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Chen L, DU JB, Jin HF, Zhang QY, Li WZ, Wang L, Wang YL. [Effect of selective alpha1 receptor agonist in the treatment of children with postural orthostatic tachycardia syndrome]. Zhonghua Er Ke Za Zhi 2008; 46:688-691. [PMID: 19099860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE The study was designed to examine the effect of selective alpha1 receptor agonist midodrine hydrochloride in the treatment of children with postural orthostatic tachycardia syndrome. METHODS Fifty-five children (23 male, 32 female, age 5 - 19 yrs, mean age 12.3 +/- 3.1 yrs) who came from Peking University First Hospital were included in the study and clinical investigations as well as standing test, basic head-up tilt test and sublingual nitroglycerin-provocated head-up tilt test under quiet circumstance were conducted. They were randomly divided into treatment group (with midodrine hydrochloride and oral rehydration salt treatment) and control group (with oral rehydration salt treatment only). At last, the disease-free rate, improvement rate and effective rate of symptoms, and the rate of HUT from positive to negative response were compared between control group and treatment group. SPSS 10.0 software was used for the statistical analysis of these data. RESULTS The symptom improvement rate in treatment group was significantly higher than that of control group after three and six weeks of treatment (100.0% vs. 42.4%, P < 0.001; 100.0% vs. 42.4%, chi2 = 19.352, P < 0.001). The disease-free rate at follow-up end-point in treatment group was significantly higher than that of control group (77.3% vs. 27.3%, chi2 = 13.239, P < 0.001). The effective rate at follow-up end-point in treatment group was also significantly higher than that of control group (100.0% vs. 36.4%, chi2 = 22.647, P < 0.001). The rate of HUT changing from positive to negative response between two groups after three weeks of treatment was not significantly different (31.8% vs. 12.1%, P > 0.05), but it was significantly different (81.0% vs. 48.5%, P < 0.05) after six weeks of treatment. CONCLUSION Selective alpha1 receptor agonist midodrine hydrochloride is effective in the treatment of children with postural orthostatic tachycardia syndrome.
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Affiliation(s)
- Li Chen
- Department of Pediatrics, Peking University First Hospital, Beijing 100034, China
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Patterson A, Bourgault AM, Crawford BR. Correction of severe hypotension by oral pseudoephedrine in a patient with idiopathic autonomic dysfunction. Am J Crit Care 2008; 17:484-483. [PMID: 18776006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The purpose of this case study was to review the use of an oral alpha-adrenergic agent to correct severe vasopressor-dependent hypotension in a patient with idiopathic autonomic dysfunction. Autonomic dysfunction resulting in severe hypotension that requires intravenous vasopressors can present challenges in the treatment of critically ill patients. Most patients are weaned from intravenous vasopressor agents once severe sepsis has resolved. Because of worsening idiopathic autonomic dysfunction during recovery from sepsis, this 76-year-old woman required prolonged care in the intensive care unit. Oral alpha-adrenergic agonist therapy in the form of pseudoephedrine proved to be a valuable treatment option to wean this patient off the vasopressor dependence and allow for placement in a long-term care facility.
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Affiliation(s)
- Anthony Patterson
- Saint Joseph Regional Medical Center, South Bend, Indiana 46617, USA.
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García-Franco CE, España A. [Usefulness of bilateral sympathectomy using video-assisted thorascopic surgery in the treatment of essential hyperhidrosis]. Actas Dermosifiliogr 2008; 99:523-527. [PMID: 18682164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
Essential, idiopathic, or primary hyperhidrosis is defined as excessive sweating in certain areas of the body due to factors unrelated to other disease. Clinical presentation can be categorized as palmar, plantar, axillary, or craniofacial. Medical treatment (aluminium salts, iontophoresis, anticholinergic drugs, and alpha2-agonists) is of questionable effectiveness. Intradermal injections of botulinum toxin are very effective for the treatment of axillary hyperhidrosis. Surgical treatment involves resection (sympathectomy) or electrocautery (sympathicolysis) of the thoracic sympathetic chain, or compression of the sympathetic chain with clips, in all cases via video-assisted thorascopic surgery. One or more ganglia between T2 and T5 are usually resected depending on the area affected by hyperhidrosis: T2 for craniofacial hyperhidrosis, T3 and T4 for palmar hyperhidrosis, and T3 to T5 for combined palmar and axillary hyperhidrosis. The technique is very useful and is effective in those patients with primary hyperhidrosis who have not responded to conservative treatment.
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Affiliation(s)
- C E García-Franco
- Departamento de Cirugía Torácica. Clínica Universitaria de Navarra (CUN). Pamplona. España.
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Tourneux P, Rakza T, Bouissou A, Krim G, Storme L. Pulmonary circulatory effects of norepinephrine in newborn infants with persistent pulmonary hypertension. J Pediatr 2008; 153:345-9. [PMID: 18534241 DOI: 10.1016/j.jpeds.2008.03.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2007] [Revised: 01/14/2008] [Accepted: 03/10/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the respiratory and the pulmonary circulatory effects of norepinephrine in newborn infants with persistent pulmonary hypertension (PPHN)-induced cardiac dysfunction. STUDY DESIGN Inclusion criteria were: 1) Newborn infants >35 weeks gestational age; 2) PPHN treated with inhaled nitric oxide; and 3) symptoms of circulatory failure despite adequate fluid resuscitation. Lung function and pulmonary hemodynamic variables assessed with Doppler echocardiography were recorded prospectively before and after starting norepinephrine. RESULTS Eighteen newborns were included (gestational age: 37 +/- 3 weeks; birth weight: 2800 +/- 700 g). After starting norepinephrine, systemic pressure and left ventricular output increased respectively from 33 +/- 4 mm Hg to 49 +/- 4 mm Hg and from 172 +/- 79 mL/kg/min to 209+/-90 mL/kg/min (P < .05). Although the mechanical ventilatory variables have not been changed, the post-ductal transcutaneous arterial oxygen saturation increased from 89% +/- 1% to 95% +/- 4%, whereas the oxygen need decreased from 51% +/- 24% to 41% +/- 20% (P < .05). The pulmonary/systemic pressure ratio decreased from 0.98 +/- 0.1 to 0.87 +/- 0.1 (P < .05). Mean left pulmonary artery blood flow velocity increased by 20% (P < .05). CONCLUSION Norepinephrine may improve lung function in newborn infants with PPHN through a decrease in pulmonary/systemic artery pressure ratio and improved cardiac performance.
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Affiliation(s)
- Pierre Tourneux
- Clinique de Médecine Néonatale, Hôpital Jeanne de Flandre, CHRU de Lille, Lille, France
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Motolko MA. Comparison of allergy rates in glaucoma patients receiving brimonidine 0.2% monotherapy versus fixed-combination brimonidine 0.2%-timolol 0.5% therapy. Curr Med Res Opin 2008; 24:2663-7. [PMID: 18691444 DOI: 10.1185/03007990802333167] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the incidence of ocular allergy in glaucoma patients prospectively treated with 0.2% brimonidine-0.5% timolol fixed combination (Combigan) compared with the incidence of ocular allergy in patients treated with 0.2% brimonidine (Alphagan) monotherapy. STUDY DESIGN AND METHODS This was a comparative, non-randomized, single-site, interventional study involving patients with primary open-angle glaucoma or exfoliation syndrome who had not previously used brimonidine in any formulation and had no history of ocular allergy. In one study arm, 102 patients were prospectively treated with twice-daily 0.2% brimonidine-0.5% timolol fixed combination. In the other study arm, medical charts at the same center were reviewed to identify a control group of 102 patients who had been treated with twice-daily 0.2% brimonidine monotherapy. Follow-up was at 1, 3, 6, 9, 12, 15, and 18 months of treatment. MAIN OUTCOME MEASURE Ocular allergy defined as the presence of follicles and redness severe enough to warrant discontinuation of the medication. RESULTS The incidence of ocular allergy over 18 months of treatment was 8.8% (9/102) in the fixed-combination group compared with 17.6% (18/102) in the brimonidine group (p=0.097). Kaplan-Meier survival analysis suggested that ocular allergy may be reduced or delayed in patients treated with the brimonidine-timolol fixed combination (p=0.066). CONCLUSIONS The brimonidine-timolol fixed combination was associated with a 50% lower incidence in ocular allergy compared with 0.2% brimonidine monotherapy. This difference between treatments was not statistically significant (p=0.097) but is likely to be clinically important. Additional studies are needed to evaluate the incidence of ocular allergy associated with brimonidine-timolol fixed combination treatment.
