Management of common symptoms in terminally ill patients: Part II. Constipation, delirium and dyspnea.
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In addition to pain, patients who are approaching the end of life commonly have other symptoms. Unless contraindicated, prophylaxis with a gastrointestinal motility stimulant laxative and a stool softener is appropriate in terminally ill patients who are being given opioids. Patients with low performance status are not candidates for surgical treatment of bowel obstruction. Cramping abdominal pain associated with mechanical bowel obstruction often can be managed with morphine (titrating the dosage for pain) and octreotide. Delirium is common at the end of life and is frequently caused by a combination of medications, dehydration, infections or hypoxia. Haloperidol is the pharmaceutical agent of choice for the management of delirium. Dyspnea, the subjective sensation of uncomfortable breathing, is often treated by titration of an opioid to relieve the symptom; a benzodiazepine is used when anxiety is a component of the breathlessness. (+info)
Double blind randomised controlled trial of topical glyceryl trinitrate in anal fissure.
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AIMS: To determine the effectiveness and safety of topical glyceryl trinitrate (GTN) in the management of acute anal fissure in children. METHODS: Individual children were randomised to receive GTN paste or placebo for six weeks in addition to oral senna and lactulose. Patients took laxatives alone for a further 10 weeks. Each week a research nurse telephoned families to assess pain scores and give advice. Main outcome measures were validated standardised pain scores and time to painless defaecation. RESULTS: Forty subjects were recruited from 46 eligible children; 31 children completed the trial (13 in the GTN group and 18 in the placebo group). No differences in the proportion of those achieving pain free defaecation with relation to time were seen between the two groups. Similarly, there were no significant differences in pain scores between the two groups over the 16 week study period. However, in both groups pain scores had decreased significantly. There were no differences in the incidence of rectal bleeding, faecal soiling, presence of visible fissure, skin tag, or faecal loading at outpatient review at the time of recruitment, or at 6 weeks and 16 weeks. No serious adverse effects were observed. CONCLUSIONS: This study suggests that 0.2% GTN paste is ineffective in the treatment of acute anal fissures in childhood. However the overall fissure healing rate is high (84%) with associated reduction in pain scores, suggesting that a nurse based treatment programme can achieve a high rate of fissure healing. (+info)
Opioid analgesic prescribing and use - an audit of analgesic prescribing by general practitioners and The Multidisciplinary Pain Centre at Royal Brisbane Hospital.
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AIMS: This study evaluated the use of and need for opioids in patients attending the Multidisciplinary Pain Centre at the Royal Brisbane Hospital (RBH). METHODS: All consecutive in-patient admissions in 1998 were reviewed. A 10-point scoring system based on the World Health Organization (WHO) analgesic ladder was devised to facilitate comparison of analgesic prescribing on admission and at the time of discharge. A conversion table was used to standardize opioid analgesic doses to an oral morphine equivalent. RESULTS: Of the 370 patients reviewed, 233 (81%) were by their general practitioners. Records of 288 (78%) were available for full review and 270 (94%) of these had noncancer pain. On admission, 239 (83%) were taking an opioid analgesic, with 135 (47%) taking strong opioids (e.g. morphine, oxycodone, methadone). There was a significant decrease in the mean total daily oral morphine equivalent prescribed on discharge 36.9 mg (95% CI: 33.4, 40.4) compared with that on admission 88.7 mg (95% CI: 77.6, 99.8) (P < 0.001). There was a significant decrease (P < 0.05) in the proportion of patients taking a primary opioid on discharge 153 (58%) compared with admission 239 (83%), although the proportion of patients taking a strong opioid on discharge 150 (52%) compared with admission 135 (47%) was not significantly different (P > 0.05). The proportion of patients taking a laxative showed a significant increase on discharge 110 (73%) compared with admission 38 (28%) (P < 0.05). CONCLUSIONS: Our analgesic prescribing scoring system and opioid conversion table have the potential to be developed further as tools for assessing opioid analgesic prescribing. The significant decrease in total daily oral morphine equivalents signifies the value of prescribing in accordance with the WHO analgesic ladder, and the necessity of general practitioner education. The management of chronic pain is complex, and it requires interventions additional to pharmacological therapy. Evaluation by a multidisciplinary team, coupled with experience in and an understanding of analgesic prescribing and rehabilitation provides an effective basis for improving the management of patients with chronic pain. (+info)
Screening and identification of proteins mediating senna induced gastrointestinal motility enhancement in mouse colon.
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AIM: To isolate the proteins involved in pharmacologic action of senna extract (SE) from mouse gastrointestinal tract and to explore the molecular mechanism of gastrointestinal motility change induced by SE. METHODS: SE was administrated to mice by different routes. Gastrointestinal motility of mice was observed using cathartic, gastrointestinal propellant movement experiments and X-ray analysis. Mouse model for gastrointestinal motility enhancement was established through continuous gastric administration of SE at progressively increased dose. At 3 h and week 3, 4, 6 and 10, morphological changes of gastrointestinal tissues were found under light microscope. Ultrastructural changes of intestinal and colonic tissues at week 6 were observed under transmission electron microscope. The colonic proteomic changes in model mice were examined by two-dimension polyacrylamide gel electrophoresis with immobilized pH gradient isoelectric focusing to screen the differentially expressed proteins, and their molecular masses and isoelectric points were determined. Two N-terminal sequences of the samples were also determined by mass spectrometry. RESULTS: SE (0.3g) caused diarrhea after gastric administration in 1-6h and enhanced gastrointestinal propellant (65.1+/-7.5%; 45.8+/-14.6%, P<0.01) in mice, but intramuscular and hypodermic injection had no cathartic effect. X-ray analysis of gastrointestinal motility demonstrated that gastric administration of SE enhanced gastric evacuation and gastrointestinal transferring function. At 3 h and week 3 and 4 after gastric administration of SE, light microscopic examination revealed no apparent change in gastrointestinal mucosal tissues, but transmission electron microscopic examination revealed inflammatory changes in whole layer of intestinal and colonic wall. Twenty differential proteins were detected in the colonic tissues of the model mice by two-dimensional electrophoresis, and the N-terminal amino acid sequences of two proteins were determined. CONCLUSION: SE causes diarrhea and enhances gastrointestinal motility through digestive tract administration. Long-term gastric administration of SE induces inflammatory changes and cell damage in the whole gastrointestinal tract. The differential proteins screened from the colonic tissues of the model mice might mediate the enhancing effect of SE on gastrointestinal motility. (+info)
Tributyrin and lactitol synergistically enhanced the trophic status of the intestinal mucosa and reduced histamine levels in the gut of nursery pigs.
