial hypercholesterolaemia is an inherited disorder characterised by a raised blood cholesterol, the presence of xanthomatosis and premature ischaemic heart disease. The aim of treatment is the reduction of blood LDL cholesterol concentrations in order to reduce the risk of ischaemic heart disease. Current treatment is based on a cholesterol lowering diet alone or in combination with drug therapy. Many of the drugs found to be effective in treating adults with this disease are not licensed for use in children, therefore diet is the main treatment of children with familial hypercholesterolaemia. In addition to the cholesterol-lowering diet, several other dietary interventions have been suggested and consensus has yet to be reached on the most appropriate dietary treatment for children and adults with familial hypercholesterolaemia. OBJECTIVES: To examine the evidence that in children and adults with familial hypercholesterolaemia, a cholesterol lowering diet is more effective at lowering cholesterol and reducing incidence of ischaemic heart disease than no intervention or than other dietary interventions. SEARCH STRATEGY: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Trials Register, a specialist trials register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and handsearching abstract books of conference proceedings. Additional studies were identified from handsearching the Journal of Inherited Metabolic Disease (from inception, 1978 to 2000) and from the reference lists of identified studies. SELECTION CRITERIA: Randomised controlled trials (RCTs), both published and unpublished, where a cholesterol lowering diet in children and adults with familial hypercholesterolaemia has been compared to other forms of dietary treatment or to no dietary intervention. Trials which include patients with familial hypercholesterolaemia alongside patients with non-familial hypercholesterolaemia were only included if the group of familial patients was well defined and the results for these patients were available. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the trial eligibility and methodological quality and one reviewer extracted the data, with independent verification of data extraction by a colleague. MAIN RESULTS: Only short term outcomes could be assessed in this review due to the length of the five eligible studies. Compliance to treatment, quality of life, mortality and evidence of ischaemic or atheromatous disease were not assessed in the studies identified. No differences were found between the cholesterol-lowering diet and all other diets for all of the short term outcomes assessed. REVIEWER'S CONCLUSIONS: No conclusions can be made about the effectiveness of the cholesterol-lowering diet, or any of the other dietary interventions suggested for familial hypercholesterolaemia, due to the lack of adequate data. A large, parallel, randomised controlled trial is needed to investigate the effectiveness of the cholesterol-lowering diet and other dietary interventions for FH. It is also possible that data from trials including subjects with both familial and non-familial hypercholesterolaemia could alter the results of future updates of this review and until further evidence is available current dietary treatment of FH should continue to be observed and monitored with care.

Adult↗
PubMed1999

Personal opinion on the date of first printing of Jing yue quan shu (Jingyue's Complete Book).

Generally, the date of the first printing is based on the description, "Introduction to the Complete Book", in the postscript written by his grandson Lin Riwei, saying that "in the year of Gengchen (1) brought (my draft) to eastern Guangdong to tell the Fangbo master Lu... (who) donated his salary for the printing which lasted for several months". By Fangbo, it is another name for the position of Buzhengsi (Provincial administrative commissioner). Here, it refers to Lu Chao, by then the commissioner of Guangdong. In the Chronicle of Qing Officials, it is recorded that Lu Chao was in charge of Guangdong provincial commissioner in the year 37-40 of Kangxi reign (1688-1671). Together with other reference data, I draw the conclusion that Jingyue's Complete Book should be first printed in the year 1700.

China↗
PubMed2001

Dopamine agonists for cocaine dependence.

