The effects of triamcinolone acetonide aqueous nasal spray on adrenocortical function in children with allergic rhinitis

BACKGROUND

Suppression of adrenocortical function, a risk associated with oral corticosteroids, is minimized with intranasal corticosteroids. Triamcinolone acetonide (TAA) aqueous nasal spray, at therapeutic doses, has no measurable effect on adrenocortical function in adults with allergic rhinitis.

OBJECTIVE

This double-blind, placebo-controlled study compared the effect of once-daily TAA aqueous nasal spray (220 or 440 microg) with placebo on adrenocortical function after 6 weeks of treatment in pediatric (children 6 to 12 years of age) patients with allergic rhinitis. The pharmacokinetic profile of TAA was examined after once-daily intranasal administration of TAA aqueous nasal spray 440 microg for 6 weeks.

METHODS

Eighty children received TAA aqueous nasal spray 220 microg or 440 microg or placebo for 6 weeks. Adrenocortical function was assessed by analyzing plasma cortisol levels before stimulation (0 hour) and at 30 and 60 minutes after a rapid 1-hour intravenous cosyntropin stimulation test performed before treatment and after 6 weeks of treatment. Samples for pharmacokinetic evaluation were collected from 19 patients at baseline (0 hour) and at 0.5, 1, 1.5, and 6 hours after the final dose of study medication.

RESULTS

After 6 weeks, no significant effects on adrenocortical function were observed at 30 or 60 minutes after cosyntropin stimulation with either dose of TAA aqueous nasal spray. TAA concentrations in plasma showed rapid elimination of the drug, with little or no accumulation.

CONCLUSIONS

TAA aqueous nasal spray (220 or 440 microg/day) has no measurable effect on adrenocortical function in pediatric patients with allergic rhinitis. Pharmacokinetic parameters after 440 microg/day of TAA aqueous nasal spray indicate a rapid decline of plasma drug levels, with little or no systemic accumulation of study drug.

Prosthetic patch stabilization of crural repair in antireflux surgery in children

Nissen fundoplication is a frequently performed procedure by pediatric surgeons for the treatment of gastroesophageal reflux. Reoperation for failed fundoplication is necessary in 10 per cent of children and in 25 per cent of neurologically impaired children. In an attempt to reduce the postoperative recurrence of gastroesophageal reflux and wrap herniation, we have modified our Nissen fundoplication by reinforcing the crural repair with a horseshoe-shaped prosthetic patch. Between 1993 and 1995, 38 children underwent a Nissen fundoplication with prosthetic patch crural repair. Tension-free crural repair was performed over an esophageal dilator by suturing a horseshoe-shaped Dacron patch posterior to the esophagus. After crural repair, the standard Nissen 360 degrees wrap was constructed. Of the 38 children, 56 per cent (n = 21) were neurologically impaired. In 18 per cent of patients, the operation was performed for recurrent reflux due to wrap herniation after a Nissen fundoplication without prosthetic patch repair. One child required esophageal dilatation postoperatively for dysphagia related to esophageal stenosis. After a mean follow-up of 15 months, all patients were without symptomatic reflux or had no radiographic evidence of recurrent reflux or wrap herniation. Tension-free crural repair with a prosthetic patch may decrease postoperative reflux and wrap herniation, particularly in neurologically impaired children and in children requiring reoperation for recurrent reflux.

On gifts, payments and disputes: divorce and changing family structures in contemporary Britain

"This article considers ethnographic data collected among divorcing men and women in Britain and adopts a Maussian view of exchange in order to understand the cultural dimensions of divorce in more depth. I argue that divorcing men and women express discontinuities and continuities in their relationships by means of particular kinds of exchanges. What is of particular interest is the way that former husbands and wives place discrepant and conflicting constructions on the transfer of money and material goods between them and between themselves and their children. The article illustrates these points by examining the conflicts between fathers, mothers and their children over the emotional and economic significance of particular transactions."