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Affiliation(s)
- Michael A Motolko
- Ivey Eye Institute, University of Western Ontario, London, ON, Canada.
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Liatsi D, Tsapas B, Pampori S, Tsagourias M, Pneumatikos I, Matamis D. Respiratory, metabolic and hemodynamic effects of clonidine in ventilated patients presenting with withdrawal syndrome. Intensive Care Med 2008; 35:275-81. [PMID: 18709354 DOI: 10.1007/s00134-008-1251-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 07/18/2008] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the respiratory, metabolic and hemodynamic effects of clonidine in ventilated patients presenting with withdrawal syndrome after sedation interruption. DESIGN Prospective, interventional, single-center study in 30 ventilated ICU patients. INTERVENTIONS Metabolic [oxygen consumption (VO(2)), CO(2) production (VCO(2)), resting energy expenditure (REE)], respiratory [minute ventilation (V (E)), tidal volume (V (T)), respiratory rate (RR)] and hemodynamic (HR, SAP, MAP) parameters were measured in 30 ventilated ICU patients. Measurements were performed first under sedation with remifentanil-propofol, then after sedation interruption, and finally after clonidine administration (0.9-1.8 mg of clonidine in two doses of 10 min interval). RESULTS Sedation interruption produced significant increases in the hemodynamic parameters (SAP and MAP by 33%, HR by 37%), and metabolic rate (increase in VO(2) by 70%, VCO(2) by 88% and REE by 74%), leading to high respiratory demands (increase in V (E) from 9 to 15 l/min). The V (E) was increased due to a twofold increase in the RR; V (T) remained constant. In 25 out of 30 patients, clonidine administration decreased the hemodynamic (SAP, MAP and HR), metabolic (VO(2), VCO(2), REE) and respiratory parameters to values close to those observed with sedation. Clonidine induced mild sedation and patients became more cooperative with the ventilator. All patients responding to clonidine were weaned from the ventilator in 2 days (median, range 1-18 days). CONCLUSION Patients with withdrawal syndrome had significantly elevated hemodynamic, metabolic and respiratory demands. Clonidine significantly decreased these demands, induced mild sedation and facilitated patient cooperation with the ventilator, enabling ventilator weaning.
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Affiliation(s)
- Domniki Liatsi
- ICU, Papageorgiou General Hospital, Thessaloniki, Greece
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Abstract
PURPOSE This article reviews the pathophysiology of vasomotor symptoms (VMS) of menopause and current management options. DATA SOURCES Current scientific literature. CONCLUSIONS In most menopausal women, loss of ovarian function results in VMS, including hot flashes, night sweats, and mood and sleep disturbances. Hormone therapy (HT) has been the mainstay of VMS treatment for many years, but safety concerns raised by publication of the Women's Health Initiative (WHI) results have dramatically reduced the use of this treatment. Since the WHI published its findings, attention has focused on other novel treatments for menopausal symptoms, including low-dose oral or transdermal HT and agents such as selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, gabapentin, and clonidine. Many women also use complementary and alternative medications to manage VMS, but little evidence from controlled clinical trials supports their efficacy. IMPLICATIONS FOR PRACTICE The increasing number of alternative treatments for VMS requires improvement in patient-provider communication about treatment risks and benefits, individualization of treatment to meet patient needs and attitudes, and careful follow-up to ensure adherence to potentially effective therapy. Nurse practitioners play a leading role in patient evaluation, discussions, and management to help women achieve control over bothersome VMS that dramatically impact their quality of life.
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Affiliation(s)
- Ivy M Alexander
- Yale University School of Nursing, New Haven, Connecticut 06536-0740, USA.
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108
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Soileau EJ. Medications for adolescents with attention-deficit/hyperactivity disorder. Adolesc Med State Art Rev 2008; 19:254-ix. [PMID: 18822831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
ADHD is recognized as a neurologic condition rather than just bad behavior. Medical treatment has been recognized as very helpful. Risks of untreated ADHD are substantial. Every life area is negatively affected including school performance, drug abuse and dependence risk, driving performance, sexually transmitted diseases, unwanted pregnancy and family cohesiveness to mention some of them. Frequent misinformation in the popular media causes apprehension about medical treatment. Even after almost 60 years stimulants remain the mainstay in treatment of ADHD. Newer release systems have produced longer acting and smoother acting medication. Side effects have always been brief and mild however, newer forms cause fewer side effects than older preparations and cover symptoms for more of the waking hours of each day. Although studies in adolescents are less numerous than in children the literature standard supports the safety and efficacy of stimulants in adolescents. In addition there are non-stimulant medications that have shown efficacy in adolescents. There are now a greater number of medications and more effective medications than ever before. Clinical pearls in medication management are shared in practical terms so that these newer treatments can be used to help those affected with ADHD more effectively than ever before.
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Affiliation(s)
- Earl J Soileau
- Department of Family Medicine, Louisiana State University Health Sciences Center, New Orleans at Lake Charles Memorial Hospital, 1525 Oak Park Blvd, Lake Charles, LA 70601, USA.
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Buijs C, Mom CH, Willemse PHB, Marike Boezen H, Maurer JM, Wymenga ANM, de Jong RS, Nieboer P, de Vries EGE, Mourits MJE. Venlafaxine versus clonidine for the treatment of hot flashes in breast cancer patients: a double-blind, randomized cross-over study. Breast Cancer Res Treat 2008; 115:573-80. [PMID: 18670875 DOI: 10.1007/s10549-008-0138-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2008] [Accepted: 07/14/2008] [Indexed: 11/28/2022]
Affiliation(s)
- Ciska Buijs
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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111
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Camilleri M. New therapeutic approaches in irritable bowel syndrome. Eur Rev Med Pharmacol Sci 2008; 12 Suppl 1:139-140. [PMID: 18924458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- M Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Program, Mayo Clinic, Rochester, MN, USA.
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112
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Abstract
Tourette's disorder is a childhood-onset neuropsychiatric disorder characterized by multiple motor and vocal tics. Many children with Tourette's disorder improve throughout adolescence. However, some adults with Tourette's disorder still experience severe symptoms and significant disability. This article examines the evidence base for current treatments for Tourette's disorder. Emerging treatments such as deep brain stimulation, habit reversal therapy, and repetitive trans-cranial magnetic stimulation are also discussed.
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Affiliation(s)
- Michael H Bloch
- Yale Child Study Center, 230 South Frontage Road, New Haven, CT 06520, USA.
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Oulis P, Karapoulios E, Masdrakis VG, Kouzoupis AV, Karakatsanis NA, Papageorgiou C, Papadimitriou GN, Soldatos CR. Levetiracetam in the treatment of antipsychotics-resistant Tourette syndrome. World J Biol Psychiatry 2008; 9:76-7. [PMID: 17853302 DOI: 10.1080/15622970701233454] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Levetiracetam, an anti-epileptic agent that enhances GABAergic neurotransmission, is one of the newest alternative treatments of Tourette syndrome (TS). We present the case of a 23-year-old female patient suffering from TS since the age of 7, who exhibited poor response to a variety of agents (haloperidol, pimozide, clonidine and various adjunctive agents) and had four hospitalizations during the previous 2 years due to the deterioration of her clinical state. On her last admission, in addition to clonidine 600 microg/day (already part of her regimen for the previous 4 years), levetiracetam was prescribed, up to 2000 mg/day, progressively titrated over a 3-week period. The patient presented a significant improvement on her TS symptomatology (the score on the Yale Global Tic Severity Scale dropped from 70 at admission, to 25 five weeks later, at discharge), which was preserved during the subsequent 4 months, without any serious side-effect.
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115
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Abstract
The catecholamine norepinephrine is a critical effector of the mammalian stress response and has been implicated in the pathophysiology of posttraumatic stress disorder (PTSD)-a syndrome intrinsically related to the experience of extraordinary stress. Symptom-linked hypernoradrenergic derangements have been observed in PTSD and several studies have examined the potential therapeutic effects of agents that dampen the centrally hyperactive noradrenergic state. These agents include compounds that decrease norepinephrine release (e.g. centrally acting alpha(2) agonists such as clonidine) and those which block post-synaptic norepinephrine receptors (e.g. centrally acting alpha(1) or beta receptor antagonists such as prazosin or propranolol). In this article, we review studies of central noreadrenergic hyperactivity under both basal and challenge conditions and explore the evidence for these derangements as potential psychopharmacologic targets in patients with PTSD. Given the significant involvement of CNS norepinephrine hyperactivity in PTSD, and its link to intrusive and hyperarousal symptoms, it is not surprising that interventions directed at this system have therapeutic potential in PTSD. The utility of these anti-adrenergics in the clinical treatment of PTSD remains to be determined, though it is possible that they may prove to have primary roles in a disorder that is only modestly responsive to antidepressant treatment.
