A regional audit of the use of COX-2 selective non-steroidal anti-inflammatory drugs (NSAIDs) in rheumatology clinics in the West Midlands, in relation to NICE guidelines.

OBJECTIVES: Whilst all non-steroidal anti-inflammatory drugs (NSAIDs) can cause adverse gastrointestinal events, COX-2-selective inhibitors (COX-2) may have improved gastrointestinal safety compared with non-selective NSAIDs (NSNSAIDs). In 2001, the National Institute for Clinical Excellence (NICE) published guidance on the use of the COX-2 agents celecoxib, rofecoxib, meloxicam and etodolac for rheumatoid arthritis (RA) and osteoarthritis (OA). This study aimed to audit the appropriateness of NSAID use in relation to NICE guidance in rheumatology out-patients. METHODS: Questionnaires were completed for all patients attending clinics in 18 rheumatology units in the West Midlands over a 2-week period. Data collected included patient demographics, NSAID type, indications, duration of use (> or =3 months was considered prolonged), and concomitant prescription of corticosteroids, warfarin and gastroprotective agents. RESULTS: Data were collected on 2846 patients; 1164 (41%) were taking NSAIDs (791 NSNSAIDs, 373 COX-2). Of the 1164 NSAID users, 753 (65%) had a diagnosis of RA or OA (483 NSNSAIDs, 270 COX-2). Overall, 37% of NSAID prescriptions were appropriate. Of the NSNSAID users, 92% had at least one risk factor for adverse gastrointestinal events and were therefore inappropriately treated. Prolonged use (in 89%) and age > or =65 yr (in 23%) were the most frequent risk factors identified. Of the COX-2 users, 97% had one or more risk factors and were appropriately treated. Analysis of the RA/OA subgroup revealed similar findings. Thirty-six per cent were taking NSAIDs appropriately; 97% of NSNSAID use was inappropriate and 97% of COX-2 use was appropriate treatment. In the whole cohort, gastroprotective agents were used in 26% of NSNSAID users, 56% of gastroprotective agents being proton pump inhibitors. CONCLUSIONS: Ninety-two per cent of patients attending rheumatology clinics who were taking NSNSAIDs should have been prescribed a COX-2-selective agent in relation to NICE guidance. Duration of use and age > or =65 yr emerged numerically as the most important risk factors. Significant numbers of patients taking NSNSAIDs may be at risk from adverse gastrointestinal events and clinicians may wish to review their prescribing patterns. Conversely, 97% of patients taking COX-2 agents were treated appropriately. Although practice overall conformed poorly with NICE guidance, NSAID prescribing also needs to be considered in the context of recent concerns regarding the cardiovascular risks of COX-2 agents.

An in vitro study of the accuracy of a new protocol for planning distraction osteogenesis of the mandible.

PURPOSE: The purpose of this study was to determine the in vitro accuracy of a new protocol for distraction osteogenesis of the mandible that involves a planning process and a surgical technique. MATERIALS AND METHODS: An experimental design was developed to simulate distraction osteogenesis on stereolithographic models of patients with craniofacial deformities. All patients had previously undergone 3-dimensional computerized scans of the craniofacial skeleton. The data from these scans were used to generate stereolithographic models. Before the fabrication of the models, the computed tomography (CT) data were manipulated to add a series of rulers and markers to the models. The 3-dimensional computerized scans were also used as the basis of the planning process. They were imported into an animation software (3D-Studio Max; Discreet, Montreal, Canada), and a virtual distractor was built and installed on the model, and the osteotomies and distraction processes were simulated. Finally, a recipe for sequencing the linear and angular changes of the distractor were calculated. A surgical technique was developed to facilitate the precise installation of the distractor as indicated in the presurgical plan. The transfer of information regarding pin position and orientation from the computer model to the patient was accomplished by creating a surgical template. This template was designed in the computer and fabricated by use of stereolithography. Mock surgery was performed on the stereolithographic models, and the results were compared with those predicted by the computer. The difference between the actual position and the predicted position was recorded. RESULTS: On the X-axis, the difference between the predicted position for the condylar marker and the actual position of the marker on the stereolithographic models was 0.6 +/- 1.1 mm. On the Y-axis, the difference between the predicted position for the condylar marker and the actual position of the marker on the stereolithographic models was -0.9 +/- 2.6. On the Z-axis, the difference between the predicted position for the condylar marker and the actual position of the marker on the stereolithographic models was 0.04 +/- 0.8 mm. There was excellent correlation between the predicted and the actual measurements for the X, Y, and Z axes: 0.98, 0.93, and 0.98, respectively. CONCLUSIONS: The results indicate that the combination of this planning process and surgical technique was very accurate. This in vitro study is the first step in determining the clinical usefulness of this protocol. If the results of this study are validated in clinical practice, this protocol will allow clinicians to improve the clinical outcomes of patients treated with distraction osteogenesis.