Analysis of form and function in North American columnar cacti (tribe Pachycereeae)

Simple and multivariate linear models were used to demonstrate the influence of mechanical design and climate on stem morphology and branching architecture in 25 species of North American columnar cacti. The effect of phyletic inertia was tested by the method of independent contrasts. Stem girth was found to increase significantly slower with increased height within taxa (cross-sectional stem area ;ps [plant height] 0.603), than across taxon (cross-sectional stem area ;ps [plant height] 1.451). Juveniles are shown to be mechanically overbuilt and subsequently grow into more slender adult forms determined in part by structural limitations and the optimization of other stem functions. We make a structural analogy of relatively rigid columnar cacti to concrete columns and compare plants and models with similar growth forms lacking woody skeletons (barrel cacti). Taxa with woody support achieved a surface-to-volume ratio six times greater than taxa without woody support. Across taxon, cooler winter temperatures were associated with larger stem girths, and greater annual precipitation was associated with less frequent branching. The relationship between total plant surface and volume approaches isometry within taxa, but across taxon average individuals are scaled replicates. We hypothesize that architecture and average plant height are adjusted, in an evolutionary sense, to maintain geometric similitude between surface and volume along a climatic gradient.

Using metaphor to clarify emerging roles in patient care management teams

Difficult economic times, competition for scarce resources and changing organizational paradigms are driving health care institutions to re-examine the ways in which they provide care. They must continually strive to provide excellent patient care and ensure positive patient outcomes while responding to increasing fiscal constraint. At Toronto's Hospital for Sick Children, consistent with current trends, nurse managers are asked to take on broad spans of responsibility. The need to decentralize much of the decision making, problem identification and problem solving functions to the multidisciplinary team is a reality of those changes. This paper describes a process the dialysis staff undertook to better understand new organizational imperatives using an orchestra metaphor as a suggestive tool to help people clarify new roles and relationships in organizations that are evolving from a hierarchical model to a knowledge-based team approach to work. The intervention was successful for some people and not others. An analysis of the outcomes is provided from the nurse manager's perspective.

Long-term safety and efficacy of triamcinolone acetonide aqueous nasal spray for the treatment of perennial allergic rhinitis

This 12-month, multicenter, open-label study to assess the long-term safety and efficacy of triamcinolone acetonide (TAA) aqueous nasal spray for perennial allergic rhinitis (PAR) symptom relief was a continuation of a 4-week, double-blind study. Patients who received TAA Aqueous (220 micrograms/day) during the 4-week, double-blind study continued with the same treatment for the open label study; those randomized to placebo during the 4-week, double-blind study received TAA Aqueous (220 micrograms/day) for the open-label study. Dose reduction to 110 micrograms/day was allowed if it was felt that symptom relief would be maintained. Safety was assessed by daily diary entries and clinical laboratory results. Long-term efficacy was assessed by visual analog scale (VAS). Of the 172 patients who began the open-label study, 94.2 percent completed 3 months of treatment, 83.6 percent completed 6 months, and 62 percent completed 12 months. PAR symptom relief improved progressively throughout the study. Adverse events were generally mild or moderate and consistent with long-term use and winter symptoms. The most common adverse events were pharyngitis (32 percent of patients), rhinitis (28.5 percent), headache (22.1 percent), and epistaxis (18 percent). Adverse events related to the local effects of the study medication were similar to those observed in long-term studies with TAA aerosol. The aqueous nasal spray formulation of triamcinolone acetonide was well tolerated and continued to relieve nasal symptoms with long-term use in adolescent and adult patients with PAR.

An educational partnership to develop acute care nurse practitioners

Hospitals currently are involved in a restructuring of the medical and nursing workforce as fiscal restraint and downsizing proceed. Changes in organizational structure, reductions in medical school enrollments and available resident positions, and the reconfiguration of nursing positions are common events. Noted gaps in the provision of care to patients are creating an opportunity to develop a new provider, an acute care nurse practitioner (ACNP). The need for ACNPs was identified in a series of consultations between the Faculty of Nursing at the University of Toronto and affiliated hospitals. In response to this need the Faculty of Nursing, with the assistance of the Max Bell Foundation, developed a three month post masters Fast Track Acute Care Nurse Practitioner Program in collaboration with 10 hospitals. Fifty-nine masters prepared nurses successfully completed one of four cycles of a concentrated program which included courses in Pharmacology, Advanced Assessment and Clinical Decision Making, Roles and Issues, and a four-week Clinical Practicum. Evaluation of graduates' competence to fulfil the nursing and medical role expectations included focus group discussions, an external review of case studies, and a questionnaire to hospital partners about their satisfaction with the program graduates.

Evidence-based nursing practice: the state of the art

Numerous nursing leaders stress the need for stronger links between research and practice. These leaders suggest that links must be strengthened in two distinct yet complementary ways. First, practitioners and researchers must collaborate on research priorities; nurses providing direct care are perhaps best placed to know what questions need to be answered. Second, practitioners need to make better use of nursing research to establish a more evidence-based practice. Evidence-based practice enables nursing to provide and justify high-quality, cost-effective care.

