Treatment considerations in dementing illness

This issue focuses on the diagnosis and treatment of a variety of disorders that cause dementia. It emphasizes that all dementias, whatever their cause, are treatable. It is aimed at primary care physicians because they are likely to be the first physicians to see these complex patients and their caregivers. Each article is briefly introduced.     

Treatment of rectal and colonic polyps showing early malignant change

Summary The entire experience of the Lahey Clinic with adenocarcinoma and benign mucosal polyps of the colon and rectum with early malignant change for nine years from 1945 to 1954 is reported. Thirty-one per cent of the patients with benign mucosal polyps showing early malignant change were treated conservatively and there was no further difficulty. We recognize that the complete story of the origin and development of rectal and colonic cancer has not been told. In our experience, many benign mucosal polyps of the rectum showing early cancer histologically can be treated safely by conservative methods. Polyps showing definite invasion of the stalk or adjacent bowel wall should be treated radically. We are not in complete agreement with the recent report by Spratt, Ackerman and Moyer that there is no evidence to support the view that there is an intimate relationship between benign mucosal polyps and cancer. Until there is further evidence to the contrary, we believe that benign mucosal polyps of the colon and rectum have a malignant potential and should be removed or destroyed when discovered. We recognize, however, that there is need for further clinical and especially pathologic study of this problem. Read at the meeting of the New England Surgical Society, Portsmouth, New Hampshire, October 16, 1959.     

Treatment of malignant colonic obstructions with metal stents and laser

BACKGROUND/AIMS: The aim of this study was to evaluate the efficacy and safety of combined endoscopic therapy with self-expanding metallic endoprostheses and laser application in the management of malignant colonic obstruction. METHODOLOGY: Between March 1998 and September 2000, obstruction of the distal colon was diagnosed in a total of 11 patients (6 M, 5 F, age range: 67-87 years, mean: 73). The site of obstruction was located in the rectosigmoid colon (n = 6), in the sigmoid colon (n = 4) and in the descending colon (n = 1). The etiology of stenosis was colorectal adenocarcinoma (n = 8), ovarian cancer (n = 2) and infiltrating bladder carcinoma (n = 1). In all patients the tumor was considered non-resectable. Six patients had confirmed metastases, one refused colostomy and 4 were unable to undergo surgery. After radiological visualization of the proximal extent of the stricture, the stenosis was dilated with Savary-like (10 patients) and pneumatic balloon dilators (1 patient-descending colon). RESULTS: Stents were placed successfully in 10 patients. Prostheses migration distal to lesion, into the sigmoid colon, was observed in one patient (bladder cancer). A mild autoresolved bleeding was observed in 8 patients. Five patients remained free of clinical colonic obstruction until their death, which occurred 6-16 weeks (mean: 10) after stent placement. A moderate non-occlusive ingrowth of tumor into the stent lumen was documented in the other 5 cases. These patients were treated with introspective application of Diomed laser in a total of 16 sessions (4120-12,476 Joules each session, mean: 6258, power 10-14 W, interval between 2 sessions 6 weeks) and died of progressive disease without clinical signs and endoscopic findings of reobstruction 22-56 weeks (mean: 32) after stent placement. CONCLUSIONS: Metallic stent placement is an adequate palliative and cost-effective option, effective and save, in advanced colonic obstruction due to non-resectable tumors. It circumvents the need for colostomy and allows the patient a better quality of life. Delayed stent occlusion with tumor ingrowth requires a regular follow-up and can be treated with introspective laser ablation.     

大黄煎剂灌肠治疗老年人急性结肠假性梗阻

目的 研究大黄煎剂灌肠治疗老年人大早期性结肠假性硬阻的疗效。方法 对５２例诊断为急性结肠假性梗阻的老年患者在常规治疗的同时加用大黄煎剂汇肠。结果 经有的中西医结合治疗。６２例患者病情均缓解,Ｘ线腹平片显示结肠扩张减轻,盲肠直径显著缩小。２９例（４６．８％）在２４ｈ内缓解,１８例（２９．０％）在２４ｈ内缓解,１８例（２９．０％）在２４～４８ｈ内缓解,１０例９１６．１％）,４８～７２ｈ缓解,５例（４６     

Treatment selection considerations for the hypertensive diabetic patient

Hypertension occurs with twice the frequency in the diabetic population as compared with the general nondiabetic population. Treatment of hypertension in diabetics can be complicated by diabetic complications and the potential for adverse effects from selected antihypertensive drugs. A rational approach to antihypertensive therapy in diabetics with or without concurrent diabetic complications incorporates a "stepped" approach to therapy that includes alternative step 1 agents (eg, angiotensin-converting enzyme inhibitors and calcium channel blockers) rather than traditional agents (eg, diuretics and beta-blockers). Evolving evidence with angiotensin-converting enzyme inhibitors reveals that they do not exacerbate complications of diabetes mellitus and also may arrest or slow the progression of diabetic nephropathy. Treatment algorithms for a stepped approach to the management of the hypertensive diabetic patient are proposed.     

