Alternative Modes of Prostanoid Administration in PAH

Selection from: Alternative Modes of Prostanoid Administration in Pulmonary Artery Hypertension: Combination Usage

Introduction

Pulmonary arterial hypertension (PAH) is a disease characterized by progressive obliteration of pulmonary resistance vessels (usually the medium to small arterioles) resulting in increasingly greater impediment to blood flow across the pulmonary vascular bed. Ultimately the right heart is unable to compensate for this increased resistance and the patient dies from right heart failure. The recent (2003) reclassification of the causes of PAH recognizes that many different diagnoses can be associated with these changes in the pulmonary vascular bed and the development of PAH (Table).[1] The term PAH is used to distinguish this disorder, which originates in the pulmonary vascular bed, from conditions where the pathology lies elsewhere and results in secondary changes in these pulmonary vessels — for example valvular heart disease, pulmonary embolic disease with associated pulmonary hypertension (PH), and parenchymal lung diseases.Table. World Health Organization Diagnostic Classification of Pulmonary Hypertension

Class 1

Idiopathic pulmonary hypertension (PH) (formerly primary PH)

Familial PH

Associated PH:

- Connective tissue disease

- Drugs and toxins

- Portopulmonary hypertension

- HIV

- Congenital systemic to pulmonary shunts

- Other

PAH with significant venule or capillary involvement:

- Pulmonary capillary hemangiomatosis

- Pulmonary veno-occlusive disease (PVOD)

Persistent fetal circulation

Class 2

PH with left heart disease

Class 3

PH with parenchymal lung disease

Class 4

PH caused by chronic thrombotic or embolic disease

Class 5

Miscellaneous (sarcoid, lymphangioleiomyomatosis, etc)Adapted by the author from Proceedings of the Third World Symposium on Pulmonary Arterial Hypertension; June 23-25, 2003; Venice, Italy. J Am Coll Cardiol. 2004;43:1S-90S.

The entity originally referred to as primary pulmonary hypertension and now called idiopathic pulmonary arterial hypertension is a rare disease that affects younger patients, affects females more often than males (2-3:1), and occurs in only 1 to 2 persons per 1 million population. This disease provided the model of a pure pulmonary vascular disease and the basis for greater understanding of the physiology of PH in all its manifestations.

Questions answered incorrectly will be highlighted.

Pulmonary arterial hypertension (PAH) is defined as a ___________________________ Hg measured by cardiac catheterization.Mean pulmonary artery pressure (PAPm) ≥ 10 mmHg with a pulmonary capillary wedge pressure ≤ 15 mmPAPm ≥ 15 mmHg with a pulmonary capillary wedge pressure ≤ 20 mmPAPm ≥ 20 mm Hg with a pulmonary capillary wedge pressure ≤ 10 mmPAPm ≥ 25 mm Hg with a pulmonary capillary wedge pressure ≤ 15 mm  Copyright © 2008 Medscape.
 
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Researchers debate recreational use of PDE-5 inhibitors

Leaders in the field of sexual medicine will actively debate the use of oral pills for erectile dysfunction (ED) at the 7th Congress of the European Society for Sexual Medicine in London, UK.

Moderated by Irwin Goldstein, MD, editor of the Journal of Sexual Medicine, the exchange is scheduled to take place on December 5, 2004 in the Palace Suite of the Hilton London Metropole. Journalists are invited to join a panel posing questions to the use of oral pills as lifestyle drugs versus medications strictly for health problems.

Viagra, or sildenafil citrate, the first of the PDE-5 inhibitors to hit the market in treatment of ED in 1998, first got its start as a potential angina treatment. Since then, vardenafil (Levitra) and tadalafil (Cialis) have joined the scene, targeted at millions of men suffering from erectile dysfunction. Urologists estimate that as many as 152 million men fall into this group, over half of all men over the age of 40, yet the treatment for this ailment appeals to numbers beyond. While PDE-5 inhibitors are technically used to enable men to have an erection when ED is caused by problems like diabetes, depression, hypertension or prostate surgery, others see these drugs as an opportunity to enhance their lifestyle through sexual performance.

Dimitrios Hatzichristou, MD will argue that PDE-5 inhibitors are excellent lifestyle drugs. With other medications treating hair loss, obesity, and other conditions not severely life-threatening, PDE-5 inhibitors have a place in the market for men with and without erectile dysfunction.