Efficacy and safety of triamcinolone acetonide aqueous nasal spray in patients with seasonal allergic rhinitis

BACKGROUND

In order to accommodate increasing patient preferences a new aqueous formulation of triamcinolone acetonide nasal spray was developed for the relief of symptoms associated with seasonal and perennial allergic rhinitis.

OBJECTIVE

This multicenter, randomized, double-blind study was designed to compare the efficacy and safety of once-daily triamcinolone acetonide aqueous nasal spray (220 micrograms/day) with placebo in relieving the symptoms of seasonal allergic rhinitis due to ragweed.

METHODS

One hundred forty patients received either a once daily 220-microgram dose of triamcinolone acetonide aqueous nasal spray or placebo for 2 weeks. Patients evaluated the severity of seasonal allergic rhinitis symptoms daily for 2 weeks according to a 4-point scale (0 = absent, 1 = mild, 2 = moderate, 3 = severe). Physician and patient global evaluations of overall treatment effectiveness were assessed at the end of the treatment period.

RESULTS

Patients receiving triamcinolone acetonide aqueous nasal spray, 220 micrograms/day, had significantly (P < .05) greater improvements in all rhinitis symptoms at weeks 1 and 2 and overall for the 2-week treatment period compared with the placebo group. A significant (P = .006) improvement in the nasal index occurred as early as 12 hours after the first dose of triamcinolone acetonide aqueous nasal spray. Both patients and physicians reported a greater overall improvement in symptoms for the triamcinolone acetonide aqueous nasal spray group. There were no differences between the two treatment groups in the incidence of adverse events.

CONCLUSIONS

This study confirmed that a 220-microgram dose of triamcinolone acetonide aqueous nasal spray, administered once daily for 2 weeks, is well tolerated and reduces effectively the severity of symptoms of seasonal allergic rhinitis due to ragweed.

A comparison of effects of triamcinolone acetonide aqueous nasal spray, oral prednisone, and placebo on adrenocortical function in male patients with allergic rhinitis

BACKGROUND

One of the risks associated with the use of oral corticosteroids is suppression of adrenocortical function. Triamcinolone acetonide (TAA) aqueous nasal spray administered once daily (110 micrograms and 220 micrograms) has been shown to reduce allergic rhinitis symptoms.

OBJECTIVE

This multicenter, placebo-controlled, double-blind study determined the effects of TAA aqueous nasal spray, placebo, and oral prednisone on adrenocortical function in patients with allergic rhinitis.

METHODS

Sixty-four patients received TAA aqueous nasal spray (220 micrograms or 440 micrograms), oral prednisone (10 mg), or placebo once daily for 6 weeks. Adrenocortical function was assessed after cosyntropin stimulation for 6 hours before treatment and after 6 weeks of treatment.

RESULTS

There was no statistically significant effect on adrenocortical function in patients who received either dose of TAA aqueous nasal spray compared with placebo. In contrast, prednisone produced statistically significant (p < 0.001) reductions in adrenocortical function compared with placebo; reductions occurred in both the mean 6-hour plasma cortisol levels and mean change in 6-hour plasma cortisol levels from pretreatment.

CONCLUSION

This study demonstrated that, unlike oral prednisone, TAA aqueous nasal spray, in therapeutic doses, did not alter adrenocortical function and was comparable to treatment with placebo in its absence of measurable effects on adrenocortical function.

Placebo-controlled, double-blind study of the efficacy and safety of triamcinolone acetonide aerosol nasal inhaler in pediatric patients with seasonal allergic rhinitis

Triamcinolone acetonide (TAA) aerosol nasal inhaler has been shown to effectively relieve the symptoms of seasonal allergic rhinitis in adults and adolescents. We conducted a study to evaluate the efficacy and safety of once-daily administration of TAA aerosol nasal inhaler in pediatric patients aged 6 to 11 years with grass seasonal allergic rhinitis. This multicenter, randomized, double-blind, placebo-controlled, parallel-group study enrolled 116 children who were treated with either TAA aerosol nasal inhaler (220 micrograms/d) or placebo once daily for 2 weeks. Patients evaluated the severity of rhinitis symptoms (nasal stuffiness, discharge, sneezing, and itching) daily according to a four-point scale (0 = absent, 1 = mild, 2 = moderate, and 3 = severe). Patients' and physicians' global evaluations of overall treatment efficacy were assessed at the end of the 2-week treatment period. Patients treated with TAA aerosol nasal inhaler had significantly greater reductions in all nasal symptom scores overall and in virtually all symptoms at the end of week 1 and week 2 compared with those in the placebo group. Both patients' and physicians' global evaluations of efficacy favored TAA aerosol nasal inhaler over placebo. This study demonstrated that once-daily administration of 220 micrograms of TAA aerosol nasal inhaler was well tolerated and effectively reduced the symptoms of seasonal allergic rhinitis in pediatric patients.