Oscars, Astronotus ocellatus, have a dietary requirement for vitamin C.

We found that vitamin C is an essential nutrient for an Amazonian ornamental fish, the oscar (Astronotus ocellatus). This was demonstrated by the absence of L-gulonolactone oxidase activity, the enzyme responsible for the biosynthesis of vitamin C, in liver or kidney of oscars and by a feeding trial in which oscars without vitamin C dietary supplementation developed clinical deficiency signs. Fish weighing 29.2 +/- 1.9 g were divided into four groups, and each group was fed a casein-based semipurified diet containing 0, 25, 75 or 200 mg ascorbic acid equivalent (AA)/kg diet for 26 wk. Vitamin C was supplemented in the diets as L-ascorbyl-2-polyphosphate, a mixture of phosphate esters of ascorbate, which is more stable to oxidation than AA. At the end of 26 wk, fish fed no AA had significantly lower weight gain than fish fed the AA-supplemented diets (P < 0.05). Oscars without dietary AA supplementation gained only 37% of their initial weight, compared with 112, 102 and 91% gained by fish fed 25, 75 and 200 mg AA/kg diet, respectively. After 25 wk without dietary supplementation of AA, fish began to develop clinical deficiency signs, including deformed opercula and jaws, hemorrhage in the eyes and fins, and lordosis. Histology indicated that fish without AA supplementation had deformed gill filament support cartilage and atrophied muscle fibers. Collagen content of the vertebral column was significantly lower in fish devoid of dietary AA (P < 0.05). Liver AA concentration varied in proportion to dietary concentration of AA. The minimum dietary AA concentration tested in this study, 25 mg AA/kg diet, was sufficient to prevent growth reduction and AA deficiency signs in oscars.

Characterization of altered calcium signalling in T lymphocytes from patients with rheumatoid arthritis (RA).

Abnormal function of peripheral blood T lymphocytes is characteristic of RA; diminished proliferation and secretion of cytokines following in vitro mitogen stimulation are observed. We have investigated the calcium flux initiating T cell activation in rheumatoid peripheral blood mononuclear cells (PBMC) to determine whether abnormalities in signalling are also present. We have found that both phytohaemagglutinin (PHA-P)- and anti-CD3-stimulated calcium fluxes were much reduced in the patients' PBMC compared with controls, with a mean six-fold difference (P < 0.01) in rate of Ca2+ flux with PHA-P stimulation. When purified T cells were examined with PHA and CD3 stimulation, a reduction in the peak and plateau [Ca2+]i was observed in RA T cells, but the rate of rise of [Ca2+]i was only reduced in those cells stimulated with PHA. These results suggest that alterations in the initiating signal may underlie the functional T cell abnormalities associated with RA, and that there may be an additional extrinsic influence from non-T cells in the PBMC population.

Altered T lymphocyte signaling in rheumatoid arthritis.

Synovial and peripheral blood T cells from patients with rheumatoid arthritis are functionally deficient. This may be secondary to their reduced cytokine (e.g. interleukin-2) synthesis. We have investigated the possibility of an alteration in pathways common to interleukin-2 production and proliferation in peripheral blood T cells from patients with active rheumatoid arthritis. Intracellular calcium levels ([Ca2+]i) were analyzed by flow cytometric methods in Indo1-loaded T cells. These were purified by negative selection from patients or age/sex-matched controls, and stimulated with phytohemagglutinin-P or anti-CD3. Rheumatoid [Ca2+]i responses to both stimuli were reduced (p < 0.005). Patient cell samples included a larger proportion of non-responding cells, but even in the responsive population the magnitude of the response in rheumatoid cells was impaired compared with those in normal cell samples (p < 0.0001) for both stimuli. Proliferation responses were also impaired (p < 0.005), and there was a positive correlation between the paired [Ca2+]i elevation and proliferative responses for both stimuli. CD2 and CD3 expression were normal, and the proportions of CD4, CD8 and CD45RO and CD45RA subsets were also unaffected by disease. Thus a signaling defect downstream of CD2 or CD3 surface molecules may contribute to functional deficiencies in rheumatoid T lymphocytes. This effect is not due to non-steroidal anti-inflammatory drugs which some patients were taking. We have demonstrated similar alterations in [Ca2+]i responses and proliferation in a smaller study of patients with inflammatory bowel disease, indicating that such changes might be present in other chronic inflammatory states.

