Phenobarbitone versus phenytoin monotherapy for partial onset seizures and generalized onset tonic-clonic seizures

BACKGROUND

Worldwide, phenytoin and phenobarbitone are commonly used antiepileptic drugs. They are more likely to be used in the developing world than the developed world, primarily because they are inexpensive. The aim of this review is to summarise data from existing trials comparing phenytoin and phenobarbitone.

OBJECTIVES

To review the effects of phenobarbitone compared to phenytoin when used as monotherapy in patients with partial onset seizures or generalized tonic-clonic seizures with or without other generalized seizure types.

SEARCH STRATEGY

Our search strategy has included: a) MEDLINE 1966 to 1998, b) the controlled trials register of the Cochrane Library, c) hand-searching relevant journals, d) the pharmaceutical industry, e) researchers in the field.

SELECTION CRITERIA

Randomized controlled trials in children or adults with partial onset seizures or generalized onset tonic-clonic seizures. Trials must have included a comparison of phenobarbitone monotherapy with phenytoin monotherapy.

DATA COLLECTION AND ANALYSIS

This was an individual patient data review. Outcomes were time to a) withdrawal of allocated treatment, b) 12 month remission, and c) first seizure post randomization. Data were analysed using a stratified logrank analysis with results expressed as hazard ratios (HR) and 95% confidence intervals (95% CI), where a HR>1 indicates an event is more likely to occur earlier on phenobarbitone than phenytoin.

MAIN RESULTS

To date, data have been obtained for four of ten studies meeting the inclusion criteria, amounting to 599 patients, or approximately 65% of the potential data. The main overall results (HR, 95% CI) were: a) time to treatment withdrawal 1.62 (1.22 to 2.14), b) time to 12 month remission 0.93 (0.70 to 1.23), c) time to first seizure 0.84 (0.68 to 1.05). These results indicate a statistically significant clinical advantage for phenytoin in terms of treatment withdrawal and a non-significant advantage in terms of 12 month remission. Results for time to first seizure suggest a non-significant clinical advantage for phenobarbitone.

REVIEWER'S CONCLUSIONS

The results of this review favour phenytoin over phenobarbitone, as phenobarbitone was significantly more likely to be withdrawn than phenytoin. Given that no significant differences for seizure outcomes were found, the higher withdrawal rate with phenobarbitone may be due to side effects.

Groin hernia repair in Scotland

BACKGROUND

The use of mesh for groin hernia repair has dramatically changed the way this common operation is performed. The aim of this study was to survey the methods of groin hernia repair in Scotland and to assess patient satisfaction with the operation.

METHODS

Between 1 April 1998 and 31 March 1999 all patients who underwent groin hernia repair in the National Health Service in Scotland were identified. As well as looking at the type of hernia repair performed and postoperative morbidity, patients were sent a Short Form-36 about 3 months after the operation to assess satisfaction and return to normal activity.

RESULTS

Information was obtained on 5506 (97 per cent) of patients who underwent groin hernia repair during the study period. Eighty-five per cent of patients had an open mesh repair and 4 per cent had a laparoscopic repair. Most operations (85 per cent) were performed using general anaesthesia on an inpatient basis (78 per cent), and 8 per cent were for repair of a recurrent hernia. Potentially serious intraoperative complications were rare (seven patients), although they were significantly (P < 0. 001) more likely to be associated with a laparoscopic approach or repair of a femoral hernia: relative risk compared with open inguinal hernia repair 33 (95 per cent confidence interval (c.i.) 6-197) and 22 (95 per cent c.i. 3-152) respectively. Wound complications were common and 10 per cent of patients required a district nurse to attend the wound. Patients expressed a high degree of satisfaction; 94 per cent would recommend the same operation to someone else if required.

CONCLUSION

An open mesh repair using general anaesthesia has become the repair of choice for a groin hernia in Scotland. Despite a high incidence of wound complications, patients are satisfied with this operation.

