How well do New Zealand patients understand and manage their asthma? A community study

Patient understanding of the nature of asthma and of its management was assessed using an interviewer administered questionnaire in a community sample of asthmatics identified through prescriptions at randomly selected Dunedin city pharmacies. Of 135 subjects whose histories, and lung function data where available, were consistent with asthma, 20 did not know they had asthma. Only half could give a simple explanation of asthma, and many were confused about therapies, especially the use of corticosteroids. Only half demonstrated satisfactory aerosol inhalation technique. Deficiencies in medical management including lack of lung function monitoring, regular followup and provision of a crisis plan for severe attacks were noted. Patients previously hospitalised more often had a crisis plan and recalled advice on management of asthma, but had little knowledge about the nature of the condition. The continuing high asthma mortality rate in New Zealand may in part reflect management deficiencies both in long term care and in recognition and management of severe attacks. These may be compounded by poor patient understanding of asthma.

Use of anti-asthma drugs in New Zealand

Increased sales of anti-asthma drugs, and a second "epidemic" of asthma mortality, raised concerns about the management of asthma in New Zealand. To study this, prescriptions were obtained from randomly selected pharmacies to identify 235 patients receiving one common anti-asthma drug, 175 of whom were willing to be interviewed. The authors considered that 80% had asthma, and only 20% suffered primarily from chronic bronchitis or emphysema. The increased sales of anti-asthma drugs could not therefore be explained by their increasing use in treatment of other respiratory disorders. One third of the identified asthmatic subjects experienced daily symptoms despite regular drug treatment. Inhaled corticosteroids were used by only 42% of this group with persistent symptoms. Regular or short course oral corticosteroids, with or without inhaled steroids, had been required by 49%. All patients with domiciliary nebulisers appeared to use these appropriately, and most had peak expiratory flow meters. Despite the increased sales of anti-asthma drugs, corticosteroids appear to be as much underused in patients with chronic asthma in the community as in those who die of their disease.

Orthopaedic problems in the elderly

Orthopaedic problems affecting the elderly are discussed and related to basic bone and joint pathology. The treatment of these problems is outlined with a special call for the highest standards of medical and surgical care, by a multidisciplinary team. Early internal fixation of pathological fractures is recommended to allow early mobilisation. Total replacement arthroplasty similarly allows an early return to normal mobility in patients disabled by osteoarthrosis of a major weight bearing joint. Some aspects of the medical treatment of metabolic bone disease are also discussed.

Diminished hepatic triiodothyronine production in Gunn rats

The liver is a major site of conversion of thyroxine (T4) to the more active thyroid hormone 3,5,3'-triiodothyronine (T3). Hepatic T4 to T3 conversion is altered by a variety of pathological processes and pharmacological agents. We studied T4 to T3 conversion in glucuronyl transferase deficient homozygous Gunn rats because they have a hepatic enzyme abnormality which leads to hyperbilirubinaemia, and also because they have been reported to have alterations in thyroid hormone metabolism. An in vitro incubation system employing the 10,000 X g supernatant of liver homogenate was used, and T3 production was measured by radioimmunoassay. Experiments were done using substrate concentrations ranging from 0.56 to 20 microM, tissue protein in concentrations ranging from 0.625 to 20 mg and incubation times of 15 to 60 min. T3 production by liver homogenates from homozygous Gunn rats in these studies ranged from 29 to 70% of that produced by liver homogenates from phenotypically normal heterozygous Gunn rats. The deficit in hepatic T3 production by homozygous rats could not be overcome by increasing cofactor concentrations. After ultracentrifugation at 100,000 X g, T4-5'-deiodinase activity was found primarily in the 100,000 X g sediment fraction. Homozygous rat liver 100,000 X g sediment T3 production was 55% of that of the heterozygous rat liver 100,000 X g sediment. Liver cytosol from both homozygous and heterozygous rats inhibited microsomal T4-5'-deiodinase activity similarly. Addition of unconjugated bilirubin to liver homogenates resulted in reduction of T3 production in livers from both homozygous and heterozygous rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychological preparation influences nitrous oxide analgesia: replication of laboratory findings in a clinical setting

In an earlier laboratory study, administration of 33% nitrous oxide yielded lower, not higher, pain thresholds when combined with appropriately altered expectations of enhanced creativity and sensitivity. The present study was undertaken in an attempt to replicate this finding in a group of clinical dental patients. It was expected that anxiety would play a significant role in our findings. The present study experimentally confirms that controlled psychological preparation of the clinical subject prior to administration of conventional dental dosages of nitrous oxide can significantly modify the perception of tooth pulp pain, neutralizing and even reversing its analgesic efficacy without increasing anxiety.

Retired executives link purchasers and providers in Greater Philadelphia

A three-year project funded by the John A. Hartford Foundation of New York used retired executives and physicians to overcome Philadelphia area employers' coolness to HMOs. Acting as evaluators, facilitators, educators and advisors, the participants achieved improved understanding and helped raise HMO enrollment from 3.5% to 11.6% of the target population. The President of the Executive Service Corps of the Delaware Valley tells how.

