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By D. Amul. Saint Thomas Aquinas College.

However cheap decadron 0.5 mg on line, particularly in the case of spinal pain decadron 1mg mastercard, the general tendency for many patients to improve spontaneously, the problem of different populations of patients and pathological conditions causing pain, coupled with the potentially potent placebo effect of treatment makes it difficult to compare these studies and determine success. Therefore, there has been a growing recognition of the role of randomized comparison trials whenever claims of efficacy are made. Whenever there is no effective placebo group included in a clinical trial, the role of the placebo effect must be considered as a potential mechanism to explain a beneficial outcome. Furthermore, it has been pointed out that designing an appropriate placebo for 41 physical interventions may be particularly difficult. It is in this setting that we will describe the pragmatic studies of chiropractic treatment. The majority of these studies have specifically evaluated outcomes of patients randomized to chiropractic treatment versus those managed by conventional medical means or by physical therapists. Low back pain The most common reason for seeking chiropractic care is pain in the lower back. Between 30 and 50% of all treatment delivered each year by chiropractors is for low back 6,12,42 pain. Completereview of the 43 trials of spinal manipulation for acute, subacute and chronic low back pain will be deferred for later (Chapter 21). However, several of these studies specifically compare chiropractic treatment to that by other practitioners. Positive responses for manipulation have been found in patients with subacute low 43 back pain (within 4–12 weeks). In a prospective, randomized trial, Hsieh and associates compared SMT with transcutaneous muscle stimulation, massage therapy or corset use in patients with subacute low back pain. At 3 weeks, the manipulation group showed the greatest improvement in lumbar flexion and in pain scores. There are a limited number of studies that have Complementary therapies in neurology 44 examined the effect of chiropractic treatment in patients with chronic low back pain. Each of the three therapeutic regimens was associated with similar and clinically important improvement, and there appeared to be a sustained reduction in medication use at the 1- year follow-up period in the SMT and therapeutic strengthening exercise group. After a median intervention period of 30 days, spinal manipulation was the only treatment that achieved statistically significant improvement, with a reduction on the Oswestry scale of 30. The authors concluded that, in spite of several shortcomings of this study, there was evidence that spinal manipulation resulted in greater improvement than acupuncture and commonly utilized medication in patients with chronic spinal pain. They found significantly greater benefits for the group treated by the chiropractors at several followup intervals: 6 weeks, 6 months, 1 year, 2 years and 3 years. One weakness of the study was the relatively high percentage of patients lost to follow-up, especially at the later time points. Nonetheless, the large size of this study (enrolling over 700 patients) and the long-term follow-up period with consistent findings over all time points provide some confidence in their findings. The group treated by chiropractors performed significantly better than the minimal intervention group at 4 weeks, but not at 12 weeks, 1 year or 2 years. There was no difference between the group undergoing spinal manipulation and the patients treated with physical therapy. Although disability scores were better for both the group treated with manipulation and those patients treated with physical therapy than the minimal intervention, this did not quite reach significance at any time point. It is noteworthy that the groups receiving active treatment were much more satisfied with the treatment, reporting that their care was good or excellent about 75% of the time (compared to 30% of the time for the patients who had been given the Chiropractic 45 booklet). This effect has the potential to limit the ability of a study to detect differences between treatment groups. These pragmatic studies, combined with the results of other studies of manipulative therapy, argue for some benefit of chiropractic in the treatment of low back pain of various durations versus several other forms of therapy. There is some question as to whether intensive physical therapy may be as effective, at similar overall cost. Additionally, the studies that have been carried out up to the present time cannot determine whether there are particular chiropractic procedures that are more effective than others or whether these treatments are cost-effective. Furthermore, studies have not been designed to address the important question of whether there are particular groups of back pain patients who are more likely to benefit.