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Affiliation(s)
- J R Strawn
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, Ohio 45267-0559, USA.
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Lechin F, van der Dijs B, Hernandez-Adrian G. Clonidine therapy for pancreatitis. Dig Dis Sci 2008; 53:1434-5. [PMID: 18320309 DOI: 10.1007/s10620-008-0220-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Accepted: 02/12/2008] [Indexed: 12/09/2022]
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Abstract
INTRODUCTION A 38-year-old man with severe head trauma complicated by paroxysmal severe intracranial pressure elevation associated with tachypnea, tachycardia, diaphoresis, and extensor posturing was diagnosed as suffering from paroxysmal autonomic instability with dystonia (PAID). These events were unresponsive to standard medical therapy, which included morphine, fentanyl, labetalol, lorazepam, metoprolol, and clonidine. METHODS A trial treatment with dexmedetomidine, a central acting alpha2-agonist, to control symptoms of PAID was initiated 12 days after injury. PAID-related events subsided during the 72-h infusion protocol of 0.2-0.7 mcg/kg/h. No further events were noted after termination of the 72-h infusion. CONCLUSIONS Dexmedetomidine may be a novel pharmacologic agent to aid in abrogating PAID.
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Affiliation(s)
- Richard P Goddeau
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
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118
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Abstract
The authors seek to highlight some of the recent advances in understanding the pharmacology and pathophysiology of sympathetically-maintained pain, and to develop alternate, and possibly more specific, diagnostic tests for this phenomenon. Mechanical hyperalgesia in sympathetically-maintained pain can be explained by central sensitization so that the activation of A-beta mechanoreceptors now causes pain. The sensitization of central pain-signaling neurons is dynamic and reversible. The authors propose that an ongoing input from peripheral nociceptive afferents is necessary to maintain central sensitization. This nociceptive input may be due to an alpha-adrenoceptor mediated excitatory action of sympathetic efferents on sensory nerves that is independent of neurovascular transmission.
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Affiliation(s)
- S N Raja
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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119
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Brkovic B, Gardasevic M, Roganovic J, Jovic N, Todorovic L, Stojic D. Lidocaine+clonidine for maxillary infiltration anaesthesia: parameters of anaesthesia and vascular effects. Int J Oral Maxillofac Surg 2008; 37:149-55. [PMID: 17822879 DOI: 10.1016/j.ijom.2007.07.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2007] [Revised: 06/10/2007] [Accepted: 07/11/2007] [Indexed: 10/22/2022]
Abstract
The local anaesthetic and haemodynamic parameters achieved by lidocaine with clonidine or epinephrine, administered for maxillary infiltration anaesthesia, were studied in 40 patients (American Society of Anesthesiologists, physical status 1) who underwent upper third molar surgery. All patients received 2 ml of 2% lidocaine with clonidine (15 microg/ml; n=20) or epinephrine (12.5 microg/ml; n=20) in a randomized, double-blind fashion. Vascular effects were evaluated on the isolated human infraorbital arteries. The parameters of maxillary infiltration anaesthsia produced by a combination of lidocaine+clonidine were similar to those obtained with lidocaine+epinephrine. In both groups, haemodynamic parameters exhibited similar variations, with the exception of a significant reduction in heart rate and systolic blood pressure in the lidocaine+clonidine group and significant increase in heart rate in the lidocaine+epinephrine group, 10 min after surgery. Clonidine (10(-7), 10(-6) and 10(-5)M) produced an endothelium-independent vasocontractile effect on the isolated human infraorbital arteries. The results of this study indicate for the first time in dental anaesthesia that the lidocaine+clonidine combination could be a useful and safe alternative to lidocaine+epinephrine for intraoral infiltration anaesthesia.
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Affiliation(s)
- B Brkovic
- Clinic of Oral Surgery, Dental School, University of Belgrade, Serbia.
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120
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Abstract
The management of hypertension continues to pose important challenges. Recent developments have established the importance of more rigorous blood pressure control in the community. In the perioperative setting, hypertension has long been recognised as undesirable, although the adverse impact of high blood pressure on the acute risks of elective surgery may have been previously overstated.A number of agents and techniques are available to control blood pressure perioperatively. These include principally general and regional anaesthetics, alpha(2)-adrenoceptor agonists, peripheral alpha(1)- and beta-adrenoceptor antagonists, dihydropyridine calcium channel antagonists, dopamine D(1A)-receptor agonists (fenoldopam), and nitric oxide donors. Recent years have seen important developments in the receptor selectivity of new compounds and in pharmacokinetics, particularly esterase metabolism. The future study of genomics may enable us to identify patients at risk for hypertension-related adverse events and target therapies most effectively to these high-risk groups.
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Affiliation(s)
- Robert Feneck
- Department of Anaesthesia, Guys and St Thomas' Hospitals, London, England.
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121
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Abstract
PURPOSE The aim of this study was to evaluate the efficacy and safety of brimonidine 0.2% versus brimonidine Purite 0.15% in Asians with ocular hypertension. METHODS This study was a prospective, randomized, observer-masked, short-term crossover trial. Eighty-six (86) Asian subjects with newly diagnosed ocular hypertension were randomly assigned to receive either brimonidine 0.2% or brimonidine Purite 0.15%, both dosed twice a day for 4 weeks. Subjects were then washed out for 6 weeks and switched to the opposite treatment for 4 weeks. RESULTS The baseline intraocular pressure (IOP) was 24.4 +/- 2.45 mmHg for brimonidine 0.2% and 24.39 +/- 2.56 mmHg for brimonidine Purite 0.15% (P = 0.985). The IOP was at trough drug effect after 4 weeks of brimonidine 0.2% and brimonidine Purite 0.15% therapy were 20.10 +/- 2.01 mmHg and 21.00 +/- 1.67 mmHg (P = 0.001), respectively. The IOP at peak drug effect after 4 weeks of brimonidine 0.2% and brimonidine Purite 0.15% treatment were 18.10 +/- 1.73 mmHg and 18.20 +/- 1.71 mmHg (P = 0.518), respectively. Brimonidine 0.2% was found to cause more allergic conjunctivitis than brimonidine Purite 0.15% (P < 0.001). CONCLUSIONS Brimonidine 0.2% has a higher potency of lowering IOP than brimonidine Purite 0.15% at trough when used twice-daily. However, ocular allergic reaction was more frequent and severe with brimonidine 0.2% than with brimonidine Purite 0.15%.
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Affiliation(s)
- Chan Yun Kim
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea
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122
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Yamakage M, Iwasaki S, Satoh JI, Namiki A. Inhibitory effects of the alpha-2 adrenergic agonists clonidine and dexmedetomidine on enhanced airway tone in ovalbumin-sensitized guinea pigs. Eur J Anaesthesiol 2008; 25:67-71. [PMID: 17888193 DOI: 10.1017/s0265021507002591] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE The alpha-2 adrenergic agonists clonidine and dexmedetomidine are used as an antihypertensive and a sedative, respectively. The aim of this study was to determine the effects of these agonists on ovalbumin-sensitized airway tone in guinea pigs. METHODS The animals were divided into two groups: control and sensitized. The sensitized group received ovalbumin intraperitoneally and was boosted by exposure to aerosolized ovalbumin. The effects of the alpha-2 agonists were investigated by measuring (1) total lung resistance and (2) smooth muscle tension using a tracheal ring preparation. RESULTS In the control group, acetylcholine significantly increased total lung resistance in a dose-dependent manner. In the sensitized animals, total lung resistance was significantly higher (by 95%) at 6 mug kg-1 acetylcholine than that in the control group. Both clonidine and dexmedetomidine had a slight but significant inhibitory effect on the response curve of lung resistance at higher concentrations of carbachol, a potent muscarinic receptor agonist. Similar to the data obtained in the control group, both clonidine and dexmedetomidine significantly decreased total lung resistance and the inhibitory effects of these alpha-2 agonists on lung resistance were significantly distinguishable. Similar direct inhibitory effects of the alpha-2 agonists on carbachol-induced muscle contraction were observed in both the control and sensitized groups, the inhibitory effects in the sensitized group being significantly greater. CONCLUSION Both clonidine and dexmedetomidine can relax the airway even in the hyper-reactive state.
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Affiliation(s)
- M Yamakage
- Sapporo Medical University School of Medicine, Department of Anesthesiology, Sapporo, Hokkaido, Japan.