Conferment of honorary fellowship on Sir Theodore Fox

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Genetically determined variability in acetylation and oxidation. Therapeutic implications

The clinical significance of two separate genetic polymorphisms which alter drug metabolism, acetylation and oxidation is discussed, and methods of phenotyping for both acetylator and polymorphic oxidation status are reviewed. Particular reference is made to the dapsone method, which provides a simple means of distinguishing fast and slow - and possibly intermediate - acetylators, and to the sparteine method which allows a clear separation of oxidation phenotypes. Although acetylation polymorphism has been known for some time, definite indications for phenotyping are few. It is doubtful whether acetylator phenotype makes a significant difference to the outcome in most isoniazid treatment regimens, and peripheral neuropathy from isoniazid in slow acetylators is easily overcome by pyridoxine administration. However, in comparison with rapid acetylators, slow acetylators receiving isoniazid have an increased susceptibility to phenytoin toxicity, and perhaps also to carbamazepine toxicity. It is also possible that rapid acetylators receiving isoniazid attain higher serum fluoride concentrations from enflurane and similar anaesthetics than do similarly treated slow acetylators. Thus, when drug interactions of these types are suspected, phenotyping for acetylator status may be advisable. If routine monitoring of serum procainamide and N-acetylprocainamide concentrations is practised, phenotyping of subjects prior to therapy with these agents should not be necessary. Although acetylator phenotype influences serum concentrations of hydralazine, when this drug is given in combination with other drugs acetylator phenotype has not been shown to influence the therapeutic response. Slow acetylator phenotype along with female gender and the presence of HLA-DR antigens appear to be risk factors in the development of hydralazine-induced systemic lupus erythematosus (SLE). Determination of acetylator phenotype may therefore help determine susceptibility to this adverse reaction. In the case of sulphasalazine, adult slow acetylators require a lower daily dose of the drug than fast acetylators in order to maintain ulcerative colitis in remission without significant side effects. It is therefore advisable to determine acetylator phenotype prior to sulphasalazine therapy. Work on the association of acetylation polymorphism with various disease states is also reviewed. It is possible that a higher incidence of bladder cancer is associated with slow acetylation phenotype - especially in individuals exposed to high levels of arylamines. The question as to whether idiopathic SLE is more common in slow acetylators remains unresolved. There appears to be no difference between fa

Presentation of The Academy Plaque to August H. Groeschel, M. D

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Cognitive modification of pain: information in combination with N2O

The present study sought to discover whether information clarifying how the analgesic/sedative drug nitrous oxide (N2O) works would result in increased analgesic responses to painful stimuli when various concentrations of N2O were administered. Subjects were provided with high and low levels of information regarding the action and use of N2O as an analgesic and sedative. Absolute sensation threshold (AST), pain threshold (PTh), and pain tolerance (PTo) to tooth pulp shock were measured in microamperes during administration of each of 3 concentrations of N2O (15%, 30%, and 45%, with oxygen). Subjects rated stimulus intensity and stimulus aversiveness in response to a fixed painful stimulus, and completed questionnaires regarding the perceived efficacy of N2O and their subjective mood state throughout the session. The marked differences observed in pain reports between the high information group and the control group confirm that providing information to people receiving a drug for pain relief yields higher sensation thresholds, pain thresholds, and tolerance of pain. In addition, we observed that in the presence of N2O an equivalent fixed painful stimulus will be perceived as less painful after appropriate information is provided. These findings suggest that experimentally influencing thought processes, in combination with an analgesic, can have the effect of increasing analgesia.

A pain microcomputer system for clinical and laboratory investigation

This report describes the design and use of a mobile "Pain Microcomputer System" (PMS). As a mobile clinical and laboratory research tool the PMS integrates four functions: (1) psychophysical measurement of behavioral pain responses; (2) psychophysiologic recording, including brain evoked potentials, cortical power spectrum analysis, EKG and EMG; (3) data acquisition, analysis and display; (4) peripheral communications via modem allows interaction with larger computers for more complex data analyses, extensive graphics, etc. A word processor disk facilitates writing of scientific and clinical reports. Present and future capabilities of the system for comprehensive pain research and patient care are discussed.

Cognitive reversal of expected nitrous oxide analgesia for acute pain

In a laboratory experiment, the expected analgesic action of 33% nitrous oxide was reversed by creating the expectancy of heightened awareness of bodily sensations. Pain threshold and tolerance of electrical tooth-pulp stimulation were significantly reduced. Results from a control study gave us a basis for comparison of changes in the verbal expression of pain when nitrous oxide was administered without introducing expectancies beyond those already held by the subjects. Contrasting results from the experimental and control studies confirm the powerful role of mental processes in mediating pain experience.

