Uptake and effectiveness of a community pharmacy intervention programme to improve asthma management.

WHAT IS KNOWN AND OBJECTIVE: Pharmacists frequently see patients with asthma in the community who have suboptimal management. This study aimed to compare the uptake and effectiveness of pharmacist-initiated mailed and face-to-face interventions for patients whose asthma may not be well managed. METHODS: Seventy-one community pharmacies in South Australia, Tasmania and Victoria (Australia) installed a software application that data-mined dispensing records, generating a list of patients who had received six or more asthma reliever inhalers in the preceding 12 months. The pharmacists were randomized, by pharmacy, to perform either a mailed or face-to-face intervention, whereby these patients received educational material and a referral to their general practitioner (GP) for an asthma management review. Matching patients from each pharmacy were also randomly assigned to a control group for 'usual care'. RESULTS AND DISCUSSION: A total of 1483 patients were identified and grouped as follows: 510 (34·4%) mailed intervention, 480 (32·4%) face-to-face intervention and 493 (33·2%) controls. Significantly fewer face-to-face interventions were offered than mailed interventions (66·6% vs. 89·4%, respectively; χ(2) = 64·2, P < 0·0001). There were significant improvements in the preventer-to-reliever ratio after the intervention period (P < 0·0001) in each group. In a per-protocol analysis, the magnitude of improvement in the face-to-face intervention group was greater than in the mailed intervention group. The reverse was true in an intention-to-treat analysis. The improvement in the P : R ratios was mainly due to significant decreases in reliever usage. WHAT IS NEW AND CONCLUSION: Community pharmacy dispensing records can effectively identify patients with suboptimal asthma management, who can then be referred to their GP for review. Time constraints in busy pharmacies may limit the uptake and effectiveness of face-to-face interventions in the 'real world' setting, making mailed interventions an attractive option.

The role of vagus nerve stimulation in the treatment of refractory epilepsy: clinical outcomes and impact on quality of life.

BACKGROUND: Vagus nerve stimulation (VNS) is used as a complementary therapy to pharmacological treatment in patients with refractory epilepsy. This study aims to evaluate the efficacy of VNS in reducing seizure frequency, severity, and duration; reducing the number of antiepileptic drugs administered; and improving patients' quality of life. MATERIAL AND METHODS: We analysed the clinical progression of 70 patients with refractory epilepsy treated with VNS at Hospital Universitario de Alicante and Hospital Clínico de Valencia. Data were collected before and after the procedure. The difference in seizure frequency pre- and post-VNS was classified using the McHugh scale. Data were also collected on seizure duration and severity, the number of drugs administered, and quality of life. RESULTS: According to the McHugh classification, 12.86% of the patients were Class I, 44.29% were Class II, 40% were Class III, and the remaining 2.86% of patients were Class IV-V. A ≥ 50% reduction in seizure frequency was observed in 57.15% of patients. Improvements were observed in seizure duration in 88% of patients and in seizure severity in 68%; the number of drugs administered was reduced in 66% of patients, and 93% reported better quality of life. CONCLUSIONS: VNS is effective for reducing seizure frequency, duration, and severity and the number of antiepileptic drugs administered. It also enables an improvement in patients' quality of life.

[Treatment of intrinsic brain tumors located in motor eloquent areas. Results of a protocol based in navigation, tractography and neurophysiological monitoring of cortical and subcortical structures]. / Tratamiento de los tumores cerebrales intrínsecos de áreas motoras elocuentes. Resultados de un protocolo basado en la navegación, tractografía y monitorización neurofisiológica de estructuras corticales y subcorticales.

