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PubMed1998

Cost savings in duodenal ulcer therapy through Helicobacter pylori eradication compared with conventional therapies: results of a randomized, double-blind, multicenter trial. Gastrointestinal Utilization Trial Study Group.

BACKGROUND: We hypothesized that treatment of duodenal ulcer disease with antibiotic therapy directed toward Helicobacter pylori infection is more cost-effective than therapy with antisecretory agents. METHODS: A randomized, double-blind, multicenter clinical trial of adult patients with active duodenal ulcer and H. pylori infection was conducted. Patients were randomized to receive 500 mg of clarithromycin 3 times a day plus 40 mg of omeprazole daily for 14 days followed by 20 mg of omeprazole daily for an additional 14 days (group 1), 20 mg of omeprazole daily for 28 days (group 2), or 150 mg of ranitidine hydrochloride twice a day for 28 days (group 3). The use of ulcer-related health care resources was documented during monthly interviews for 1 year after the initial therapy. Clinical success was evaluated 4 to 6 weeks and 1 year after the end of therapy. RESULTS: Of the 819 patients enrolled, 727 completed the study. Group 1 included 243 patients; group 2, 248 patients; and group 3, 236 patients. Patients in group 1 used fewer ulcer-related health care resources during the 1 year after therapy compared with groups 2 and 3 (comparisons are given as group 1 vs group 2 and group 1 vs group 3, respectively): the number of endoscopies performed, 28 vs 76 (P<.001) and vs 71 (P<.001); patients receiving drugs to treat an ulcer, 118 vs 180 (P<.001) and vs 168 (P<.001); clinic visits, 83 vs 135 (P=.05) and vs 161 (P<.001); hospitalizations, 0 vs 5 (P=.045) and vs 6 (P=.02); and length of hospital stay, 0 vs 24 days (P=.04) and vs 37 (P=.04). When ulcer-related costs were defined as the outcome variable in a multivariate linear regression analysis, therapy was determined to have a significant influence on costs (group 1 vs group 2, P<.001; group 1 vs group 3, P=.008). Clinical success rates at the end of the study and cure of H. pylori infection were significantly greater in group 1 compared with groups 2 and 3 (P<.001). Therapy with clarithromycin plus omeprazole provided savings of $1.94 and $2.96 (compared with therapy with omeprazole and with ranitidine hydrochloride, respectively) per dollar spent within the first year after therapy. This incremental cost-benefit translates to savings of $547 or $835 per patient in group 1 (compared with patients in group 2 or group 3, respectively) during the first year after therapy. CONCLUSIONS: Combination therapy with clarithromycin and omeprazole resulted in significantly fewer uses of ulcer-related health care resources than conventional antisecretory therapy during a 1-year follow-up and significant savings in associated costs during the same period. Patients who received clarithromycin plus omeprazole also showed a significantly improved clinical outcome compared with patients who received only omeprazole or ranitidine.

Adult↗
PubMed2002

[Interventions for improvement of primary care in patients with low back pain: how effective are advice to primary care physicians on therapies and a multimodal therapy program arising out of cooperation of outpatient health care structures?].

BACKGROUND: Treatment for chronic low back pain in primary care has a poor-quality outcome. There is evidence that multimodal therapy is the most successful approach to its management. We tried to evaluate whether giving primary care physicians evidence-based recommendations on therapy of chronic back pain or directly implementing a multimodal program would improve the outcome of patients with low back pain treated in primary care. METHODS: In the first phase, physicians were asked to document the course of patients suffering from low back pain of at least 4 weeks' duration with no decrease in intensity, noting pain intensity before and after 6 months of conventional, nonsurgical treatments. In the present, second, phase of the study, recommendations issued by the Medicines Committee of the German Medical Profession and the U.S. Agency for Health Care Policy and Research for the management of back pain were presented to doctors in printed form and at conferences. In parallel with this, a multimodal program for the treatment of chronic low back pain (4 h/day for 20 days: medical training therapy, cognitive-behavioral therapy, physiotherapy, and patient education) was organized in a private health-oriented sports center in cooperation with three private physiotherapy practices, and a psychologist and a pain specialist from the outpatient pain clinic at the University Hospital in Erlangen. We examined how physicians changed the therapy and how effective it was, the latter as reflected in the mean sum value of the percent pre- to posttreatment changes in pain intensity, how much pain interfered with daily living, depressivity, and quality of life. Data after interventions were compared with baseline data from the first phase. RESULTS: Data relating to 36 patients following treatment by 14 primary care physicians who had been given information about therapy recommendations and to 51 patients who had participated in the multimodal therapy program were compared with baseline data recorded in 157 patients. Recommendations changed neither the therapy preferred by primary care physicians nor the quality of outcome of conventional treatment. In contrast, the multimodal program of therapy for chronic low back pain improved the outcome significantly more than conventional therapy (mean improvement in general outcome score 22 vs. 7%, respectively, compared with baseline data; P<0.001). CONCLUSIONS: Giving primary care physicians information on the therapy recommended for treatment of low back pain does not lead to any change in physicians' preferred therapy. Multimodal programs for treatment of chronic low back pain should be organized locally, with existing health care providers joining forces to improve the quality of outcome in chronic low back pain managed in primary care.