Analgesic effects of nitrous oxide with controlled painful stimuli

This study was designed to provide statistical estimates of the effects of N2O on pain and anxiety associated with tooth-pulp shock in a clinical and in a laboratory setting. Amounts of electric stimulation needed to first feel sensation, amounts to feel pain, and pain tolerance were measured. N2O had a significant effect on raising levels of absolute sensation, pain threshold, and pain tolerance in response to increasing electrical stimulation of teeth. These effects were noted when N2O and pulp stimulation were delivered in a clinical dental setting or in a pain-research laboratory. Subjects also decreased their evaluation of the intensity of the same stimulus as N2O was inhaled at various concentrations; their aversion to the same stimulus tended to be influenced by N2O to a greater extent than perceived intensity. Anxiety levels were reduced to a statistically significant degree.

Presentation of Academy plaque to Iago Galdston, M.D

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Microcomputer analysis of cortical power spectrum: calibration and correlates of behavioral artifacts

Cortical power spectrum (CPS) is a quantitative estimate of EEG spectral power density. The CPS provides suitably precise data for quantification and statistical inference compared to the qualitative evaluation of EGG when interpreted by clinicians or researchers. In the past decade, the CPS has been applied to the studies of cognitive functions, memory, psi phenomena, speech laterality, and states of consciousness including coma, sleep, anesthesia, pathophysiology and pain state. However, few systematic evaluations of CPS methodology have been reported, rendering cross-laboratory comparisons difficult and external validity of experimental results uncertain. This report first describes a calibration procedure employing a microcomputer system for measuring the functional relationship between input signals and output cortical powers. Second, we examine controlled behavioral artifact effects on the CPS. The behavioral artifacts observed in the CPS can provide a measurement anchor for less ambiguous interpretation of CPS experiments conducted in clinical or laboratory settings.

Asparagine-linked carbohydrate does not determine the cellular location of yeast vacuolar nonspecific alkaline phosphatase

The nonspecific alkaline phosphatase of Saccharomyces sp. strain 1710 has been shown by phosphatase cytochemistry to be exclusively located in the vacuole, para-Nitrophenyl phosphate-specific alkaline phosphatase is not detected by this procedure because the activity of this enzyme is sensitive to the fixative agent, glutaraldehyde. To determine whether the oligosaccharide of nonspecific alkaline phosphatase is necessary to transport the enzyme into the vacuole, protoplasts were derepressed in the absence or in the presence of tunicamycin, an antibiotic which interferes with the glycosylation of asparagine residues in proteins. The location of the enzyme in the tunicamycin-treated protoplasts, as determined by electron microscopy and subcellular fractionation, was identical to its location in control protoplasts. In addition, carbohydrate-free alkaline phosphatase was found in vacuoles from tunicamycin-treated protoplasts. Our findings indicate that the asparagine-linked carbohydrate moiety does not determine the cellular location of the enzyme.

Peripheral cardiovascular effects in rats after central administration of histamine and antihistamines

1. Vascularly isolated but nervously intact rat right hind limbs were perfused with blood at a constant flow rate and changes in perfusion pressure (proportional to vascular resistance), heart rate and blood pressure were monitored. 2. Histamine administered into the right lateral cerebral ventricle (i.c.v.) through guide cannulae, induced dose-dependent increases in perfusion pressure, heart rate and blood pressure. 3. Prior i.c.v. or i.v. administration of metiamide (an H2-antagonist) did not prevent the cardiovascular responses to i.c.v. histamine but rather prolonged them. Following i.c.v. or i.v. administration of chlorpheniramine (an H1-antagonist), however, changes in vascular resistance, heart rate and blood pressure were not significant. 4. Metiamide administration appeared to have some agonist activity on its own. Thus the role of H2-receptors in cardiovascular responses to centrally administered histamine remains unclear. 5. The work shows that in rats increases in nervous dishcarge to at least the hind limb vascular bed occur following central administration of histamine and conforms that increases occur in heart rate and blood pressure. These responses appear likely to be mediated through stimulation of central H1-receptors.

Blood pressure and vascular resistance in genetically hypertensive rats treated at birth with 6-hydroxydopamine

Genetically hypertensive (GH) rats of the New Zealand strain and normotensive (N) rats were sympathectomized from birth with 6-hydroxydopamine (100 mg/kg,s.c, on alternate days, seven treatments). In adult treated rats from each strain (GHTr and NTr), blood pressure was lower than normal. Functional tests and electron microscopy showed that denervation was virtually complete in mesenteric and hindlimb arteries; the innervation of the renal artery was little affected. Ganglionic blockade still caused a large fall in blood pressure in treated rats. Vascular resistance was higher in blood-perfused hindlimbs and tails of GH rats than in those of N rats; in contrast, resistance was similar in limbs and tails of GHTr and NTr rats and was greater than that found in untreated N rats. Saline-perfused limb vessels had neither neurogenic nor myogenic tone and resistance was higher in GH limbs (whether these were from treated rats or not) than in untreated N limbs. In saline-perfused NTr limbs, there was a paradoxical structural adaptation (probably luminal narrowing) of the hindlimb blood vessels and resistance was higher than in untreated N rats. The resistance of saline-perfused GH and GHTr limbs was similar. A high peripheral resistance appears to be the main mechanism sustaining genetic hypertension, and the integrity of the vasomotor sympathetic nerves is necessary for the development of this form of experimental hypertension.