Asthma inhalers and subsurface enamel demineralisation: an in situ pilot study.

AIM: The purpose of this pilot study was to identify the subsurface enamel demineralising potential of two possible acidogenic lactose-based powders and their corresponding generic pump inhalers. METHODS: Ten healthy non-asthmatic adults participated in a 5- leg randomised crossover study including a 10% sucrose control. A twice-daily 400 microg dose of inhaler was applied in vitro to a demineralised enamel slab on the buccal flange of a mandibular removable appliance before in situ placement for 14 days each. Lesion parameters were determined using transverse microradiography and digitised image analysis. RESULTS: Minimal demineralisation occurred with sucrose, both pump and one powder inhaler. The remaining powder was associated with remineralisation (p = 0.29). Overall, mean lesion depth increased (p = 0.12). CONCLUSION: Asthma inhalers failed to demonstrate a significant acidogenic/cariogenic effect.

Comparison of the efficacy and safety of a combination topical gel formulation of benzoyl peroxide and clindamycin with benzoyl peroxide, clindamycin and vehicle gel in the treatments of acne vulgaris.

BACKGROUND: Topical clindamycin and benzoyl peroxide have each demonstrated clinical efficacy in the treatment of acne vulgaris. When used in combination, they promise greater efficacy than either individual agent used alone and the combined use of benzoyl peroxide with topical antibacterial has been shown to decrease the emergence of antibacterial resistant species. OBJECTIVE: The objective was to determine the efficacy and safety of a combination benzoyl peroxide plus clindamycin in a gel formulation compared with each of its 2 active constituents in gel vehicle, and gel vehicle given alone in the treatment of acne vulgaris. METHODS: In this 10-week, multicenter, double-blind trial, 480 patients with moderate to moderately severe acne were randomized to receive twice-daily treatment with 5% benzoyl peroxide plus 1% clindamycin, 5% benzoyl peroxide, 1% clindamycin, or vehicle. RESULTS: Significantly greater reductions in the number of inflammatory and total lesions were demonstrated in patients using combination therapy compared with those using any of its 3 individual components. Likewise, both physicians' and patients' global evaluations showed significantly greater improvements with the combination therapy than with its individual components. The most frequent adverse effect, dry skin, occurred to a similar extent in the combination and benzoyl peroxide treatment groups. CONCLUSION: The improved efficacy obtained with the combination therapy was accompanied by a tolerability profile similar to that of benzoyl peroxide alone, making this new combination product an alternative antimicrobial therapy for acne vulgaris.

A combination benzoyl peroxide and clindamycin topical gel compared with benzoyl peroxide, clindamycin phosphate, and vehicle in the treatment of acne vulgaris.

A topical gel combining 5% benzoyl peroxide and 1% clindamycin as phosphate was evaluated in a 10-week randomized double-blind trial involving 287 patients with moderate to moderately severe acne. The combination agent demonstrated significantly greater reductions in inflammatory lesions than either of its active constituents (5% benzoyl peroxide and 1% clindamycin) or vehicle when used alone. Significantly greater reductions in comedos and improvements, as measured by both physicians' and patients' global evaluations, were obtained with the combination agent than with clindamycin or vehicle. The reduction in comedos and the global improvements were similar between the combination agent and benzoyl peroxide. The combination agent was well tolerated; the incidence of dry skin was similar to that found with benzoyl peroxide, and other adverse events were similar to that with vehicle. The improved efficacy obtained with combination therapy was accompanied by a safety profile similar to that of either constituent used alone.

Black, white, and shades of gray: common abnormalities in chest radiographs.

Chest radiographs remain one of the oldest, noninvasive methods for identifying chest diseases. This tool is relatively inexpensive, low risk, and important for the advanced practice nurse to use in making an initial differential diagnosis. Timely intervention depends on the advanced practice nurse's ability to recognize the radiographic abnormalities commonly associated with acute pulmonary disease. When linked with the history, presenting signs and symptoms, and a thorough physical assessment, the chest radiograph is key to appropriate diagnosis and management. This article reviews the basic radiographic lung densities, describes a systematic approach to ensure thorough chest radiographic interpretation, and presents characteristic chest radiographs found in the acute care setting. Selected examples of diffuse lung diseases, localized alveolar opacities, pleural effusions, and hyperlucency of the lungs will also be presented.