Triamcinolone acetonide aqueous nasal spray for the treatment of patients with perennial allergic rhinitis: a multicenter, randomized, double-blind, placebo-controlled study

In this multicenter, randomized, double-blind, placebo-controlled study, 178 patients with symptoms of perennial allergic rhinitis (PAR) were treated with either triamcinolone acetonide (TAA) Aqueous nasal spray (220 micrograms once daily) or placebo for 4 weeks. Symptoms of PAR (nasal stuffiness, nasal discharge, sneezing, nasal index, and nasal itching) were evaluated throughout the treatment period through the use of patient diaries. In addition, both patients and physicians completed independent global evaluations of treatment efficacy at the conclusion of the study. TAA Aqueous provided clinically and statistically (P < or = 0.05) greater improvements in nasal stuffiness, sneezing, nasal index, and nasal itching over the 4-week study period than did placebo. Significant improvements in sneezing (P = 0.022) were observed as early as the first day (within 12 to 16 hours based on treatment in the morning and assessment of symptoms at bedtime), and in the nasal index (P = 0.009) by the third day after treatment with TAA Aqueous. Patients' and physicians' global evaluations of overall efficacy were concordant: 65% of patients rated their nasal symptoms greatly or somewhat improved with TAA Aqueous compared with 48% in the placebo group; physicians rated 66% of patients as having greatly or somewhat improved symptoms with the study drug compared with 48% of patients who received placebo. Adverse events were mild and the incidences were comparable for both groups; no significant changes in vital signs or clinical laboratory parameters were observed. This study demonstrated that TAA Aqueous administered once daily was well tolerated and provided relief of PAR symptoms in adults and adolescents.

Triamcinolone acetonide Aqueous nasal spray in patients with seasonal ragweed allergic rhinitis: a placebo-controlled, double-blind study

Because some patients may prefer aqueous nasal sprays and once-daily dosing for relief of seasonal allergic rhinitis symptoms, a new aqueous formulation of triamcinolone acetonide (TAA Aqueous) was developed. We conducted a randomized, placebo-controlled, double-blind study to compare the efficacy and safety of once-daily administration of 220 micrograms/d of TAA Aqueous for 1 week, followed by either 220 micrograms/d or 110 micrograms/d for an additional 2 weeks, with that of placebo in 429 patients with seasonal allergic rhinitis. Patients recorded the severity of symptoms (nasal stuffiness, discharge, sneezing, nasal index [the sum of the first three variables], nasal itching, and eye symptoms) on daily diary cards. Patients' and physicians' global evaluations of efficacy were made at the end of the 3-week study period. Both regimens of TAA Aqueous significantly improved symptoms compared with placebo at most time points. Patients demonstrated significant improvements in nasal symptoms as early as the first day of treatment (within 12 to 16 hours based on treatment in the morning and symptom assessment at bedtime). Although TAA Aqueous 220 micrograms/d provided numerically greater reductions in nasal symptoms compared with 110 micrograms/d, these differences in efficacy over the last 2 weeks were not statistically significant. The incidence of adverse effects with both TAA Aqueous regimens was low and comparable to that of placebo. In summary, during the first week of therapy, TAA Aqueous 220 micrograms/d significantly reduced nasal symptoms. During the last 2 weeks of therapy, the 110 micrograms/d regimen of TAA Aqueous was effective as continued therapy for most patients. Both the 110 micrograms/d and 220 micrograms/d regimens of TAA Aqueous provided significantly better relief of nasal symptoms than did placebo.