Acceleration perturbations of daily living. A comparison to 'whiplash'.

STUDY DESIGN: This study measured repeated human head accelerations (g) during daily activities. OBJECTIVES: Perturbations of daily living were compared to similar data from low velocity rear-end motor vehicle accidents. SUMMARY OF BACKGROUND DATA: Past assumptions suggest that motor vehicle accident severity does not correlate with the degree of sustained injury. Early engineering studies indicated that occupant disturbance in a low velocity motor vehicle accident is minor. METHODS: Eight volunteers were perturbed with 13 daily activities. Helmets on the heads of volunteers were instrumented with tri-planar accelerometers with output sampling of 500 Hz, sensitivity of 0.02 g, and a range of +/- 20 g. RESULTS: There was wide inter-subject response for various perturbations. Plopping backward into a chair caused maximum peak acceleration horizontally at 5.6 g and vertically at 8.5 g, with force vector of 10.1 g at 54.9 degrees. Mean impulse duration was 0.19 sec. There was no hint of injury in any subject. CONCLUSIONS: Perturbations of daily living compared similarly to the jostling expected in low velocity "whiplash"-type motor vehicle accidents.

Master's degree nursing education: state of the art.

This study examines the state of the art in master's nursing education in the United States in light of projected national trends in the health care delivery system. The specific questions addressed are: What are the general characteristics of master's programs, including admission requirements and prerequisites, program requirements, major and minor areas of clinical concentration, functional role preparation, and career mobility options? What is the curricular organization, particularly with respect to required core courses? Is there a difference between master's programs in schools with a doctoral program in nursing and those with master's programs only? Is there a difference between master's programs with public support and master's programs with private support? Data were collected from 175 accredited master's programs in 1990. Study results and the projected trends derived from Nursing's Agenda for Health Care Reform, Healthy People 2000: National Health Promotion and Disease Prevention Objectives, and Healthy America: Practitioners for 2005 provide the foundation for recommendations. Recommendations are organized around communication and curricular issues that master's nursing education needs to address as the profession approaches the 21st century.

Effects of carbamazepine and phenytoin on EEG and memory in healthy adults.

Using a randomized, double-blind, cross-over design, we investigated the effects of carbamazepine (CBZ) and phenytoin (PHT) on memory and spectral EEG components in 15 healthy adults. Each subject was treated with each drug for 1 month, separated by a 1-month washout. Evaluations were conducted at baseline, at the end of each treatment month, and 1 month after the last treatment phase. EEG was collected during an eyes-closed resting condition and a verbal memory activation task. Spectral analysis of the EEG in the nondrug conditions showed that the memory task significantly reduced theta components and increased delta components. As compared with nondrug conditions, the antiepileptic drugs (AEDs) significantly impaired memory performance and produced mild EEG slowing. Memory performance did not differ statistically between the AEDs, but minor differences in spectral EEG components were noted. The results suggest that differences in the cognitive and EEG effects of CBZ and PHT are not clinically significant.

Cutaneous versus Muscular Perception of Electrically Evoked Tetanic Pain.

This work was supported in part by Laval University (sabbatical leave of Dr. A.Y. Bélanger), the School of Kinesiology at Simon Fraser University, and Medtronic of Canada Inc. There is much speculation in athletic, physical therapy, and sports medicine circles about the relative cutaneous (superficial) vs. muscular (deep) perception of pain felt during maximum electrically evoked tetanic muscle contraction. To date, very few studies have addressed the basic question of whether pain perception during electrical stimulation is more superficial (cutaneous) or deep in muscular tissue. The purpose of this study was to determine, in a group of 10 healthy male subjects, the effect of a complete sensory nerve block at the thigh on the qualities (intensity, sensory, affective) of pain (elicited by electrically induced tetanic muscle contraction) as measured by the Short-Form McGill Pain Questionnaire felt during high amplitude, 50-Hz electrical stimulation (ES) of the vastus lateralis muscle. The findings from this study provide clear evidence that a healthy individual's tolerance level to pain induced during electrically evoked maximum tetanic muscle contraction depends as much on deep muscle stimulation as it does on cutaneous or superficial stimulation. Indeed, the results show a statistically significant decrease of approximately 50% in all three qualities of pain (intensity, sensory, and affective) following the elimination of cutaneous pain pathways via the nerve blocking procedure (p < 0.05). Until it is demonstrated that the same results hold for patients who often experience pain prior to ES treatments, any clinical implications would seem to be premature. For now, clinicians must be aware that muscle, as much as skin, may limit one's ability to tolerate high amplitude ES treatments. Further research is needed on the cutaneous vs. muscular perception of electrically evoked pain in healthy and diseased populations as well as on the issue of subject and patient experience vs. nonexperience with ES. J Orthop Sports Phys Ther 1992;16(4):162-168.