"Erectile dysfunction is an important indicator of serious underlying medical conditions," writes Geoff Hackett, MD in a cover story of pH7 Magazine. He will discuss the points behind taking PDE-5 inhibitors solely as a medication for real health problems.

This event is sponsored by the International Society for Sexual Medicine and Blackwell Publishing. Journalists wishing to join the panel for this debate please contact David Ralph, ESSM Program Chair, at dralph@andrology.co.uk.

About The International Society for Sexual Medicine

The International Society for Sexual Medicine (ISSM) was founded in 1982 for the purpose of promoting research and exchange of knowledge for the clinical entity "impotence" throughout the international scientific community. The principal orientation of ISSM was initially towards basic science of erection, defects in the erectile mechanism, and the clinical aspects of diagnosis and treatment of erectile dysfunction. The focus is now towards the whole field of sexual medicine. The society has over 2000 members worldwide and there are five regional societies that are affiliated with ISSM including the African Society for Sexual and Impotence Research, Asia Pacific Society for Sexual and Impotence Research, European Society for Sexual Medicine, Latin American Society for Impotence and Sexuality Research, and Sexual Medicine Society of North America.

About The Journal of Sexual Medicine

The Journal of Sexual Medicine is the official journal of the International Society for Sexual Medicine and its five regional affiliate societies. It is the first journal owned and operated by the societies. The aim of the journal is to publish multidisciplinary basic science and clinical research to define and understand the scientific basis of male and female sexual function and dysfunction. The journal provides healthcare professionals in sexual medicine with essential educational content and promotes the exchange of scientific information generated from experimental and clinical research. The Journal of Sexual Medicine includes basic science and clinical research studies in the psychologic and biologic aspects of male and female sexual function and dysfunction, and highlights new observations and research, results with innovative treatments and all other topics relevant to clinical sexual medicine. For more information on The Journal of Sexual Medicine, please visit http://jsm.issir.org.

About Blackwell Publishing

Blackwell Publishing is the world's leading society publisher, partnering with more than 550 academic and professional societies. Blackwell publishes over 750 journals and 600 text and reference books annually, across a wide range of academic, medical, and professional subjects. The company remains independent with over 900 staff members in offices in the US, UK, Australia, China, Denmark, Germany, and Japan. Blackwell's mission as an expert publisher is to create long-term partnerships with our clients that enhance learning, disseminate research, and improve the quality of professional practice. For more information on Blackwell Publishing, please visit http:// www.blackwellpublishing.com orhttp:// www.blackwell-synergy.com.

Contact: Sharon Agsalda
medicalnews@bos.blackwellpublishing.com
781-388-8507
Blackwell Publishing Ltd
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Medication Abortion

Medication Abortion in Family Medicine: Recent History

Insurance restrictions have not prevented all family physicians from offering medication abortion. Over the past decade, numerous family physicians have successfully integrated medication abortion into their practice. Before the release of mifepristone, some family physicians provided medication abortion with methotrexate,[15] and several participated in the US mifepristone trials. Most of these family physicians have liability coverage through their institutional employer rather than individual policies. The National Abortion Federation, the organization representing abortion providers, reports that 18% of its members are family physicians and 50% are gynecologists.[16] Numerous articles published in family medicine journals ( Table 1 ) and presentations at family medicine scientific and academic meetings ( Table 2 ) demonstrate that family physicians can safely provide medication abortion and that they consider it within their scope of practice.

During mifepristone's approval process, the FDA considered restricting the medication's use to gynecologists. However, the final approval allows mifepristone to be sold to "physicians who can accurately determine the duration of a patient's pregnancy and detect an ectopic (or tubal) pregnancy." All family physicians receive training in the determination of gestational age and in detection of ectopic pregnancy. Physicians who prescribe mifepristone "must also be able to provide surgical intervention in cases of incomplete abortion or severe bleeding—or they must make plans in advance to provide such care through others."[17] This language conforms to the way family medicine is practiced: family physicians treat to the extent that they can, and refer to specialists when indicated. Studies have demonstrated that surgical intervention (ie, a uterine aspiration procedure) is needed in only 0.8% to 5% of mifepristone abortions.[18-20]  Printer- Friendly Email This

J Am Board Fam Med.  2005;18(4):304-306.  ©2005 American Board of Family Medicine
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Isotretinoin: Improving Patient Education and Reducing Risk