Adult↗
PubMed1998

Discontinuing anticytomegalovirus therapy in patients with immune reconstitution after combination antiretroviral therapy.

PURPOSE: To describe our experience with discontinuation of anticytomegalovirus maintenance therapy in patients who have had immune reconstitution after initiation of highly active antiretroviral therapy. METHODS: Fifteen patients with treated cytomegalovirus retinitis, who had immune reconstitution after initiation of highly active retroviral therapy, had anticytomegalovirus maintenance therapy discontinued. Patients were followed closely for relapse of retinitis. RESULTS: Median nadir CD4+ T-cell count, before institution of highly active antiretroviral therapy, was 20 cells/microl. At the time of discontinuation of anticytomegalovirus therapy, median CD4+ T-cell count was 297 cells/microl. Patients were followed for a median of 8 months off anticytomegalovirus therapy (range, 3 to 16 months). The median CD4+ T-cell count at last follow-up was 267 cells/microl. No patient off anticytomegalovirus therapy relapsed. CONCLUSION: In selected patients with immune reconstitution after initiation of highly active antiretroviral therapy, anticytomegalovirus therapy may be safely discontinued, at least temporarily. Longer follow-up of these patients is needed to determine how long such therapy may be interrupted, and when anticytomegalovirus therapy should be reinstituted.

AIDS-Related Opportunistic Infections↗
PubMed1994

High-dose, short-duration ribavirin aerosol therapy compared with standard ribavirin therapy in children with suspected respiratory syncytial virus infection.

Children with suspected respiratory syncytial virus infection were examined prospectively in a randomized evaluation of standard ribavirin aerosol therapy (6 gm/300 ml water for 18 hours daily) compared with high-dose, short-duration ribavirin aerosol therapy (6 gm/100 ml water given for a period of 2 hours three times a day) by means of an oxygen hood (n = 20) or a ventilator (n = 12). Viral shedding was quantitated daily; clinical observations were recorded daily by 2 physicians aware and one unaware of treatment assignments. Study characteristics evaluated at entry were not significantly different in the high-dose and the standard-dose groups. Viral titers and clinical scores decreased similarly in both groups during the study; pulmonary function test results were also similar at discharge in children not receiving mechanical ventilation. Potential complications related to aerosol therapy were noted in three patients (one hood patient who was receiving standard therapy; two patients with an endotracheal tube in place who were receiving high-dose therapy); substantial crystallization was noted in the tubing of the patients undergoing intubation and receiving high-dose therapy. Environmental sampling revealed that ribavirin was nearly undetectable near patients supported by mechanical ventilation who were receiving either form of therapy, and was significantly decreased on a daily basis in patients without an endotracheal tube who were receiving high-dose therapy compared with those receiving standard therapy. The effects of high-dose, short-duration aerosol ribavirin therapy were similar to those of standard-dose therapy in our study patients and resulted in a decreased release of ribavirin into the room of patients receiving therapy by means of an oxygen hood.

Aerosols↗
PubMed1998

Maintenance therapy after quadruple induction therapy in HIV-1 infected individuals: Amsterdam Duration of Antiretroviral Medication (ADAM) study.