Cost of care for individuals with cystic fibrosis: a regression approach to determining the impact of recombinant human DNase.

We estimated direct medical costs of care and important determinants of the costs in patients with cystic fibrosis (CF), including therapy with recombinant human DNase (rhDNase). Costs were estimated with resource use data from the Epidemiologic Study of Cystic Fibrosis. Ordinary least squares regression was used to determine the effect of clinical and demographic variables on individual cost of care. The estimated cost of caring for 303 patients in Alberta was $2,279,801 in 1996. The mean cost of care was $7524 (range $386-92,376)/patient. Regression results indicated that age and forced expiratory volume predicted had a negative association with costs. Being female, receiving rhDNase, and having Pseudomonas aeruginosa or Burkholderia cepacia were all associated with high costs. Our estimates indicated large interindividual variation in cost of care for patients with CF.

Mycoplasma orale has a sequence similar to the insertion-like sequence of M. fermentans.

Polymerase chain reaction (PCR) using the Mycoplasma fermentans insertion sequence-like element (ISLE) RW primer set amplifies DNA from Mycoplasma orale when more than 1 ng is present in the reaction tube. In this study, amplified products from 11 different clinical isolates and the ATCC prototype of M. orale were sequenced and compared to 206 bp amplicons from eight isolates and the ATCC strain of M. fermentans. The nucleotide sequences of the amplified M. orale products had high sequence homology (88-92%) to those from M. fermentans, but differed at several key positions. The M. orale products contained a DraI restriction enzyme site not found in any of the M. fermentans amplified products. Consistent with this finding, the PCR products from M. orale were digested by DraI while the PCR products from M. fermentans were resistant to DraI digestion. The results suggest that M. orale may carry a similar IS-like element that complicates but does not negate using the ISLE PCR assay designed to detect M. fermentans. It appears possible for the RW primers to amplify M. orale if the mycoplasmas are present at higher concentrations. The amplified products can be differentiated from those from M. fermentans by a rapid DraI restriction endonuclease digestion or by Southern blot analysis using the RW006 internal probe under highly stringent conditions.

Lung volume reduction surgery: new hope for emphysema patients.

Lung volume reduction is a new surgical procedure for patients with severe emphysema. The hyperinflated portion of the lung or lungs is removed so the patient's chest wall and diaphragm can return to normal positions, easing breathing. This article describes the patient criteria, surgical procedure, and nursing problems and interventions related to the care of the lung volume reduction patient.

Measuring quality of life in paediatric patients.

The purpose of this paper is to highlight important considerations in the measurement of health-related quality of life (HR-QOL) in paediatric populations. Considerations specific to the evaluation of HR-QOL in children include children's understanding of the questions being asked, their understanding of their own disease, using parents as proxies, time perception problems and simply the fact that children are continually changing. We provide a review of the currently available literature regarding paediatric HR-QOL assessments to examine the different instruments and approaches taken to assess HR-QOL in paediatrics. Asthma-specific measures are discussed as examples of condition-specific HR-QOL instruments because of the considerable amount of methodological and developmental work that has been conducted in this disease. Our search strategy revealed 15 main generic and 5 main asthma-specific instruments that met our criteria for inclusion. The main points high-lighted for each instrument are the description of domains, respondent (i.e. the child, parent or clinician), age group, number of items, format of instrument (usually self-administered or by interview), original country and language, and the existence of translations. For the various studies in which the different instruments are used, the issues of patient population tested, sample size, reliability and validity are addressed. Although this paper does not attempt to be an exhaustive study of paediatric HR-QOL instruments, we provide an overview of the main generic and asthma-specific instruments, as well as an examination of the different methods used in assessing paediatric HR-QOL. Many challenges exist in the measurement of HR-QOL in paediatric patients. With increased attention to the considerations high-lighted, the field will continue to grow, and the usefulness and application of HR-QOL measures in paediatric patients is likely to improve.

Predictors of response to acute treatment of chronic and double depression with sertraline or imipramine.

