The Brussels Declaration: the need for change in asthma management.

Asthma is a highly prevalent condition across Europe and numerous guidelines have been developed to optimise management. However, asthma can be neither cured nor prevented, treatment choices are limited and many patients have poorly controlled or uncontrolled asthma. The Brussels Declaration on Asthma, sponsored by The Asthma, Allergy and Inflammation Research Charity, was developed to call attention to the shortfalls in asthma management and to urge European policy makers to recognise that asthma is a public health problem that should be a political priority. The Declaration urges recognition and action on the following points: the systemic inflammatory component of asthma should be better understood and considered in assessments of treatment efficacy; current research must be communicated and responded to quickly; the European Medicines Agency guidance note on asthma should be updated; "real world" studies should be funded and results used to inform guidelines; variations in care across Europe should be addressed; people with asthma should participate in their own care; the impact of environmental factors should be understood; and targets should be set for improvement. The present paper reviews the evidence supporting the need for change in asthma management and summarises the ten key points contained in the Brussels Declaration.

Changes in asthma drug therapy costs for patients receiving chronic montelukast therapy in the U.K.

The aim of this study was to assess changes in the costs of asthma drug therapy before and during the use of chronic montelukast treatment in the U.K. A retrospective cohort analysis of a primary care database in the U.K. was carried out. Patients with chronic montelukast use (> or = 140 once-daily doses) were selected for analysis. Benchmarking data were obtained for matched patients with chronic inhaled corticosteroid (ICS) use and patients with chronic salmeterol therapy with concomitant ICS use. The main outcome measures were changes in utilization and monthly cost of asthma therapies costs. Asthma patients experienced significant (P<0.05) reductions in the monthly costs of ICS, short-acting beta-agonists and antibiotics following chronic montelukast therapy. Monthly concomitant drug costs were reduced by Pound Sterling 7.49 per month, which offset 27.5% of the additional cost of montelukast, yielding an increase in total drug costs of Pound Sterling 19.78 per month. Meanwhile, increased total drug costs for matched patients with chronic ICS use, and matched patients with chronic salmeterol therapy and concomitant ICS use, increased by Pound Sterling 5.37 per month and Pound Sterling 44.55 per month respectively. Additionally, patients using chronic montelukast therapy experienced a statistically significant (P<0.05) reduction in the use of short acting beta-agonists, and antibiotics, suggesting improvement in asthma control. Chronic use of montelukast therapy is associated with a reduction of concomitant drug therapy costs.

Bilateral synchronous mixed tumors of the parotid glands.

Bilateral synchronous mixed tumors of the parotid glands are uncommon. In this case, they occurred in association with multiple benign tumors elsewhere in the body. The larger of the two parotid neoplasms was asymptomatic and undetected on physical examination, even after its presence had been established by computed tomographic scan.

Effect of montelukast on lung function in asthma patients with allergic rhinitis: analysis from the COMPACT trial.

BACKGROUND: The Clinical Outcomes with Montelukast as a Partner Agent to Corticosteroid Therapy (COMPACT) trial demonstrated that montelukast added to budesonide (MNT + BD) was as efficacious as double the dose of budesonide (dBD) in improving morning peak expiratory flow (AM PEF) in adult asthmatics. Recent studies have demonstrated that montelukast is also effective in treating daytime and nighttime allergic rhinitis (AR) symptoms in asthmatic patients. This analysis was designed to examine whether asthmatic patients with comorbid AR respond differently than patients without comorbid AR in terms of asthma control (lung function). METHODS: There were 216 asthmatic patients in the MNT+BD group and 184 patients in the dBD group with AR. Treatment differences in the change from baseline in AM PEF were compared. Least square (LS) mean and 95% confidence interval (CI) were derived from an anova model adjusting for baseline and study site. RESULTS: There was a 9.2% increase in AM PEF from baseline in the MNT+BD group compared with a 6% increase in the dBD group. The LS mean difference [(MNT+BD)-dBD] was 14.2 l/min (P=0.028). Other secondary endpoints were similar between groups. CONCLUSION: In the subgroup of asthmatic patients with AR, a combined treatment approach that included montelukast and budesonide provided significantly greater efficacy in reducing airflow obstruction compared with doubling the dose of budesonide. These results support recommendations by the Allergic Rhinitis and its Impact on Asthma initiative that suggest a unified approach aimed at treating the airway inflammation common to both diseases is beneficial for the large proportion of asthmatics who also suffer from AR.

Phantom limb phenomenon in patients with leprosy.

The phantom limb phenomenon (PLP) was studied in 42 patients with leprosy who had limb amputation and/or digital shortening; some of the patients also had another type of limb deformity, such as claw-hand or foot-drop, which did not involve significant loss of tissue. Thirty-eight (90 per cent) of the patients reported having at least one phantom limb (PL) for a missing or deformed part. Associated with each of the three types of limb defects, two descriptively and experientially distinct types of PLs were found: the paresthetic or typical (TPL) and the painless or natural (NPL). Descriptions of the TPL and the NPL are given. The findings were compared to various reports, particularly those of Stetter and Frederiks. The leprosy TPL was similar both to the PL of amputees as frequently described in the literature, and to what Stetter and Frederiks termed the PL sensations. A close correspondence, if not identity, was noted between the NPL of leprosy patients and the equivalent categories of Stetter's PL experience and Frederiks' PL as such. Included in these three designations are aspects of the PLP that are associated with the normal, intact limb; these aspects are thought to be usual concomitants of the PLP and to constitute manifestations of the persistence of the normal body image. From our findings, we conclude that for the appearance of a PLP, the actual loss of a part of a limb, whether slow or sudden, is not required, but the loss of its sensorimotor functions is sufficient.