BACKGROUND: Highly active antiretroviral therapy (HAART) has led to health benefits for patients infected with HIV-1. However, long-term use of multidrug regimens is difficult to sustain. Simplifying antiretroviral treatment regimens would increase patients' adherence and minimise toxicity. We investigated the feasibility of a strategy of induction therapy followed by maintenance therapy with HAART in a randomised open-label study. METHODS: From March, 1997, we enrolled patients infected with HIV-1 with at least 200 CD4 cells/microL, at least 1000 HIV-1 RNA copies/mL in plasma, and no previous exposure to antiretroviral drugs. After 26 weeks of induction therapy (stavudine, lamivudine, saquinavir, and nelfinavir) patients were randomly allocated maintenance therapy (either stavudine and nelfinavir or saquinivir and nelfinavir) or prolonged induction therapy (if the plasma HIV-1 RNA concentration at weeks 24 and 25 was <50 copies/mL). FINDINGS: In February, 1998, we discontinued randomisation after an interim analysis. 62 patients had been enrolled. 39 (91%) of the 43 patients who were followed up for at least 26 weeks had an undetectable plasma HIV-1 RNA concentration at week 16. At week 26, 31 patients were randomly allocated treatment. Of these patients 25 had a total follow-up of at least 36 weeks. At week 36, a higher proportion of patients on maintenance therapy (nine [64%] of 14) had a detectable HIV-1 RNA than patients on prolonged induction therapy (one [9%] of 11, p=0.01). The initial virion-clearance rate during induction therapy was higher in five patients on maintenance therapy with a sustained undetectable plasma HIV-1 RNA concentration than in nine patients with recurrence of a detectable plasma HIV-1 RNA concentration at week 36 (0.35 vs 0.19 per day, respectively; p=0.0008). INTERPRETATION: The induction regimen provided a rapid suppression of viral replication to below 50 copies/mL. However, suppression was not sustained in a considerable number of patients who went onto maintenance therapy. It is currently inadvisable to continue attempts at moving from induction to maintenance therapy in day-to-day practice.

Adult↗
PubMed1997

Therapies in practice: a survey assessing nurses' use of complementary therapies.

This paper reports the findings of an informal survey to assess nurses' use of complementary therapies within the health care setting. Increasing interest amongst the general public and health care professionals appears to have resulted in an assumption that there is currently widespread use of therapies such as massage, homoeopathy, aromatherapy, reflexology and acupuncture within the health care setting. However, to date there have been no national research studies undertaken to substantiate this assumption. This study attempted to identify the range of practices and magnitude of use by nurses who are members of the Royal College of Nursing Complementary Therapy Forum (RCNCTF) UK. A convenience sample was used and a semi-structured questionnaire was inserted into the group's bi-annual newsletter and sent to all members of the RCNCTF (n = 1662). A total of 178 subjects completed and returned the questionnaire, representing a 9.3% response rate. Given the informal nature of this survey, and the fact that it was an insert in a newsletter, a relatively low response was anticipated. Contrary to expectation, findings indicated that the majority of respondents were aged between 41 and 50 years. The six principal therapies practised were (in order of use) massage, aromatherapy, reflexology, relaxation, visualization and acupuncture. The three most common areas of practice, both in the NHS and private sector, were in the community, palliative care and oncology. Findings also indicated that complementary therapies were more commonly practised in the private sector as part of formal working practice. This was in contrast to nurses working in the NHS, where complementary therapies appeared to form less than 20% of their formal nursing care and respondents indicated that, when used, it was often in addition to daily nursing care. Results indicate that nurses are practising complementary therapies less than has been assumed. Those therapies commonly practised form a broader mantle than therapies commonly presented as the primary therapies in complementary medicine, namely homoeopathy, acupuncture, herbalism, chiropractic and osteopathy. This survey represents a single snapshot of nurses' use of complementary therapies. The convenience sample focused upon a self-selected group of people who were members of the RCNCTF and this has to be borne in mind when considering the results. The intention is to report the findings and no attempt is made to generalize upon the results. However, there is clearly a need to identify national utilization of complementary therapies within the health care sector.

Adult↗
PubMed1992

Manual therapy: a critical assessment of role in the profession of physical therapy.

Interest in manual therapy appears to continue to grow among physical therapy clinicians and educators throughout the world even though the underlying concepts and techniques have not been justified by a knowledge base. The purposes of this article are to critically assess the role of manual therapy within the physical therapy profession and to provide an introduction to the other articles in this special issue. Eisner's model of explicit, implicit, and null curricula is used as a framework for our analysis and our discussion of manual therapy. The explicit area of manual therapy includes discussions of the definition and the role of manual therapy, the scientific rationale for manual therapy, and manual therapy in education and a comparison of manual therapy evaluative frameworks. The implicit area deals with the role of clinical decision making and critical thinking in manual therapy in education and rehabilitation. In the null (unaddressed) area of manual therapy, we suggest directions for future development and research.

