Stromal rejection after big bubble deep anterior lamellar keratoplasty: case series and review of literature.

PURPOSE: The aim of this study was to report three cases of stromal rejection after deep anterior lamellar keratoplasty using big bubble technique in keratoconus. METHODS: Deep anterior lamellar keratoplasty was performed in 3 cases of keratoconus (11-19 years of age) using the "big bubble" technique. All of them presented 4 to 19 months after uneventful surgeries with variable decrease of vision (1/200-20/200) along with foreign body sensation, mild pain, and corneal edema. Suture infiltrates were present in all eyes. Ultrasound pachymetry showed variable increase in central corneal thickness (711-894 µm). These patients with stromal rejection were administered pulse intravenous methylprednisolone, 500 mg in 150 mL of 5% dextrose and were started on 1% prednisolone acetate eye drops 1 hourly, moxifloxacin hydrochloride 0.5% 4 times a day along with homatropine 2% eye drops 4 times a day. RESULTS: Complete recovery of the stromal rejections was attained with clear graft and recovery of visual acuity (≥20/40) in all eyes. Central corneal thickness returned to prerejection values in all the eyes after 7 days. There was no significant change in specular count. CONCLUSIONS: Deep anterior lamellar keratoplasty does not eliminate the risk of stromal rejection. Suture-related factors in the form of suture infiltrates and loose suture are an important risk factor for graft rejection. Graft rejection if treated promptly is reversible.

[Nutricional support in the complex treatment of a patient with esophageal spasm].

In the presented clinical case the theme of the need for an integrated therapeutic intervention has been disclosed, including nutritional support on the various links of the pathogenesis of esophagospasm to the effectiveness of the patient's treatment.

Geriatric inflammatory bowel disease: phenotypic presentation, treatment patterns, nutritional status, outcomes, and comorbidity.

BACKGROUND AND AIMS: The U.S. population is aging and the burden of geriatric inflammatory bowel disease (IBD) patients has increased. Systematic data describing phenotypic presentation, treatment regimens, outcomes and comorbidities in elderly IBD patients is limited. We performed a retrospective observational study of IBD patients age ≥65 followed in a 20-hospital system to determine patterns of phenotypic presentation, treatment, polypharmacy, nutritional status and comorbidity. METHODS: Data were extracted from electronic medical record based on ICD-9 coding/indexed terms on Crohn's disease (CD) and ulcerative colitis (UC) patients. RESULTS: A total of 393 geriatric IBD patients were identified (49.1% males; 50.9% females; 61.8% UC; 38.2% CD; 73.4 ± 6.6 years old). Younger age at diagnosis of CD (≤64) was associated with greater prevalence of small bowel surgeries (63.6%) compared with those diagnosed after age ≥65 (20.9%) (p < 0.005). Fistulizing/penetrating disease was frequent in patients diagnosed with CD at a younger age (43.6% compared to 7%) (p < 0.005). IBD maintenance treatment included: 44% 5-ASA agents; 31.6% maintenance prednisone (defined as ≥6 months treatment duration); 4.8% steroid suppositories; 5.6% 6MP/azathioprine; 1.3% methotrexate; 1.3% adalimumab; 1.3% infliximab; 9.4% loperamide/diphenoxylate/atropine; 0.5% had no IBD medications. Longer duration of CD disease correlated with vitamin B12, vitamin D and iron deficiency. CONCLUSION: Geriatric patients diagnosed with CD earlier in life had greater small bowel involvement compared with new onset geriatric CD. There is low utilization of immunomodulator and biologic agents in geriatric IBD patients. Duration of CD correlates with nutrient deficiency. Prospective studies are warranted in this respect.

An overview on mixed action drugs for the treatment of overactive bladder and detrusor overactivity.