MR angiography of peripheral posterior inferior cerebellar artery aneurysms.

OBJECTIVE: A small subset of posterior inferior cerebellar artery (PICA) aneurysms arise distal to the vertebral artery origin of the PICA. We present two such cases seen on conventional angiography and MR angiography (MRA). MATERIALS AND METHODS: The findings in two patients are presented. In one the aneurysm presented with subarachnoid hemorrhage. The second was found incidentally but later ruptured. RESULTS: There was good agreement between the appearance of the aneurysms on MRA and conventional angiography. CONCLUSION: Awareness of the possibility of peripheral PICA aneurysms and their features is important. The positioning of the volume of excitation for MRA may have to be adjusted to include a very low PICA caudal loop.

Mandibular osteotomy complicated by styloid pain.

Although temporomandibular joint pain is not a rare complication of mandibular surgery, styloid pain syndrome has not been recognized heretofore as a complication of mandibular osteotomy. Usually styloid pain syndrome occurs following tonsillectomy or de novo. Most styloid syndromes involve the styloid process, the stylohyoid attachments, or the carotid artery. This article presents a case of stylohyoid pain syndrome caused by stretching of the stylomandibular ligament following mandibular osteotomy. Additional surgical intervention was required to relieve the symptoms in this case. Styloid process pain syndromes are reviewed.

Evaluation of nondistended pyriform sinus without respiratory maneuvers.

Detection of a nondistended pyriform sinus on cross-sectional imaging studies represents a diagnostic dilemma. The finding may be an inconstant physiologic phenomenon without clinical significance, or it may be due to tissue thickening and lack of pliability related to neoplasia or inflammation. Rescanning during respiratory maneuvers may clarify the anatomy, but full patient cooperation is needed. We demonstrate a method (turning the patient's head away from the side of the nondistended sinus) that induces distention of the pyriform sinus but does not require active patient participation.

A within-patient comparison of subcutaneous and oral sumatriptan in the acute treatment of migraine in general practice.

This study compared, for the first time in the United Kingdom, the efficacy and safety of oral 100 mg and subcutaneous 6 mg sumatriptan within a patient for the acute treatment of migraine. The patient's preference for the two formulations of sumatriptan were also recorded. The study was a multicentre, randomized, open, crossover design with an optional open parallel group extension. Individual attacks were treated with one formulation only. Over 70% of patients who treated attack 1 in both treatment periods of the crossover phase reported headache relief with each formulation at 4 h. Only 3% of patients failed to respond to at least one of the formulations at this time point. At the end of the crossover phase patient preference for the injection more than doubled from the pretreatment level in those patients who were previously naive to sumatriptan. During the optional phase of the study, 38% of patients chose to treat some attacks with oral and some with subcutaneous sumatriptan. The main reason for choosing injection was speed of relief, whilst convenience was the major reason for the use of the tablet.

Venous air embolization as a complication of pressure injection of contrast media: CT findings.

Pressurized contrast medium infusion for CT carries a risk of potentially fatal air embolization if improperly or carelessly administered. Two cases of intracardiac air embolization and three cases of subclavian venous air due to faulty contrast medium administration have been seen by the authors during a 2 year period.

Improved technique for rethreading and modifying Cope loop retention catheters.

In patients with high proximal biliary obstructions, the standard Cope biliary retention catheter may not drain the proximally obstructed bile ducts. Placing additional side holes proximally in the catheter will usually cut the retention string. We have therefore devised a simple technique for removing the string prior to making the side holes and replacing it, using the stiffening cannula provided with the catheter. The technique has proved successful in 5 cases.

Pontine calcification following radiotherapy: CT demonstration.

Development of pontine calcifications following radiation therapy for suprasellar tumors is described in two patients, 5 and 9 years old. Post-radiotherapy brain calcifications are rare in the brain stem.

Congenital ganglioglioma: report of a case with an unusual imaging appearance.

A newborn presented with a cerebral ganglioglioma. This is a rare diagnosis in a neonate. The imaging appearance (hyperdense on CT, hyperintense on T1-weighted and hypointense on T2-weighted MRI) is very unusual for this type of tumor.

Handling and acceptability of the Easi-Breathe device compared with a conventional metered dose inhaler by patients and practice nurses.

This study compared the handling and acceptability of the Easi-Breathe, a breath-actuated metered dose inhaler (MDI), with that of a conventional MDI. A total of 104 patients and 14 practice nurses took part in interviews at a central location. An additional 100 practice nurses were interviewed in a telephone study. Significantly more patients (86%) found Easi-Breathe easier than a conventional MDI to use correctly (p < or = 0.001). Overall, more patients preferred Easi-Breathe (82% vs 18%; p < or = 0.001), ease of use and confidence in successful dose delivery being the main reasons for their preference. Nurses thought that Easi-Breathe was easier for the vast majority of patients (97%) to use correctly, as well as being easier to teach and to use correctly in a crisis (p < or = 0.001). Overall, 79% of nurses preferred the Easi-Breathe to the conventional MDI (p < or = 0.001), ease of use and ease of teaching being the main reasons for their preference.