Clinical Competence↗
PubMed1998

Continuous and more effective duodenal ulcer healing under therapy with bismuth and two antibiotics than with dual therapy comprising omeprazole and amoxicillin.

OBJECTIVE: To determine the speed of the healing process of duodenal ulcers during eradication regimens with and without a high-dose anti-secretory drug. SETTING: An outpatient department of a university hospital as a community-based and referral centre. MATERIALS: A total of 101 patients with proven duodenal ulcer and a positive urease test were randomized into two groups: one group received the classic triple therapy (bismuth subnitrate 3 x 375 mg for 4 weeks + tetracycline 3 x 500 mg + metronidazole 3 x 250 mg daily, both for 2 weeks ), the other group received dual therapy comprising amoxicillin 2 x 1000 mg + omeprazole 2 x 20 mg daily, both for 2 weeks. All patients underwent a control endoscopy 2 and 6 weeks after the beginning of treatment. Eradication was assumed if a urease test and culture were negative in all specimens taken from antral and corpus mucosa. RESULTS: In total, 93 patients completed all 6 weeks of the study (45 patients in the triple therapy group and 48 patients in the dual therapy group). The disappearance of ulcer pain was faster in the group under the regimen including omeprazole (dual therapy) than in the group with triple therapy (2.4+/-2.7 days versus 4.5+/-3.5 days; P< 0.01). The two-week healing rate was significantly higher in the patients treated with dual therapy than in the group treated with triple therapy (77% versus 33.3%; P< 0.01); however, 12 out of 37 patients with a healed ulcer in the dual therapy group had an ulcer relapse at 6 weeks (six became symptomatic). Only in one of these 12 patients was Helicobacter pylori eradicated. Fifteen of the 45 patients with triple therapy had healed ulcers at 2 weeks, and of these 14 remained healed at 6 weeks (H. pylori was eradicated in eight patients). The six-week healing rate with dual therapy was the same as with classic triple therapy (64.6% versus 77.6%); the eradication rate was lower in the former group than in the latter (30.4% versus 51.1% respectively; P=0.056). CONCLUSION: A high dose of a proton pump inhibitor (PPI) combined with amoxicillin results in rapid ulcer healing and pain disappearance, but is associated with early ulcer relapse due to lack of eradication of H. pylori. Its addition to regimens with bismuth and antibiotics is not necessary to achieve ulcer healing.

Adult↗
PubMed2005

Retrospective observational case-control study comparing prehospital thrombolytic therapy for ST-elevation myocardial infarction with in-hospital thrombolytic therapy for patients from same area.

OBJECTIVES: To compare a system of prehospital thrombolytic therapy, delivered by paramedics under medical guidance, with in-hospital thrombolytic therapy in meeting National Service Framework (NSF) targets for treatment of acute myocardial infarction at a District General Hospital setting in England. DESIGN: Retrospective observational case-control study comparing patients with suspected acute myocardial infarction (AMI) treated with thrombolytic therapy in the prehospital environment with patients treated in hospital. SETTING: Wyre Forest District and Worcestershire Royal Hospital, UK. PARTICIPANTS: (A) All patients who received prehospital thrombolytic therapy for suspected AMI accompanied by electrocardiographic features considered diagnostic.(B) Patients who received thrombolytic therapy after arrival at hospital for the same indication, matched with group A by age, gender and postcode. MAIN OUTCOME MEASURES: 1. Call to needle time. 2. Percentage of patients treated within one hour of calling for medical help. 3. Appropriateness of thrombolytic therapy. 4. Safety of thrombolytic therapy RESULTS: 1. The median call to needle time for patients treated before arriving in hospital (n = 27) was 40 minutes with an inter-quartile range 25-112 (mean 43 minutes). Patients from the same area who were treated in hospital (n = 27) had a median time of 106 minutes with an inter-quartile range 50-285 (mean 126 minutes). This represents a median time saved by prehospital treatment of 66 minutes. 2. 60 minutes after medical contact, 96 % of patients treated before arrival in hospital had received thrombolytic therapy; this compares with 4% of patients from similar areas treated in hospital. 3. Myocardial infarction was confirmed in 92% (25/27) of patients who received prehospital thrombolytic therapy and similarly 92% (25/27) of those given in-hospital thrombolytic therapy. 4. No major bleeding occurred in either group. Group A suffered fewer in-hospital deaths than group B (1 versus 4). Cardiogenic shock (3 patients) and ventricular arrhythmia (5 patients) were seen only in group B. CONCLUSION: Paramedic-delivered thrombolytic therapy can be delivered appropriately, safely, and effectively. Time gains are substantial and can meet the national targets for early thrombolytic therapy in the majority of patients.