BACKGROUND: Cocaine is a major drug of abuse. Cocaine dependence is a common and serious condition, which has become nowadays a substantial public health problem. There is a wide and well documented range of consequences associated to chronic use of this drug, such as medical, psychological and social problems, including the spread of infectious diseases (e.g. AIDS, hepatitis and tuberculosis), crime, violence and neonatal drug exposure. Therapeutic management of the cocaine addicts includes an initial period of abstinence from the drug. During this phase the subjects may experience, besides the intense craving for cocaine, symptoms such as depression, fatigue, irritability, anorexia, and sleep disturbances. It was demonstrated that the acute use of cocaine may enhance dopamine transmission and chronically it decreases dopamine concentrations in the brain. Pharmacological treatment that affects dopamine could theoretically reduce these symptoms and contribute to a more successful therapeutic approach. OBJECTIVES: To evaluate the efficacy and acceptability of dopamine agonists for treating cocaine dependence. SEARCH STRATEGY: We searched: The Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2000), MEDLINE (from 1966 - 2000), EMBASE (from 1980 - 2000), LILACS (from 1982 - 2000), PsycLIT (from 1974 - 2000), Biological Abstracts (1982 to 2000). Reference searching; personal communication; conference abstracts; unpublished trials from pharmaceutical industry; book chapters on treatment of cocaine dependence. SELECTION CRITERIA: The inclusion criteria for all randomised controlled trials were that they should focus on the use of dopamine agonists on the treatment of cocaine dependence. Trials including patients with additional diagnosis such as opiate dependence were also eligible. DATA COLLECTION AND ANALYSIS: The reviewers extracted the data independently and Relative Risks, weighted mean difference and number needed to treat were estimated. The reviewers assumed that people who died or dropped out had no improvement and tested the sensitivity of the final results to this assumption. MAIN RESULTS: Twelve studies were included, with 587 participants randomised. Amantadine and Bromocriptine were compared to placebo in most of trials. In two studies amantadine was directly compared to bromocriptine, while amantadine was compared to desipramine, an antidepressant in three. The main efficacy outcome presented was positive urine sample for cocaine metabolites, with no significant differences between interventions. When retention in treatment was assessed as an acceptability measure, it was found a similar rate of patients remaining in treatment in both placebo and active drugs. There were no significant differences in trials where participants had primary cocaine dependence or had additional diagnosis of opioid dependence and/or were in methadone maintenance treatment. REVIEWER'S CONCLUSIONS: Current evidence does not support the clinical use of dopamine agonists in the treatment of cocaine dependence. Given the high rate of dropouts in this population, clinicians may consider adding psychotherapeutic supportive measures aiming to keep patients in treatment.

Amantadine↗
PubMed2001

Antidepressants for cocaine dependence.

BACKGROUND: Cocaine dependence is a common and serious condition, which has become nowadays a substantial public health problem. The past decade has witnessed a sustained search for an effective pharmacotherapeutic agent for the treatment of cocaine dependence. While administration of cocaine acutely increases intercellular dopamine, serotonin, and norepinephrine levels by blocking their presynaptic reuptake, chronic cocaine abuse leads to down-regulation of monoamine systems. Post-cocaine use depression and cocaine craving may be linked to this down-regulation. Antidepressant pharmacotherapy, by augmenting monoamine levels, may alleviate cocaine abstinence symptomatology, as well as relieving dysphoria and associated craving by general antidepressant action. OBJECTIVES: To conduct a systematic review of all RCTs on the use of antidepressants for treating cocaine dependence. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2000), MEDLINE (from 1966 - 2000), EMBASE (from 1980 - 2000), LILACS (from 1982 - 2000), PsycLIT (from 1974 - 2000), Biological Abstracts (1982 to 2000). Other searches:reference searching; personal communication; conference abstracts; unpublished trials from pharmaceutical industry; book chapters on treatment of cocaine dependence. SELECTION CRITERIA: The inclusion criteria for all randomised controlled trials were that they should focus on the use of antidepressants on the treatment of cocaine dependence. Trials including patients with additional diagnosis such as opiate dependence were also eligible. DATA COLLECTION AND ANALYSIS: The reviewers extracted the data independently and Relative Risks, weighted mean difference and number needed to treat were estimated. The reviewers assumed that people who died or dropped out had no improvement and tested the sensitivity of the final results to this assumption. MAIN RESULTS: 18 studies were included in the review, with 1177 people randomised. Positive urine sample for cocaine metabolites was the main efficacy outcome, with no significant results obtained regardless the type of antidepressant. Compared to other drugs, desipramine performed better but showing just a non significant trend with heterogeneity present as revealed by the chi-square test (8.6, df=3; p=0.04). One single trial showed imipramine performed better than placebo in terms of clinical response according to patient's self-report. A similar rate of patients remaining in treatment was found for both patients taking desipramine or placebo. Results from one single trial suggest fluoxetine patients on SSRIs are less likely to dropout. Similar results were obtained for trials where patients had additional diagnosis of opioid dependence and/or were in methadone maintenance treatment. REVIEWER'S CONCLUSIONS: There is no current evidence supporting the clinical use of antidepressants in the treatment of cocaine dependence. Given the high rate of dropouts in this population, clinicians may consider adding psychotherapeutic supportive measures aiming to keep patients in treatment.