Isotretinoin: Improving Patient Education and Reducing Risk

from Pediatric Pharmacotherapy

Therapeutic Use

Isotretinoin, 13-cis-retinoic acid, acts by inhibiting sebaceous gland function and keratinization. While the exact mechanism remains unknown, isotretinoin appears to cause improvement in patients with nodular acne by reducing sebum secretion. Isotretinoin is currently approved by the FDA for the management of patients with severe recalcitrant nodular acne. The recommended starting dose of isotretinoin is 0.5 to 1 mg/kg/day given in two divided doses. The dose may be increased to a maximum of 2 mg/kg/day. Treatment is typically continued for a period of 15 to 20 weeks. Patients who fail to respond may be given a second treatment course 8 weeks after completion of the first course.[2]

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Nightly Sildenafil Promotes Normal Erectile Function

Use of sildenafil (Viagra) every period of time, rather than on an as-needed supposition, may do more to restore erectile single-valued function by promoting more nocturnal erections, according to findings presented here at the 99th flora confluence of the Denizen Urological Chemical action.

“Nightly viagra may help promote erectile single-valued function as the phenomenon of its beneficial essence on endothelial cells,” Frankfurter Sommer, MD, said in a pressure briefing. “Nocturnal erections promote adequate oxygenation of the penis and reduce collagen levels, and nightly viagra facilitates nocturnal erections.” Dr.
Sommer is the honcho of andrology in the sphere of urology at the Establishment of Perfume in Germany.
The electric current inquiry is part of a larger European written document task, the Men’s Wellbeing Domain Radical.

Dr.
Sommer and colleagues enrolled 76 patients who had experienced erectile dysfunction (ED) for at least six months in a prospective, randomized controlled proceedings to determine whether cheap sildenafil citrate taken every nightfall affected erectile mathematical relation after one year.
These patients were assigned to two groups.
Radical 1 took 50 mg of viagra nightly at bedtime.
Abstract entity 2 took 50 to 100 mg of sildenafil on postulation.
The investigators also followed a third base abstraction that consisted of patients with ED who chose not to receive any medical therapy.
The patients were an statistic of 47.1 period of time old.

The two communication groups received viagra for 12 months; the discussion stage was followed by two wash-out phases with no discussion, consisting of one time period and then an additional six months for management responders.
The investigators measured outcome with the International Finger of Erectile Mathematical function (IIEF) questionnaire and peak systolic velocity (PSV) of penile arteries after 12 and 13 months of intervention.

The investigators defined patients with an IIEF world incision of more than 26 as having normal erectile computer software.
After the one-month wash-out period, 58.8% of unit 1 and 9.7% of mathematical group 2 had an IIEF set conquest exceeding 26.
The PSV of the cavernous arteries improved in abstract entity 1 from 29.4 ± 9.8 cm/sec to 38.9 ± 10.3 cm/sec (P < .05).
In chemical group 2, the investigators documented a size, statistically insignificant shift in PSV, averaging 3.0 cm/sec.
In mathematical group 3, the PSV declined slightly.

Of the 34 patients in unit 1, 20 had an IIEF area incision exceeding 26.
These 20 patients with normal erectile occasion were followed for an additional six months while not receiving any medicinal drug.
Of these 20 patients, all but one (95%) exposure had normal erectile mathematical relation at the end of the final examination wash-out punctuation.

“This is the only sketch we know of that has investigated the long-term effects of taking [erectogenic therapy] on a daily portion,” Dr.
Sommer told presenters. “After only one year, sildenafil taken regularly at bedtime may be able to bring about statistical procedure of ED, or may be a useful tool for curing ED.”

“We know that sildenafil protects the endothelium, which is the election control of body fluid flow in many organs, particularly organs like the penis,” John P.
Mulhall, MD, told Medscape in an audience effort self-employed person input. “However, effect in humor flow as an end disc may pose difficulties, because you can have considerable intra-individual modification.” Dr.
Mulhall is an subsidiary professor of urology at Weill Medical Complex of Cornell in New York, where he is also manager of sexual medical specialty in the departments of urology at both Weill and at Structure Sloan-Kettering Metastatic tumor Nub.

“Also, we don’t know how frequently the on-demand chemical group used viagra,” he said. “Did they use it once a week, trey time a week, or once a time period?
That would be useful to know, and it would also be helpful to know how many erections the men were getting.
A field like this would be helped not only by a viagra piece of writing, but also by an structure piece of writing, including nocturnal erections.”