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Although there is great variation the alkylating metabolites are bound to plasma pro- among normal and tumor tissues in their sensitivity to teins buy generic decadron 0.5 mg online. Since cyclophosphamide and its metabolites are mechlorethamine discount 1 mg decadron otc, the drug is generally more toxic to eliminated primarily by the kidneys, renal failure will proliferating cells than to resting or plateau cells. Mechlorethamine has a chemical and biological half-life Cyclophosphamide has a wide spectrum of antitu- in plasma of less than 10 minutes after intravenous in- mor activity. High dosages of in- men (mechlorethamine, vincristine, procarbazine, pred- travenously administered cyclophosphamide are often nisone; see Chapter 55). Cyclophosphamide in combination may pro- Melphalan duce complete remissions in some patients with ovarian Melphalan (Alkeran) is an amino acid derivative of cancer and oat cell (small cell) lung cancer. Other tu- mechlorethamine that possesses the same general spec- mors in which beneficial results have been reported in- trum of antitumor activity as do the other nitrogen mus- clude non–oat cell lung cancers, various sarcomas, neu- tards. However, the bioavailability of the oral prepara- roblastoma, and carcinomas of the testes, cervix, and tion is quite variable (25–90%) from one patient to bladder. Because it does not produce alopecia, cells more than platelets is the major dose-limiting tox- melphalan is occasionally substituted for cyclophos- icity. Cyclophos- does cyclophosphamide; however, its bone marrow sup- phamide reduces the number of circulating lympho- pression tends to be more prolonged and affects both cytes and impairs the function of both humoral and white cells and platelets. Rarely, fibro- Chlorambucil (Leukeran) is an aromatic nitrogen mus- sis and a permanently decreased bladder capacity may tard that is intermediate in chemical reactivity between ensue. Chlorambucil shares the immuno- suppressive, teratogenic, and carcinogenic properties of Ifosfamide the nitrogen mustards. Ifosfamide (Ifex) is an analogue of cyclophosphamide that requires metabolic activation to form 4-hydroxy- Nitrosoureas ifosfamide. In general, the metabolism, serum half-life, Carmustine, Lomustine, and Semustine and excretion of ifosfamide are similar to those of cy- clophosphamide. The nitrosoureas are alkylating agents that are highly Ifosfamide is active against a broad spectrum of tu- lipid soluble and share similar pharmacological and mors, including germ cell cancers of the testis, lym- clinical properties. Carmustine (BCNU), lomustine phomas, sarcomas, and carcinomas of the lung, breast, (CCNU), and semustine (methyl-CCNU) are chemi- and ovary. It is thought to be more active than cy- cally unstable, forming highly reactive decomposition clophosphamide in germ cell cancers and sarcomas. The chemical half-life of these drugs in plasma Ifosfamide is less myelosuppressive than cyclophos- is only 5 to 15 minutes. It also may cilitates distribution into the brain and cerebrospinal produce alopecia, nausea, vomiting, infertility, and sec- fluid (CSF). Neurological The chloroethyl moiety of these nitrosoureas is capa- symptoms including confusion, somnolence, and hallu- ble of alkylating nucleic acids and proteins and produc- cinations have also been reported. It is recommended ing single-strand breaks and interstrand cross-linkage 642 VI CHEMOTHERAPY of DNA. Both alkylation and carbamoylation contribute Alkyl Sulfonates to the therapeutic and toxic effects of the nitrosoureas. Busulfan These agents can kill cells in all phases of the cell Busulfan (Myleran) is a bifunctional methanesulfonic cycle. Oral absorption of lomustine and semustine is com- The drug is well absorbed after oral administration and plete, but degradation and metabolism are so rapid that has a plasma half-life of less than 5 minutes. Metabolites the parent drug cannot be detected after oral adminis- and degradation products are excreted primarily in the tration. Daily oral therapy re- Carmustine and lomustine can produce remissions sults in decreased peripheral white blood cells and im- that last from 3 to 6 months in 40 to 50% of patients proved symptoms in almost all patients during the with primary brain tumors. Unusual side effects of busulfan include gyneco- ing in most patients 4 to 6 hours after administration. Ethylenimines Pulmonary toxicity, manifested by cough, dyspnea, and Thiotepa interstitial fibrosis, is becoming increasingly recognized Although thiotepa is chemically less reactive than the ni- as a complication of long-term nitrosourea treatment. However, it has been Streptozocin (Zanosar), a water-soluble nitrosourea largely supplanted by cyclophosphamide and other ni- produced by the fungus Streptomyces achromogenes, trogen mustards for treatment of these diseases. Streptozocin is not well absorbed from the gastroin- testinal tract and must be administered intravenously or Triazenes intraarterially. Streptozocin produces remission in 50 to 60% of pa- Dacarbazine (DTIC-Dome) is activated by photode- tients with islet cell carcinomas of the pancreas.

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