Treatment of rheumatic diseases in children: special considerations

The goals of treatment of rheumatic diseases in children are to control the disease process while ensuring normal nutrition, growth, and development. The choice of antirheumatic drugs is similar in children and adults, but the doses, treatment schedules, and susceptibility to toxicity can differ considerably. In addition to differences between adult and pediatric diseases themselves, it is important for the rheumatologist who treats children to be cognizant of the impact of nutritional, developmental, and growth issues and differential susceptibility to toxicity of various treatments.     

Treatment of pneumonia in the elderly: pharmacological considerations

Aging is associated with a number of physiological changes, including alterations in body mass, changes in organ blood flow, and reductions in renal function. The use of any drug in an older patient requires a knowledge of the effect of these physiological changes on the pharmacokinetics of that drug. Drugs with high renal clearance, such as penicillins and aminoglycosides, have a longer half-life in elderly patients. Erythromycin and ciprofloxacin, antibiotics that use both hepatic and renal clearance, require little or no dosage adjustment when used in older patients. Side effects and drug interactions occur much more commonly in older individuals and those antibiotics used in the management of pneumonia in the elderly are reviewed in detail.     

Treatment considerations for the management of fibrodysplasia ossificans progressiva

The ultimate goal of research on fibrodysplasia ossificans progressiva (FOP) is the development of treatments that will prevent, half, or even reverse the progression of the condition. Despite advances in understanding the pathophysiology of FOP, there are no therapies with scientifically proven benefits for the prevention or treatment of FOP. Insights obtained from the research laboratory and from the treatment of hundreds of patients world wide have allowed us to identify targets for potential therapies. Some of these therapies involve the use of currently available medications, whereas others involve novel therapeutic approaches that are in preclinical testing. In this article, we will review the scientific basis for considering various therapeutic options based on the known pathophysiology of FOP. Because there are presently no proven preventions or treatments for the condition, this article is intended to represent an opinion of the authors that may be helpful to others who face similar situations.     

Treatment of acute colonic pseudoobstruction (Ogilvie's syndrome) with cisapride

A 73-yr-old white woman admitted with lobar pneumonia and congestive heart failure developed progressive colonic pseudoobstruction (Ogilvie's syndrome) 2 days after admission which was unrelieved by diatrizoate meglumine (Gastrografin, Squibb Canada, Montreal) enema and rectal tube. Cisapride, a new gastrointestinal prokinetic agent, was administered intravenously with full resolution of the syndrome. To the authors' knowledge, this is the first reported case of successful treatment of acute colonic pseudoobstruction with cisapride.     

Treatment considerations in patients with hepatitis C and cirrhosis

Patients with cirrhosis due to hepatitis C have a high chance of dying from progressive liver disease and thus have much to gain from successful antiviral therapy. The highest sustained virologic responses in patients with cirrhosis have been achieved using pegylated interferon alfa plus Ribavirin; 43% or more remain with undetectable virus 6 months after the cessation of 48 weeks of treatment. In those who achieve a sustained virologic response, the degree of fibrosis is less as judged on posttreatment liver biopsy; cirrhosis may even regress. In those individuals with cirrhosis who achieve a sustained virologic response, the risk of developing hepatocellular carcinoma is significantly reduced and it is likely that their chance of developing liver failure is less. Patients who do not achieve sustained virologic response can still show histologic improvement as demonstrated on liver biopsy posttherapy as compared to baseline. Patients with compensated cirrhosis can benefit from therapy while those who are decompensated are prone to more safety issues. Thus, individuals with any evidence of hepatic decompensation should generally not be given interferon-based antiviral therapy, but treatment should be encouraged for those whose status is Child Class A.     

Treatment considerations for recurrent MRSA bacteremia leading to cholecystitis

We present an end-stage renal disease patient with acute cholecystitis caused by a recurrence of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Timely antibiotic therapy with vancomycin did not eradicate the patient’s infection. In this patient, the minimum inhibitory concentration (MIC) of the organism for vancomycin was at the upper limit of susceptibility. The ability to thoroughly understand and interpret mean inhibitory concentrations is crucial in antibiotic selection. For high-risk patients with Staphylococcus aureus infection with reduced susceptibility to vancomycin as demonstrated by an MIC of 2 mg/L or greater, we suggest further investigation into linezolid as an alternative antibiotic to vancomycin therapy. Compared to vancomycin, linezolid has similar effectiveness in patients with MRSA bacteremia as well as improved penetration, particularly in bile.