Forum.

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Formulated diets versus seed mixtures for psittacines.

Psittacines are often classified as seed eaters despite studies that have established great diversity in food habits in the wild. While seeds are consumed, so are flowers, buds, leaves, fruits and cambium. Some psittacines consume part of greater than 80 species of grasses, forbs, shrubs and trees. In addition, insects may be important. Although there are few controlled studies of the requirements of psittacines, it is probable that most nutrient needs are comparable to those of domesticated precocial birds that have been thoroughly studied. Commercial seed mixes for psittacines commonly contain corn, sunflower, safflower, pumpkin and squash seeds, wheat, peanuts, millet, oat groats and buckwheat, although other seeds may be present. Because hulls/shells comprise 18-69% of these seeds and they are removed before swallowing, a significant proportion of typical seed mixtures is waste. Some of the seeds also are very high in fat and promote obesity. Common nutrient deficiencies of decorticated seeds include lysine, calcium, available phosphorus, sodium, manganese, zinc, iron, iodine, selenium, vitamins A, D, E and K, riboflavin, pantothenic acid, available niacin, vitamin B-12 and choline. Attempts to correct these deficiencies by incorporating pellets into seed mixes are usually thwarted by rejection of the pellets and disproportionate consumption of items that are more highly favored. An extruded diet formulated to meet the projected nutrient needs of psittacines was fed with fruits and vegetables to eight species of psittacines for 1 y. Fledging percentage was increased to 90% from the 66% observed during the previous 2 y when these psittacines were fed seeds, fruits and vegetables. Although this extruded diet was well accepted in a mixture of fruits and vegetables and met nutrient needs, analyses have shown that not all commercial formulated diets are of equal merit.

Comparative cognitive effects of carbamazepine and phenytoin in healthy adults.

We investigated neuropsychological effects of carbamazepine and phenytoin in 21 healthy adults using a randomized, double-blind, double-crossover design and treating each subject with each drug for 1 month, separated by a 1-month washout. There were neuropsychological evaluations at baseline, the end of each treatment month, and 1 month after the last treatment phase. Cognitive measures included Symbol Digit Modalities Test, Selective Reminding Test, Complex Figures, Paced Auditory Serial Addition Test, Stroop, Finger Tapping, Grooved Pegboard, Choice Reaction Time, P3 Event-Related Potential, Hopkins Symptom Checklist, and Profile of Mood States (POMS). Compared with nondrug conditions, the anticonvulsants significantly impaired Stroop, Choice Reaction Time, Grooved Pegboard, Hopkins, and POMS. Employing anticonvulsant blood levels as covariates, there were only two significant differences between drugs, one in favor of carbamazepine (ie, Finger Tapping) and one in favor of phenytoin (ie, Stroop). The results suggest that differences in cognitive effects of carbamazepine and phenytoin are not clinically significant.

Quality circles in the public health sector: implementation and effect.

Although the quality circle (QC) process has been used in health care, there is a conspicuous gap in the literature about its use in community health nursing. The purpose of this service/education project was to implement QCs in the public health nursing sector throughout a southern central state. The major objective was to provide QC training to approximately 250 supervisors and staff nurses so that this participative group problem-solving approach might be used as a systematic method of dealing with concerns related to quality of care. Evaluation tools, such as the Science Research Associates' attitude scale and the quality management maturity index, were used to determine whether or not the implementation of the QC program influenced the level of morale and quality management maturity. The data obtained reflected positive changes and favorable supervisory responses.

Allochiria vs allesthesia. Is there a misperception?

Allochiria is the mislocation of sensory stimuli to the corresponding opposite half of the body or space. Obersteiner (1882) introduced the term allochiria (Greek allos = other + chiria = hand), and more than 20 authors employed it in this context over the next 25 years. Stewart (1894) described a related phenomenon in which stimuli are displaced to a different point on the same extremity. He noted that the displacements were different than allochiria and coined the term allachaesthesia (ie, allesthesia) (Greek allaché = elsewhere + aisthésis = perception). Despite this historical background, Jones (1907) redefined both terms in an attempt to increase diagnostic specificity and attributed allochiria to hysteria. Jones' reinterpretation does not appear to be justified historically, etymologically, or scientifically and has resulted in contradictory definitions of allochiria and allesthesia in present-day medical dictionaries and neurologic textbooks. We advocate a return to usage consistent with the original descriptions and word derivations.