BACKGROUND: The literature on predictors of response to treatment of nonchronic major depression has identified shorter duration of illness, acute onset, and less severity of illness as positive predictors. Unfortunately, there are almost no data on predictors of response to treatment for chronic depression. This study examined predictors of response to pharmacotherapy (sertraline or imipramine) in the treatment of outpatients who had DSM-III-R-defined chronic major or double depression. METHOD: The acute phase of the Chronic Major Depression and Double Depression Study is a double-blind, randomized, parallel-group 12-week comparison of sertraline and imipramine. Analyses are based on 623 patients who comprised the intent-to-treat sample, of whom 299 were nonresponders and 324 were responders, defined by a priori criteria as either remission or satisfactory therapeutic response. A stepwise logistic multiple regression analysis was performed on candidate clinical, psychosocial, and demographic variables previously identified as statistically significant in an attempt to develop a predictive model of positive antidepressant response. RESULTS: The sociodemographic variables that were predictive of positive response included living with spouse or partner or being at least a high school graduate. With regard to symptomatology and clinical history, responders had significantly lower baseline depression severity scores. In general, comorbid anxiety, substance abuse, and personality disorders did not influence rates of response. However, the presence of depressive personality traits was associated with a higher nonresponse rate. Among psychosocial variables, longer duration of personal relationships as well as higher baseline quality of life were associated with positive response. A stepwise logistic multiple regression identified 5 variables-living with spouse or partner, higher educational level, passive-aggressive personality, lower introverted-tense personality traits, and higher quality of life--that significantly and independently contributed to the predictive model. This model correctly classified 67% of patients. CONCLUSION: A higher baseline quality of life, living with spouse or partner, and having more education were the strongest predictors of response to acute pharmacotherapy among chronically depressed patients. Clinical variables and comorbidity were not identified as independent predictors, although personality traits did appear to influence treatment response. Overall, the predictive value of these baseline measures was modest, and therefore of limited clinical utility.

Health practices of critical care nurses: are these nurses good role models for patients?

BACKGROUND: Few studies have explored the health practices of critical care nurses. Critical care nurses routinely teach patients about using healthy practices such as low-fat diets, exercise, and routine screening examinations. However, it may be even more important that the nurses themselves have a healthy lifestyle, thus serving as role models for patients. Nurses are selling a product, and that product is health. The best salespersons are those who are genuinely committed to their product and model its benefits. Therefore, critical care nurses' healthful practices can have a profound effect on their patients. OBJECTIVES: The purpose of this descriptive exploratory study was to examine critical care nurses' responses to three questions about health practices in their daily lives: (1) What are critical care nurses doing currently to stay healthy? (2) Do they anticipate making any changes in their lifestyle in the future? (3) Would they recommend their lifestyle to their patients? METHODS: One hundred twenty-seven critical care nurses attending a midwestern critical care conference completed a two-part questionnaire designed to produce a health profile. In a man-on-the-street approach, 23 nurses participated in an interview via video camera. Descriptive statistics were used to analyze the data retrieved from the questionnaires. Interviews were transcribed verbatim and analyzed for themes with a constant comparative method. RESULTS: More than 70% of the critical care nurses who responded engage in exercise and follow a healthy, low-fat diet. Seventy-one percent said that they anticipate making a change in their lifestyle in the future, and 70% said that they would recommend their lifestyle to their patients. Five themes emerged from the videotaped interviews: (1) Heart-healthy practices predominated the responses. (2) Incorporating a healthy lifestyle was easy for some and a struggle for others. (3) Critical care nurses readily listed barriers to healthy living. (4) The nurses had a positive attitude about their healthy lifestyles and felt optimistic about being role models for their patients. (5) Future plans were either singular in focus or limited to maintenance of current health habits. CONCLUSIONS: The majority of the nurses reported practicing a healthy lifestyle and thought that they were good role models for patients.

An audit of in-patients aged 18-65 in acute psychiatric wards who are inappropriately placed three months after admission.

OBJECTIVE: To identify acute psychiatric patients considered inappropriately placed three months after admission and expedite a more suitable placement by improving liaison with social work. DESIGN: A survey established the point prevalence of inappropriately placed patients. Changes in usual practice were implemented with the identification of a named social worker for each ward and the introduction of a 'contact sheet' which updated the progress of these patients monthly. A repeat survey one year later assessed the impact of these changes. SETTING: Gartnavel Royal Hospital, Greater Glasgow Community and Mental Health NHS Trust. SUBJECTS: Patients aged 18-65 in the acute psychiatric wards who were resident beyond three months. RESULTS: Use of the contact sheet and improved liaison with a named social worker did not shorten the length of stay of the inappropriately placed patients. Conversely, their mean value for in-patient weeks on the dates surveyed increased from 41.8 in 1994 to 64.7 in 1995. (p = 0.05, 95% confidence intervals from -1 to 42. The length of stay of patients who were still considered to be appropriately placed beyond three months after admission decreased from a mean of 47.7 to 31.9 weeks. (p > 0.5, 95% confidence intervals from -16 to 16). By 1995 the mean length of stay was significantly greater for inappropriately placed patients (p = 0.008, 95% confidence intervals from 10 to 47). CONCLUSIONS: Improved liaison with social work at an operational level was not sufficient to solve the problem of inappropriately placed patients on acute wards. Additional factors such as limited access to rehabilitation placements and patients having complex physical or behavioural problems made placement elsewhere difficult. Such patients with unmet needs place increasing strain on acute psychiatric beds. A reappraisal of current services is required.