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Cortese S, Risso M. [Drug therapy of opioid withdrawal]. Vertex 2008; 19:522-526. [PMID: 18443666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Although the opiate dependence is of low frequency in our midst, it is important to know its management because it requires medical treatment in most cases. At present, in our country, we may classify the different patient populations able to submit an opioid withdrawal syndrome in patients undergoing chronic treatment with opioids, patients in intensive care units, neonatal mother addicted patients and addicts from the general population or linked to the health system. Detoxification programs are typically characterized by a low rate of completion of treatment and a high rate of relapse. The opioid withdrawal syndrome is objectively and subjectively severe and moderate and the goals of the therapy for the Opiates Withdrawal Syndrome are: to prevent or reduce the objective and subjective symptoms of abstinence; to prevent or treat its most serious complications; to treat preexisting or concurrent psychiatric disorders; to reduce the frequency or severity of relapses and to rehabilitate in the long term.
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Affiliation(s)
- Silvia Cortese
- Hospital Fernández, Toximed (Toxicología Clínica Privada), Cátedra de Toxicología, UBA.
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124
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Tong IL. Treatment of menopausal symptoms. Compr Ther 2008; 34:41-47. [PMID: 18681111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Vasomotor symptoms affect the majority of postmenopausal women. Given the risks of hormone replacement therapy, alternative treatments for hot flashes have emerged over recent years. This article will review currently available treatments for hot flashes, including hormonal and non-hormonal therapies.
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Affiliation(s)
- Iris L Tong
- Department of Medicine, The Warren Alpert Medical School of Brown University, Women and Infants Hospital, 100 Dudley Street, Providence, RI 02905, USA
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125
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Vetrugno M, Cantatore F, Ruggeri G, Ferreri P, Montepara A, Quinto A, Sborgia C. Primary open angle glaucoma: an overview on medical therapy. Prog Brain Res 2008; 173:181-93. [PMID: 18929109 DOI: 10.1016/s0079-6123(08)01113-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
The purpose of this review is to discuss the topics relevant to the use of intraocular pressure-lowering strategies, which remains the first line in the management of glaucoma. Estimates of blindness from glaucoma and identification of risk factors remain of interest for all ophthalmologists. New functional tests offer promise for better detection and more accurate diagnosis of glaucoma. We finally discuss the impact of various glaucoma therapies, the principles of monotherapy and fixed combinations, which offer benefits of convenience, cost, and safety.
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Affiliation(s)
- Michele Vetrugno
- Glaucoma Center, Department of Ophthalmology, University of Bari, Bari, Italy.
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126
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Lafuma A, Laurendeau C, Berdeaux G. Costs and persistence of brimonidine versus brinzolamide in everyday glaucoma care: an analysis conducted on the UK General Practitioner Research Database. J Med Econ 2008; 11:485-97. [PMID: 19450100 DOI: 10.3111/13696990802211107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the persistence and costs of brimonidine versus brinzolamide therapy according to data collected by the UK General Practitioner Research Database (GPRD). METHODS Patients with diagnoses of ocular hypertension or glaucoma, or treated for glaucoma by surgery or laser therapy were identified. Selected patients were prescribed either brimonidine or brinzolamide as monotherapy. Treatment failure was defined as a glaucoma prescription change (adding, removing or replacing a drug, or initiating surgery or laser therapy). Times to treatment failure were compared with an adjusted Cox model using a propensity score method. RESULTS A total of 2,172 patients received brimonidine and 485 brinzolamide. Mean age was 69.5 years and 46.4% were male. Age and gender did not differ significantly whereas disease duration was longer with brinzolamide. Treatment failure at 1 year was experienced by 47.7% of patients given brinzolamide and by 55.9% given brimonidine (p<0.001). The hazard ratio for failure was less with brinzolamide (0.79: p<0.001) compared to brimonidine, after adjusting for age, gender, comorbidities and duration of follow-up. Adjusted annual costs of glaucoma management (in pound2005) were significantly (p<0.0042) lower with brinzolamide (pound196) than brimonidine (pound230). CONCLUSIONS According to data from everyday practice collected by the UK GPRD, brinzolamide was found to be more persistent than brimonidine when given as glaucoma monotherapy. Patients continued longer with brinzolamide treatment at a lower cost.
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Braque S, Bernard-Bertrand F, Guillou N, Guezennec D, Canciani JP, Gentili ME. Successful but prolonged resuscitation after local anesthetic-induced cardiac arrest: is clonidine effective? Acta Anaesthesiol Belg 2008; 59:91-94. [PMID: 18652106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Local anesthetics when injected intravascularly result in serious cardiac complications including therapy-resistant cardiac arrest. We report a case of cardiac arrest after lumbar plexus block using a combination of 0.5% bupivacaine and 2% lidocaine with epinephrine (1:200.000). Resuscitation was performed by a combination of chest compression, repeated external countershocks and i.v.epinephrine. Clonidine had poor effect. The whole resuscitation required 90 minutes. The patient was discharged four days later without any sequelae. Blood sampling at 10 minutes showed a concentration of 2.02 mg/l lidocaine and 0.87 mg/l bupivacaine. Prolonged resuscitation is necessary in local anesthetic-induced cardiac arrest.
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Affiliation(s)
- S Braque
- Centre Hospitalier Privé Saint-Grégoire, 35760 Saint-Grégoire, France
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128
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Zislis G, Desai TV, Prado M, Shah HP, Bruijnzeel AW. Effects of the CRF receptor antagonist D-Phe CRF(12-41) and the alpha2-adrenergic receptor agonist clonidine on stress-induced reinstatement of nicotine-seeking behavior in rats. Neuropharmacology 2007; 53:958-66. [PMID: 17976662 PMCID: PMC2330281 DOI: 10.1016/j.neuropharm.2007.09.007] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Revised: 09/10/2007] [Accepted: 09/12/2007] [Indexed: 11/25/2022]
Abstract
Tobacco dependence is a chronic disorder that is characterized by relapse after periods of abstinence. It has been hypothesized that the activation of brain stress systems mediates stress-induced relapse to smoking. The aim of these experiments was to investigate the role of corticotropin-releasing factor (CRF) and norepinephrine in stress-induced reinstatement of extinguished nicotine-seeking behavior. Rats were allowed to self-administer nicotine under a fixed-ratio 5 schedule for 14 days and then nicotine-seeking behavior was extinguished by substituting saline for nicotine. In experiment 1, footshocks reinstated extinguished nicotine-seeking behavior. In experiment 2, there was a trend for the CRF(1/2) receptor antagonist D-Phe CRF((12-41)) (5, 25microg, icv) to decrease stress-induced reinstatement of nicotine-seeking behavior. Footshock-induced reinstatement of nicotine-seeking behavior was observed only in a subset of stress-responsive rats (71%). D-Phe CRF((12-41)) significantly attenuated stress-induced reinstatement of nicotine-seeking behavior in this subset of rats. In experiment 3, the alpha2-adrenergic receptor agonist clonidine (20, 40microg/kg, sc) attenuated footshock-induced reinstatement of nicotine-seeking behavior. In experiment 4, the effects of D-Phe CRF((12-41)) and clonidine on responding for chocolate-flavored food pellets was investigated in order to determine if these compounds have sedative effects. D-Phe CRF((12-41)) did not affect responding for food pellets. Clonidine slightly, but significantly, decreased responding for food pellets. Clonidine decreased responding for food to a lesser degree than it decreased stress-induced reinstatement of nicotine-seeking behavior. These data provide support for the hypothesis that an increased activity of brain CRF and norepinephrine systems mediates stress-induced relapse to nicotine-seeking behavior.
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Affiliation(s)
- George Zislis
- University of Florida, Department of Psychiatry, Gainesville, FL 32610, USA
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Park JS, Kang SB, Kim DW, Namgung HW, Kim HL. The efficacy and adverse effects of topical phenylephrine for anal incontinence after low anterior resection in patients with rectal cancer. Int J Colorectal Dis 2007; 22:1319-24. [PMID: 17569063 DOI: 10.1007/s00384-007-0335-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anal incontinence is experienced by some patients with rectal cancer who received low anterior resection. This study was to examine the efficacy and adverse effects of the alpha-1 adrenergic agonist phenylephrine, which causes contraction of the internal anal sphincter and raises the resting pressure in these patients. PATIENTS AND METHODS Thirty-five patients with anal incontinence were treated with 30% phenylephrine or a placebo randomly allocated in a double-blind study. The efficacy of the drug was assessed by changes in the following standardized questionnaire scores: the fecal incontinence severity index (FISI), fecal incontinence quality of life (FIQL) scales, and a global efficacy question. Anal sphincter function was evaluated using anorectal manometry. RESULTS Phenylephrine did not improve either the FISI score or any of the four FIQL scores. Five of 17 (29%) patients reported subjective improvement after phenylephrine compared with 4 of 12 (33%) using the placebo. The maximum resting anal pressure did not differ between baseline and after 4 weeks application of phenylephrine (30.0 to 27.3 mmHg). In the phenylephrine group, allergic dermatitis was developed in five patients and headache in two. CONCLUSION In the patients with anal incontinence after low anterior resection for rectal cancer, phenylephrine gel did not seem to be helpful in relieving symptoms with some adverse effects.