Electrocardiography↗
PubMed1996

Elapsed radiation therapy treatment time as a predictor of survival in patients with advanced head and neck cancer who receive chemotherapy and radiation therapy.

PURPOSE: To determine whether elapsed radiation therapy treatment time relates to survival in patients with head and neck cancer treated sequentially with chemotherapy and radiation therapy. MATERIALS AND METHODS: From 1981 to 1988, 76 adult patients with bulky stage II-IV head and neck cancer received induction chemotherapy (fluorouracil and cisplatin). Those with a complete or partial response (n = 46) received full-dose definitive radiation therapy (range, 64.0-77.5 Gy; median, 70 Gy). Those with less than a partial response (n = 21) underwent surgery and postoperative radiation therapy (n = 15), palliative radiation therapy (n = 4), or palliative chemotherapy (n = 2). Nine patients refused to undergo radiation therapy after induction chemotherapy. RESULTS: The 5-year overall survival rates were as follows: 32% in all patients, 38% in patients who underwent chemotherapy and radiation therapy, and 27% in patients who underwent chemotherapy, surgery, and radiation therapy. The number of days between radiation therapy treatments was highly predictive of overall survival. In the groups with treatments less than 55 days apart, 56-65 days apart, and more than 66 days apart, the 5-year survival rates were 56%, 46%, and 15%, respectively (P = .02). CONCLUSION: The time between radiation therapy treatments is strongly predictive of survival in patients undergoing sequential chemotherapy and radiation therapy. The use of induction chemotherapy does not negate the need to avoid treatment interruptions during definitive radiation therapy.

Adult↗
PubMed2003

Interferon therapy induces the improvement of lung function by inhaled corticosteroid therapy in asthmatic patients with chronic hepatitis C virus infection: a preliminary study.

STUDY OBJECTIVES: Several reports have suggested that subsets of asthmatic patients with chronic viral infection fail to respond to corticosteroid therapy. Therefore, this study was designed to determine that asthmatic patients with chronic hepatitis C virus (HCV) infection fail to improve lung function by inhaled corticosteroid therapy, and that interferon (IFN) therapy against HCV is effective for such patients. DESIGN: Prospective observational study. SETTING: University hospital. PATIENTS: Forty asthmatic patients with chronic HCV infection. INTERVENTIONS: After a 4-week run-in period, all asthmatic patients received therapy with inhaled beclomethasone dipropionate (BDP), 400 micro g twice daily for 6 weeks. After the first study, all asthmatic patients continued to receive inhaled BDP, and 30 HCV-positive asthmatic patients received IFN-alpha therapy for 6 months. MEASUREMENTS AND RESULTS: Prebronchodilator and postbronchodilator FEV(1) values were examined after a 4-week run-in period, after 6 weeks of BDP therapy, and at 1 year from the end of IFN therapy. After a 4-week run-in period as well as after 6 weeks of BDP therapy, there were no significant differences in either prebronchodilator or postbronchodilator FEV(1) values among the three groups. However, 1 year after the end of IFN therapy, the mean prebronchodilator and postbronchodilator FEV(1) values were significantly higher in the IFN responder group (n = 11) [prebronchodilator FEV(1), 1.93 L (SD, 0.13 L); postbronchodilator FEV(1), 2.28 L (SD, 0.15 L)] than in the IFN nontreatment group (n = 10) [prebronchodilator FEV(1), 1.78 L (SD, 0.10 L); p = 0.01; postbronchodilator FEV(1), 2.07 L (0.13 L); p = 0.005] or the IFN nonresponder groups (n = 19) [prebronchodilator FEV(1), 1.79 L (SD, 0.15 L); p = 0.006; postbronchodilator FEV(1), 2.07 L (SD, 0.18 L); p = 0.002]. Moreover, prebronchodilator and postbronchodilator FEV(1) values were significantly higher only in the IFN responder group at 1 year after the end of IFN therapy than after the 4-week run-in period (prebronchodilator FEV(1), p = 0.028; postbronchodilator FEV(1); p = 0.002) or after 6 weeks of BDP therapy (p = 0.016 and p = 0.004, respectively). CONCLUSIONS: Our findings suggest that chronic HCV infection in asthmatic patients is associated with impaired responses to inhaled BDP therapy and that intervention with IFN reverses such responses only in the IFN responder group.