Laryngospasm and noncardiogenic pulmonary edema.

The incidence of laryngospasm in the PACU after extubation remains low despite the number of extubations that are performed annually. A study of general anesthesia patients conducted by Olsson and Hallen in 1977 & reported by Holmes et al (Am J Sports Med 19:365-371, 1991) showed the incidence of laryngospasm to be 8.7/1,000 patients. A literature review since 1977 presents a clinical picture of an emergent situation that may be anticipated by nursing staff (Hamlin et al: J Post Anesth Nurs 6:43-49, 1991). Noncardiogenic pulmonary edema (NCPE), also called negative-pressure pulmonary edema (NPPE) (De Franco M: Crit Care Nurse 9:20-22, 1993), and postextubation laryngospasm induced pulmonary edema (LIPE), can be a serious complication of laryngospasm. Its etiology and thus its treatment differs from other forms of noncardiogenic pulmonary edema, such as acute respiratory distress syndrome (ARDS). The PACU nurse must be aware that any patient has the potential for postextubation laryngospasm, and must be prepared to initiate appropriate treatment of noncardiogenic pulmonary edema.

Neurotrophic actions of nonimmunosuppressive analogues of immunosuppressive drugs FK506, rapamycin and cyclosporin A.

We show that the nonimmunosuppressive analogues of the immunosuppressive drugs FK506, rapamycin and cyclosporin A promote neurite outgrowth both in PC12 cells and sensory neuronal cultures of dorsal root ganglia with potencies resembling their immunosuppressive homologues. Neurotrophic potencies of the immunophilin ligands resemble their potencies in binding to and inhibiting the rotamase activity of FKBP-12 of cyclophilin. Since nonimmunosuppressive immunophilin ligands, which are devoid of calcineurin inhibitory activity, are equally neurotrophic, inhibition of calcineurin activity is not the mediator of the neurotrophic effects. The immunophilin ligands are neurotrophic in intact animals. FK506 and L-685,818 (the C18-hydroxy, C21-ethyl derivative of FK506) treatment of rats with crushed sciatic nerves enhances both functional and morphologic recovery. The striking potency of these agents, their bioavailability and the dissociation of neurotrophic from immunosuppressant actions argue for their therapeutic relevance in the treatment of neurodegenerative diseases.

Neurotrophic immunophilin ligands stimulate structural and functional recovery in neurodegenerative animal models.

Although immunosuppressant immunophilin ligands promote neurite outgrowth in vitro, their neurotrophic activities are clearly independent of their immunosuppressive activity. In the present report, a novel nonimmunosuppressive immunophilin ligand, GPI-1046 (3-(3-pyridyl)-1-propyl (2S)-1-(3,3-dimethyl-1,2-dioxopentyl)-2-pyrrolidinecarboxylate+ ++) is described. In vitro, GPI-1046 bound to FK506 binding protein-12 and elicited neurite outgrowth from sensory neuronal cultures with picomolar potency with maximal effects comparable to nerve growth factor. In vivo, GPI-1046 stimulated the regeneration of lesioned sciatic nerve axons and myelin levels. In the central nervous system, GPI-1046 promoted protection and/or sprouting of serotonin-containing nerve fibers in somatosensory cortex following parachloroamphetamine treatment. GPI-1046 also induced regenerative sprouting from spared nigrostriatal dopaminergic neurons following 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine toxicity in mice or 6-hydroxydopamine (6-OHDA) toxicity in rats. The rotational abnormality in 6-OHDA treated rats was alleviated by GPI-1046. These neurotrophic actions in multiple models suggest therapeutic utility for GPI-1046 in neurodegenerative diseases.