OBJECTIVES: The role of the microsurgical management of intrinsic brain tumors is to maximize the volumetric resection of the tumoral tissue minimizing the postoperative morbidity. The purpose of our paper has been to study the benefits of an original protocol developed for the microsurgical treatment of tumors located in eloquent motor areas where the navigation and electrical stimulation of motor subcortical pathways have been implemented. MATERIALS AND METHODS: A total of 17 patients operated on for resection of cortical or subcortical tumors in motor areas were included in the series. Preoperative planning for multimodal navigation was done integrating anatomic studies, motor functional MRI (f-MRI) and subcortical pathways volumes generated by diffusion tensor imaging (DTI). Intraoperative neuromonitorization included motor mapping by direct cortical and subcortical electrical stimulation (CS and sCS) and localization of the central sulcus using cortical multipolar electrodes and the N20 wave inversion technique. The location of all cortical and subcortical stimulated points with positive motor response was stored in the navigator and correlated with the cortical or subcortical motor functional structures defined preoperatively. RESULTS: The mean tumoral volumetric resection was 89.1±14.2% of the preoperative volume, with a total resection (≥100%) in twelve patients. Preoperatively a total of 58.8% of the patients had some motor deficit, increasing 24 hours after surgery to 76.5% and decreasing to 41.1% a month later. There was a great correlation between anatomic and functional data, both cortically and subcortically. However, in six cases it was not possible to identify the central sulcus and in many cases fMRI gave contradictory information. A total of 52 cortical points submitted to CS had positive motor response, with a positive correlation of 83.7%. Also, a total of 55 subcortical points had positive motor response, being in these cases 7.3±3.1 mm the mean distance from the stimulated point to the subcortical tract. CONCLUSIONS: The integration of preoperative and intraoperative anatomic and functional studies allows a safe functional resection of the brain tumors located in eloquent areas, compared to the tumoral resection based on anatomic imaging studies. Multimodal navigation allows the integration and correlation among preoperative and intraoperative anatomic and functional data. Cortical motor functional areas are anatomically and functionally located preoperatively thanks to MRI and fMRI and subcortical motor pathways with TDI and tractography. Intraoperative confirmation is done with CS and N20 inversion wave for cortical structures and with sCS for subcortical pathways. With this protocol we achieved a mean of 90% of volumetric resection in cortical and subcortical tumors located in eloquent motor areas with an increase of neurological deficits in the immediate postoperative period that significantly decreased one month later. Ongoing studies will define the safe limits for functional resection taking into account the intraoperative brain shift. Finally, it must be demonstrated if this protocol has any benefit for patients concerning disease free or overall survival.

Neuromodulation in headache and craniofacial neuralgia: guidelines from the Spanish Society of Neurology and the Spanish Society of Neurosurgery. / Neuromodulación en cefaleas y neuralgias craneofaciales: Guía de la Sociedad Española de Neurología y de la Sociedad Española de Neurocirugía.

INTRODUCTION: Numerous invasive and non-invasive neuromodulation devices have been developed and applied to patients with headache and neuralgia in recent years. However, no updated review addresses their safety and efficacy, and no healthcare institution has issued specific recommendations on their use for these 2 conditions. METHODS: Neurologists from the Spanish Society of Neurology's (SEN) Headache Study Group and neurosurgeons specialising in functional neurosurgery, selected by the Spanish Society of Neurosurgery (SENEC), performed a comprehensive review of articles on the MEDLINE database addressing the use of the technique in patients with headache and neuralgia. RESULTS: We present an updated review and establish the first set of consensus recommendations of the SEN and SENC on the use of neuromodulation to treat headache and neuralgia, analysing the current levels of evidence on its effectiveness for each specific condition. CONCLUSIONS: Current evidence supports the indication of neuromodulation techniques for patients with refractory headache and neuralgia (especially migraine, cluster headache, and trigeminal neuralgia) selected by neurologists and headache specialists, after pharmacological treatment options are exhausted. Furthermore, we recommend that invasive neuromodulation be debated by multidisciplinary committees, and that the procedure be performed by teams of neurosurgeons specialising in functional neurosurgery, with acceptable rates of morbidity and mortality.

The role of vagus nerve stimulation in the treatment of refractory epilepsy: Clinical outcomes and impact on quality of life. / Papel de la estimulación del nervio vago en el tratamiento de la epilepsia refractaria. Resultados clínicos e impacto en la calidad de vida.

BACKGROUND: Vagus nerve stimulation (VNS) is used as a complementary therapy to pharmacological treatment in patients with refractory epilepsy. This study aims to evaluate the efficacy of VNS in reducing seizure frequency, severity, and duration; reducing the number of antiepileptic drugs administered; and improving patients' quality of life. MATERIAL AND METHODS: We analysed the clinical progression of 70 patients with refractory epilepsy treated with VNS at Hospital Universitario de Alicante and Hospital Clínico de Valencia. Data were collected before and after the procedure. The difference in seizure frequency pre- and post-VNS was classified using the McHugh scale. Data were also collected on seizure duration and severity, the number of drugs administered, and quality of life. RESULTS: According to the McHugh classification, 12.86% of the patients were Class I, 44.29% were Class II, 40% were Class III, and the remaining 2.86% of patients were Class IV-V. A≥50% reduction in seizure frequency was observed in 57.15% of patients. Improvements were observed in seizure duration in 88% of patients and in seizure severity in 68%; the number of drugs administered was reduced in 66% of patients, and 93% reported better quality of life. CONCLUSIONS: VNS is effective for reducing seizure frequency, duration, and severity and the number of antiepileptic drugs administered. It also enables an improvement in patients' quality of life.