Antidepressive Agents↗
PubMed2002

Guide for the practical application of the ICRP Human Respiratory Tract Model. A report of ICRP supporting guidance 3: approved by ICRP committee 2 in October 2000.

The ICRP Publication 66 Human Respiratory Tract Model for Radiological Protection (HRTM) has been applied to calculate dose coefficients (doses per unit intake) and bioassay functions in ICRP Publications 68, 71, 72 and 78. For these purposes, ICRP assigned numerical values to a range of model parameters, such as the size of the inhaled particles and the breathing rate of the subjects. These are known as 'default' or 'reference' values, and were chosen to be typical, representative values. In any particular situation the actual values of many parameters can be considerably different from the reference values. Usually, doses from intakes of radionuclides are low compared with the relevant limit or constraint, and the resulting difference is unimportant. There are, however, circumstances where more reliable assessments of intake and dose are desirable. This Guidance Document therefore gives advice on applying specific information within the framework of the HRTM for assessing occupational and environmental exposures and for interpreting bioassay data. Chapters on each aspect of the model (morphometry, physiology, deposition, clearance, gases and vapours, dosimetry) provide: A summary of how the HRTM treats that topic;Information on the reference values of relevant parameters;Guidance on choosing between default values;Information on how doses and bioassay quantities (lung retention, urine, and faecal excretion) vary with the values of selected parameters, giving guidance on the importance of obtaining specific information;Simple examples of the use of specific information relating to the topic.Annexes give additional information for those directly involved in applying the HRTM to specific situations, including guidance on obtaining parameter values. A brief overview is given of the deposition, characterisation, and sampling of aerosols, with references to further information, as there are relevant text books already available. Issues specific to radioactive aerosols, such as low particle number concentrations for high specific activity materials are, however, addressed. Guidance on obtaining information about absorption of inhaled radionuclides into blood is given in greater detail, because this is a topic on which ICRP has traditionally given guidance, and because a compilation of such information is not readily available elsewhere. Several detailed examples are also provided. One involves assessment of an individual's intake and committed dose from comprehensive bioassay monitoring data. The others deal with the derivation of HRTM absorption parameter values from experimental data, and their application, with additional information on e.g. size distribution, to calculate dose coefficients and interpret bioassay data.

Adolescent↗
PubMed2000

Cranial irradiation for preventing brain metastases of small cell lung cancer in patients in complete remission.

BACKGROUND: Prophylactic cranial irradiation halves the rate of brain metastases in patients with small cell lung cancer. Individual randomized trials conducted on patients in complete remission were unable to clarify whether this treatment improves survival. OBJECTIVES: This study aims to test whether prophylactic cranial irradiation prolongs survival of patients with small cell lung cancer in complete remission. SEARCH STRATEGY: Published and unpublished trials were eligible. Electronic databases, reference lists of trial publications, review articles and relevant books were used to identify potentially eligible trials. The search was also guided by discussions with investigators and experts, and the examination of meeting proceedings and of the Physician Data Query clinical trial registry. SELECTION CRITERIA: Randomized trials comparing prophylactic cranial irradiation with no prophylactic cranial irradiation in patients with small cell lung cancer in complete remission. DATA COLLECTION AND ANALYSIS: Meta-analysis based on updated individual data. The main endpoint was survival. MAIN RESULTS: The relative risk of death in the treatment group compared to the control group was 0.84 (95% confidence interval=0.73 to 0.97, P=0.01), corresponding to a 5.4 percent increase in the 3-year survival rate (from 15.3 percent in the control group to 20.7 percent in the treatment group). Prophylactic cranial irradiation also increased disease-free survival (relative risk=0.75, 95% confidence interval=0.65 to 0.86, P<0.001) and decreased the risk of brain metastases (relative risk=0.46, 95% confidence interval=0.38 to 0.57, P<0.001). Increasing doses of irradiation decreased the risk of brain metastases when four groups (8 Gy, 24-25 Gy, 30 Gy, 36-40 Gy) were analyzed [trend test, P=0.02], but the effect on survival did not differ significantly according to the dose. We found a trend (P=0.01) for a decrease in the brain metastasis risk in favour of earlier administration of cranial irradiation after the initiation of induction treatment. REVIEWER'S CONCLUSIONS: Prophylactic cranial irradiation significantly improves survival and disease-free survival for patients with small cell lung cancer in complete remission. Further clinical trials are needed to confirm the potential greater benefit on brain metastasis rate suggested when cranial irradiation is given earlier or at higher doses.

