Current Issue : January - March Volume : 2014 Issue Number : 1 Articles : 7 Articles
Background: Acute behavioural disturbance (ABD) is a common problem in psychiatry and both physical restraint\r\nand involuntary parenteral sedation are often required to control patients. Although guidelines are available, clinical\r\npractice is often guided by experience and there is little agreement on which drugs should be first-line treatment\r\nfor rapid tranquilisation. This study aimed to investigate sedation for ABD in an acute mental healthcare unit,\r\nincluding the effectiveness and safety of high dose sedation.\r\nMethods: A prospective study of parenteral sedation for ABD in mental health patients was conducted from July\r\n2010 to June 2011. Drug administration (type, dose, additional doses), time to sedation, vital signs and adverse\r\neffects were recorded. High dose parenteral sedation was defined as greater than the equivalent of 10 mg\r\nmidazolam, droperidol or haloperidol (alone or in combination), compared to patients receiving 10 mg or less\r\n(normal dose). Effective sedation was defined as a fall in the sedation assessment tool score by two or a score of\r\nzero or less. Outcomes included frequency of adverse drug effects, time to sedation/tranquilisation and use of\r\nadditional sedation.\r\nResults: Parenteral sedation was given in 171 cases. A single drug was given in 96 (56%), including droperidol (74),\r\nmidazolam (19) and haloperidol (3). Effective sedation occurred in 157 patients (92%), and the median time to\r\nsedation was 20 min (Range: 5 to 100 min). The median time to sedation for 93 patients receiving high dose\r\nsedation was 20 min (5-90 min) compared to 20 min (5-100 min; p = 0.92) for 78 patients receiving normal dose\r\nsedation. Adverse effects occurred in 16 patients (9%); hypotension (14), oxygen desaturation (1), hypotension and\r\noxygen desaturation (1). There were more adverse effects in the high dose sedation group compared to the normal\r\ndose group [11/93 (12%) vs. 5/78 (6%); p = 0.3]. Additional sedation was given in 9 of 171 patients (5%), seven in\r\nthe high dose and two in the normal dose groups.\r\nConclusions: Large initial doses of sedative drugs were used for ABD in just over half of cases and additional\r\nsedation was uncommon. High dose sedation did not result in more rapid or effective sedation but was associated\r\nwith more adverse effects....
Background: Recently, a number of studies using intra-articular application of tranexamic acid (IA-TXA), with\r\ndifferent dosage and techniques, successfully reduced postoperative blood loss in total knee replacement (TKR).\r\nHowever, best of our knowledge, the very low dose of IA-TXA with drain clamping technique in conventional TKR\r\nhas not been yet studied. This study aimed to evaluate the effectiveness and dose-response effect of two low-dose\r\nIA-TXA regimens in conventional TKR on blood loss and blood transfusion reduction.\r\nMethods: Between 2010 and 2011, a triple-blinded randomized controlled study was conducted in 135 patients\r\nundergoing conventional TKR. The patients were allocated into three groups according to intra-articular solution\r\nreceived: Control group (physiologic saline), TXA-250 group (TXA 250 mg), and TXA-500 group (TXA 500 mg). The\r\nsolution was injected after wound closure followed by drain clamping for 2 hours. Blood loss and transfusion were\r\nrecorded. Duplex ultrasound was performed. Functional outcome and complication were followed for one year.\r\nResults: There were forty-five patients per groups. The mean total hemoglobin loss was 2.9 g/dL in control group\r\ncompared with 2.2 g/dL in both TXA groups (p > 0.001). Ten patients (22%, control), six patients (13%, TXA-250) and\r\nnone (TXA-500) required transfusion (p = 0.005). Thromboembolic events were detected in 7 patients (4 controls, 1\r\nTXA-250, and 2 TXA-500). Functional outcome was non-significant difference between groups.\r\nConclusions: Combined low-dose IA-TXA, as 500 mg, with 2-hour clamp drain is effective for reducing postoperative\r\nblood loss and transfusion in conventional TKR without significant difference in postoperative knee function or\r\ncomplication....