[Vagus nerve stimulation for the treatment of refractory epilepsy. State of the art]. / Estimulación eléctrica vagal en el tratamiento de la epilepsia rebelde. Situación actual.

The vagus nerve stimulation (VNS) therapy is a new neurostimulation technique used for treating pharmacoresistant epilepsy. It can be considered an effective and safe alternative for the treatment of refractory epilepsy patients. In the present review, we describe the surgical implantation technique, its indications and results achieved until now. We will also summarize the possible mechanisms of action of VNS therapy. Finally, we will comment on the difficulties and inconveniences that did not allow this antiepileptic surgical technique to become more widely used.

Optic nerve avulsion.

OBJECTIVE: To characterize the presentation, role of diagnostic imaging, and course in patients with optic nerve avulsion. METHODS: A retrospective review of medical records of all 6 patients with optic nerve avulsion who were seen at the Massachusetts Eye and Ear Infirmary, Boston, from January 1, 1991, to July 31, 1995. RESULTS: The initial visual acuity ranged from 20/100 to no light perception. All 6 patients underwent neuroimaging, including computed tomography, magnetic resonance imaging, or both. B-scan ultrasonography was performed on 4 patients, and the condition of 1 patient was evaluated with color Doppler ultrasonography to assess the optic nerve vasculature. In 1 patient, a computed tomographic scan was suggestive of an optic nerve avulsion. Neuroimaging in the other 5 patients, including 2 patients who underwent magnetic resonance imaging, failed to demonstrate an avulsion. During a follow-up period of up to 25 months, 4 patients showed no improvement in visual acuity, 1 patient improved from no light perception to bare light perception, and 1 patient improved from 20/100 to 20/25. CONCLUSIONS: These data suggest that final visual outcome was dependent on initial postinjury visual acuity. Neuroimaging, B-scans, and Doppler ultrasonography were usually not helpful in establishing the presence of optic nerve avulsion, although they may be useful in evaluating comorbid conditions.

Spinal cord stimulation in peripheral arterial disease. A cooperative study.

Percutaneous epidural stimulation of the low thoracic spinal cord was carried out in 41 patients with pain from peripheral arterial disease of the lower limbs. Results are reported relating to pain, claudication distance, peripheral blood flow, and trophic lesion changes. Following a trial period of stimulation, 37 patients had stimulators permanently implanted. After a mean poststimulation follow-up period of 25 months, substantial pain relief (75% to 100%) was obtained in 29 cases; claudication distance significantly increased in 15 cases; Doppler ultrasound recordings of lower-limb distal arteries showed a tendency toward normalization of pulse-wave morphology, with increase of amplitude in 12 of the 23 patients studied; a rise in skin temperature was also detected by thermography. Distal arterial blood pressure remained unchanged with stimulation. Ischemic cutaneous trophic lesions of less than 3 sq cm healed, but gangrenous conditions were not benefited. A placebo effect or the natural history of the disease can be excluded as the reason for these improvements. It is concluded that spinal cord stimulation is a valid alternative treatment for moderate peripheral arterial disorders when direct arterial surgery is not possible or has been unsuccessful.

Quantitative assessment of factors contributing to mottling of colored tablets I: manufacturing variables.

By using a recently developed method for quantifying the degree of mottling of colored tablets, the effects of manufacturing variables such as the method and temperature of granule drying, granule size, and compaction pressure were investigated. Tablets of dibasic calcium phosphate colored with FD&C Blue No. 1 dye were used. Drying temperature had little effect, but the method of granule drying, granule size, and compaction pressure were major influences on mottling. Mechanisms to explain these results, based on the migration of dye during the drying process, are proposed.

Quantitative assessment of factors contributing to mottling of colored tablets II: formulation variables.

The effects of several formulation variables were quantified with respect to factors affecting tablet mottling. Tablet mottling occurred with several commonly used binders and could not be prevented by using highly viscous binding solutions. However, mottling was reduced initially by increasing granule strength. Tablet diluents and dye-adsorbent materials had a profound effect on mottling, not by preventing dye migration but by affecting granule fragmentation on compression and the extent to which the dye-deficient material at the center of the granule was revealed. The lake form of FD&C Blue No. 1 was found to bleed in the presence of diluents that raised the pH of the granulating fluid above 6.4. Anionic impurities in the diluents also caused leaching of free dye and, consequently, increased tablet mottling. The conclusions from this study and previous papers were drawn together to give general principles for the production of uniformly colored tablets by aqueous granulation techniques.