Brain Neoplasms↗
PubMed2004

Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery.

BACKGROUND: Post-operative atrial fibrillation is a common complication of cardiac surgery and has been associated with increased incidence of other complications including post-operative stroke, increased hospital length of stay and increased cost of hospitalisation. Prevention of atrial fibrillation is a reasonable clinical goal and, consequently, many randomised trials have evaluated the effectiveness of pharmacological and non-pharmacological interventions. We systematically reviewed the literature and prepared meta-analyses to better understand the role and effects of various prophylactic therapies against post-operative atrial fibrillation. OBJECTIVES: To assess the effects of pharmacological and non-pharmacological interventions for preventing post-cardiac surgery atrial fibrillation. SEARCH STRATEGY: We searched CENTRAL, MEDLINE, EMBASE and CINAHL from earliest achievable date to June 2003. We hand searched references from reports and earlier reviews. We searched abstract books and CD-ROMs from annual scientific meetings of American College of Cardiology, American Heart Association, North American Society of Pacing and Electrophysiology and European Heart Organization between 1997-2003. No language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials comparing pharmacological interventions or non-pharmacological interventions with control treatment, placebo or usual care for the prevention of post-operative atrial fibrillation in post-coronary artery bypass grafting or combined CABG and valvular surgery. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Fifty eight studies were included with a total of 8565 participants. Interventions included were amiodarone, beta blockers, solatol and pacing. Results favoured treatment for post-operative atrial fibrillation. The data for stroke favoured treatment by a non-significant effect size of 0.81, 95% confidence interval 0.51 to 1.28. Similarly, a positive indication for length of stay was derived but it too was not significant with a weighted mean difference of -0.66, 95% confidence interval -0.95 to -0.37. A positive result for cost of hospitalisation in favour of treatment was achieved, but the statistic is not significant due to low power and large standard deviations: a weighted mean difference of -2717, 95% confidence interval 7518 to 2084. Beta-blockers had the greatest magnitude of effect across 28 trials (4074 patients) with an odds ratio (random) of 0.35, 95% confidence interval 0.26 to 0.49. Across all treatment, the odds ratio favoured treatment with a ratio (random) of 0.43, 95% confidence interval 0.37 to 0.51. REVIEWERS' CONCLUSIONS: Intervention is favoured across the three pharmacological interventions studied and the one non-pharmacological intervention, pacing. The length of stay data favoured treatment (-0.66, 95% confidence interval -0.95 to -0.37).

Adrenergic beta-Antagonists↗
PubMed2004

Quality of life after rectal resection for cancer, with or without permanent colostomy.

BACKGROUND: For almost one hundred years abdominoperineal excision has been the standard treatment of choice for rectal cancer. With advances in the techniques for rectal resection and anastomosis, anterior resection with preservation of the sphincter function has become the preferred treatment for rectal cancers, except for those cancers very close to the anal sphincter. The main reason for this has been the conviction that the quality of life for patients with a colostomy after abdominoperineal excision was poorer than for patients undergoing a sphincter-preserving technique. However, patients having sphincter-preserving operations may experience symptoms affecting their quality of life that are different from those withstoma-patients. OBJECTIVES: To compare the quality of life in rectal cancer patients with or without permanent colostomy. SEARCH STRATEGY: We searched PubMed, EMBASE, LILACS, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Colorectal Cancer Group's specialised register. Abstracts books from major gastroenterological and colorectal congresses were searched. Reference lists of the selected articles were scrutinized. SELECTION CRITERIA: All controlled clinical trials and observational studies in which quality of life was measured in patients with rectal cancer having either abdominoperineal excision or low anterior resection, using a validated quality of life instrument, were considered. DATA COLLECTION AND ANALYSIS: One reviewer (JP) checked the titles and abstracts identified from the databases and hand search. Full text copies of all studies of possible relevance were obtained. The reviewer decided which studies met the inclusion criteria. Both reviewers independently extracted data. If information was insufficient the original author was contacted to obtain missing data. Extracted data were crosschecked and discrepancies resolved by consensus. MAIN RESULTS: Twenty five potential studies were identified. Eight of these, all non-randomised and representing 620 participants, met the inclusion criteria. Four trials found that people undergoing abdominoperineal excision did not have poorer quality of life measures than patients undergoing anterior resection. One study found that a stoma only slightly affected the persons quality of life. Three studies found that patients receiving abdominoperineal excision had significantly poorer quality of life than after anterior resection. Due to heterogeneity, meta-analysis of the included studies was not possible. REVIEWERS' CONCLUSIONS: The studies included in this review do not allow firm conclusions as to the question of whether the quality of life of people after anterior resection is superior to that of people after abdominoperineal excision. The included studies challenged the assumption that anterior resection patients fare better.Larger, better designed and executed prospective studies are needed to answer this question.