Significance of IgG and IgM HCV antibody secretion in vitro in patients with chronic hepatitis C: correlation with disease activity and response to interferon-alpha

Hepatitis C virus antibodies are found in the serum of most patients with chronic hepatitis C. However, the significance of the humoral response is still uncertain. In this study, in vitro IgG and IgM anti-hepatitis C virus secretion by peripheral blood mononuclear cells of patients with chronic hepatitis C was analyzed. Peripheral-blood mononuclear cells from 21 of 36 patients (58.3%) secreted IgG anti-hepatitis C virus in vitro, as demonstrated with anti-hepatitis C virus-specific enzyme immunoassays and recombinant immunoblot assays. Ten of the 36 patients (27.8%) showed both IgG and IgM anti-hepatitis C virus core in vitro. In 9 of these 10 patients, IgM anti-hepatitis C virus was also detected in serum. Patients with in vitro IgM or IgG anti-hepatitis C virus secretion had higher ALT levels in serum than did patients without such secretion in vitro (99.5 +/- 22.1 and 85.6 +/- 34.4 vs. 38.1 +/- 37.4 U/L; p < 0.0001, p < 0.001). Furthermore, with a histology activity score it was demonstrated that patients with in vitro IgM or IgG HCV antibodies (or both) had more severe chronic active hepatitis than did patients without in vitro hepatitis C virus antibody secretion (p < 0.01). To analyze the therapy outcome, we included in this study 18 patients who had received interferon-alpha previously. Seven of eight in vitro hepatitis C virus antibody-positive patients were nonresponders, whereas the in vitro hepatitis C virus antibody-negative patients were mostly complete therapy responders (8 of 10).(ABSTRACT TRUNCATED AT 250 WORDS)

Biodegradable estradiol microspheres do not affect uterine involution or characteristics of postpartum estrus in mares

Quarterhorse mares were used to investigate effects of estradiol-17beta on uterine involution, duration of estrus, interval to ovulation, and fertility achieved by breeding on the first postpartum estrus. On the day of foaling, mares were injected with biodegradable poly (DL-lactide) microspheres containing either 100 mg estradiol-17beta (25 mares) or no drug (27 mares). The treatment period was considered to last for 12 to 15 d. Estrus was determined by teasing mares (n=16) with a stallion. Ovulation was detected by transrectal ultrasonographic examination of ovaries (n=48). On Days 6, 11 and 16 post partum, transrectal ultrasonography was used to measure cross-sectional diameters of the uterine body, uterine horns, and fluid within the uterine lumen (n=28). Uteri were swabbed for bacteriologic culture, and uterine biopsies were obtained from the previously gravid uterine horn on Days 11 and 16 post partum, for assessment of endometritis and morphometric analysis of endometrial histioarchitecture (n=19). Twenty-two mares were bred on foal-heat, and pregnancy was determined by transrectal ultrasonography on 14 to 16 and 30 to 35 d after breeding. With only one exception (diameter of previously gravid uterine horn on Day 11), mean values for all measures of uterine involution did not differ between treatment groups (P > 0.05). No differences were detected between treatment group means for length of estrus or interval to ovulation (P > 0.05). No differences were detected between treatment group liklihoods for recovery of potential bacterial pathogens, presence of endometritis, or presence of intrauterine fluid at 11 or 16 d post partum (P > 0.05). Pregnancy rate of mares treated with estradiol (5 11 ; 45%) was not different from that of control mares (9 11 ; 82%; P > 0.05). Estradiol treatment did not hasten uterine involution, increase duration of estrus, delay ovulation, or increase fertility in these postpartum mares.

Incidence of hepatitis C virus infection in burn patients: detection of anti-C100, anti-C33c and anti-Core antibodies

Anti-hepatitis C virus antibodies were searched for in 45 burnt patients, at the time of burn injury and more than 6 months after burn injury. HCV infection was detected in 18% as a consequence of the numerous transfusions of blood or blood derivatives used during the post-burn treatment. Five patients displayed evidence of anti-C100, anti-C33c and anti-Core antibodies together; two patients had only anti-C100 and anti-C33c antibodies, and the last one showed only anti-Core antibodies. Chronic hepatitis was observed in 83% of HCV infections. Kinetics of appearance of anti-HCV antibodies varied between patients. Anti-Core is generally the first to be detected at high levels; however, in at least one case it was detected only two and a half months after C100 and C33c antibodies.

The role of the professional nurse. A report from the Task Force of the Department of Nursing at the Montreal General Hospital, Montreal, Quebec

In order to deal with the nursing shortage the Department of Nursing at the Montreal General Hospital commissioned a series of task forces to study recruitment and retention issues and to develop recommendations for the department. Welcoming the involvement of nurses at all levels in the organization, the task forces became a method of developing objectives and strategies to foster decentralized decision-making and professional practice, to organize care efficiently and effectively and to market nursing. This article examines the work of the Task Force on the Professional Role of the nurse. Background information on the development of the task forces, a description of current behaviours of nurses, a vision of the future role and recommendations for the support required to develop the role are included.

Tropical sprue in Hong Kong

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