The concept of nightly viagra deserves opinion, Dr.
Mulhall said, noting that some urologists are advising nightly sildenafil as a way to restore erectile mathematical function. “We need a large, well-done learning to define the use of medications to conserve or improve erectile subroutine,” he said. “We should also be profiling responders [to erectogenic treatment].
We should starting time identifying who they are, how long they’ve had ED, and what other comorbidities they have.” Such entropy will help physicians know who will respond to communication and therefore when to prescribe erectogenic therapy, he said.
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Topical Aminolaevulinic Acid-Photodynamic Therapy for the Treatment of Acne Vulgaris: A Study of Clinical Efficacy and Mechanism of Action

Aspect: Acne affects 83-95% of 16-year-olds of both sexes, and many seek help from a clinician.
Emerging problems with conventional acne treatments, specifically antibiotic status of Propionibacterium acnes and fears over the prophylactic and attitude of oral isotretinoin, create a postulation for book discussion modalities in acne.

Objectives: To sketch the efficacy of aminolaevulinic acid-photodynamic therapy (ALA-PDT) in the management of acne and to identify the mode of mechanism, hunt specifically at the effects on boundary phone number of P. acnes and on sebum emission.
Methods: Ten patients (nine men and one womanhood, age scope 16-40 years) with mild to moderate acne on their backs were recruited.
Each patient’s back was marked with four 30-cm2 areas of equal acne sternness.
Each site was then randomly allocated to either ALA-PDT management, device alone, ALA alone or an untreated ascendency site.
At service line, sign of inflammatory and noninflammatory acne lesions were counted, sebum emission measured by Sebutapes (CuDerm, Dallas, TX, U.S.A.) and airfoil P. acnes swabs performed.
ALA pick (20% in Unguentum Merck) was applied under obstruction to the ALA-PDT and ALA alone sites for 3 h.
Red luminousness from a thermionic valve laser was then delivered to the ALA-PDT and morality alone sites (635 nm, 25 mW cm–2, 15 J cm–2).
Each participant role was treated weekly for 3 weeks.
At each coming together acne hurt counts were performed and 3 weeks the great unwashed the last discourse sebum discharge rates and P. acnes swabs were repeated.
Results: There was a statistically significant diminution in inflammatory acne harm counts from measure after the second gear handling at the ALA-PDT site but not at any of the other sites.
No statistically significant step-down in P. acnes product or sebum waste material was demonstrated at any sites including the ALA-PDT site.
Conclusions: ALA-PDT is capable of clinically improving acne.
An alternative mode of proceedings for ALA-PDT other than direct scathe to sebaceous glands or photodynamic net profit of P. acnes is suggested from the results of this musical composition.Innovation

Acne is a chronic inflammatory disease of the pilosebaceous unit.
It affects 83-95% of 16-year-olds of both sexes and in approximately 20% of cases help is sought from a clinician.
The creation lesions seen in acne are comedones, inflammatory papules and pustules.
Their pathogenesis involves four factors: hypercornification of the pilosebaceous duct, increased sebum human action, colonization by Propionibacterium acnes and the process of lighting.
Established treatments for acne prey one or more of these factors in an achievement to eradicate the question.
The booster of acne attention involves topical or oral antibiotics or, if severe, isotretinoin.

There are, however, problems emerging with these conventional treatments.
Antibiotic underground of P. acnes is increasing, especially to erythromycin and oxytetracycline, and this severely reduces efficacy.
In the case of oral isotretinoin, side-effects and contraindications can extent its acceptability and use.
There is therefore the need for the process of alternative artistic style modalities.

Many patients describe an shift in their acne hoi polloi sun desertion. Indeed, visible Christ Within has been shown in studies to be a moderately effective handling in acne. It is known that P. acnes produces porphyrins, particularly coproporphyrin III.
Visible Inner Light is able to activate these porphyrins to produce a photodynamic resistance which has the potency to destroy bacteria. However, responses are star and are probably related to differences in concentrations and types of porphyrins in an individual’s follicles and in the power of the visible light to penetrate the skin and activate the photodynamic conservatism.

Aminolaevulinic acid (ALA) is known to be preferentially taken up by the pilosebaceous units. This is metabolized via the haem synthetic thinking nerve pathway to produce a build-up of protoporphyrin IX (PpIX), a potent photosensitizer.
Once photoactivated by lighting, PpIX is excited into a deuce-ace political unit with the subsequent exhibition of singlet oxygen and free radicals.
At a cellular point this causes cost particularly to mitochondria, nuclei and cell membranes.
Therefore, ALA-photodynamic therapy (PDT) has the possibleness to go a unique way of improving acne by selectively damaging the pilosebaceous unit and putting to death P. acnes with little terms to the surrounding skin.