Colostomy↗
PubMed2005

Quality of life after rectal resection for cancer, with or without permanent colostomy.

BACKGROUND: For almost one hundred years abdominoperineal excision has been the standard treatment of choice for rectal cancer. With advances in the techniques for rectal resection and anastomosis, anterior resection with preservation of the sphincter function has become the preferred treatment for rectal cancers, except for those cancers very close to the anal sphincter. The main reason for this has been the conviction that the quality of life for patients with a colostomy after abdominoperineal excision was poorer than for patients undergoing a sphincter-preserving technique. However, patients having sphincter-preserving operations may experience symptoms affecting their quality of life that are different from those with stoma-patients. OBJECTIVES: To compare the quality of life in rectal cancer patients with or without permanent colostomy. SEARCH STRATEGY: We searched PUBMED, EMBASE, LILACS, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Colorectal Cancer Group's specialised register. Abstract books from major gastroenterological and colorectal congresses were searched. Reference lists of the selected articles were scrutinized. SELECTION CRITERIA: All controlled clinical trials and observational studies in which quality of life was measured in patients with rectal cancer having either abdominoperineal excision or low anterior resection, using a validated quality of life instrument, were considered. DATA COLLECTION AND ANALYSIS: One reviewer (JP) checked the titles and abstracts identified from the databases and hand search. Full text copies of all studies of possible relevance were obtained. The reviewer decided which studies met the inclusion criteria. Both reviewers independently extracted data. If information was insufficient the original author was contacted to obtain missing data. Extracted data were crosschecked and discrepancies resolved by consensus. MAIN RESULTS: Thirty potential studies were identified. Eleven of these, all non-randomised and representing 1412 participants met the inclusion criteria. Six trials found that people undergoing abdominoperineal excision did not have poorer quality of life measures than patients undergoing anterior resection. One study found that a stoma only slightly affected the person's quality of life. Four studies found that patients receiving abdominoperineal excision had significantly poorer quality of life than after anterior resection. Due to heterogeneity, meta-analysis of the included studies was not possible. AUTHORS' CONCLUSIONS: The studies included in this review do not allow firm conclusions as to the question of whether the quality of life of people after anterior resection is superior to that of people after abdominoperineal excision. The included studies challenged the assumption that anterior resection patients fare better.Larger, better designed and executed prospective studies are needed to answer this question.

Colostomy↗
PubMed2004

Luteal phase support in assisted reproduction cycles.

