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1.
Medical treatment of urinary stones.
Skolarikos, A
Current opinion in urology. 2018;(5):403-407
Abstract
PURPOSE OF REVIEW To identify the latest progression on medical treatment of urinary stones. RECENT FINDINGS Nonsteroidal anti-inflammatory drugs should be the preferred analgesic option for patients presenting to the emergency department with renal colic. A-blockers could be of patient benefit when used for distal ureteral stones more than 5 mm in size. However, the quality of the randomized controlled studies on medical expulsive therapy (MET) is still low based on the Consolidated Standards for Reporting Trials (CONSORT) criteria. MET should be used with caution in children and pregnant women. In patients with renal stones, the evaluation of the comorbidities of developing chronic Kidney Disease (CKD) or End Stage Renal Disease (ESRD) is mandatory. It is highly recommended to follow the European Association of Urology Urolithiasis Guidelines Panel Diagnostic and Therapeutic algorithms to prevent stone recurrence. SUMMARY Medical treatment of urinary stone disease should be supported by well designed higher level of evidence clinical research.
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2.
Treatment options for hyperemesis gravidarum.
Abramowitz, A, Miller, ES, Wisner, KL
Archives of women's mental health. 2017;(3):363-372
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Free full text
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Abstract
Hyperemesis gravidarum (HG) is a severe and prolonged form of nausea and/or vomiting during pregnancy. HG affects 0.3-2% of pregnancies and is defined by dehydration, ketonuria, and more than 5% body weight loss. Initial pharmacologic treatment for HG includes a combination of doxylamine and pyridoxine. Additional interventions include ondansetron or dopamine antagonists such as metoclopramide or promethazine. The options are limited for women who are not adequately treated with these medications. We suggest that mirtazapine is a useful drug in this context and its efficacy has been described in case studies. Mirtazapine acts on noradrenergic, serotonergic, histaminergic, and muscarinic receptors to produce antidepressant, anxiolytic, antiemetic, sedative, and appetite-stimulating effects. Mirtazapine is not associated with an independent increased risk of birth defects. Further investigation of mirtazapine as a treatment for HG holds promise to expand treatment options for women suffering from HG.
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Common Questions About Chronic Prostatitis.
Holt, JD, Garrett, WA, McCurry, TK, Teichman, JM
American family physician. 2016;(4):290-6
Abstract
Chronic prostatitis is relatively common, with a lifetime prevalence of 1.8% to 8.2%. Risk factors include conditions that facilitate introduction of bacteria into the urethra and prostate (which also predispose the patient to urinary tract infections) and conditions that can lead to chronic neuropathic pain. Chronic prostatitis must be differentiated from other causes of chronic pelvic pain, such as interstitial cystitis/bladder pain syndrome and pelvic floor dysfunction; prostate and bladder cancers; benign prostatic hyperplasia; urolithiasis; and other causes of dysuria, urinary frequency, and nocturia. The National Institutes of Health divides prostatitis into four syndromes: acute bacterial prostatitis, chronic bacterial prostatitis (CBP), chronic nonbacterial prostatitis (CNP)/chronic pelvic pain syndrome (CPPS), and asymptomatic inflammatory prostatitis. CBP and CNP/CPPS both lead to pelvic pain and lower urinary tract symptoms. CBP presents as recurrent urinary tract infections with the same organism identified on repeated cultures; it responds to a prolonged course of an antibiotic that adequately penetrates the prostate, if the urine culture suggests sensitivity. If four to six weeks of antibiotic therapy is effective but symptoms recur, another course may be prescribed, perhaps in combination with alpha blockers or nonopioid analgesics. CNP/CPPS, accounting for more than 90% of chronic prostatitis cases, presents as prostatic pain lasting at least three months without consistent culture results. Weak evidence supports the use of alpha blockers, pain medications, and a four- to six-week course of antibiotics for the treatment of CNP/CPPS. Patients may also be referred to a psychologist experienced in managing chronic pain. Experts on this condition recommend a combination of treatments tailored to the patient's phenotypic presentation. Urology referral should be considered when appropriate treatment is ineffective. Additional treatments include pelvic floor physical therapy, phytotherapy, and pain management techniques. The UPOINT (urinary, psychosocial, organ-specific, infection, neurologic/systemic, tenderness) approach summarizes the various factors that may contribute to presentation and can guide treatment.
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The Efficacy of Medical Expulsive Therapy (MET) in Improving Stone-free Rate and Stone Expulsion Time, After Extracorporeal Shock Wave Lithotripsy (SWL) for Upper Urinary Stones: A Systematic Review and Meta-analysis.