OBJECTIVES: To provide an overview on the efficacy, tolerability, safety and health-related quality of life (HRQoL) of drugs with a mixed action used in the treatment of overactive bladder (OAB). EVIDENCE ACQUISITION: MEDLINE database and abstract books of the major conferences were searched for relevant publications from 1966 to 2011 and using the key words 'overactive bladder', 'detrusor overactivity', 'oxybutynin', 'propiverine', and 'flavoxate'. Two independent reviewers considered publications for inclusion and extracted relevant data, without performing a meta-analysis. EVIDENCE SYNTHESIS: Old and conflicting data do not support the use of flavoxate, while both propiverine and oxybutynin were found to be more effective than placebo in the treatment of OAB. Propiverine was at least as effective as oxybutynin but with a better tolerability profile even in the pediatric setting. Overall, no serious adverse event for any product was statistically significant compared to placebo. Improvements were seen in HRQoL with treatment by the oxybutynin transdermal delivery system and propiverine extended release. CONCLUSIONS: While there is no evidence to suggest the use of flavoxate in the treatment of OAB, both oxybutynin and propiverine appear efficacious and safe. Propiverine shows a better tolerability profile than oxybutynin. Both drugs improve HRQoL of patients affected by OAB. Profiles of each drug and dosage differ and should be considered in making treatment choices.

[Neuro-autonomic inhibition and haemodynamics management optimization during cesarean section under spinal anaesthesia in pregnant women with gestosis].

Results showed that autonomic nervous system (ANS) and blood circulation system (BCS) dysfunction in 3rd trimester pregnant women with gestosis are more pronounced, than in healthy pregnant women, despite the prescribed treatment. The most significant disturbances were vagotonia and hypokinetic haemodynamics type (often iatrogenic). Spinal anaesthesia (SA) during Cesarean section in pregnant women is accompanied by blood pressure decrease to the level demanding on vasopressors use. Considering normal indicators of SI, CI, oxygen transportation and electrocardiogram vasopressor was not introduced Apgar score assessment of newborns was within normal. However, vagotonia and hypokinetic haemodynamics type during anaesthesia that certifies autoregulation reserves insufficiency. Atropine introduction in pregnant women with vagotonia and hypokinetic haemodynamics type (often iatrogenic, owing to irrational therapy) before SA beginning of promoted neurovegetative inhibition optimization and haemodynamics stabilization in eukinetic range. Vagus blockade (elimination of ANS dysfunction) was accompanied by more physiologic sympathicotonia development with smaller decrease of blood pressure (without stroke index reduction!), absence of bradycardia and vomiting. Research showed that the blood pressure cannot be the only objective criterion of vasopressors use.

Pain in irritable bowel syndrome: Does anything really help?

Pain relief remains a significant challenge in the management of irritable bowel syndrome (IBS): "Does anything really help relieve the pain in patients with IBS?". Interventions aimed at pain relief in patients with IBS include diet, probiotics or antibiotics, antidepressants, antispasmodics, and drugs targeting specific gastrointestinal receptors such as opioid or histamine receptors. In the systematic review and meta-analysis published in this journal, Lambarth et al. examined the literature on the role of oral and parenteral anti-neuropathic agents in the management of pain in patients with IBS. This review article appraises their assessment of the efficacy of the anti-neuropathic agents amitriptyline, pregabalin, gabapentin, and duloxetine in the relief of abdominal pain or discomfort, and impact on overall IBS severity and quality of life. This commentary provides an update of current evidence on the efficacy of the dietary and pharmacological treatments that are available or in development, as well psychological and cognitive behavioral therapy for pain in IBS. Advances in recent years augur well for efficacious treatments that may expand the therapeutic arsenal for pain in IBS.

An alternative to treat palmar hyperhidrosis: use of oxybutynin.