Administration, Inhalation↗
PubMed2000

Antiplatelet therapy for acute ischaemic stroke.

BACKGROUND: In patients with acute ischaemic stroke, platelets become activated. Antiplatelet therapy might reduce the volume of brain damaged by ischaemia and reduce the risk of early recurrent ischaemic stroke. This might reduce the risk of early death and improve long-term outcome in survivors. However, antiplatelet therapy might also increase the risk of fatal or disabling intracranial haemorrhage. OBJECTIVES: The aim of this review is to assess the net result of antiplatelet therapy in acute ischaemic stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register (most recent date of search March 1999), the register of trials held by the Antiplatelet Trialists' Collaboration, and MedStrategy (1995). We also contacted relevant pharmaceutical companies. SELECTION CRITERIA: Randomised trials comparing antiplatelet therapy started within 14 days of the stroke with control in patients with definite or presumed ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied the inclusion criteria and assessed trial quality, and for the included trials, extracted and cross-checked the data. MAIN RESULTS: Eight trials involving 41,325 patients were included. Two trials testing aspirin 160 to 300 mg once daily started within 48 hours of onset contributed 98% of the data. The maximum follow-up was six months. With treatment, there was a significant decrease in death or dependency at the end of follow-up (OR = 0.94; 95% CI 0.91 - 0.98). In absolute terms, 13 more patients were alive and independent at the end of follow-up for every 1000 patients treated. Furthermore, treatment increased the odds of making a complete recovery from the stroke (OR = 1.06; 95% CI 1.01 - 1.11). In absolute terms, 10 patients made a complete recovery for every 1000 patients treated. Antiplatelet therapy was associated with a small but definite excess of 2 symptomatic intracranial haemorrhages for every 1000 patients treated, but this was more than offset by a reduction of 7 recurrent ischaemic strokes for every 1000 patients treated. REVIEWER'S CONCLUSIONS: Antiplatelet therapy with aspirin 160 to 300 mg daily, given orally (or per rectum in patients who cannot swallow), and started within 48 hours of onset of presumed ischaemic stroke reduces the risk of early recurrent ischaemic stroke without a major risk of early haemorrhagic complications and improves long-term outcome.

Brain Ischemia↗
PubMed1998

Transurethral alprostadil as therapy for patients who withdrew from or failed prior intracavernous injection therapy.

OBJECTIVES: Patients experiencing erectile dysfunction who fail intracavernous injection (ICI) therapy are commonly believed to have exhausted pharmacologic options. We evaluated the efficacy and safety of transurethral alprostadil (MUSE) in patients experiencing erectile dysfunction who underwent prior ICI therapy (alprostadil, papaverine, phentolamine, or a combination of these). METHODS: Of the 1511 patients enrolled in a multicenter trial of transurethral alprostadil, 452 (30%) reported prior ICI therapy and its effects. These patients tested up to four dose levels of transurethral alprostadil in the clinic, and those who achieved an erection satisfactory for intercourse were treated at home in a double-blind, placebo-controlled trial. RESULTS: Prior ICI therapy was reported to be "not effective" by 95 of 452 patients (21%), "sometimes effective" by 119 of 452 (26%), and "effective" by 238 of 452 (53%). In patients reporting ICI therapy as "not effective," 58% achieved an erection sufficient for intercourse following transurethral alprostadil therapy in the clinic; 47% of these responsive patients reported successful sexual intercourse after transurethral alprostadil therapy during home treatment. For patients reporting ICI therapy as "sometimes effective" or "effective," 68% achieved an erection sufficient for intercourse following transurethral alprostadil therapy in the clinic setting and 67% of these responsive patients reported successful intercourse following transurethral alprostadil therapy at home. Few adverse effects were encountered. The most common adverse effect was penile pain, which occurred with 7.8% of administrations. CONCLUSIONS: Transurethral alprostadil therapy is an effective therapeutic option for patients with erectile dysfunction and may even "rescue" some patients who have failed prior intracavernous injection therapy.