Background: Although some studies conducted outside of Japan have addressed the effectiveness of intravenous\r\nimmunoglobulins (IVIG) in treating infections, the dosing regimens and amounts used in Japan are very different\r\nfrom those reported. Here, we investigate the effectiveness of single-dose administration of IVIG in sepsis patients\r\nin Japan.\r\nMethods: We analyzed 79 patients admitted to the intensive care unit (ICU) of a tertiary care institution due to\r\nsevere sepsis or septic shock. Patients were randomly divided into a group that was administered standard divided\r\ndoses of IVIG (5 g/day for 3 days, designated the S group) or a group that was administered a standard single dose\r\nof IVIG (15 g/day for 1 day, H group); freeze-dried sulfonated human IVIG was used. The longitudinal assessment of\r\nprocalcitonin (PCT) levels, C-reactive protein (CRP) levels, white blood cell count, blood lactate levels, IL-6 levels,\r\nSequential Organ Failure Assessment (SOFA) score, and Systemic Inflammatory Response Syndrome (SIRS) was\r\nconducted. We also assessed mechanical ventilation duration (days), ICU stay (days), 28-day survival rate, and 90-day\r\nsurvival rate.\r\nResults: The study showed no significant differences in PCT levels, CRP levels, 28-day survival rate, and 90-day\r\nsurvival rate between the two groups. However, patients in the H group showed improvements in the various SIRS\r\ndiagnostic criteria, IL-6 levels, and blood lactate levels in the early stages after IVIG administration. In light of the\r\nnon-recommendation of IVIG therapy in the Surviving Sepsis Campaign Guidelines 2012, our findings of significant\r\nearly post-administration improvements are noteworthy. IVIG''s anti-inflammatory effects may account for the early\r\nreduction in IL-6 levels after treatment, and the accompanying improvements in microcirculation may improve\r\nblood lactate levels and reduce SOFA scores. However, the low dosages of IVIG in Japan may limit the anti-cytokine\r\neffects of this treatment. Further studies are needed to determine appropriate treatment regimens of single-dose\r\nIVIG.\r\nConclusions: In this study, we investigated the effectiveness of single-dose IVIG treatment in patients with severe\r\nsepsis or septic shock. Although there were no significant effects on patient prognoses, patients who were\r\nadministered single-dose IVIG showed significantly improved IL-6 levels, blood lactate levels, and disease severity\r\nscores....
assessment of kidney function by estimating glomerular filtration rate (eGFR) and several different clinical\r\nrecommendations for drug dose adjustment in renal failure are published, choosing the correct approach for drug\r\ndosage is difficult for the practitioner. The aims of our study were to quantify the agreement between eGFR-equations\r\ngrouped by creatinine-based or cystatin C-based and within the groups of creatinine and cystatin C-based equations\r\nand to investigate whether use of various literature and online references results in different recommendations for drug\r\ndose adjustment in renal disease in very elderly primary care patients.\r\nMethods: We included 108 primary care patients aged 80 years and older from 11 family practices into a crosssectional\r\nstudy. GFR was estimated using two serum creatinine-based equations (Cockroft-Gault, MDRD) and three\r\nserum cystatin C-based equations (Grubb, Hoek, Perkins). Concordance between different equations was quantified\r\nusing intraclass correlation coefficients (ICCs). Essential changes in drug doses or discontinuation of medication were\r\ndocumented and compared in terms of estimated renal function as a consequence of the different eGFR-equations\r\nusing five references commonly used in the US, Great Britain and Germany.\r\nResults: In general, creatinine-based equations resulted in lower eGFR-estimation and in higher necessity of drug dose\r\nadjustment than cystatin C-based equations. Concordance was high between creatinine-based equations alone (ICCs\r\n0.87) and between cystatin C-based equations alone (ICCs 0.90 to 0.96), and moderate between creatinine-based\r\nequations and cystatin C-based equations (ICCs 0.54 to 0.76). When comparing the five different references consulted\r\nto identify necessary drug dose adjustments we found that the numbers of drugs that necessitate dose adjustment in\r\nthe case of renal impairment differed considerably. The mean number of recommended changes in drug dosage\r\nranged between 1.9 and 2.5 per patient depending on the chosen literature reference.\r\nConclusions: Our data suggest that the choice of the literature source might have even greater impact on drug\r\nmanagement than the choice of the equation used to estimate GFR alone. Efforts should be deployed to standardize\r\nmethods for estimating kidney function in geriatric patients and literature recommendations on drug dose adjustment\r\nin renal failure....
Background: Azathiopurine (AZA) is efficacious for maintenance remission of Crohn�s disease (CD) at the standard\r\ndose of 2.0-2.5 mg/kg for Caucasian. It has been reported that the lower dose (1.0-2.0 mg/kg) in some Asian\r\ncountries was as effective as the standard dose. In the present study we analyzed the efficacy of <1.0 mg/kg AZA in\r\nmaintaining remission for Chinese patients.\r\nMethods: The clinical data of all CD patients were reviewed from 1993 to December 2012. The patients who\r\ninitiated AZA treatment and were followed for = 2 years with complete medical data were included. We divided\r\nthe patients into two groups according to their initial dose: <1.0 mg/kg group and 1.0-2.0 mg/kg group.\r\nResults: Among 77 patients, 39 (50.6%) started treatment with <1.0 mg/kg AZA and 38 (49.4%) with 1.0-2.0 mg/kg.\r\nThe mean dose of <1.0 mg/kg group remained under 1.0 mg/kg at 6, 12 and 24 months, even if the doses were\r\nadjusted according to efficacy and tolerance. The remission rate in patients of <1.0 mg/kg group was significantly\r\nhigher than that in those of 1.0-2.0 mg/kg group (P = 0.025). A dose of <1.0 mg/kg AZA was more commonly\r\nassociated with male gender, older age, heavier body weight and L1 location. Adverse events were observed in 21\r\nof 77 patients (27.3%) and no significant difference in occurrence of adverse events or leucopenia between two\r\ngroups.\r\nConclusions: <1.0 mg/kg AZA was effective as 1.0-2.0 mg/kg in maintaining remission among Chinese patients\r\nwith CD....