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Affiliation(s)
- Jun-Seok Park
- Department of Surgery, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, 463-707, Sungnam, South Korea
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130
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Freshwater-Turner D, Udy A, Lipman J, Deans R, Stuart J, Boots R, Hegde R, McWhinney BC. Autonomic dysfunction in tetanus - what lessons can be learnt with specific reference to alpha-2 agonists? Anaesthesia 2007; 62:1066-70. [PMID: 17845661 DOI: 10.1111/j.1365-2044.2007.05217.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Severe tetanus is seen infrequently in the developed world, but often requires intensive care support. Mechanical ventilation with neuromuscular blockade and heavy sedation, good wound care and prompt administration of antitoxin are important. The management of autonomic dysfunction remains challenging. We measured serum catecholamine levels in a patient with severe tetanus in whom autonomic crises were a major and persistent feature, and investigated the impact of sedatives plus alpha(2)-agonists on these levels. Serum adrenaline levels were elevated up to 100-fold with clinically observed crises, although noradrenaline levels were much more difficult to interpret. There was no appreciable difference in catecholamine levels following administration of alpha(2)-agonists in the doses we used, although clonidine did allow easier control of crises with other agents. This case highlights some important lessons in the management of severe tetanus.
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Affiliation(s)
- D Freshwater-Turner
- Department of Anaesthesiology and Critical Care, University of Queensland, Level 3 Ned Hanlon Building, RBWH, Butterfield Street, Herston, Qld 4029, Australia
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131
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Abstract
Centrally acting agents stimulate alpha(2) receptors and/or imadozoline receptors on adrenergic neurons situated within the rostral ventrolateral medulla and, in so doing, sympathetic outflow is reduced. Centrally acting agents also stimulate peripheral alpha(2) receptors, which, for the most part, is of marginal clinical significance. Central a agonists have had a lengthy history of use, starting with alpha-methyldopa, which has had a dramatic decline in use, in part, because of bothersome side effects. Patients who require multidrug therapy with otherwise resistant hypertension, such as diabetic and/or renal failure patients, are typically responsive to these drugs, as are patients with sympathetically driven forms of hypertension. Perioperative forms of hypertension respond well to clonidine, a circumstance where the additional anesthesia- and analgesia-sparing effects of this drug may offer additional clinical benefits. Clonidine can be used adjunctively with other more traditional therapies in heart failure, particularly when hypertension is present. Sustained-release moxonidine, however, is associated with early mortality and morbidity when used in patients with heart failure. Escalating doses of drugs in this class often give rise to salt and water retention, in which case diuretic therapy becomes a valuable adjunctive therapy.
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Affiliation(s)
- Domenic A Sica
- Division of Nephrology, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA 23298-0160, USA.
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132
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Abstract
Orthostatic hypotension is a common problem among elderly patients, associated with significant morbidity and mortality. While acute orthostatic hypotension is usually secondary to medication, fluid or blood loss, or adrenal insufficiency, chronic orthostatic hypotension is frequently due to altered blood pressure regulatory mechanisms and autonomic dysfunction. The diagnostic evaluation requires a comprehensive history including symptoms of autonomic nervous system dysfunction, careful blood pressure measurement at various times of the day and after meals or medications, and laboratory studies. Laboratory investigation and imaging studies should be based upon the initial findings with emphasis on excluding diagnoses of neurodegenerative diseases, amyloidosis, diabetes, anemia, and vitamin deficiency as the cause. Whereas asymptomatic patients usually need no treatment, those with symptoms often benefit from a stepped approach with initial nonpharmacological interventions, including avoidance of potentially hypotensive medications and use of physical counter maneuvers. If these measures prove inadequate and the patient remains persistently symptomatic, various pharmacotherapeutic agents can be added, including fludrocortisone, midodrine, and nonsteroidal anti-inflammatory drugs. The goals of treatment are to improve symptoms and to make the patient as ambulatory as possible rather then trying to achieve arbitrary blood pressure goals. With proper evaluation and management, the occurrence of adverse events, including falls, fracture, functional decline, and myocardial ischemia, can be significantly reduced.
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Affiliation(s)
- Vishal Gupta
- Beth Israel Deaconess Medical Center, Hebrew SeniorLife, and Harvard Medical School, Boston, Mass 02131, USA
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133
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Abstract
BACKGROUND The clinical use of naltrexone (NTX) in the treatment of opioid dependence has been limited because of poor compliance and inconsistent outcomes. In particular, the therapeutic benefit of extended treatment with NTX after opioid detoxification is unclear. The present study evaluated whether the augmentation with low-dose NTX during the post-detoxification treatment of opioid dependence would improve outcomes. METHODS In an open-label naturalistic design, 435 opioid-dependent patients who had completed inpatient detoxification were offered the choice of entering 1 of the 2 outpatient treatment arms: clonidine extended treatment (CET) (clonidine + psychosocial treatment), or enhanced extended treatment (EET) (oral NTX [1-10 mg/d] + CET) for 21 days. The primary outcome measure was retention in treatment. Secondary outcomes included abstinence from opioids, dropouts, and adherence to postdischarge care. RESULTS One hundred sixty-two patients (37.2%) accepted EET. Subjects receiving EET stayed longer in the program (F = 64.4; P = 0.000), were less likely to drop out, used less opioids, and followed through with referral to long-term outpatient treatment in a higher number, compared with patients in the CET arm (P = 0.000 in each case). The NTX + clonidine combination was safe and well tolerated. CONCLUSIONS This preliminary study indicates the potential benefit of augmentation with low-dose NTX to improve outcomes after opioid detoxification for a preferred group of patients. Randomized controlled trials are necessary to further evaluate the role of low-dose NTX in the outpatient treatment of opioid dependence.
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Affiliation(s)
- Paolo Mannelli
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27705, USA.
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Meybohm P, Renner J, Boening A, Cavus E, Gräsner JT, Grünewald M, Scholz J, Bein B. Impact of norepinephrine and fluid on cerebral oxygenation in experimental hemorrhagic shock. Pediatr Res 2007; 62:440-4. [PMID: 17667840 DOI: 10.1203/pdr.0b013e3181425858] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Few data exist regarding resuscitation of hypovolemic shock in infants, and alternative strategies such as vasopressor therapy merit further evaluation. However, the effects of norepinephrine on cerebral perfusion and oxygenation during hemorrhagic shock in the pediatric population are still unclear. Eight anesthetized piglets were subjected to hypotension by blood withdrawal of 25 mL/kg. Norepinephrine was titrated to achieve baseline mean arterial blood pressure (MAP), and cerebral oxygenation was determined by brain tissue Po2 (Ptio2) and near-infrared spectroscopy-derived tissue oxygen index (TOI). Then, norepinephrine was stopped, MAP was allowed to decrease again below 30 mm Hg, and shed blood was retransfused. During hemorrhage, TOI dropped from 69+/-3 to 59+/-3%, and Ptio2 from 29+/-6 to 13+/-1 mm Hg (mean+/-SEM; p<0.001). Following norepinephrine, cerebral perfusion pressure (CPP) could be restored immediately, whereas TOI and Ptio2 did not increase significantly. In contrast, following retransfusion, TOI and Ptio2 increased to 68+/-3% and 27+/-7 mm Hg reaching baseline values, respectively. In conclusion, while norepinephrine increased CPP immediately, cerebral oxygenation as reflected by TOI and Ptio2 could not be improved by norepinephrine, but only by retransfusion.
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Affiliation(s)
- Patrick Meybohm
- Department of Anesthesiology and Intensive Care Medicine, Pediatric Anesthesia Research Unit, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany.