Administration, Topical↗
PubMed2004

Meta-analysis: Helicobacter pylori eradication therapy vs. antisecretory non-eradication therapy for the prevention of recurrent bleeding from peptic ulcer.

AIM: To perform a meta-analysis comparing the efficacy of Helicobacter pylori eradication therapy vs. antisecretory non-eradication therapy for the prevention of recurrent bleeding from peptic ulcer. METHODS: A search was made of the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL and several congresses for controlled clinical trials comparing the efficacy of H. pylori eradication therapy vs. antisecretory non-eradication therapy for the prevention of peptic ulcer re-bleeding. Studies with all patients taking non-steroidal anti-inflammatory drugs were excluded. Extraction and quality assessment of the studies were performed by two reviewers. RESULTS: In the first meta-analysis, the mean percentage of re-bleeding in the H. pylori eradication therapy group was 4.5%, compared with 23.7% in the non-eradication therapy group without long-term antisecretory therapy [odds ratio, 0.18; 95% confidence interval (CI), 0.09-0.37; 'number needed to treat' (NNT), 5; 95% CI, 4-8]. In the second meta-analysis, the re-bleeding rate in the H. pylori eradication therapy group was 1.6%, compared with 5.6% in the non-eradication therapy group with maintenance antisecretory therapy (odds ratio, 0.25; 95% CI, 0.08-0.76; NNT, 20; 95% CI, 12-100). When only patients with successful H. pylori eradication were included, the re-bleeding rate was 1%. CONCLUSIONS: The treatment of H. pylori infection is more effective than antisecretory non-eradication therapy (with or without long-term maintenance antisecretory treatment) in the prevention of recurrent bleeding from peptic ulcer. Consequently, all patients with peptic ulcer bleeding should be tested for H. pylori, and eradication therapy should be prescribed to infected patients.

Antacids↗
PubMed2005

[Cost-utility analysis of antithyroid drug therapy versus 131I therapy for Graves' disease].

There is no comparative cost-utility study between 131I therapy and antithyroid drugs (ATD) therapy for Graves' disease, though 131I therapy has higher remission rate and less side effects. The objective of the study was to analyze the cost-utility of ATD therapy versus 131I therapy by calculating life-long medical costs and utility, based on the responses of Graves' disease patients to questionnaires. To determine the expected cost and expected utility, a decision tree analysis was designed on the basis of the 2 competing strategies of ATD therapy versus 131I therapy. A simulation of 1000 female patients weighing > or =50 kg who assumed to experience the onset of Graves' disease at the age of 30, to first complain of thyrotoxic symptoms and moderate goiter 2-3 mo. previously, and to undergo a 40-years-long cohort study, was created for each strategy using a decision tree and baselines of other relevant variables. The variables and costs were based on the literature and hospital bills. The maximum and minimum values of utility were defined as 1.0 and 0.0, respectively. Future costs and utilities were discounted 5%. The medical costs and utilities were 85,739-88,650 yen/patient/40 years and 16.47-16.56/patient/40 years, respectively, for the ATD therapy strategy, and 81,842 yen/patient/40 years and 17.41/patient/40 years, respectively, for the 131I therapy strategy. These results quantitatively demonstrated that the 131I therapy strategy was superior to the ATD therapy strategy in terms of both cost and utility. 131I therapy should be used more widely in Japan because of its greater utility and lower cost.

Adult↗
PubMed1985

[One-shot therapy and transcatheter arterial embolization (TAE) therapy of unresectable hepatocellular carcinoma].

407 cases of unresectable hepatocellular carcinoma (HCC) occurring from 1970 to March 1985, including 107 cases receiving conservative therapy, 176 cases receiving one-shot therapy and 124 cases receiving transcatheter arterial embolization (TAE) therapy, were studied and the efficacy of chemotherapy was compared with that of TAE therapy. The results were as follows; One-year survival rate was 2.8% with a median survival time of 1.3 months in conservative therapy. In the 176 cases of one-shot therapy, one-year survival rate was 21.0%, two-year 6.8% and three-year 2.3% and the median survival time was 4.8% months. In 120 cases of one-shot therapy which were compatible with criteria for one-shot injection of anticancer drugs via the hepatic artery for HCC, one-year survival rate was 30%. However the rate was 1.8% in 56 cases which were not compatible with the criteria. In 37 cases in which Mitomycin C (MMC) and Adriamycin (ADR) were administered alternately, one-year survival rate was 41.7%, two-year 16.1% and three-year 4.3%. The highest survival rate was obtained by TAE therapy. One-year survival rate was 66.9%, two-year 33.8% and three-year 28.9%. Decrease of AFP after therapy was noted in 42.4% of cases given one-shot therapy and in 95.2% of cases given TEA therapy. The results suggest that alternate administration of anticancer agents produces good chemotherapeutic effects and that the best life-prolongation is obtained by TAE therapy.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1992

