Pharmacology and therapeutic applications of thyroxine

Hippokratia 1997, 1(2):73-82

F. Harsoulis, J. Gouni

Abstract

Thyroxine (L-T4) is administered as substitution therapy in primary and secondary hypothyroidism as well as suppressive therapy in thyroid disease states like cold nodules, goiter and thyroid neoplasm. Substitution therapy requires titration of the dose based mainly on the serum TSH levels that have to be within the normal range. It is very important to establish from the beginning if the hyphothyroidism is permanent or transient and if a subclinical hypothyroidism will or will not become clinical and/or permanent. Thyroxine administration is absolutely necessary in neonatal hypothyroidism, where the most critical point is starting therapy as soon as possible. The suppression of goiter is successful more often in the diffuse than in multinodular form. The complete disappearance of a thyroid nodule after thyroxine treatment is quite rare, so the treating doctor must examine the data of each individual patient before surgery is recommended, as a definitive way to obtain a tissue diagnosis. If L-T4 should be administered in order to prevent recurrences of nodular goiters after lobectomy or subtotal thyroidectomy is questionable. In thyroid cancer, postoperatively, suppression of TSH by the administration of L-T4 is mandatory. The side-effects of L-T4, when the drug is misused can be serious because of the potential cardiotoxicity and the acceleration of osteoporosis, especially in postmenopausal women. Administration of L-T4 has no place in the treatment of obese euthyroid individuals.

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Recombinant human Granulocyte-Colony Stimulating Factor (rh-G-CSF) improves neutrophil phagocytic capability, without enhancing the systemic inflammatory response in septic patients with severely impaired neutrophil function

Hippokratia 1997, 1(2):83-92

H. Makriyiannaki, K. Chatzinikolaou, H. Vagdatli, E. Fragopoulou, C. Tsiotras, M. Economou

Abstract

In the present pilot study recombinant human Granulocyte Colony Stimulating Factor (rh G-CSF) was adjunctively administered in septic ICU patients with severe structural abnormalities of their Polymorfonuclear Leucocytes (PMNL) and a phagocytic activity (NBT-test) lower than 50% of the normal value. The drug was administered subcutaneously in a dose of 0.5 IU (5 µg)/kg B.W. / day until the phagocytic activity of the circulating PMNL increased over 80%. This was done after 3-12 days (median 5) of administration. The following changes (means ? SD) have been occurred during rh G-CSF administration: The number and the phagocytic activity of the circulating PMNL increased significantly from 13.454 ? 7.158?109/L and 34 ? 15% to 31.987 ? 16.150 ?109/L and 81 ? 6% respectively (p < 0.001), while the morphological picture of the peripheral PMNL experienced a drastic improvement. Platelets number increased from 122 ? 30.7 to 220 ? 45,25 ? 109/L (p < 0.001). Cardiac index decreased significantly from 4.9 ? 1,9 to 3,4 ? 0,6 L/min/m2 (p < 0.001) and systemic vascular resistance increased significantly from 642 ? 141 to 1034 ? 220 dyn.sec.cm-5 (p < 0.001). The APACHE II score decreased from 21,5 ? 1,8 to 16,2 ? 4,5 (p < 0.001), due to regression of fever, tachycardia, hypotensive episodes and hypernatremia. The serum iron concentration raised from 40 ? 10.6 to 82 ? 22 µg/dL (p < 0.001). These changes indicate a limitation of the inflammatory process. It is concluded that the hematopoietic growth factor G-CSF reverses the structural and functional derangements of the PMNL in critically ill patients. This effect may imply a limitation of the infectious stimulus and hereby the host's inflammatory response, contributing to reduction of hospitalization and mortality in septic patients. A prospective randomized clinical trial could show the impact of adjunctive G-CSF therapy on the outcome of these septic patients.

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Comparative exploration of psychopathology in heart, liver and lung transplantation

Hippokratia 1997, 1(2):93-97

A. Vidalis, G. Kaprinis, I. Fessatidis, P. Argyropoulou, D. Takoudas, G. Imvrios, V. Papanicolaou, E. Koutlas, A. Antoniadis

Abstract

Purpose of this study was the comparative exploration of transplantation's psychopathology in order to improve the methodology of therapeutic intervention in these patients. The total number of patients included in the study was 48, 27 of them referred from the Cardiothoracic Centre of Northern Greece (heart n=22, lung n=5) and 21 from the Transplant Unit of Aristotelian University of Thessaloniki, Hippokratio G.P. Hospital (liver n=21). Mental status was evaluated by psychiatric interviews as well as by psychological tests (SCL90-R, Beck Depression Inventory, Mini Mental State Examination, ??PI). Results revealed in the majority of patients, subjective somatization complaints: obsession, anger, paranoid indention and depression. Regarding the objective complaints, patients were presented with symtomatology of: somatization, depression, anxiety and phobic anxiety. From the total sample, 37% of liver recipients and 20% of lung had cognitive disorders compared to only 9% of heart recipients. In general terms, different psychopathology appeared to depend on the phase of transplantation and the organ transplanted. Intervention requires individualized and pluralistic manipulations from medical specialties while psychiatrists should offer a regular and stable collaboration to the transplants units.

