Alert Any patient with a wound that has lasted more than 8 weeks and who has tried standard wound care and revascularization without improvement should consider hyperbaric oxygen therapy. This treatment may speed healing by allowing more oxygen to get to the wound and may therefore result in fewer amputations.
Keeping glucose at near-normal levels for 5 years or more reduces both the onset and progression of retinopathy, nephropathy, and neuropathy. In type 2 diabetes, blood pressure control as well as smoking cessation reduces the onset and progression of complications, including cardiovascular disease.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Pancreatitis:
Treatment (Tx)
(Professional Guide to Diseases (Eighth Edition))
I.V. fluid replacement, morphine, diazepam, antibiotics, calcium gluconate, insulin
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Pancreatic cancer:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Treatment of pancreatic cancer is rarely successful because this disease has usually metastasized widely at diagnosis. Therapy consists of surgery and, possibly, radiation and chemotherapy. Standard chemotherapy for patients with locally unresectable cancer includes gemcitabine. Gemcitabine has been demonstrated to improve the quality of life through better pain control, adequate performance status, decreased analgesic consumption, shrinkage of tumor, and prolonged survival. (See Staging pancreatic cancer, page 90.)
Other medications used in pancreatic cancer include:
❑antacids (by mouth or by nasogastric [NG] tube) — to decrease secretion of pancreatic enzymes and to suppress peptic activity, thereby reducing stress-induced damage to gastric mucosa
❑ antibiotics (oral, I.V., or I.M.) — to prevent infection and relieve symptoms
❑ anticholinergics (particularly propantheline) — to decrease GI tract spasm and motility and reduce pain and secretions
❑ diuretics — to mobilize extracellular fluid from ascites
❑ insulin — to provide adequate exogenous insulin after pancreatic resection
❑ opioids — to relieve pain, but only after analgesics fail because morphine, meperidine, and codeine can lead to biliary tract spasm and increase common bile duct pressure
❑ pancreatic enzymes (average dose 0.5 to 1 mg with meals) — to assist in digestion of proteins, carbohydrates, and fats when pancreatic juices are insufficient because of surgery or obstruction.
Small advances have been made in the survival rate with surgery:
❑ Total pancreatectomy may increase survival time by resecting a localized tumor or by controlling postoperative gastric ulceration.
❑ Cholecystojejunostomy, choledochoduodenostomy, and choledochojejunostomy have partially replaced radical resection to bypass obstructing common bile duct extensions, thus decreasing the incidence of jaundice and pruritus.
❑ Whipple's operation, or pancreatoduodenectomy, has high mortality but can produce wide lymphatic clearance, except with tumors located near the portal vein, superior mesenteric vein and artery, and celiac axis. This rarely used procedure removes the head of the pancreas, the duodenum, and portions of the body and tail of the pancreas, stomach, jejunum, pancreatic duct, and distal portion of the bile duct.
❑Gastrojejunostomy is performed if radical resection isn't indicated and duodenal obstruction is expected to develop later.
Radiation therapy is usually ineffective except as an adjunct to chemotherapy or as a palliative measure.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Malignant spinal neoplasms:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Treatment of spinal cord tumors generally includes decompression or radiation. Laminectomy is indicated for primary tumors that produce spinal cord or cauda equina compression; it isn't usually indicated for metastatic tumors. If the tumor is slowly progressive or if it's treated before the cord degenerates from compression, symptoms are likely to disappear, and complete restoration of function is possible. In a patient with metastatic carcinoma or lymphoma who suddenly experiences complete transverse myelitis with spinal shock, functional improvement is unlikely, even with treatment, and his outlook is ominous. If the patient has incomplete paraplegia of rapid onset, emergency surgical decompression may save cord function. Steroid therapy with dexamethasone minimizes cord edema and temporarily relieves symptoms until surgery can be performed. Partial removal of intramedullary gliomas, followed by radiation, may alleviate symptoms for a short time. Metastatic extradural tumors can be controlled with radiation, analgesics and, in the case of hormone-mediated tumors (breast and prostate), appropriate hormone therapy. Transcutaneous electrical nerve stimulation (TENS) may control radicular pain from spinal cord tumors and is a useful alternative to opioid analgesics. In TENS, an electrical charge is applied to the skin to stimulate large-diameter nerve fibers and thereby inhibit transmission of pain impulses through small-diameter nerve fibers. Chemotherapy generally hasn't proven effective against most spinal tumors, but may be recommended in some cases.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Diabetes mellitus:
Treatment
(Handbook of Diseases)
Effective treatment for both types of diabetes normalizes blood glucose and decreases complications.