Ocular myasthenia gravis.

Ocular dysfunction accounts for nearly 70% of the initial manifestations of myasthenia gravis. Since the prevalence rate of myasthenia gravis is two to 10 cases per 100,000 population, it is important for clinicians to be cognizant of this disorder and its varied ocular presentations. The clinical manifestations, diagnosis, treatment, and prognosis of ocular myasthenia gravis are reviewed.

Recent Outbreak of "Mal de Rio Cuarto" Virus on Corn in Argentina.

"Mal de Río Cuarto" (MRC) is the most important viral disease affecting corn in Argentina. Reovirus-like particles were observed in diseased plants (1,4) and were later serologically related to an isolate of maize rough dwarf virus (3), though this relationship was recently questioned (2). Based on estimates of the prevalence and severity of MRC and yield losses, government agencies, corn hybrid seed companies, and growers agreed that the worst epidemic in the country occurred during the 1996 to 1997 agricultural year. Approximately 300,000 ha of corn were affected by the disease and yield losses were estimated at $120 million. Affected areas included the central and southern Santa Fe, the central, northern, southeastern, and western Buenos Aires, and the eastern and southern (originally the endemic center of MRC in Río Cuarto County) parts of Córdoba. Virus infections were confirmed by double-antibody sandwich-enzyme-linked immunosorbent assay (DAS-ELISA) in root samples from each surveyed location, using an antiserum to MRC virus. The occurrence of MRC in non-endemic areas suggests an unusual phenological coincidence of high vector populations, abundant natural virus reservoirs, and susceptible stages in the crop. Most commercial hybrids surveyed were apparently susceptible to the virus, although some were tolerant. References: (1) O. E. Bradfute et al. Phytopathology 71:205, 1981. (2) C. Marzachi et al. Sem. Virol. 6:103, 1995. (3) R. G. Milne et al. Phytopathology 73:1290, 1983. (4) S. F. Nome et al. Phytopathol. Z. 101:7, 1981.

The effects of lead poisoning on various plasma constituents in the Canada goose.

Plasma glucose, free fatty acid and uric acid levels were measured in lead-poisoned Canada geese (Branta canadensis). Although plasma glucose levels were only slightly elevated, uric acid was significantly higher and free fatty acids were significantly lower. Altered plasma levels were attributed to increased protein catabolism and perhaps renal disfunction. Plasma level of growth hormone and prolactin was assessed by radioimmunoassay. Growth hormone remained unchanged while prolactin was unusually high. The increased prolactin levels may reflect an effort to stabilize free fatty acids.

[Ocular loiasis in a patient with chronic hypereosinophilia]. / Loiasis ocular en paciente con hipereosinofilia crónica.

CASE REPORT: We present a case of ocular loiasis with a subconjunctival filaria, 5.5cm long, and a severe microfilaremia, 1 microfilaria/ml, on a previously asymptomatic woman from Equatorial Guinea, with a past medical history of hypereosinophilia of unknown origin. DISCUSSION: Ocular loiasis is an imported infestation with a very low rate in our country. Nevertheless, chronic infestation in immigrants coming from endemic areas of Africa may increase the rate of this disease in our country.

Label-free and reagentless electrochemical detection of PCR fragments using self-assembled quinone derivative monolayer: application to Mycobacterium tuberculosis.

We report a signal-on, label-free and reagentless electrochemical DNA biosensor, based on a mixed self-assembled monolayer of thiolated hydroxynaphthoquinone and thiolated oligonucleotide. Electrochemical changes resulting from hybridization were evidenced with oligonucleotide targets (as models), as well as with polymerase chain reaction (PCR) products related to different lineages of Mycobacterium tuberculosis strains. With pure oligonucleotides, this system achieves high sensitivity (∼300 pM of DNA target, i.e. 30 fmol in a 100 µL sample) and excellent selectivity, allowing to detect a single mismatch on a sequence of 20 bases. With PCR products, current changes are specific to the bacterial strain from which the PCR fragment is produced. In addition, the sensor response is of the signal-on type, giving a positive signal change upon hybridization, and therefore does not suffer from false positive responses due to non-specific adsorption of DNA.