Pilot study of Sandostatin (octreotide) therapy of refractory HIV-associated diarrhea

Seventeen AIDS patients were enrolled in a prospective open-label dose-finding study of octreotide (Sandostatin) therapy for refractory diarrhea. Five were nonevaluable due to progression of AIDS symptomatology, and one was excluded because of lack of confirmation of HIV infection. Five of 11 evaluable patients responded to therapy (45%); two each at 50 g and 100 g, and one at 250 g thrice daily doses. A sixth patient demonstrated a moderate reduction in stool volume at 250 g thrice daily, which, although deemed clinically relevant, did not meet the criteria for response. On discontinuation of therapy, diarrhea recurred in all patients within 1–12 days, and responded to reinitiation of octreotide in those five patients who resumed treatment. Only one of the three patients with concurrent cryptosporidial infection responded to treatment. The drug was well tolerated, with mild symptomatology in three patients. Long-term treatment at a stable dose was effective in three of five treated patients for periods for seven months in one (moderate responder) and one year in two. One patient required dose increases to control symptoms, but after one year of treatment developed severe nausea following injections, which required dose cessation. One patient had partial control of his diarrhea for only three months despite two dose increases. These data suggest that octreotide may be of useful therapeutic value in HIV-associated diarrhea and that further studies are indicated.This study was supported by Sandoz Canada Inc.     

Discrimination and abuse in internal medicine residency

OBJECTIVE: To survey the extent to which internal medicine housestaff experience abuse and discrimination in their training. DESIGN: Through a literature review and resident focus groups, we developed a self-administered questionnaire. In this cross-sectional survey, respondents were asked to record the frequency with which they experienced and witnessed different types of abuse and discrimination during residency training, using a 7-point Likert scale. PARTICIPANTS: Internal medicine housestaff in Canada. MEASUREMENTS AND MAIN RESULTS: Of 543 residents in 13 programs participating (84% response rate), 35% were female. Psychological abuse, as reported by attending physicians (68%), patients (79%), and nurses or other health workers (77%), was widespread. Female residents experienced gender discrimination by attending physicians (70%), patients (88%), and nurses (71%); rates for males were 23%, 38%, and 35%, respectively. Females reported being sexually harassed more often than males, by attending physicians (35% vs 4%,p<.01), peers (30% vs 6%,p<.01), and patients (56% vs 18%,p<.01). Physical assault by patients was experienced by 40% of residents. Half of the residents surveyed reported racial discrimination and homophobic remarks in the workplace, perpetrated by all groups of health professionals. CONCLUSIONS: Psychological abuse, gender discrimination, sexual harassment, physical abuse, homophobia, and racial discrimination are prevalent problems during residency training. Housestaff, medical educators, allied health workers, and the public need to work together to address these problems in the training environment. Dr. Cook is a Career Scientist with the Ontario Ministry of Health. For a complete listing, see Appendix A. This study was supported by the Royal College of Physicians and Surgeons of Canada.     

Acute Migraine Treatment in Adults

There are many options for acute migraine attack treatment, but none is ideal for all patients. This study aims to review current medical office‐based acute migraine therapy in adults and provides readers with an organized approach to this important facet of migraine treatment. A general literature review includes a review of several recent published guidelines. Acetaminophen, 4 nonsteroidal anti‐inflammatory drugs (NSAIDs) (ibuprofen, acetylsalicylic acid [ASA], naproxen sodium, and diclofenac potassium), and 7 triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) have good evidence for efficacy and form the core of acute migraine treatment. NSAID–triptan combinations, dihydroergotamine, non‐opioid combination analgesics (acetaminophen, ASA, and caffeine), and several anti‐emetics (metoclopramide, domperidone, and prochlorperazine) are additional evidence‐based options. Opioid containing combination analgesics may be helpful in specific patients, but should not be used routinely. Clinical features to be considered when choosing an acute migraine medication include usual headache intensity, usual rapidity of pain intensity increase, nausea, vomiting, degree of disability, patient response to previously used medications, history of headache recurrence with previous attacks, and the presence of contraindications to specific acute medications. Available acute medications can be organized into 4 treatment strategies, including a strategy for attacks of mild to moderate severity (strategy one: acetaminophen and/or NSAIDs), a triptan strategy for patients with severe attacks and for attacks not responding to strategy one, a refractory attack strategy, and a strategy for patients with contraindications to vasoconstricting drugs. Acute treatment of migraine attacks during pregnancy, lactation, and for patients with chronic migraine is also discussed. In chronic migraine, it is particularly important that medication overuse is eliminated or avoided. Migraine treatment is complex, and treatment must be individualized and tailored to the patient's clinical features. Clinicians should make full use of available medications and formulations in an organized approach.     