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This study determined whether tributyrin and lactitol could synergistically facilitate the transition from milk to solid feed in nursery pigs. At 21 d after birth, 64 piglets were moved from the piggery to a production barn and fed a medicated diet. At 28 d after birth, the piglets were weighed and allotted into four groups and fed a standard nonmedicated diet (control) or the control diet with tributyrin (butanoic acid 1,2,3-propanetriyl ester; 10 g/kg), or with lactitol (beta-D-galactopyranosyl-(1-->4)-D-sorbitol; 3 g/kg), or with tributyrin (10 g/kg) plus lactitol (3 g/kg). On d 0, 14, and 42 after being fed the control or experimental diets, the animals were weighed, and animal health, feed intake, and feed conversion ratio were determined. On d 42, four piglets from each treatment were killed to measure the empty and full weight of the gut, as well as the weights of the liver and kidneys. The jejunum and cecum were sampled to analyze the luminal concentrations of lactic acid; short-chain fatty acids; and mono-, di-, and polyamines and to assess the mucosal status. Mortality after 42 d ranged from 19% for animals fed the control diet, to 6% for animals fed the tributyrin or lactitol diets, and to 0% for animals fed the tributyrin+lactitol diet. After 14 d, the ADG was 127% greater (P < 0.05) in animals fed the tributyrin+lactitol diet than in animals fed the control or tributyrin diets. After 42 d, animals fed the tributyrin+lactitol diet were heavier (P < 0.05) than animals fed the tributyrin diet. At slaughter, no differences (P > 0.05) in organ weights were observed. With the exception of animals fed the lactitol diet, wherein cecal lactic acid levels increased threefold (P < 0.01), the luminal concentrations of lactic acid and short-chain fatty acids were not different (P > 0.05). Among the various amines analyzed, the only response (P < 0.05) was a 66 and 49% decrease in histamine levels in the jejunum and cecum, respectively, in animals fed the tributyrin+lactitol diet compared to the control diet. In the jejunum of animals fed the lactitol or tributyrin+lactitol diets, the length of the villi was increased by 12% (P < 0.05) compared to animals fed the control diet, whereas the tributyrin diet did not have any effect on the villi (P > 0.05). In the cecum, the depths of the crypts were reduced (P < 0.001) by 18% in animals fed the lactitol diet and 45% in animals fed the tributyrin or tributyrin+lactitol diets compared to animals fed the control diet. In conclusion, a diet containing tributyrin and lactitol as nutribiotics resulted in lower histamine levels in the jejunum and cecum, as well as longer jejunal villi and shallower cecal crypts. (+info)
Safety and efficacy of two reduced dosing regimens of sodium phosphate tablets for preparation prior to colonoscopy.
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OBJECTIVES: To evaluate the safety and efficacy of two reduced dosing regimens of sodium phosphate tablets (Visicol, InKine Pharmaceutical Co. Inc., Blue Bell, PA, USA) for colon cleansing prior to colonoscopy. METHODS: In a randomized, multicentre, endoscopist-blinded clinical study, adults undergoing colonoscopy received either 28 tablets (42 g) or 32 tablets (48 g) of sodium phosphate for colon cleansing. The endoscopist used a validated four-point scale to rate the overall quality of colon cleansing, as well as cleansing in the ascending colon. Adverse events were collected and evaluated. RESULTS: The quality of overall colon cleansing was 'excellent' or 'good' in 84% or more of both groups, with no significant difference between the two doses. No patient had a preparation rated as 'inadequate' or required a repeat procedure. All patients were able to complete the assigned dose of tablets, and there were no deaths, serious adverse events or dropouts from the study. CONCLUSIONS: A reduced tablet regimen for sodium phosphate tablets, using either 28 or 32 tablets, is well tolerated and effective for colon cleansing prior to colonoscopy. (+info)
Body packers: grading of risk as a guide to management and intervention.
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The dual aims of management of the drug smuggler are for low morbidity and mortality combined with a low operation rate. In our experience, presented in this paper, adherence to the principle of identifying the high-risk patient by symptoms and signs combines safety with low rates of intervention. (+info)
Status of certain additional over-the-counter drug category II and III active ingredients. Final rule.
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The Food and Drug Administration (FDA) is issuing a final rule stating that the stimulant laxative ingredients aloe (including aloe extract and aloe flower extract) and cascara sagrada (including casanthranol, cascara fluidextract aromatic, cascara sagrada bark, cascara sagrada extract, and cascara sagrada fluidextract) in over-the- counter (OTC) drug products are not generally recognized as safe and effective or are misbranded. This final rule is part of FDA's ongoing OTC drug product review. (+info)