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135
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Amaki M, Kamide K, Takiuchi S, Niizuma S, Horio T, Kawano Y. A case of neurally mediated syncope induced by laughter successfully treated with combination of propranolol and midodrine. Int Heart J 2007; 48:123-7. [PMID: 17379987 DOI: 10.1536/ihj.48.123] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A 69-year-old man had been suffering from recurrent syncope induced by laughter since the age of 58. His syncope was reproduced by head-up tilt testing with isoproterenol infusion and we concluded that his laughter-induced syncope was one type of neurally mediated syndrome (NMS). His daughter also had NMS and her syncope was treated with propranolol. Propranolol and midodrine hydrochloride, an alpha(1)-adrenergic stimulant, were effective at preventing his laughter-induced syncope. This is a case report of laughter-induced syncope with a familial predisposition successfully treated with the combination of the nonselective beta-blocker propranolol and the alpha(1)-stimulator midodrine.
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Affiliation(s)
- Makoto Amaki
- Division of Hypertension and Nephrology, Department of Medicine, National Cardiovascular Center, Suita, Osaka, Japan
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136
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Abstract
OBJECTIVES This study examined trends in physician-prescribing of medications for children with sleep difficulties in outpatient settings in the US. Additionally, we explored the incidence of physician prescribing patterns of medications with high abuse potential for children with sleep difficulties. METHODS A cross-sectional study was conducted on patients aged < or =17 years with sleep difficulties from 1993-2004 using data from the National Ambulatory Medical Care Survey (NAMCS). Office visits were considered related to sleep difficulties if relevant ICD-9 codes were recorded and if sleep difficulties were reported as the reason for the visits. Medications were retrieved using the NAMCS drug codes, and all analyses were weighted to determine national estimates. RESULTS During 1993 to 2004, approximately 18.6 million visits occurred for sleep related difficulty in children. The highest percentage of visits were by school-aged children (6 to 12 years). Pediatricians saw 35% of patients, psychiatrists saw 24%, and general/family practice physicians saw 13% of the patients. Eighty-one percent of visits among children with sleep difficulties resulted in a prescription for a medication. Many of these medications prescribed lack FDA approved labeling to assure their effectiveness and safety in this population. CONCLUSION The findings of this study suggest that physicians frequently prescribed medications for sleep difficulties in children in US outpatient settings. Of particular concern is prescribing of many unapproved medications for this population.
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Affiliation(s)
- Sasko D. Stojanovski
- Division of Pharmacy Practice and Administration, The Ohio State University College of Pharmacy, Columbus, OH
- Children's Hospital and Research Institute, Columbus, OH
| | - Rafia S. Rasu
- Division of Pharmacy Practice, University of Missouri Kansas City School of Pharmacy, Kansas City, MO
| | - Rajesh Balkrishnan
- Division of Pharmacy Practice and Administration, The Ohio State University College of Pharmacy, Columbus, OH
- College of Public Health, The Ohio State University, Columbus, OH
| | - Milap C. Nahata
- Division of Pharmacy Practice and Administration, The Ohio State University College of Pharmacy, Columbus, OH
- Children's Hospital and Research Institute, Columbus, OH
- College of Medicine, The Ohio State University, Columbus, OH
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Soler JM, Previnaire JG, Plante P, Denys P, Chartier-Kastler E. Midodrine improves ejaculation in spinal cord injured men. J Urol 2007; 178:2082-6. [PMID: 17869290 DOI: 10.1016/j.juro.2007.07.047] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Indexed: 12/24/2022]
Abstract
PURPOSE We evaluated the effect of the alpha1-adrenergic agonist midodrine given orally for anejaculation in spinal cord injured men. MATERIALS AND METHODS A total of 185 spinal cord injured patients who reported absent ejaculation during sexual intercourse and who failed to respond to penile vibratory stimulation were treated with midodrine 30 to 120 minutes before a new stimulation. The procedure was repeated weekly, increasing doses by 7.5 mg to a maximum of 30 mg. Cardiovascular effects were monitored throughout the procedure. RESULTS Antegrade or retrograde ejaculation was achieved in 102 spinal cord injured men (64.6%). A positive response was more frequent in patients with complete lesions (American Spinal Injury Association A) and upper motor neuron lesions above T10. Midodrine induced a significant but moderate increase (maximum 10 mm Hg) in mean arterial pressure in all patients. The highest systolic blood pressure (more than 200 mm Hg) was seen in patients with quadriplegia. No other significant side effect was recorded. The average dose of midodrine required for ejaculation was 18.7 mg. CONCLUSIONS Midodrine is a safe and efficient adjunct to penile vibratory stimulation for anejaculation in spinal cord injured patients.
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Affiliation(s)
- J M Soler
- Laboratoire d'urodynamique et de sexologie, Centre Bouffard Vercelli, Cap Peyrefite, Cerbère, France
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Stone LS, Kitto KF, Eisenach JC, Fairbanks CA, Wilcox GL. ST91 [2-(2,6-diethylphenylamino)-2-imidazoline hydrochloride]-mediated spinal antinociception and synergy with opioids persists in the absence of functional alpha-2A- or alpha-2C-adrenergic receptors. J Pharmacol Exp Ther 2007; 323:899-906. [PMID: 17855473 DOI: 10.1124/jpet.107.125526] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Agonists acting at alpha2-adrenergic receptors (alpha2ARs) produce antinociception and synergize with opioids. The alpha2ARs are divided into three subtypes, alpha(2A)AR, alpha(2B)AR, and alpha(2C)AR. Most alpha2AR agonists require alpha(2A)AR activation to produce antinociception and opioid synergy. The same subtype also mediates the side effect of sedation, which limits the clinical utility of these compounds. Identification of a non-alpha(2A)AR-mediated antinociceptive agent would enhance the therapeutic utility of alpha2AR agonists in pain management. Previous studies have suggested that the alpha2AR agonist ST91 [2-(2,6-diethylphenylamino)-2-imidazoline hydrochloride] has a nonsedating, non-alpha(2A)AR mechanism of action. We examined the pharmacology of spinal ST91 and its interaction with the delta-opioid agonist deltorphin II (Tyr-D-Ala-Phe-Glu-Val-Val-Gly amide) in mice lacking either functional alpha(2A)ARs or alpha(2C)ARs. All drugs were administered by direct lumbar puncture, and drug interactions were evaluated using isobolographic analysis. In contrast to the majority of alpha2AR agonists, ST91 potency was only moderately reduced (3-fold) in the absence of the alpha(2A)AR. Studies with the alpha2AR subtype-preferring antagonists BRL-44408 (2-[2H-(1-methyl-1,3-dihydroisoindole)methyl]-4,5-dihydroimidazole maleate) and prazosin [[4-(4-amino-6,7-dimethoxy-quinazolin-2-yl) piperazin-1-yl]-(2-furyl)methanone] and the pan-alpha2AR antagonist SKF-86466 (6-chloro-2,3,4,5-tetrahydro-3-methyl-1-H-3-benzazepine) suggest a shift from alpha(2A)AR to the other alpha2AR subtype(s) in the absence of alpha(2A)AR. Antinociceptive synergy with deltorphin II was preserved in the absence of either alpha(2A)AR or alpha(2C)AR. In conclusion, ST91 activates both alpha(2A)AR and non-alpha(2A)AR subtypes to produce spinal antinociception and opioid synergy. This study confirms that the spinal pharmacology of ST91 differs from that of other alpha2AR agonists and extends those data to include spinal synergy with opioid agonists. The unique profile of ST91 may be advantageous in pain management.
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Affiliation(s)
- Laura S Stone
- Faculty of Dentistry, McGill Centre for Research on Pain, 3640 University Street, Montreal, Quebec H3A 2B2, Canada.
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139
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Okada H, Kurita T, Mochizuki T, Morita K, Sato S. The cardioprotective effect of dexmedetomidine on global ischaemia in isolated rat hearts. Resuscitation 2007; 74:538-45. [PMID: 17391832 DOI: 10.1016/j.resuscitation.2007.01.032] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Revised: 01/09/2007] [Accepted: 01/17/2007] [Indexed: 01/10/2023]
Abstract
AIM Dexmedetomidine is a highly specific and selective alpha-2 adrenergic agonist that is now widely used in the intensive care setting. Many intensive care unit (ICU) patients are at risk of respiratory or cardiac arrest. This study was conducted to determine whether dexmedetomidine exhibits a cardioprotective effect on global ischaemia and subsequent myocardial infarction. METHODS Isolated rat hearts were subjected to 30 min of global ischaemia followed by 120 min reperfusion, with administration of 0, 1 and 10nM dexmedetomidine during the pre-ischaemic period (n=7 each group). Secondly, 1 microM yohimbine, an alpha-2 antagonist, was given during the pre-ischaemic period, alone or in combination with 10 nM dexmedetomidine (n=7 each group). RESULTS Dexmedetomidine administration reduced coronary flow significantly (103.6+/-4.7%, 77.9+/-3.7, 63.7+/-6.1%, of the baseline values for 0, 1 and 10 nM dexmedetomidine, respectively), and yohimbine administration reversed this effect (88.0+/-2.2%). Dexmedetomidine improved the infarct size at each concentration (45.3+/-3.6, 30.2+/-3.3, and 21.2+/-2.3% of the total left ventricular mass for 0, 1, and 10nM dexmedetomidine, respectively), which was also reversed by yohimbine (43.6+/-1.4%). CONCLUSION Dexmedetomidine exhibited a cardioprotective effect on global ischaemia in the isolated rat heart model, which was mediated by alpha-2 adrenergic stimulation.