Type 1 diabetes
Treatment includes insulin replacement, diet, and exercise. Current forms of insulin replacement include single-dose, mixed-dose, split-mixed dose, and multiple-dose regimens. The multiple-dose regimens may use an insulin pump.
Human insulin may be rapid-acting (Regular), intermediate-acting (NPH or Lente), long-acting (Ultralente, Lantus), or a combination of rapid-acting and intermediate-acting (70/30, 75/25, or 50/50 of NPH and Regular).
Clinical tip Insulin Lispro or Novalogue may be used in place of Regular insulin. It’s rapid in onset (15 minutes) and makes waiting to eat after injection unnecessary. It has a short duration of action (4 hours), which decreases between-meal and nocturnal hypoglycemia.
Islet cell or pancreas transplantation is available and requires chronic immunosuppression.
Type 2 diabetes
Patients may require oral antidiabetic drugs to stimulate endogenous insulin production, increase insulin sensitivity at the cellular level, suppress hepatic gluconeogenesis, and delay GI absorption of carbohydrates.
UNDER STUDY: Studies have shown that treatment with a lipase inhibitor (such as orlistat) combined with a low-calorie diet significantly decreases the weight of overweight patients with type 2 diabetes. Patients following this therapy also displayed improvements in glycemic control and cardiovascular risk profile; levels of glycosylated hemoglobin, fasting glucose, and postprandial glucose improved significantly.
Both types
Treatment of both types of diabetes requires a diet planned to meet nutritional needs, to control blood glucose levels, and to reach and maintain appropriate body weight.
For the obese patient with type 2 diabetes, weight reduction is a goal. In type 1, the calorie allotment may be high, depending on growth stage and activity level. For success, the diet must be followed consistently and meals eaten at regular times.
UNDER STUDY: Vitamin E is under investigation for its cellular effects that can possibly reduce the risk of macrovascular disease in patients with type 2 diabetes mellitus. The antioxidant effects of vitamin E were supported, and it was found that, in high doses, vitamin E acts as an anti-inflammatory. It’s postulated that heart disease and stroke risk can be decreased because vitamin E reduces plaque formation at the endothelial level. Vitamin E may also have an effect on the metabolic syndrome that causes diabetes mellitus and may prevent the disease from occurring.
Complications
Treatment of long-term diabetic complications may include transplantation or dialysis for renal failure, photocoagulation for retinopathy, and vascular surgery for large-vessel disease. Meticulous blood glucose control is essential.
The Diabetes Control and Complications Trial has proved that intensive insulin therapy that focuses on keeping glucose at near-normal levels for 5 years or more reduces both the onset and progression of retinopathy (up to 63%), nephropathy (up to 54%), and neuropathy (up to 60%).
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Pancreatitis:
Treatment
(Handbook of Diseases)
The goal of therapy is to maintain circulation and fluid volume. Treatment measures must also relieve pain and decrease pancreatic secretions. In 90% of patients with acute pancreatitis, the disease occurs as a mild self-limiting illness and requires only simple supportive care alone. In the remaining 10% of patients, the disease can evolve into a severe form of acute pancreatitis with significant complications, a lengthy duration of illness and, for many, death.
Emergency measures
Emergency treatment of shock (which is the most common cause of death in early-stage pancreatitis) consists of vigorous I.V. replacement of electrolytes and proteins. The patient receives nothing by mouth, a nasogastric tube is inserted for abdominal distention, and an anticholinergic may be administered.