PURPOSE: To evaluate the effectiveness and patient satisfaction with the use of oxybutynin at low doses for treating palmar hyperhidrosis in a large series of patients. METHODS: From January 2007 to June 2009, 180 consecutive patients with palmar hyperhidrosis were treated with oxybutynin. Data were collected from 139 patients (41 patients were lost to follow-up). During the first week, patients received 2.5 mg of oxybutynin once per day; from the 8th to the 42nd day, 2.5 mg twice per day; and from the 43rd day to the end of the 12th week, 5 mg, twice per day. All of the patients underwent three evaluations before and after the oxybutynin treatment (at 6 and 12 weeks), using a clinical questionnaire and a clinical protocol for quality of life (QOL). RESULTS: More than 80% of the patients experienced an improvement in palmar hyperhidrosis. Most of the patients showed improvements in their QOL (74.6%). The side effects were minor, with dry mouth being the most frequent (70.5%). CONCLUSION: The use of oxybutynin is an alternative as the first step in the treatment of palmar hyperhidrosis, given that it presents good results and improves QOL.

[Modern approaches to the therapy of biliary system diseases].

The therapeutic efficacy of duspatalin was evaluated in 72 patients with chronic cholecystitis and dyskinesia of the biliary tract (BT). Supplementation of duspatalin to the combined therapy in the patients with chronic cholecystitis shown to exert a pronounced therapeutic effect. This caused positive changes in clinical symptoms and BT function and quality of life, diminished the lithogenic properties of bile.

[Spasmolytics indication in renal colic: a literature review]. / La place des spasmolytiques dans la colique néphrétique.

UNLABELLED: Spasmolytics are often prescribed by general practitioners or by emergency services as soon as renal colic is diagnosed. This practice has however been widely contested. This article presents a literature review on the efficiency of spasmolytics for the treatment of renal colic. Furthermore, it draws a comparison with daily practice, and finally summarizes side effects of this treatment. CONCLUSION: Based on the EBM review, it cannot be concluded that spasmolytics are effective in renal colic. A better practice is to use diclofenac as a unique drug, and to complement the treatment with tramadol and antalgics for uncontrolled patients. Furthermore, the use of tamsulosin is proved to be efficient for lithiasis in the lower part of the ureter.

[The effectiveness of spasmolytic therapy in chronic acalculous cholecystitis].

The therapeutic efficacy of duspatalin was evaluated in 69 patients with chronic cholecystitis and dyskinesia of the biliary tract (BT). Supplementation of duspatalin to the combined therapy in the patients with chronic cholecystitis shown to exert a pronounced therapeutic effect. This caused positive changes in clinical symptoms and BT function and quality of life, diminished the lithogenic properties of bile.

Progress in Pharmacological and Surgical Management of Tourette Syndrome and Other Chronic Tic Disorders.

BACKGROUND: Tourette syndrome (TS) and other chronic tic disorders are clinically heterogenous and cause physical discomfort, social difficulties, and emotional distress. In addition to tics, TS patients have a variety of behavioral comorbidities, including obsessive-compulsive disorders and attention-deficit hyperactivity disorders. TS treatment is multidisciplinary, involving behavioral therapy, oral medications, and botulinum toxin injections. METHODS: Relevant studies on pharmacological and surgical treatment options for TS and other chronic tic disorders, their limitations and current recommendations were reviewed using the PubMed search till April 2, 2018. Besides, the reference lists of the retrieved publications were manually searched to explore other relevant studies. This review aims to discuss the progress in pharmacological and surgical treatment options for TS and other chronic tic disorders. RESULTS AND CONCLUSIONS: Both typical and atypical antipsychotic agents are mainstays of pharmacological treatment of TS and other chronic tic disorder patients; however, their use is limited by serious side effects considering their potential of dopamine blockade. Because of the phenotypic variability, no medication has proven effective for all persons with TS and other chronic tic disorders. Botulinum toxin has emerged as a good therapeutic option, especially for focal and dystonic tics. But, their uses are limited by lack of sufficient evidence and high cost. Surgical treatment is considered in medically refractory and severely disabled tics patients. Deep brain stimulation has replaced lesional surgeries; however, there is uncertainty regarding the selection of patients and target of stimulation.

[Child poisoning after ingestion of a wild apiaceae: a case report]. / Intoxication par une apiacée sauvage: à propos d'une observation pédiatrique.