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Affiliation(s)
- Hisako Okada
- Department of Anaesthesiology and Intensive Care, Hamamatsu University School of Medicine, 1-20-1, Handayama, Hamamatsu, Shizuoka 431-3192, Japan.
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140
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Abstract
BACKGROUND Effective management of ocular hypertension requires patients to be persistent with their treatment regimen. We evaluated patients' persistency with hypotensive eyedrops commonly used to treat glaucoma and ocular hypertension. METHODS This large, population-based, retrospective, cohort study used pharmacy claims data for concessional patients from the Australian Pharmaceutical Benefits Scheme (July 1999-June 2005). Resupply rates for prostaglandins, beta-blockers, alpha-agonists and carbonic anhydrase inhibitors were analysed using life tables and Cox regression. Two populations, based on patients' supply histories, were examined: (i) 'new to this eyedrop'- patients who had used other hypotensive eyedrops before (presumably, previously diagnosed with glaucoma or ocular hypertension); and (ii) 'new to any eyedrop'- patients who were using their first hypotensive eyedrop (presumably, newly diagnosed with glaucoma or ocular hypertension). RESULTS Data were obtained for 14,359,618 supplies of commonly used hypotensive eyedrops to 357,099 concessional patients. For both populations, resupply rates were highest for prostaglandins or the dorzolamide-timolol combination eyedrops, compared with beta-blockers, alpha-agonists or carbonic anhydrase inhibitors. Among the prostaglandins, there was no significant difference in the risk of ceasing supply between latanoprost and bimatoprost, but the risk was significantly higher for travoprost. CONCLUSIONS Based on resupply rates from a national pharmacy claims database, patients supplied with ocular hypotensive eyedrops were most persistent with prostaglandin (bimatoprost, latanoprost and travoprost) and dorzolamide-timolol combination eyedrops. Among the prostaglandins, persistency was highest with, and similar between, bimatoprost and latanoprost. Persistency should be taken into account when selecting the most appropriate eyedrop to treat glaucoma and ocular hypertension.
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Affiliation(s)
- Julian L Rait
- Centre for Eye Research Australia, East Melbourne, Victoria, Australia.
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141
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Hong S, Kim CY, Seong GJ, Han SH. Effect of prophylactic brimonidine instillation on bleeding during strabismus surgery in adults. Am J Ophthalmol 2007; 144:469-70. [PMID: 17765438 DOI: 10.1016/j.ajo.2007.04.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Revised: 04/13/2007] [Accepted: 04/17/2007] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the effects of preoperative brimonidine-purite 0.15% instillation on intraoperative bleeding and postoperative subconjunctival hemorrhage during strabismus surgery in adult patients. DESIGN Randomized comparative interventional case series. METHODS One hundred and eighteen eyes of 90 consecutive adult patients were instilled with either a single drop of brimonidine-purite 0.15% (42 eyes), phenylephrine 1% (38 eyes), or sodium hyaluronate 0.1% (38 eyes) 15 minutes prior to strabismus surgery. Intraoperative bleeding and postoperative subconjunctival hemorrhage were graded on a scale of one to three. The scores were compared among the study groups. RESULTS Scores of the intraoperative bleeding and the postoperative subconjunctival hemorrhage of the treatment groups were significantly less than that of the control group (P < .001). The scores of the brimonidine group were similar to those of the phenylephrine group (intraoperative bleeding score, P = .405; subconjunctival hemorrhage score, P = .722). CONCLUSIONS Topical brimonidine administration before strabismus surgery may reduce intraoperative bleeding and postoperative subconjunctival hemorrhage in adult patients.
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Affiliation(s)
- Samin Hong
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea
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142
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Koudouna E, Xanthos T, Bassiakou E, Goulas S, Lelovas P, Papadimitriou D, Tsirikos N, Papadimitriou L. Levosimendan improves the initial outcome of cardiopulmonary resuscitation in a swine model of cardiac arrest. Acta Anaesthesiol Scand 2007; 51:1123-9. [PMID: 17697310 DOI: 10.1111/j.1399-6576.2007.01383.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardiac arrest remains the leading cause of death in Western societies. Advanced Life Support guidelines propose epinephrine (adrenaline) for its treatment. The aim of this study was to assess whether a calcium sensitizer agent, such as levosimendan, administered in combination with epinephrine during cardiopulmonary resuscitation, would improve the initial resuscitation success. METHODS Ventricular fibrillation was induced in 20 Landrace/Large-White piglets, and left untreated for 8 min. Resuscitation was then attempted with precordial compressions, mechanical ventilation and electrical defibrillation. The animals were randomized into two groups (10 animals each): animals in Group A received saline as placebo (10 ml dilution, bolus) + epinephrine (0.02 mg/kg), and animals in Group B received levosimendan (0.012 mg/kg/10 ml dilution, bolus) + epinephrine (0.02 mg/kg) during cardiopulmonary resuscitation. Electrical defibrillation was attempted after 10 min of ventricular fibrillation. RESULTS Four animals in Group A showed restoration of spontaneous circulation and 10 in Group B (P = 0.011). The coronary perfusion pressure, saturation of peripheral oxygenation and brain regional oxygen saturation were significantly higher during cardiopulmonary resuscitation in Group B. CONCLUSIONS A calcium sensitizer agent, when administered during cardiopulmonary resuscitation, significantly improves initial resuscitation success and increases coronary perfusion pressure during cardiopulmonary resuscitation.
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Affiliation(s)
- E Koudouna
- Department of Experimental Surgery and Surgical Research, Medical School, University of Athens, 15B Agiou Thoma Street, 11527 Athens, Greece
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143
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Burgherr T, Reichler I, Hung L, Hubler M, Arnold S. [Efficacy, tolerance and acceptability of Incontex in spayed bitches with urinary incontinence]. SCHWEIZ ARCH TIERH 2007; 149:307-13. [PMID: 17702490 DOI: 10.1024/0036-7281.149.7.307] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED A clinical study about efficacy and acceptance of Incontex in spayed bitches with urinary incontinence was performed. In a randomised, double-blinded study the efficacy and acceptance of Incontex (Dr. E. Gräub AG, Bern, Schweiz) in bitches with urethral sphincter incompetence due to spaying was evaluated under field conditions. The active ingredient of the Incontex Syrup is phenylpropanolamine (PPA), an alpha1-adrenergic agonist. The study was performed using 24 spayed, incontinent bitches. Over a first period of treatment of 30 days the bitches received either Incontex, at 1.5 mg/kg twice per day, or a placebo. In the second period of 30 days all 24 bitches were treated with Incontex at the recommended dose. Any changes in the incontinence compared with the situation before the study were evaluated. RESULTS Of 24 bitches 21 (88%) became continent and in 2 bitches (8%) urinary incontinence improved. In only 1 bitch (4%) the medication did have no effect. Five bitches (21%) showed side effects. The acceptance of Incontex was good. CONCLUSION AND CLINICAL RELEVANCE Incontex can be recommended as an efficient and well-tolerated medication for the treatment of bitches with urinary incontinence after spaying. The oral application of 1.5mg/kg BW phenylpropanolamine twice daily has been approved.
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Affiliation(s)
- T Burgherr
- Klinik für Fortpflanzungsmedizin der Universität Zürich
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144
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Abstract
Low-pressure (low-tension) glaucoma is reviewed in relation to neuroprotection, that is, the therapeutic strategy to keep neurons living and functionally connected to targets within the brain. Baseline results of the Low-Pressure Glaucoma Treatment Study (LoGTS) are reviewed.