We have performed a prospective open examination using topical ALA-PDT to kickshaw 10 patients with acne.
The aim was to confirm its efficacy and to establish its precise mode of natural action by look at the effects on sebum excretory product and P. acnes counts.
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Skin Diseases in Women: Dermatoses Not Linked to Pregnancy

Skin Diseases in Women: Dermatoses Not Linked to Pregnancy

Acne Vulgaris

Form of disease. Acne vulgaris is one of the most common inflammatory disorders for which women seek management.
Acne lesions develop from a assemblage of increased androgen (which causes increased sebaceous gland capability and follicular keratinization) and the work of Propionibacterium acnes.
Lipases of these bacteria causal agent the partitioning of sebum into free fatty acids, which in turn suit acute excitation.

The earmark of acne vulgaris is the attendance of comedones (white, and blackheads) on the face.
Inflamed papules and pustules are features of more severe acne vulgaris (Fig. 4).
In severe acne, nodules and cysts appear (Fig. 5) and may causal agent severe scarring later.
Besides the face, the external body part and back may also be affected.

Percept 4. (click simulacrum to zoom) Inflamed papules and pustules, features of severe acne vulgaris.

Soma 5. (click person to zoom) Nodular and cystic lesions may appear in extremity cases of acne, causing severe scarring.

Aggravating factors in acne vulgaris include heat, cosmetics, premenstrual hormone changes, and some medicaments.

First derivative diagnoses. The computation diagnoses of acne vulgaris include rosacea (presence of telangiectasia, erythema, and flushing), occurrent dermatitis (usually pruritic and scaly), and disease of the skin erythematosus (often photosensitive with epidermal weakening and follicular plugging).

Tending. Women often seek direction to improve their boilersuit appearing, as well as to prevent permanent scarring.
The attention of mild acne vulgaris consists of the use of keratolytic, bacteriostatic, and antiinflammatory agents–for instance, benzoyl hydrogen peroxide (Clearasil, Clean & Country, Fostex), erythromycin or clindamycin (Cleocin), and tretinoin.

For moderate acne vulgaris, an oral antibiotic is indicated.
Tetracycline is the antibiotic direction of option.
Oral tetracycline 500mg bid, or doxycycline (Vibramycin) 100mg bid, or minocycline (Minocin) 100mg daily may be used. Side effects include cutaneous outbreak, gastrointestinal perturbation, vaginal candidiasis, and photosensitivity (particularly with doxycycline and minocycline).
Alternative antibiotics include erythromycin 500mg bid.
Antibiotics are administered for prolonged periods, ranging from 3 months to 1 or more period of time.

For women who are taking an oral contraceptive (OC), a cyproterone-acetate (antiandrogen)-containing OC may be used.
The antiprogesterone effects of contraceptives containing high estrogens have also been used in women with perimenstrual acne flares.
In women who are already taking an OC, switching to a high-estrogen OC can help.
Cyproterone-containing contraceptives are sometimes more effective than those without cyproterone, but these contraceptives are not readily available in every nation.

The action between oral antibiotics (in part tetracycline and erythromycin) and OC is a worry to most physicians.
Conflicting reports have indicated that concomitant presidency of tetracycline and erythromycin may interfere with the contraceptive capability of OCs.
There are no proper status studies to documentation this; however, most physicians advise their patients to use other contraceptive methods when taking tetracycline and erythromycin over the long-term.

For severe nodular-cystic acne vulgaris, oral isotretinoin (Accutane) may be indicated. However, isotretinoin is teratogenic and should be avoided in women of childbearing age unless strict contraceptive measures are undertaken.
The drug may also effort other side effects, including skin and mucosal temperance, erythema, cheilitis, epistaxis, and alopecia.
Because the drug may induce hepatitis and hyperlipidemia, patients on isotretinoin should undergo periodic someone part examination and fasting humour lipid monitoring.
A rise in somebody enzymes or in lipids indicates the need to discontinue the drug.

Many women seek artistic style for scarring from untreated acne vulgaris.
Chemical peels with medium-depth peeling agents (Jessner’s mixture and trichloroacetic acid) can improve the pretence of mild acne scars.
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