Adapting a natural (lay) helpers model of change for worksite health promotion for women

Social network interventions that utilize informal systems of helping can be an important strategy for health promotion change. This article describes the development, implementation and evaluation of a natural (lay) helping intervention for health promotion change, specifically designed for women in small rural blue-collar worksites. One hundred and four women in four intervention worksites were recruited as natural helpers, and received health and skill-building education over an 18-month period. Qualitative evaluation showed: (1) two patterns of natural helping for women, i.e. participation due to a specific health concern with either themselves or others in their personal networks, and participation due to a larger sense of the importance of health and prevention; (2) over time natural helpers expanded the diffusion of health promotion information from close network members to co-workers and were more likely to be approached by their co-workers for information; (3) group activities at the worksite, particularly around physical activity, increased over time; and (4) because of time constraints at the workplace, written materials were a major way of spreading information to co-workers. This study shows that women can be recruited and trained to diffuse health promotion information and provide support to co-workers for health behavior change.

An analysis of the interaction between mouse apolipoprotein B100 and apolipoprotein(a)

The assembly of lipoprotein(a) (Lp(a)) involves an initial noncovalent interaction between apolipoprotein (apo) B100 and apo(a), followed by the formation of a disulfide bond between apoB100 cysteine 4326 and apo(a) cysteine 4057. The structural features of apoB100 that are required for its noncovalent interaction with apo(a) have not been fully defined. To analyze that initial interaction, we tested whether apo(a) could bind noncovalently to two apoB proteins that lack cysteine 4326: mouse apoB100 and human apoB100-C4326G. Our experiments demonstrated that both mouse apoB and the human apoB100-C4326G bind noncovalently to apo(a). We next sought to gain insights into the apoB amino acid sequences required for the interaction between apoB100 and apo(a). Previous studies of truncated human apoB proteins indicated that the carboxyl terminus of human apoB100 (amino acids 4330-4397) is important for Lp(a) assembly. To determine whether the carboxyl terminus of mouse apoB100 can interact with apo(a), transgenic mice were produced with a mutant human apoB gene construct in which human apoB100 amino acids 4279-4536 were replaced with the corresponding mouse apoB100 sequences and tyrosine 4326 was changed to a cysteine. The mutant apoB100 bound to apo(a) and formed bona fide disulfide-linked Lp(a), but Lp(a) assembly was less efficient than with wild-type human apoB100. The fact that Lp(a) assembly was less efficient with the mouse apoB sequences provides additional support for the notion that sequences in the carboxyl terminus of apoB100 are important for Lp(a) assembly.

Concentrations of nevirapine, lamivudine and stavudine in semen of HIV-1-infected men

OBJECTIVE

To determine the concentrations of nevirapine (NVP), lamivudine (3TC) and stavudine (D4T) in seminal and blood plasma in HIV-1-infected men.

METHODS

Twelve HIV-1-infected men on NVP-containing regimens including 3TC (n = 8) or D4T (n = 11) provided 23 blood plasma and 22 seminal plasma samples for drug concentration and viral load quantitation. Concentrations of all drugs were assessed by sensitive validated high performance liquid chromatography (HPLC) assays. Blood plasma and seminal plasma viral loads were measured using nucleic acid sequence-based amplification (NASBA). Samples were grouped according to time after drug ingestion, 0-2, 2-4, 4-8 and 8-12 h. For matched seminal and blood plasma samples, obtained within 1 h of each other, a seminal:blood plasma ratio was calculated.

RESULTS

The concentration of NVP in seminal plasma appeared to mirror the concentrations in blood plasma. Absolute median seminal plasma NVP concentrations at 0-2, 2-4, 4-8 and 8-12 h were 3.1 microg/ml (range 1.7-4.89), 2.68 microg/ml (2.5-3.9), 2.5 microg/ml (2.3-2.7) and 3.09 microg/ml (1.3-9.1). The median seminal:blood plasma ratios for the four time periods were 0.54 (range 0.34-0.85), 0.83 (range 0.43-1.08), 0.53 (0.48-0.59), and 0.61 (0.59-0.78). 3TC and D4T appeared to reach concentrations in seminal plasma of a similar magnitude or higher than concentrations in blood plasma. The median seminal plasma viral load for all patients was less than 800 copies/ml (range < 800-11000). The median blood plasma viral load was less than 400 copies/ml (< 400-1100).