Apiaceae family (formerly Umbelliferae) contains several highly toxic species, including Poison Hemlock (Conium maculatum), Water Hemlock (Cicuta virosa) and Hemlock Water Dropwort (Oenanthe crocata) which are the three main poisonous Apiaceae species growing in France. Thinking he was identifying wild carrots, an 11-year-old boy without previous history ingested the root from a wild Apiaceae. One hour later, he was confused, had drowsiness, headache as well as abdominal pain, vomiting and diarrhoea. Upon hospital admission, myosis, ophtalmoplegia and a moderate rhabdomyolysis were noted. The patient recovered after 24 h of symptomatic treatments. In this case, the description of the ingested plant allowed to identify the Apiaceae family but not the species involved. The geographical location (Southern France in a humid area), the clinical features and the aspect of the ingested root, with an orange secretion led to implicate Oenanthe crocata as the origin of this unusual poisoning.

Review article: the role of antibiotics vs. conventional pharmacotherapy in treating symptoms of irritable bowel syndrome.

BACKGROUND: The concept of augmenting the management of irritable bowel syndrome with antibiotics is evolving, and many questions remain regarding this therapy relative to known and hypothesized irritable bowel syndrome pathophysiology. The clinical evidence of small intestinal bacterial overgrowth as an important aetiology of irritable bowel syndrome continues to accumulate. Clinical symptoms of bacterial overgrowth and irritable bowel syndrome are similar; however, a definitive cause-and-effect relationship remains unproven. It is unclear whether motility dysfunction causes bacterial overgrowth or gas products of enteric bacteria affect intestinal motility in irritable bowel syndrome. AIM: To discusses the efficacy and tolerability of current symptom-directed pharmacotherapies and of antibiotics in the treatment of irritable bowel syndrome. METHODS: A computerized search of PubMed was performed with search terms "IBS", "pharmacotherapy" and "antibiotics". Relevant articles were selected, and the reference list of selected articles was reviewed to identify additional references. RESULTS: Antibiotic treatment benefits a subset of irritable bowel syndrome patients. The non-absorbed antibiotic rifaximin has a favourable safety and tolerability profile compared with systemic antibiotics and demonstrates a therapeutic efficacy comparable with symptom-based irritable bowel syndrome pharmacotherapies. CONCLUSION: Rifaximin is the only antibiotic with demonstrated sustained benefit beyond therapy cessation in irritable bowel syndrome patients in a placebo-controlled trial. Whether antibiotics can improve quality of life in patients with irritable bowel syndrome warrants further research.

Therapeutic options in childhood nocturnal enuresis.

Monosymptomatic nocturnal enuresis, a heterogeneous condition, is frequently treated in children aged >5 years. Of the various treatment options, enuresis alarm has been widely advocated as being effective for treating nocturnal enuresis, while extracorporeal pelvic floor magnetic stimulation for overactive bladder, urge incontinence and urgency-frequency syndrome has not yet been confirmed by controlled studies as primary treatment for monosymptomatic nocturnal enuresis. Desmopressin, an antidiuretic hormone (ADH) analog, or arginine vasopressin (AVP), can resolve primary nocturnal enuresis by decreasing night-time urine production. Enuretic children requiring either desmopressin or desmopressin plus oxybutynin to achieve dryness have polyuria. Tricyclic antidepressants (i.e. imipramine) are used successfully in enuretic children. Although tricyclics and desmopressin are effective in reducing the number of wet nights, most children relapse after discontinuation of active treatment. Combined therapy (enuresis alarm, bladder training, motivational therapy and pelvic floor muscle training) is more effective than each component alone or than pharmacotherapy. Furthermore, desmopressin combined with alarm therapy has a positive effect on enuresis. Pharmacotherapy can provide early relief of enuresis, while behavioral intervention may lead to greater long-term benefits. The positive effect of achieving dry nights with pharmacotherapy can encourage the child to sustain behavioral therapy.

Acute retinal necrosis complicating chickenpox in a healthy adult--a case report and review of literature.