Background: Tacrolimus is an immunosuppressive drug used to prevent acute rejection following organ\r\ntransplantation and to treat autoimmune disease. Tacrolimus is usually prescribed in such situation at a dose of\r\n3.0 mg/day. Pneumocystis pneumonia induced by this dose of tacrolimus has been reported in many cases; however,\r\nwe encountered a rare case of Pneumocystis pneumonia induced by low-dose tacrolimus and methylprednisolone.\r\nCase presentation: We herein report the case of an 82-year-old Asian Japanese female with rheumatoid arthritis and\r\nPneumocystis pneumonia who was being treated with low-dose tacrolimus and low-dose methylprednisolone therapy.\r\nShe was diagnosed with rheumatoid arthritis at 52 years of age and was administered oral low-dose methylprednisolone\r\nand salazosulfapyridine. Her condition had been stable under this treatment for 30 years. However, her arthralgia\r\nworsened three months before admission. The salazosulfapyridine was changed to tacrolimus (0.5 mg/day) by her\r\nphysician, and her arthralgia almost completely disappeared. She was admitted to our hospital for Pseudomonas\r\npneumonia, and her symptoms improved almost completely with intravenous ceftazidime therapy. However, on the\r\n14th day of admission, she developed acute respiratory failure due to Pneumocystis pneumonia and died on the\r\n17th day of admission in spite of adequate treatment.\r\nConclusion: Our report highlights the importance of providing prompt prevention, diagnosis and treatment of\r\nPneumocystis pneumonia in rheumatoid arthritis patients under tacrolimus and low-dose methylprednisolone therapy....
Background: Subcutaneous immunotherapy with high dose grass pollen (typically microgram quantities) was first\r\ndescribed over 100 years ago. This treatment suppresses allergen-induced cutaneous late responses, with lesser effects\r\non early responses. We previously reported that repeated 2-weekly intradermal injections of grass pollen - containing\r\napproximately 7 ng of major allergen Phl p 5 ââ?¬â?? led to a progressive suppression of the allergen-induced cutaneous\r\nresponse, and that by the sixth injection, this was inhibited by over 90%. The purpose of this trial is to investigate the\r\nclinical efficacy of intradermal desensitisation with low doses (i.e. nanogram quantities) of grass pollen allergen for\r\nseasonal allergic rhinitis.\r\nMethods/design: The Pollen Low dose Intradermal therapy Evaluation (PollenLITE) is a single centre double-blind\r\nrandomised parallel group controlled trial of the efficacy and safety of intradermal grass pollen injections plus standard\r\ntreatment, versus histamine injections plus standard treatment, in adults with moderate-severe grass pollen-induced\r\nallergic rhinitis (ââ?¬Ë?summer hay feverââ?¬â?¢). A minimum of ninety adults with a history of moderate-severe persistent allergic\r\nrhinitis during the UK grass pollen season will be randomised into two equal groups to receive 7 or 8 intradermal\r\ninjections of grass pollen extract (containing approximately 7 ng of major allergen Phl p 5) or histamine, before the\r\ngrass pollen season. In the summer, participants will score their symptoms, medication requirements, visual analogue\r\nscores, and complete EuroQOL (EQ-5D-5 L) and mini Rhinoconjunctivitis Quality of Life Questionnaires. Global\r\nassessments will also be recorded at the end of the pollen season. Blood samples will be collected from all participants\r\nfor mechanistic immune assays. Skin punch biopsies will also be collected in 40 participants selected at random from\r\nintradermal injection sites after the grass pollen season for mechanistic assays. Finally, to investigate if the desensitising\r\neffect of intradermal immunotherapy on cutaneous responses is long-lasting, all participants will be randomised to\r\nreceive a follow up intradermal injection after 3, 6 or 12 months with measurement of early and late response sizes.\r\nDiscussion: Randomisation began in February 2013 and the final participant will complete the trial protocol in\r\nAugust 2014....
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