CONCLUSION

NVP reaches concentrations in the semen approximately 60% of those in the blood plasma throughout the 12 h dosing period. In a smaller dataset, 3TC and D4T concentrations in blood plasma and seminal plasma were similar. These data may well have implications for the evolution of drug-resistant virus within the genital tract.

Efficacy of virtual reality exposure therapy to treat driving phobia: a case report

An AB case design was used to examine the efficacy of virtual reality exposure therapy (VRET) in treating driving phobia. After a one week baseline, the patient received three treatment sessions over a ten day period. Treatment included practice of four VR driving scenarios. Peak anxiety decreased within and across sessions. Ratings of anxiety and avoidance declined from pre-treatment and post-treatment, with gains maintained at seven month followup. Phobia-related interference in daily functioning similarly decreased. The results suggest that it would be useful to further evaluate the efficacy of VRET for driving phobia in controlled clinical trials.

Incidence and impact of resistance against approved antiretroviral drugs

More than 15 antiretroviral drugs are now available for clinical use, and have led to significant reductions in morbidity and mortality for HIV infected individuals. Nevertheless, antiviral drug resistance emerges to all these drugs, which limits their benefit. This review addresses the biological basis of antiretroviral drug resistance, and the prevalence of specific drug resistance associated mutations in patients treated with the three currently available classes of agents, namely nucleoside analogue reverse transcriptase inhibitors, non nucleoside reverse transcriptase inhibitors and protease inhibitors. In addition, data on prevalence of HIV drug resistance in untreated individuals published to date are summarised, and the implications of potential transmission of drug resistant HIV is discussed.

Cloning and sequencing of feline and canine ice-related cDNAs encoding hybrid caspase-1/caspase-13-like propeptides

Caspases are cysteine proteases which have important roles in the activation of cytokines and in apoptosis. The ICE subfamily of caspases comprise peptides closely related to caspase-1, or interleukin-1beta (IL-1beta) converting enzyme (ICE), which promotes maturation of interleukin IL-1beta and interleukin-18 (IL-18) by proteolytic cleavage of precursor forms to generate biologically active peptides. Other members of this subfamily include caspase-4, -5, -13 and isoforms of these proteins. We report the cloning and sequencing of two feline and canine ICE-related cDNAs amplified by RT-PCR. The predicted proteins are 410 and 404 amino acids in length respectively and are most closely related to caspase-1 sequences across the N-terminal 115 amino acids and to human caspase-13 across the C-terminal sequence.

Reversed-phase high-performance liquid chromatography combined with on-line UV diode array, FT infrared, and 1H nuclear magnetic resonance spectroscopy and time-of-flight mass spectrometry: application to a mixture of nonsteroidal antiinflammatory drugs

A prototype multiply hyphenated system has been applied to the analysis of a mixture of nonsteroidal antiinflammatory drugs separated by reversed-phase HPLC. Characterization of the model NSAIDs was achieved via a combination of diode array UV, 1H NMR, FT-IR spectroscopy, and time-of-flight mass spectrometry. This combination of spectrometers allowed the collection of UV, 1H NMR, IR, and mass spectra together with atomic composition data enabling almost complete structural characterization to be performed.

Subthalamic stimulation in Parkinson's disease. Preliminary results

OBJECTIVES

We wanted to evaluate chronic subthalamic nucleus (STN) stimulation as an alternative to pallidotomy for severe Parkinson's disease symptomatology.

METHODS

Nine patients met clinical criteria for unilateral standard pallidotomy. All had severe medically refractory drug-induced dyskinesia and had reached maximal daily levodopa therapy. Pre- and postoperative videos, neuropsychometric testings and clinical stagings were administered. Three patients were selected to undergo stereotactic implantation of a deep brain stimulator (DBS) after Institutional Review Board approval and informed consent. These were performed using digitized microrecordings. The other group received unilateral pallidotomy.

RESULTS

At a mean follow-up of 6 months, our results support recent findings of significant major improvement in motor scores, activity of daily living and decrease in amount of daily levodopa intake by close to 50% after 3 months of stimulation.

CONCLUSIONS

Chronic stimulation of the STN appears to provide significant motor improvement in patients with severe Parkinson's disease and is more beneficial than pallidotomy.