Skolarikos, A, Grivas, N, Kallidonis, P, Mourmouris, P, Rountos, T, Fiamegos, A, Stavrou, S, Venetis, C, ,
Urology. 2015;(6):1057-64
Abstract
In this meta-analysis, we included randomized studies on medical expulsive therapy implemented following shock wave lithotripsy for renal and ureteral stones. Pooled results demonstrated the efficacy of α-blockers, nifedipine, Rowatinex, and Uriston in increasing stone clearance. In addition, the time to stone elimination, the intensity of pain, the formation of steinstrasse, and the need for auxiliary procedures were reduced mainly with α-blockers. Expulsion rate was not correlated with the type of α-blocker, the diameter, and the location of stone. Our results show that medical expulsive therapy for residual fragments after shock wave lithotripsy should be implemented in clinical practice.
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5.
[Alpha blocker x beta-blocker].
Ishikawa, J, Kario, K
Nihon rinsho. Japanese journal of clinical medicine. 2014;(8):1485-9
Abstract
To control blood pressure for throughout a day, one of antihypertensive drugs will be administered at bedtime. Calcium channel blocker or angiotensin II receptor blocker will be the first line drug for bedtime administration. Alpha-blocker or beta-blocker will be the last choice.
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6.
Anti-hypertensive treatment in pheochromocytoma and paraganglioma: current management and therapeutic features.
Mazza, A, Armigliato, M, Marzola, MC, Schiavon, L, Montemurro, D, Vescovo, G, Zuin, M, Chondrogiannis, S, Ravenni, R, Opocher, G, et al
Endocrine. 2014;(3):469-78
Abstract
Pheochromocytoma (PH) and paraganglioma (PG) are neuroendocrine neoplasms arising from chromaffin cells of the adrenal medulla and the sympathetic ganglia, respectively. Although are unusual cause of hypertension (HT) accounting for at most 0.1-0.2 % of cases, they may lead to severe and potentially lethal hypertensive crisis due to the effects of the released catecholamines. However, both PH and PG may be asymptomatic as ~30 % of subjects are normotensive or have orthostatic hypotension and in these cases the 24 h ambulatory blood pressure (BP) monitoring is an important toll to diagnose and treat HT. HT treatment may be difficult when PH or PG occurs in pregnancy or in the elderly subjects and in these cases a multidisciplinary team is required. When surgical excision is mandatory the perioperative management requires the administration of selective α1-adrenergic blocking agents (i.e., doxazosin, prazosin or terazosin) followed by a β-adrenergic blockade (i.e., propranolol, atenolol). This latter should never be started first because blockade of vasodilatory peripheral β-adrenergic receptors with unopposed α-adrenergic receptor stimulation can lead to a further elevation of BP. Although labetalol is traditionally considered the ideal agent due to its α- and β-adrenergic antagonism, experimental studies do not support its use in this clinical setting. As second regimen, the administration of vasodilators as calcium channel blockers (i.e., nicardipine, nifedipine) may be required to control BP. Oral and sublingual short-acting nifedipine are potentially dangerous in patients with hypertensive emergencies and are not recommend. The latest evidences into the diagnosis and treatment of hypertensive crisis due to PH and PG are reviewed here.
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Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4: Alpha blockers v calcium blockers to increase spontaneous passage of renal calculi.
Stewart, A, Ferguson, C
Emergency medicine journal : EMJ. 2013;(2):168-9
Abstract
A short cut review was carried out to establish the administration of an alpha-1 receptor antagonist or a calcium channel blocker would facilitate the most rapid and successful expulsion of a stone from a patient with uncomplicated renal colic. 597 articles were found using the reported search, of which five trials were selected as providing the best evidence to answer this question. The authors, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that in a patient with an uncomplicated ureteric calculus tamsulosin is more effective than nifedipine in promoting speedy and successful expulsion of the stone.
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8.
[Preoperative α-receptor block in patients with pheochromocytoma? Against].
Groeben, H
Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2012;(6):551-4
Abstract
Perioperative mortality regarding the resection of catecholamine-producing tumors has been markedly improved. This improvement has been attributed to the preoperative treatment with α-receptor blocking agents. An α-receptor block is still recommended prior to the resection of pheochromocytoma or paraganglioma. However, the effect has never been tested in a randomized clinical trial. Despite an assumed effective α-receptor block, many centers report systolic blood pressure increases beyond 200 mmHg. Out of 200 consecutive resections of catecholamine-producing tumors, 73 patients without an α-receptor blockade were treated. There was no significant difference in the maximum systolic blood pressure or in the incidence of hypertensive episodes. There was no correlation between the individual dose of phenoxybenzamine and the maximum blood pressure. Overall it can be concluded that with the improvement of surgical techniques, diagnostic tools and highly effective short acting substances to control hemodynamics intraoperatively, the question must be raised whether a time-consuming, unreliable pretreatment burdened with significant side effects is still required.