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Malposition of central venous access catheters

Hippokratia 1997, 1(2):98-105

C. Tsiotras, D. Gakis, G. Papaioannou, K. Chatzinikolaou

Abstract

Erroneous insertion and positioning of central venous catheters is the main reason of complication occurrence. The majority of life-threatening injuries, occur at the time of initial catheter insertion. Rarely primary or delayed catheter tip malpositioning is related with the development of serious complications. We reviewed our experience, in a two year period, with the percutaneous insertion or correction of 314 central venous catheters. Special attention was given to the malposition of these catheters. All catheters were inserted in different departments of our hospital. 182 catheters were placed with infraclavicular subclavian approach, (130 single lumen, 16 double lumen and 36 double lumen hemodialysis catheters). Through the internal jugular vein were placed 58 catheters (51 single lumen, 4 double lumen hemodialysis and 3 Hickmann catheters). Through the external jugular vein were introduced 32 catheters (10 single lumen, 6 Hickmann, 4 Infuse-A-Ports and 12 double lumen hemodialysis catheters). Through antecubital vein were placed 42 single lumen long central venous catheters. Catheter malposition occurred in 10 patients (3%). In 4 patients catheter was mal-positioned in the contralateral subclavian vein, in 3 in the ipsilateral internal jugular vein. In a patient, hydropneumothorax was developed as the result of intrapleural catheter malposition after cannulation of the right subclavian vein. In one case a catheter placed through the right external jugular vein was curled into the ipsilateral subclavian vein. Finally a long peripheral venous catheter, placed through the right external jugular vein, was advanced, until the tip was located in the peripheral lung vessels thus producing a peripheral pulmonary infarct. In 7 cases catheter malposition was diagnosed early, after catheter insertion, before catheter use, by a bedside confirming x-ray. In the rest three cases, on site confirming x-rays, were not diagnostic, because of poor quality. That resulted in major complication occurrence (subclavian vein thrombosis, pulmonary infarct, hydrothorax). Confirming of catheter tip placement in the superior vena cava (SVC), by an on site x-ray, is an expensive and time consuming method and involves the danger of allergic reactions due to use of contrast media. Its diagnostic accuracy depends on the quality of x-rays, contrast use and results in patient and personnel radiation. Recently we used, in 7 patients, a technique for electrocardiographic (ECG) guided percutaneous placement of central venous catheters. Using a small metallic tube, placed between the catheter and a syringe filled with normal saline and connected with an ECG monitor, the ECG is recorded with the catheter tip functioning as one of the electrodes. If the catheter tip is situated in the right atrium the ECG will record a biphasic or elevated P-wave. When the catheter is pulled back into the SVC the atrial-P will assume a normal shape. The method proved to be inexpensive, time saving and could be applied in emergency situation and intraoperatively permitting the im-mediated use of the catheter.

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Legionnaire's disease in a patient with renal transplantation

Hippokratia 1997, 1(2):106-110

G Vergoulas, Gr. Miserlis, F. Solonaki, V. Papanikolaou, G. Imvrios, A. Papagiannis, D. Gakis, N. Georgilas, D. Takoudas, A. Antoniadis

Abstract

A 58-year-old male patient with polycystic kidneys as primary renal disease, who was in chronic haemodialysis program for two years, had a successful cadaveric renal transplantation in Oct 1992. He was discharged on the 15th postoperative day with a serum creatinine 1.3 mg/dl in very good condition and came back 8 days later with headache, fever, cough, myalgias, arthralgias, dry rales and consolidation of right lung in chest x-rays. Azathioprine was stopped and cefuroxime, amikacine and vancomycine were given. Pseudomonas was cultured in the sputum and ceftazidime, netelmicin and vancomycin was given. Erythromycin firstly and trimethoprime-sulfomethoxazol secondly were added to the above drugs because there was no response to treatment and the indirect immunofluorecence for legionella antibodies was repeatedly positive. Cyclosporin dose was lowered, antifungal agents were given and haemodialysis was instituted because of acute renal failure and oropharyngeal mycosis. In spite of the efforts, there was expansion of the lung lesions, patient was intubated and finally died because of septic shock on the 68th day.

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Spinal myoclonus

Hippokratia 1997, 1(2):111-113

E. Koutlas, L. Nikolaidou-Tokalaki, G. Zacharakis

Abstract

We present a case report of a patient 63 years old, male, who was admitted because of generalized, symmetric myoclonic seizures with intact consciousness. The brain C.T. scan and the E.E.G. were within normal limits. Fourteen months ago he had an extended laminectomy L1-L4 because of severe spondylosis. The MRI scan of the lumbar spine revealed a chronic arachnoiditis, a rare cause of myoclonus originating from the spinal cord. We noticed a complete remission of the seizures after treatment with phenytoin 375 mg, clonazepam 4 mg and piracetam 5g.

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