Investigation of the metabolism of 14C/13C-practolol in rat using directly coupled radio-HPLC-NMR-MS

1. The metabolic fate of 14C/13C-practolol was investigated using on-line HPLC-NMR-MS following oral administration to rat. The major route of elimination for the radiolabel was via the urine with the principal biotransformation products confirmed as the 2-hydroxy- and 2-hydroxyglucronide metabolites. 2. In addition, futile deacetylation, determined by the replacement of 13C-labelled acetyl groups with endogenous 12C-acetyls accounted for approximately 7-10% of the urinary metabolites, corresponding to approximately 5% of the dose undergoing N-deacetylation. 3. Evidence for chiral metabolism was sought via NMR of isolated metabolites using beta-cyclodextrin as a chiral shift agent. Practolol was excreted as a racemate. However, some enantioselective metabolism/excretion had occurred as the hydroxy- and hydroxyglucuronide were not excreted as racemic mixtures. 4. Directly coupled radio-HPLC-NMR-MS is extremely effective for the identification of the metabolites of radiolabelled xenobiotics in urine samples.

Incidence and impact of resistance against approved antiretroviral drugs

More than 15 antiretroviral drugs are now available for clinical use, and have led to significant reductions in morbidity and mortality for HIV infected individuals. Nevertheless, antiviral drug resistance emerges to all these drugs, which limits their benefit. This review addresses the biological basis of antiretroviral drug resistance, and the prevalence of specific drug resistance associated mutations in patients treated with the three currently available classes of agents, namely nucleoside analogue reverse transcriptase inhibitors, non nucleoside reverse transcriptase inhibitors and protease inhibitors. In addition, data on prevalence of HIV drug resistance in untreated individuals published to date are summarised, and the implications of potential transmission of drug resistant HIV is discussed.

Are there age and sex differences in the investigation and treatment of heart failure? A population-based study

BACKGROUND

Heart failure is a serious, common, and growing problem. Hospital admissions, which account for the bulk of health service costs associated with heart failure, are becoming more frequent.

AIM

To determine whether management of heart failure differs by age and sex.

METHOD

A retrospective case note review of prevalent cases in 16 general practices in West London. Five hundred and eighty-three patients (57% women) with a diagnosis of heart failure were reviewed.

RESULTS

Mean age of patients with heart failure was 78 years (SD = 9.5)--74 years at diagnosis (SD = 10)--and was higher for women than men (76 years versus 71 years, P < 0.001). In 32% of patients there was no record of a chest X-ray, electrocardiogram, or echocardiogram to support diagnosis. Echocardiography, performed in 34% of patients, was less likely in older patients in both sexes (test for trend P = 0.04 in women and 0.02 in men) and, overall, in women (29% compared with 40% of men, P = 0.006). Angiotensin-converting enzyme (ACE) inhibitor treatment, recorded in 54% of patients, decreased with age in both sexes (P < 0.001) and, on unadjusted data, was more likely in men than in women (61% compared with 49%, P = 0.005). On adjustment for age, sex differences in the use of echocardiography and ACE inhibitors were reduced and no longer significant.

CONCLUSIONS

With increasing age, men and women with heart failure were less likely to have undergone echocardiography or to have received an ACE inhibitor. When account was taken of age, there were no statistically significant sex differences in management; however, because of the demographic distribution of heart failure, women are disproportionately affected by age differences in management. Clinical trials, physician practice, and service developments in heart failure have neglected older people. This balance should be redressed.

Redressing the power and effect of significance. A new approach to an old problem: teaching statistics to nursing students

Many barriers to learning are present when teaching research methods. Developing, within students of nursing, the skills of reading and interpreting research reports is vital if the profession is to contribute to the general aim of achieving a sound basis for all health care interventions. This paper overviews the current move toward evidence based practice, the challenges that are present when teaching research to nursing students and offers an approach to teaching quantitative research that will help students of nursing to understand the key concepts that form the basis of inferential statistics. In this work we argue that the traditional emphasis on probability and statistical significance needs to be redressed and that effect size and power should form the basis of teaching students the concepts involved in inferential statistics. We argue that introducing students to the key concepts in statistical decision making in a particular order, effect size then power and lastly statistical significance, will lead to a better understanding of Type I and Type II errors. After all, the purpose of hypothesis testing is to detect a treatment or intervention effect. Power is dependent upon the size of the treatment effect, thus it must be introduced after effect size. Students, we argue, must be able to understand the concept of effect size. We consider this to be a foundational concept that will help to develop a firmer grasp of the decision making processes involved in hypothesis testing. Such an approach will form a more logical approach to teaching this subject and will allow for the use of real world examples to form the basis of learning.