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Affiliation(s)
- Theodore Krupin
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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145
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Abstract
BACKGROUND A reflex cough is often observed after an intravenous bolus of fentanyl. This study was conducted to determine whether pre-treatment with intravenous clonidine could effectively attenuate fentanyl-induced cough. METHODS Three hundred ASA I-II patients, aged between 18 and 80 years, undergoing various elective surgeries, were enrolled in this study. All patients were randomly assigned to one of two groups treated with intravenous clonidine 2 microg/kg (clonidine group) or the same volume of normal saline (control group). Intravenous fentanyl (2 microg/kg in 2 s) was injected 2 min after the clonidine or normal saline injection. Changes in the hemodynamics, auditory evoked potentials (AEPs) and Observer Assessment of Alertness/Sedation (OAA/S) rating scale were recorded before and 2 min after the clonidine or normal saline injection and 1 min after the fentanyl injection. The number of coughs 1 min after the fentanyl injection was also recorded. RESULTS Patients in the clonidine group showed a significantly lower incidence of cough than those in the control group (17.3% vs. 38.7%, respectively; P < 0.01). The blood pressure was lower in the clonidine group than in the control group. There were no significant differences in AEP or OAA/S rating scale. CONCLUSIONS Pre-treatment with intravenous clonidine (2 microg/kg) suppressed the reflex cough induced by fentanyl, with mild hemodynamic changes. Therefore, intravenous clonidine may be a clinically useful method of suppressing fentanyl-induced cough.
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Affiliation(s)
- H-C Horng
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
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146
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Affiliation(s)
- Barbara Coffey
- NYU Child Study Center, 577 First Avenue, New York, NY 10016, USA.
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147
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Arnsten AF, Scahill L, Findling RL. alpha2-Adrenergic receptor agonists for the treatment of attention-deficit/hyperactivity disorder: emerging concepts from new data. J Child Adolesc Psychopharmacol 2007; 17:393-406. [PMID: 17822336 DOI: 10.1089/cap.2006.0098] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Recent developments in the field of neuroscience have illuminated the understanding of the neural circuits impaired in attention-deficit/hyperactivity disorder (ADHD) and the mechanism of action of treatments used to treat this condition. There is an exciting confluence between emerging studies in basic neurobiology and the genetic, neuroimaging, and neuropsychological analyses of ADHD. The following provides a brief review of this field, explaining how compounds like guanfacine and the traditional stimulant medications can reduce the core symptoms of ADHD by optimizing the neurochemical environment in the prefrontal cortex (PFC). Knowledge of these basic mechanisms may inform our medication choices and facilitate treatment of ADHD and related disorders.
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Affiliation(s)
- Amy F Arnsten
- Director of Graduate Studies, Deparment of Neurobiology, Yale Medical School, New Haven, Connecticut 06520-8001, USA.
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148
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Kim HS, Chang YI, Kim JH, Park CK. Alteration of retinal intrinsic survival signal and effect of
α2–adrenergic receptor agonist in the retina of the chronic
ocular hypertension rat. Vis Neurosci 2007; 24:127-39. [PMID: 17640403 DOI: 10.1017/s0952523807070150] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 02/12/2007] [Indexed: 11/07/2022]
Abstract
The purpose of this study is to examine the retinal expression of
intrinsic cell survival molecules and to elucidate the effect of an
α2-adrenergic receptor agonist in the chronic ocular hypertensive rat
model. Chronic ocular hypertension was induced in both eyes of each rat by
episcleral vein cauterization. Two five-microliter drops of the selective
α2-adrenoceptor agonist brimonidine 0.2% (Alphagan; Allergan Inc.,
Irvine, CA, USA) were topically administered twice daily for up to eight
weeks in one eye. The fellow eye received balanced salt solution as a
control. Protein and mRNA expression were evaluated at 1, 4, and 8 weeks
after injury. Retinal expression of BDNF, Akt, and GFAP was assessed using
immunohistochemistry. Retinal levels of mRNA for BDNF, bcl-2, and bcl-xL
were determined using semi-quantitative RT-PCR. Retinal ganglion cell
(RGC) density was evaluated after retrograde labeling with 4-Di-10-ASP
(DiA). A significant decrease in RGC density was observed in ocular
hypertensive eyes. Cauterized eyes showed an increase in GFAP expression
from one week after injury, and the expression of bcl-2, bcl-xL, and BDNF
mRNA was also increased. Treatment of ocular hypertensive eyes with
brimonidine resulted in a reduction in RGC loss, a decrease in the level
of GFAP immunoreactivity, and an increment in BDNF mRNA and p-Akt
expression. Brimonidine appears to protect RGCs from neurodegeneration
through mechanisms involving α2-adrenergic receptor mediated survival
signal activation and up-regulation of endogenous neurotrophic factor
expression in the chronic ocular hypertensive rat retina.
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Affiliation(s)
- Hwa Sun Kim
- Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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149
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Vaidyanathan S, Soni BM, Hughes PL. Midodrine: insidious development of urologic adverse effects in patients with spinal cord injury: a report of 2 cases. Adv Ther 2007; 24:712-20. [PMID: 17901021 DOI: 10.1007/bf02849965] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Midodrine, a prodrug, is converted after oral administration into its active drug, desglymidodrine, which acts as an alpha(1)-adrenoceptor stimulant. Midodrine is prescribed for the treatment of neurogenic orthostatic hypotension in patients with spinal cord injury. By virtue of its alpha(1)-adrenergic effects, midodrine causes an increase in the tone of the vesical sphincter, which may silently lead to progressive retention of urine, particularly in patients with spinal cord injury who void urine spontaneously. Further, midodrine may aggravate detrusor-sphincter dyssynergia, which can lead to hydroureteronephrosis. A 68-year-old man with C-4 tetraplegia was voiding urine satisfactorily through reflex detrusor contractions. He was prescribed midodrine (5 mg at 8:00 AM, 5 mg at 1:00 PM, and 2.5 mg at 10:00 PM) for postural hypotension. During the next 7 wk, this patient experienced severe leg spasms while passing urine, and the flow of urine became very slow. Intravenous urography showed bilateral hydroureteronephrosis, although an earlier study had revealed normal kidneys. Midodrine therapy was stopped, and intermittent catheterization 4 times a day, along with oral oxybutynin, was started. After midodrine was discontinued, the leg spasms during passage of urine and slowing of the urine stream coincident with the spasms disappeared completely. The patient was able to pursue activities of daily living without taking midodrine. A 40-year-old man with C-7 tetraplegia was passing urine spontaneously with no problem. For postural hypotension, he was prescribed midodrine (5 mg in the morning and 2.5 mg at lunchtime), fludrocortisone (100 microg daily), and ephedrine (15 mg by mouth, taken 10 min before getting up in the morning). Three months later, the patient presented with sweating. During the day, he would pass only small amounts of urine, but from evening onward, he would void large volumes of urine, and the sweating would diminish. Intravenous urography showed vesical diverticula; a postmicturition film revealed moderate residual urine. This patient was able to stop taking the second dose of midodrine, but he required midodrine and ephedrine in the morning to enable him to get up without feeling dizzy. After the noon midodrine dose was stopped, the patient's sweating diminished by late afternoon. During the morning hours, however, he continued to sweat and had difficulty passing urine. Intermittent catheterization was not possible in the community setting, and the patient remains under close follow-up. These cases illustrate that patients with cervical spinal cord injury who void spontaneously may develop insidious urologic adverse effects after taking midodrine for postural hypotension. When patients with spinal cord injury develop urologic adverse effects while taking midodrine, the drug should be stopped, and other pharmacologic agents (eg, fludrocortisone) and nonpharmacologic methods should be prescribed for management of orthostatic hypotension. If a patient continues to require midodrine to control postural hypotension, intermittent catheterization combined with antimuscarinic therapy (eg, oxybutynin) should be recommended instead of spontaneous voiding.
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150
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Abstract
Midodrine hydrochloride is a potent peripherally-acting alpha1 agonist that is well absorbed and rapidly metabolized to its active metabolite. It has been used for the treatment of refractory syncope but has the important side effect of supine hypertension. A 10-year-old boy with severe symptomatic orthostatic hypotension was treated with midodrine. After therapy, syncope attacks ceased but he suffered nighttime headaches, nausea, transient rash and itchy/prickly scalp. Midodrine was discontinued when supine hypertension was noticed. However, his supine hypertension continued until day 19 after discontinuation. This case shows that patients receiving midodrine should be observed for supine hypertension for a prolonged period.
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Affiliation(s)
- S Olgar
- Department of Pediatric Cardiology, Istanbul University, Istanbul Faculty of Medicine, 34390, Capa, Istanbul, Turkey.
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