Metabolic acidosis that develops secondary to hypovolemia and impaired cellular perfusion requires vigorous fluid volume replacement.
Drug treatment may include morphine sulfate for pain, diazepam for restlessness and agitation, and antibiotics for documented bacterial infections.
Specific metabolic complications — such as hypokalemia, hypocalcemia, hemorrhage, and coagulopathy — must be treated with appropriate replacement products, such as potassium chloride, I.V. calcium gluconate or chloride, red blood cells, and fresh frozen plasma. Hyperglycemia and glycosuria are manifestations of altered carbohydrate metabolism. Treatment consists of careful titration of glucose and insulin to maintain a euglycemic state.
CLINICAL TIP: Treating the underlying condition may prevent recurrent attacks.
After the emergency
After the emergency phase, continuing I.V. therapy should provide adequate electrolytes and protein solutions. If the patient is unable to resume oral feedings, total parenteral nutrition may be necessary. Nonstimulating enteral feedings may be safer because of the decreased risk of infection and maintenance of normal physiology.
Surgery for acute pancreatitis is reserved for treating specific complications and correcting anatomic problems. Surgery is usually required for patients with necrotizing pancreatitis to debride devitalized tissue and to provide external drainage. Debridement, usually at 24- to 48-hour intervals, until the necrotic tissue is replaced by a granulating wound, is commonly required.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Pancreatic cancer:
Treatment
(Handbook of Diseases)
Treatment of pancreatic cancer is rarely successful because this disease has usually metastasized widely by the time it’s diagnosed.
Therapy consists of surgery and, possibly, radiation and chemotherapy. Small advances have been made in the survival rate with surgery:
❑ Total pancreatectomy may increase survival time.
❑ Cholecystojejunostomy, choledochoduodenostomy, and choledochojejunostomy have partially replaced radical resection to bypass obstructing common bile duct extensions, thus decreasing the incidence of jaundice and pruritus.
❑ Whipple’s operation, or pancreatoduodenectomy, has a high mortality but can produce wide lymphatic clearance, except with tumors located near the portal vein, superior mesenteric vein and artery, and celiac axis. This procedure removes the head of the pancreas, the duodenum, gall bladder, end of the common bile duct, and possibly portions of the body and tail of the pancreas and stomach.
❑ Gastrojejunostomy is performed if radical resection isn’t indicated and duodenal obstruction is expected to develop later.
If the tumor is confined to the pancreas and can’t be removed, a combination of radiation and chemotherapy may be used. If the tumor has metastasized to other organs such as the liver, chemotherapy is usually the lone treatment. Gemcitabine is the standard agent and produces improvement in 50% of patients.
Other medications used in the treatment of pancreatic cancer include:
❑ anticholinergics (particularly propantheline) — to decrease GI tract spasm and motility and reduce pain and secretions
❑ antacids (oral or by nasogastric [NG] tube) — to decrease secretion of pancreatic enzymes and suppress peptic activity, thereby reducing stress-induced damage to gastric mucosa
❑ insulin — to provide adequate exogenous insulin supply after pancreatic resection
❑ narcotics — to relieve pain, but only after analgesics fail because morphine, meperidine, and codeine can lead to biliary tract spasm and increase common bile duct pressure
❑ pancreatic enzymes (average dose is 0.5 to 1 mg with meals) — to assist in the digestion of proteins, carbohydrates, and fats when pancreatic juices are insufficient because of surgery or obstruction.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Pancreatitis:
Pancreatitis - TREATMENT
(The 5-Minute Pediatric Consult)
- NPO for pancreatic rest.
- In moderate to severe cases of pancreatitis and in cases with vomiting, nasogastric decompression by placement of nasogastric (NG) tube:
- Acid suppression with H
» READ BOOK EXCERPT ONLINE »
Source: The 5-Minute Pediatric Consult, 2008
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