Computer-aided learning for the education of patients and family practice professionals in the personal care of diabetes

Diabetes Mellitus is approaching pandemic proportions across the globe. It is a disproportionately expensive condition, accounting for 5-9% of annual NHS expenditure. Family practices often play a huge role in the care of diabetic patients. Many GPs elect to play a larger role in diabetes care, but the increasing burden on the multidisciplinary secondary care team means that some of the burden has to fall to family practitioners. In order to provide a high standard of care, the practitioner requires access to continuing education regarding diabetes care. The value of patient education is undisputed. In light of this situation a computer-aided learning (CAL) system is being developed for the education of both patients and practitioners concerning diabetes and its care. The proposed system takes a two pronged approach, being aimed at both patient and practitioner. This interactive system employs multimedia technology to teach practical skills and promote and consolidate theoretical understanding. It is hoped this system will improve patient self-care, and in the long-term reduce the incidence of diabetic complications and their associated costs.

Spread of Mycobacterium tuberculosis in a community implementing recommended elements of tuberculosis control

CONTEXT

Despite improvements in tuberculosis (TB) control during the past decade, Mycobacterium tuberculosis transmission and resulting disease continue to occur in the United States.

OBJECTIVE

To determine the primary reasons for disease development from a particular strain of M tuberculosis.

DESIGN

Population-based, molecular epidemiological study.

SETTING

Urban community in the San Francisco Bay area of California with recommended elements of TB control in place.

PATIENTS

Seventy-three TB cases were reported in 1996-1997 that resulted from 1 strain of M tuberculosis as identified by TB genotyping and epidemiological linkage.

MAIN OUTCOME MEASURES

Transmission patterns involving source and secondary case-patients; primary reasons for disease development.

RESULTS

Seventy-three (33%) of 221 TB case-patients in this community resulted from this strain of M tuberculosis. Thirty-nine (53%) of the 73 case-patients developed TB because they were not identified as contacts of source case-patients; 20 case-patients (27%) developed TB because of delayed diagnosis of their sources; and 13 case-patients (18%) developed TB because of problems associated with the evaluation or treatment of contacts; and 1 case-patient (1%) developed TB because of delay in being elicited as a contact. Of the 51 TB cases identified with sources, 49 (96%) were infected within the 2 years prior to diagnosis.

CONCLUSIONS

Our results indicate that in a community that has implemented the essential elements of TB control, TB from ongoing transmission of M tuberculosis will continue to develop unless patients are diagnosed earlier and contacts are more completely identified. JAMA. 2000.

A phase II trial of topotecan in esophageal carcinoma: a Southwest Oncology Group study (SWOG 9339)

BACKGROUND

Chemotherapeutic treatments containing topoisomerase I inhibitors have shown antitumor activity against a number of solid tumors. Responses have been seen in Phase I trials using topotecan in ovarian, lung, and esophageal cancer. A phase II trial using continuous infusion topotecan was completed to assess activity in esophagus cancer.

METHODS

Forty-five eligible patients with locally-advanced or metastatic squamous cell carcinoma or adenocarcinoma of the esophagus received a regimen consisting of 24-hour continuous infusion topotecan at 1.5 mg/m2/day on Days 1, 8, 15, 22 (of 42-day cycle). Patients continued on treatment until evidence of disease progression or unacceptable toxicity.

RESULTS

Partial response was demonstrated in 1 patient (2% confirmed response rate). Thirty-six patients progressed during the first cycle of treatment. The median survival was 3 months, and the median progression-free survival was 1 month. Toxicity was mild with only one Grade 4 toxicity reported.

CONCLUSIONS

This phase II trial indicates no significant anti-neoplastic activity for topotecan administered in the dose and schedule to patients with squamous cell or adenocarcinoma of the esophagus.