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9.
Advances in non-surgical treatments for urinary tract infections in children.
Yang, SS, Chiang, IN, Lin, CD, Chang, SJ
World journal of urology. 2012;(1):69-75
Abstract
OBJECTIVE With growing antibiotics failure due to emerging resistance of bacteria, non-surgical management of pediatric UTI plays a more important role because of its non-invasive characteristics and little adverse effects. METHODS We searched the Pubmed for management of UTI in children other than surgical correction and antibiotics using terms: risk factor, prepuce/phimosis, steroid cream/steroid, behavioral therapy, urotherapy, biofeedback/pelvic floor exercise, adrenergic antagonist, anticholinergics, diet/dietary, dysfunctional voiding/dysfunctional elimination syndrome, constipation, dietary, clean intermittent catheterization, probiotics/lactobacillus, cranberry, vitamin supplement, breastfeeding, breast milk, with infant/child/children/pediatrics/pediatrics and urinary tract infection. RESULTS The proposed non-surgical management of pediatric UTI included behavioral modification (timed voiding and adequate fluids intake), topical steroid for phimosis, nutrient supplements (breast milk, cranberry, probiotics, and vitamin A), biofeedback training for dysfunctional voiding, anticholinergics for reducing intravesical pressure, alpha-blockers in dysfunctional voiding and neurogenic bladder, and intermittent catheterization for children with large PVR. CONCLUSION The published reports usually included small number of patients and were lacking of randomization and controlled group. Further well-designed studies are warranted to support the concepts of non-operative management for pediatric UTI.
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10.
Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis.
Anothaisintawee, T, Attia, J, Nickel, JC, Thammakraisorn, S, Numthavaj, P, McEvoy, M, Thakkinstian, A
JAMA. 2011;(1):78-86
Abstract
CONTEXT Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is common, but trial evidence is conflicting and therapeutic options are controversial. OBJECTIVE To conduct a systematic review and network meta-analysis comparing mean symptom scores and treatment response among α-blockers, antibiotics, anti-inflammatory drugs, other active drugs (phytotherapy, glycosaminoglycans, finasteride, and neuromodulators), and placebo. DATA SOURCES We searched MEDLINE from 1949 and EMBASE from 1974 to November 16, 2010, using the PubMed and Ovid search engines. STUDY SELECTION Randomized controlled trials comparing drug treatments in CP/CPPS patients. DATA EXTRACTION Two reviewers independently extracted mean symptom scores, quality-of-life measures, and response to treatment between treatment groups. Standardized mean difference and random-effects methods were applied for pooling continuous and dichotomous outcomes, respectively. A longitudinal mixed regression model was used for network meta-analysis to indirectly compare treatment effects. DATA SYNTHESIS Twenty-three of 262 studies identified were eligible. Compared with placebo, α-blockers were associated with significant improvement in symptoms with standardized mean differences in total symptom, pain, voiding, and quality-of-life scores of -1.7 (95% confidence interval [CI], -2.8 to -0.6), -1.1 (95% CI, -1.8 to -0.3), -1.4 (95% CI, -2.3 to -0.5), and -1.0 (95% CI, -1.8 to -0.2), respectively. Patients receiving α-blockers or anti-inflammatory medications had a higher chance of favorable response compared with placebo, with pooled RRs of 1.6 (95% CI, 1.1-2.3) and 1.8 (95% CI, 1.2-2.6), respectively. Contour-enhanced funnel plots suggested the presence of publication bias for smaller studies of α-blocker therapies. The network meta-analysis suggested benefits of antibiotics in decreasing total symptom scores (-9.8; 95% CI, -15.1 to -4.6), pain scores (-4.4; 95% CI, -7.0 to -1.9), voiding scores (-2.8; 95% CI, -4.1 to -1.6), and quality-of-life scores (-1.9; 95% CI, -3.6 to -0.2) compared with placebo. Combining α-blockers and antibiotics yielded the greatest benefits compared with placebo, with corresponding decreases of -13.8 (95% CI, -17.5 to -10.2) for total symptom scores, -5.7 (95% CI, -7.8 to -3.6) for pain scores, -3.7 (95% CI, -5.2 to -2.1) for voiding, and -2.8 (95% CI, -4.7 to -0.9) for quality-of-life scores. CONCLUSIONS α-Blockers, antibiotics, and combinations of these therapies appear to achieve the greatest improvement in clinical symptom scores compared with placebo. Anti-inflammatory therapies have a lesser but measurable benefit on selected outcomes. However, beneficial effects of α-blockers may be overestimated because of publication bias.