Effects of diuretic therapy on the development of tolerance during continuous therapy with nitroglycerin.

OBJECTIVES: This study examined the effects of concurrent diuretic therapy on the hemodynamic responses to short-term and sustained therapy with transdermal nitroglycerin. BACKGROUND: Sodium retention and plasma volume expansion occur during therapy with nitroglycerin and may play a role in the loss of nitroglycerin effects during sustained therapy. METHODS: Twenty-two normal male volunteers were treated for 1 week with either hydrochlorothiazide and amiloride (50 + 5 mg) (n = 11) or placebo (n = 11) in a randomized, double-blind fashion. All 22 subjects then received continuous transdermal nitroglycerin (19 +/- 1 mg/24 h) for 5 to 7 days. RESULTS: On the first and last day of transdermal nitroglycerin therapy, standing heart rate, systolic blood pressure and hematocrit values were assessed at 8, 9 and 10 AM and 12 noon. Heart rate and blood pressure responses to sublingual nitroglycerin (0.6 mg) were also evaluated before and after sustained transdermal nitroglycerin therapy. A significant loss of the hemodynamic effects of transdermal and sublingual nitroglycerin occurred during sustained therapy in both the diuretic and placebo therapy groups. In both groups, transdermal nitroglycerin therapy was associated with a significant decrease in hematocrit that persisted for the entire treatment period. CONCLUSIONS: These results suggest that diuretic therapy does not prevent plasma volume expansion or the loss of hemodynamic effects during sustained transdermal nitroglycerin therapy. The persistent decrease in hematocrit suggests that plasma volume expansion plays a role in the attenuation of nitrate effects. It also provides evidence of continued vascular activity of nitroglycerin despite loss of systemic hemodynamic effects.

Administration, Cutaneous↗
PubMed1993

Effect of therapy with an angiotensin-converting enzyme inhibitor on hemodynamic and counterregulatory responses during continuous therapy with nitroglycerin.

OBJECTIVES: We sought to characterize the reflex counterregulatory responses throughout a 6-day period of continuous nitroglycerin therapy and to examine the effect of concurrent administration of a non-thiol angiotensin-converting enzyme inhibitor (benazepril) on the nature of those responses. BACKGROUND: Therapy with nitroglycerin has been shown to be associated with reflex counterregulatory responses. METHODS: Standing systolic blood pressure, hormonal responses, urinary sodium and hematocrit levels were monitored during 6 days of continuous transdermal nitroglycerin therapy in normal volunteers. Using a double-blind randomized parallel design, 11 subjects received placebo and 9 received benazepril. Hemodynamic responses to sublingual nitroglycerin administration were evaluated before and after sustained therapy with transdermal nitroglycerin. RESULTS: Attenuation of the hypotensive response to transdermal nitroglycerin was rapid in the group receiving placebo and the group receiving benazepril. There were no significant hormonal responses to transdermal nitroglycerin in either group, and sodium retention was modest and transient. Hematocrit levels decreased after transdermal nitroglycerin therapy and remained depressed for the duration of nitroglycerin therapy, a finding that suggests plasma volume expansion. Blood pressure responses to sublingual nitroglycerin in both groups were similar before and after continuous transdermal nitroglycerin therapy. CONCLUSIONS: These data suggest that plasma volume expansion plays a more important role than neurohormonal responses in the loss of nitrate effects during sustained therapy. That therapy with an angiotensin-converting enzyme inhibitor did not modify the hemodynamic responses to continuous nitroglycerin therapy supports this conclusion. Further investigation will be necessary to confirm whether therapy with an angiotensin-converting enzyme inhibitor has any role in the prevention of nitrate tolerance.

Administration, Cutaneous↗