Acute retinal necrosis (ARN) is known to occur in conjunction with primary varicella or chickenpox infection. The majority of ARN cases reported in the literature were of milder form with mild to moderate vitritis, limited retinitis, and rare occurrence of retinal breaks or detachment that responded well to intravenous acyclovir, with or without oral prednisolone. We report a case of unilateral ARN with marked vitritis and retinal necrosis leading to retinal breaks following chickenpox in a 32-year-old healthy lady. This patient was successfully treated with intravenous acyclovir followed by oral acyclovir and orbital floor triamcinolone injections to contain the inflammation with barrier laser therapy to secure the retinal breaks with good visual outcome. This case is unusual in its severity, and to our knowledge, orbital floor triamcinolone therapy was not used earlier to contain ARN inflammation.

Systematic review: the efficacy of treatments for irritable bowel syndrome--a European perspective.

BACKGROUND: Irritable bowel syndrome (IBS) is a common, chronic disorder, characterized by abdominal pain/discomfort, bloating and altered bowel habit. AIM: To conduct a systematic evidence-based review of pharmacological therapies currently used, or in clinical development, for the treatment of IBS in Europe. The safety and tolerability of these therapies are the subject of an accompanying review. METHODS: A literature search was completed for randomized controlled studies which included adult patients with IBS and an active or placebo control, assessed IBS symptoms, and were published in English between January 1980 and June 2005. The level of evidence for efficacy was graded according to the quality of the trial design and the study outcome. RESULTS: There is some evidence for improvement of individual IBS symptoms with antidiarrhoeals (diarrhoea), antispasmodics (abdominal pain/discomfort), bulking agents (constipation), tricyclic antidepressants (abdominal pain/discomfort) and behavioural therapy. In contrast, there is strong evidence for the improvement of global IBS symptoms with two new serotonergic agents: the 5-HT4 selective agonist tegaserod (IBS with constipation) and the 5-HT3 antagonist alosetron (IBS with diarrhoea). Further data are required for the 5-HT3 antagonist, cilansetron, and the mixed 5-HT3 antagonist/5-HT4 agonist renzapride before their utility in IBS can be appraised. CONCLUSIONS: There is limited evidence for the efficacy, safety and tolerability of therapies currently available in Europe for the treatment of IBS. Overall, there is an absence of pharmacological agents licensed specifically for the treatment of IBS subtypes, and new agents are awaited in Europe that will allow changes in clinical practice to focus on and improve global IBS symptoms.

Cognitive behavioural therapy in addition to antispasmodic therapy for irritable bowel syndrome in primary care: randomised controlled trial.