BACKGROUND: The aspiration of the granulosa cells that surround the oocyte and the use of gonadotropin releasing hormone agonists (GnRHa) during assisted reproduction technology (ART) treatment can interfere with the production, during the luteal phase, of progesterone, which is necessary for successful implantation of the embryo. Providing hormonal supplementation during the luteal phase with either progesterone itself, or human chorionic gonadotropin (hCG), which stimulates progesterone production, may improve implantation and, thus, pregnancy rates. OBJECTIVES: To determine (1) if luteal phase support after assisted reproduction increases the pregnancy rate, (2) the optimal hormone for luteal phase support, i.e. hCG, progesterone, or a combination of both, and (3) the optimal route of progesterone administration. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders & Subfertility Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1971 to Dec 2003), EMBASE (1985 to Dec 2003). We handsearched reference lists of relevant articles were scanned, and abstract books from scientific meetings up to December 2003. SELECTION CRITERIA: Randomized controlled trials of luteal phase support after ART treatment, comparing hCG or progesterone with placebo or no treatment, comparing progesterone with hCG, progesterone plus hCG, or progesterone plus estrogen, or comparing different routes of progesterone administration. Quasi-randomized trials were excluded from the main analyses, but included in a secondary analysis for each comparison. DATA COLLECTION AND ANALYSIS: For each comparison, data on live birth, ongoing and clinical pregnancy per embryo or gamete transfer procedure, miscarriage per clinical pregnancy, ovarian hyperstimulation syndrome (OHSS) per transfer, and multiple pregnancy per clinical pregnancy were extracted into 2 x 2 tables and subgrouped by use of GnRHa in the ovarian stimulation regimen. The odds ratio (OR) and risk difference (RD) were calculated. MAIN RESULTS: Fifty-nine studies were included in the review. Luteal phase support with hCG provided significant benefit, compared to placebo or no treatment, in terms of increased ongoing pregnancy rates (odds ratio (OR) 2.38, 95% confidence interval (CI) 1.32 to 4.29) and decreased miscarriage rates (OR 0.12, 95% CI 0.03 to 0.50), but only when GnRHa was used. The odds of OHSS increased 20-fold when hCG was used in cycles with GnRHa. Progesterone use resulted in a small but significant increase in pregnancy rates (OR 1.34, 95% CI 1.01 to 1.79) when trials with and without GnRHa were grouped together, but no effect on the miscarriage rate was observed. No significant difference was found between progesterone and hCG or between progesterone and progesterone plus hCG or estrogen in terms of pregnancy or miscarriage rates, but the odds of OHSS were more than 2-fold higher with treatments involving hCG than with progesterone alone(OR 3.06, 95% CI 1.59 to 5.86). Comparing routes of progesterone administration, reductions in clinical pregnancy rate with the oral route, compared to the intramuscular or vaginal routes, did not reach statistical significance, but there was evidence of benefit of the intramuscular over the vaginal route for the outcomes of ongoing pregnancy and live birth. No significant difference in pregnancy rate was observed between vaginal progesterone gel and other types of vaginal progesterone. REVIEWERS' CONCLUSIONS: Luteal phase support with hCG or progesterone after assisted reproduction results in an increased pregnancy rate. hCG does not provide better results than progesterone, and is associated with a greater risk of OHSS when used with GnRHa. The optimal route of progesterone administration has not yet been established.

Chorionic Gonadotropin↗
PubMed1976

Voyeurism: a review of literature.

The most striking thing about the literature on voyeurism is the relative lack of material in print. In the present work, the author was able to find only 15 articles and no books that deal specifically with voyeurism. Of the 57 references compiled for this review, not one involves an experimental manipulation of variables. An attempt is made to review as many aspects of voyeurism as possible, giving illustrative case material whenever available. The areas of troilism and coprophilia are covered in some detail to establish to what degree they belong to the deviation of voyeurism. Theory of perversion has centered around the psychoanalytic and behavioral schools because of the lack of material from other approaches. The voyeur is found to be a relatively young man of low socioeconomic status, who sociosexually is said to be "not retarded but a late bloomer." He is prone to minor crimes and not major offenses. It is suggested that moyeurism be considered a deviation from normal sexual behavior and that deviations are not in and of themselves criminal behavior. At present, punishment is genera-ly mild but highly variable and unpredictable. Treatment is usually analysis or group therapy, but other forms of therapy such as aversion and avoidance conditioning are being attempted with increasing success.

Behavior Therapy↗
PubMed1994

[Opioids, cerebral circulation and intracranial pressure].