Proportion of Patients With Hypertension Resolution Following Adrenalectomy for Primary Aldosteronism: A Systematic Review and Meta‐Analysis

Unilateral primary aldosteronism (PA) is often treated with adrenalectomy, but hypertension resolution rates are variable. A valid estimate of the postoperative normotension rate is necessary to inform the utility of PA testing and treatment. The authors searched MEDLINE In‐Process & Other Non‐Indexed Citations, Embase, and Cochrane Central Register of Controlled Trials. Prospective adult cohort studies with surgically treated PA that reported resolution of hypertension without the aid of medications were included. Among 2620 abstracts identified by the search, 25 studies in the systematic review with data on 1685 patients were investigated. The pooled proportion of normotension following adrenalectomy was 52% (95% confidence interval, 0.44–0.60). Meta‐regression demonstrated a significant negative association between length of follow‐up and proportion of normotension, with normotension dropping by 6.7% per year of follow‐up (coefficient −0.006; 95% confidence interval, −0.01 to 0.002). Overall, approximately half of the patients experienced hypertension resolution, although this outcome may not be durable in all patients.

Primary aldosteronism (PA) is defined as a form of drug‐resistant and potentially curable hypertension with evidence of excess aldosterone secretion, suppressed plasma renin activity, and often hypokalemia.¹ Initially thought to be rare, PA is the leading cause of secondary hypertension. With increased screening and detection, the incidence of PA among hypertensive patients is currently reported at approximately 10%.² This syndrome has multiple etiologies, including inherited gene mutations,³ development of autoantibodies,⁴ and ectopic aberrant functional adrenal receptors.⁵ The clinical management is guided by the definition of unilateral vs bilateral adrenal involvement. With rare exception, adrenalectomy is reserved for unilateral adrenal disease.The proportion “cured” following adrenalectomy for patients with PA has been reported to range from 0% to 100%.⁶ However, “cure” is variably defined in the literature. These definitions include normal blood pressure (BP), normal BP without aid of antihypertensive medications, a reduced need for antihypertensive medications, and biochemical normalization, among others. Biochemical normalization of the aldosterone‐renin ratio is likely a necessary part of a definition of “cure.” At this time, however, there is no global consensus on the interpretation of postoperative aldosterone‐renin ratios with the existence of variable assays and cutoffs for even initial diagnosis. Therefore, from the patient''s perspective and in the absence of patient‐level clinical end point data, attainment of medication‐free normotension may be the most uniform and recognizable health benefit of surgical PA treatment. Individually reported results of long‐term resolution of hypertension without antihypertensive medications are between 30% and 70% following adrenalectomy.⁷ The primary aim of this systematic review and meta‐analysis was to determine the proportion of hypertension resolution without the aid of antihypertensive agents following adrenalectomy in patients with PA. To our knowledge, no previous meta‐analysis has been performed. A secondary objective was to identify patient‐level factors reported to be associated with hypertension resolution in patients managed with adrenalectomy.     

Infolding of covered stents used for aortic coarctation: Report of two cases

Covered stents have been used for the treatment of aortic coarctation to protect the arterial wall during dilation. Early results have shown them to be safe and effective. We report two cases of infolding of the proximal edge of a covered aortic coarctation stent. Management required implantation of a second stent. Poor stent apposition to the vessel wall and/or recoil may allow conditions for these events to occur. © 2013 Wiley Periodicals, Inc.