OBJECTIVES: To determine whether cognitive behavioural therapy (CBT) in addition to antispasmodic treatment offers a cost-effective benefit to primary care patients with irritable bowel syndrome (IBS) and to identify predictors of outcome. DESIGN: This was a randomised controlled trial in primary care of the addition of CBT to standard general practice management of IBS, using the antispasmodic agent mebeverine hydrochloride. The study set out to compare the addition of a standardised package of IBS-specific CBT to treatment with mebeverine hydrochloride. SETTING: Ten general practices, serving a population of around 45,000 patients, located principally in south London, with some patients resident in north London. PARTICIPANTS: Patients identified as having IBS by their GPs, aged between 17 and 54 (mean 34) years and predominantly white; 82% were female and half had had IBS for more than 5 years. INTERVENTIONS: Practice nurses delivered CBT in a randomised trial of the addition of CBT to mebeverine in patients who had IBS of moderate or greater severity after 2 weeks of GP care and 4 weeks of mebeverine. The Symptom Severity Scale (SSS) was used to identify patients with moderate or severe IBS. Patients who continued to report moderate or severe IBS after 4 weeks of mebeverine at a dose of 270 mg three times a day were randomised to receive six sessions of CBT in addition to mebeverine (72 patients) or mebeverine alone (77 patients). These patients were followed at 3, 6 and 12 months after treatment. As part of the baseline evaluation, blood tests for antiendomysial and antigliadin antibodies were carried out on 141 patients to determine the prevalence of coeliac disease in this population. MAIN OUTCOME MEASURES: The principal outcome measure was the SSS. Others included the Hospital Anxiety and Depression Scale, psychopathology, the Work and Social Adjustment Scale (WASA, disability), a modified version of the Illness Perception Questionnaire (illness perceptions), the Beliefs about Medicine Questionnaire (attitudes to medication), the Reported Adherence to Medication Scale (adherence to prescribed medication), the Client Service Receipt Inventory (economic analysis), the Cognitive Scale for Functional Bowel Disorders (illness cognitions) and the Behaviour Scale for IBS (IBS coping behaviour). RESULTS: The addition of CBT produced a significant benefit compared with the mebeverine-only group at 3 months after treatment on all outcome measures, except for the adherence to medication scales. The difference between the groups was 107.8 points on the SSS, 24.5 points on question 4 of the SSS and 6.3 points on the WASA, representing therapeutic gains of approximately 20%, 28% and 40%, respectively. However, there was also evidence that these improvements began to wane, so that at 6 and 12 months follow-up significant therapeutic benefit of the addition of CBT could only be detected on question 4 of the SSS and on the WASA. The behaviour scale for IBS detected significant, positive changes in coping behaviours at up to 6 months after treatment. Three factors predicting a poor outcome were identified: male gender, believing that IBS had serious consequences and belief in an external aetiology, all of which were associated with greater than average disability at follow-up. The addition of CBT to mebeverine did not reduce overall treatment or social costs. The nested study on testing for coeliac disease provides cautious support for the inclusion of antiendomysial and antigliadin antibody testing in the investigation of patients thought to have IBS. CONCLUSIONS: Specially trained practice nurses can provide effective CBT to primary care patients with a clinical diagnosis of IBS, which although effective does not reduce service or social costs. Using a variety of measures the beneficial therapeutic effects of the addition of CBT to antispasmodic therapy persist for up to 6 months. Future research might include studies of the long-term follow-up of IBS patients treated with CBT, cost-benefit analyses comparing CBT with other therapeutic approaches to IBS, and evaluating means of training both non-specialist health professionals and GPs to deliver CBT.

Prehospital and emergency department care to preserve neurologic function during and following cardiopulmonary resuscitation.

Considerable progress has been made in providing high-quality prehospital and emergency cardiac care for OHCA victims. The use of early CPR, early defibrillation, early ACLS, and state-of-the-art postresuscitation care offers the best promise for improved community survival and neurologic outcome statistics in the future. The NIH-sponsored Resuscitation Outcomes Consortium represents the largest governmentally sponsored effort of its kind that that will test the value of promising pharmacologic and device interventions on improving survival and neurologic outcome in OHCA patients.

The treatment of amblyopia.

Recent studies suggest that children with amblyopia associated with anisometropia, strabismus, or both should be treated initially with best refractive correction until visual acuity is stable. This may take several months, and a proportion of children will achieve equal visual acuity with glasses alone. For residual anisometropic and strabismic amblyopia, the initial choice of patching or atropine should involve the parent and the child. The dose of prescribed patching or atropine may initially be quite modest, such as 2 hours of patching a day or twice weekly atropine. Treatment should be offered to children until at least 12 years of age and possibly to teenagers. Ongoing studies are addressing the role of undertaking near activities while patched and the role of atropine for severe amblyopia and for older amblyopic children. Future studies are needed to investigate the best treatment strategies for residual amblyopia, whether weaning treatment is needed at the end of a course, and how compliance can be enhanced.

[Tuberculosis of the urinary bladder: diagnosis and treatment].

Tuberculosis of the urinary bladder (UB) is registered in 10-45.6% patients with urogenital tuberculosis. It is a severe incapacitating complication of kidney tuberculosis which significantly lowers quality of life. The results of the standard therapy of 76 patients with tuberculous cystitis are analysed. UB tuberculosis is diagnosed more often in women, outcomes of their treatment are worse. Twenty six patients with UB tuberculosis at the stage of overactive bladder received polychemotherapy and adjuvant trospium. After 3 months urination frequency decreased 4.3 times, on the average; UB volume increased 4.7 times, on the average. Complications were not registered.