The effects of the opioids alfentanil (A), fentanyl (F), and sufentanil (S) on cerebral blood flow (CBF) and intracranial pressure (ICP) have been discussed in several recent publications. The purpose of this review is to describe the results of studies in animals, healthy volunteers, and patients with and without intracranial diseases. Clinical relevance and mechanisms of the reported ICP and CBF increases are analysed. METHODS. Approximately 70 original articles and abstracts were retrieved by a systematic literature search using the key word list at the end of this abstract. The cited studies came from computerised database systems like Silver Platter and DIMDI, the SNACC reference list, and the bibliographies of pertinent articles and books. These studies were classified into three groups: significant increase of ICP and/or CBF; no significant or clinically relevant alterations; and significant decreases of ICP and/or CBF. RESULTS. The numerical relationship was 6:7:3 for A, 7:16:9 for F, and 5:11:8 for S. Increases of previously normal or only slightly elevated ICP were registered in some studies in connection with a decrease in mean arterial pressure (MAP). On the other hand, in patients with brain injury and elevated ICP opioids did not further increase ICP despite MAP decreases. In studies monitoring ICP and/or CBF continuously, transient and moderate increases of questionable clinical relevance became apparent a few minutes after bolus injection of opioids. Alterations of systemic and cerebral haemodynamics observed after bolus application were not registered during continuous infusion of A and S. DISCUSSION AND CONCLUSIONS. The cerebral effects of opioids are dependent on several factors, e.g., age, species, ventilation, anaesthesia before and during measurements, systemic haemodynamics, and underlying diseases. The probable mechanism of ICP increase during decreasing MAP is cerebral vasodilatation due to maintained autoregulation. With increasing severity of the cerebral lesion autoregulation is often disturbed. Therefore, ICP often remains unaltered despite MAP decreases. However, the resulting decrease in cerebral perfusion pressure makes such patients more susceptible to develop ischaemic neurological deficits. Induction of somatic rigidity or (with high doses) convulsions, exceeding the upper limit of autoregulation, histamine release, cerebral vasodilatation, increased cerebral oxygen consumption, or carbon dioxide accumulation during spontaneous breathing were discussed as mechanisms for transient ICP/CBF increases. It is concluded that opioids are often beneficial and not generally contraindicated for patients with cerebral diseases and compromised intracranial compliance. However, since negative side effects cannot be excluded, opioid effects and side effects should be monitored (MAP, ICP, cerebrovenous oxygen saturation, transcranial Doppler sonography) in patients at risk. It has to be stressed that opioids should be administered only to patients with stable haemodynamic situations and preferably in well-titrated, continuous infusions.

Alfentanil↗
PubMed2002

A critical appraisal of cesarean section rates at teaching hospitals in India.

OBJECTIVES: To obtain an estimate of cesarean section rates and examine the indications and consequences at teaching hospitals in India. METHODS: Information was obtained on total number of normal and cesarean deliveries during 1993-1994 and 1998-1999 from 30 medical colleges/teaching hospitals. In addition, prospective data were recorded for a period of 2 months on 7017 consecutive cesarean sections on indications for cesarean delivery, associated complications and mortality. RESULTS: The overall rate of cesarean section increased from 21.8% in 1993-1994 to 25.4% in 1998-1999. Among the 7,017 cesarean section cases, 42.4% were primigravidas, 31% had come from rural areas, 20.8% were referred including 8% with history of interference, 66% were booked cases, period of gestation was less than 37 weeks in 21.7% and in 18% the surgery was elective. Major indications for cesarean section included dystocia (37.5%), fetal distress with or without meconium aspiration (33.4%), repeat section (29.0%), malpresentation (14.5%) and PIH (12.5%). Maternal and perinatal mortality was 299/100,000 and 493/1,000 deliveries, respectively, and is high in spite of the increase in the cesarean section rates. CONCLUSIONS: There is need for standardized collection of information on all aspects of childbirth to ascertain the incidence and indications of cesarean section nationally so that comparison and improvements of care can take place.

Adult↗
PubMed1996

Cost-effective management of dyspepsia and gastroesophageal reflux disease.

Dyspepsia and heartburn are common symptoms in primary care practice. This article outlines the diagnosis and management of these problems with an emphasis on cost-effectiveness as well as the prevention of complications. It reviews what evaluations and treatments have been shown in the literature to be helpful and which have been found to be ineffective or much more expensive without clear benefit. It also clarifies the various diseases that can present as dyspepsia and refers readers to the appropriate articles included in this book.

Cost-Benefit Analysis↗
PubMed1998

[Surgery of the supratentorial and ventral spine: view-point of the surgeon].

The prone position for posterior fossa and cranio-spinal surgery is becoming the standard posture for neurosurgical teams. We analyze the reasons of such a change and specify indications of this posture. Thereafter, the procedure for optimal positioning is considered and the benefits of the prone position for the neurosurgeon and the anaesthetist are discussed. The selected references originate from Medline search (1991-1997), the Year Book of Neurology and Neurosurgery and the major neurosurgical review articles published between 1980 and 1996.

Humans↗
PubMed2003

Occupational rhinitis.

OBJECTIVE: To define occupational rhinitis, classify its various causes, review the steps in diagnosis, and describe the nonpharmacologic and pharmacologic management principles. DATA SOURCES: A review of MEDLINE articles in English on occupation rhinitis for January 1, 1970, through December 31, 2001, was performed. In addition, references were identified from bibliographies of relevant articles and books. STUDY SELECTION: The expert opinion of the author was used to select the relevant articles for the review. RESULTS: Occupational rhinitis is the episodic, work-related occurrence of sneezing, nasal discharge, and nasal obstruction. It frequently coexists with asthma but may present alone. Occupational rhinitis can be caused by heightened olfactory awareness, nonspecific inflammation of the nose, exposure to a high concentration of irritating and soluble chemical gases, or IgE mechanisms. The history and physical examination are the most important components to the workup of the patient. A site visit to the specific work area may give helpful insights to the patients' exposure. In the case of IgE-mediated allergic occupational rhinitis, skin testing or serologic testing may be useful. Greater objectivity to the diagnosis can be obtained through nasal challenge and the rapidly developing technique of rhinomanometry. Nonpharmacologic management (environmental control) and pharmacotherapy, such as that used in allergic rhinitis, should both be instituted. CONCLUSIONS: Although it does not have the same impact as occupational asthma, occupational rhinitis causes distress, discomfort, and work inefficiency. Attention to principles of management involving nonpharmacologic and pharmacologic measures will spare the patient the symptoms of occupational rhinitis.

Humans↗
PubMed2003

Fatigue associated with stroke and other neurologic conditions: Implications for stroke rehabilitation.

OBJECTIVES: To examine the general phenomenon of fatigue in stroke and other neurologic disorders and to review what is currently known about its occurrence, including its frequency, duration, severity, and associated factors, to develop a strategy for treatment. DATA SOURCES: Computerized databases (eg, PubMed, PsycInfo, Science Citation Index, Ovid EMBASE, Ovid MEDLINE) searched from inception to May 2002. Additional references were identified from bibliographies of pertinent articles and books. STUDY SELECTION: Over 1000 articles were identified as relevant to fatigue experienced by patients with neurologic or nonneurologic disorders. Articles on fatigue in stroke and neurologic disorders, mechanisms, and/or treatment were selected for inclusion. DATA EXTRACTION: Authors reviewed the articles and assessed the purpose, study design, and conclusions for validity and relevance to the topic of fatigue in stroke. DATA SYNTHESIS: Fatigue is a common complaint among patients with neurologic disorders including stroke. Few studies have documented the high frequency of fatigue in poststroke patients and its negative impact on daily functioning and quality of life. Little is known about associated factors or about therapeutic strategies that may be used to alleviate it. Examination of fatigue in other neurologic populations suggests common characteristics and associated factors that may be useful in the development of potential therapeutic strategies. Pharmacologic and nonpharmacologic therapeutic interventions, such as stimulants, amantadine, or sleep and stress-management education, have been used with some success in neurologic and other patient populations (eg, multiple sclerosis, human immunodeficiency virus, acquired immune deficiency syndrome, cancer), but evidence of effectiveness based on randomized clinical trials is rare. CONCLUSIONS: Poststroke fatigue is common. Therapeutic strategies have been used to treat fatigue in other patient populations, but it is unclear whether these will be beneficial to poststroke patients. Frequency, severity, duration, impact, predisposing factors, and causes of poststroke fatigue, as well as the development of effective treatment, require further research. Criteria for assessment of fatigue and potential therapeutic interventions are outlined as a first step for stimulating further research.

Activities of Daily Living↗
PubMed2002

Homeopathic treatment of hot flushes: a pilot study.

Hot flushes are a common problem, especially for menopausal women for whom hormone replacement therapy (HRT) is contra-indicated or who prefer not to take it and patients receiving Tamoxifen. Some seek homeopathic treatment. We report an uncontrolled, pilot outcome study, conducted at the Tunbridge Wells Homeopathic Hospital (TWHH) in 1998-1999. The study was conducted in out-patient consultations booked in the usual way. Thirty-one patients referred to the Department for menopausal flushes and seen for an initial consultation and at least one follow-up review, were assessed in three groups: Hot flushes: No history of carcinoma of the breast. Hot flushes: Treatment for breast carcinoma, not receiving Tamoxifen. Hot flushes: Treatment for breast cancer including Tamoxifen. For all patients, the initial and follow-up assessments included review of hot flush frequency and severity. Patients also completed their own self-assessment rating after follow-up consultations. The results indicate useful symptomatic benefit for all three groups of patients.

Antineoplastic Agents↗