Fluticasone propionate 750 micrograms/day versus beclomethasone dipropionate 1500 micrograms/day: comparison of efficacy and adrenal function in paediatric asthma

BACKGROUND

Previous studies have suggested a 2:1 efficacy advantage of fluticasone propionate (FP) over beclomethasone dipropionate (BDP) in adults on high dose inhaled steroids and children on low dose inhaled steroids. The lower doses of FP required to provide equivalent efficacy to BDP also appear to have fewer systemic effects as measured by adrenal function.

METHODS

The efficacy and safety of FP 750 micrograms/day and BDP 1500 micrograms/day were compared in 30 children with persistent asthma (requiring 1000-2000 micrograms/day of inhaled corticosteroids) in a 12 week randomised double blind crossover study. Medication was delivered by a spacer device in two divided doses. Primary efficacy variables were peak expiratory flows (PEF). Adrenal function was assessed by 24 hour urinary free cortisol levels at eight and 12 weeks and ACTH and low dose synacthen tests (LDST) at 12 weeks. The results were adjusted for sequence and period differences.

RESULTS

There was no difference in the primary efficacy variables over the two 12 week treatment periods (difference in adjusted means for morning PEF 1.3 l/min (95% CI -6.1 to 8.8), p = 0.112) and symptom scores (cough, tachypnoea, wheeze, shortness of breath; difference in adjusted means of night time scores: -0.06 (95% CI -0.14 to 0.03); p = 0.136). Similar degrees of mild adrenal dysfunction were found during BDP and FP treatment phases. Identical height gain velocities were shown during the corresponding periods.

CONCLUSIONS

FP 750 micrograms/day is as effective as BDP 1500 micrograms/day in children with persistent asthma. At these very high doses we were unable to demonstrate a safety advantage of FP over BDP as assessed by adrenal function. However, measures of adrenal function may have been influenced by concurrent and previous systemic steroid usage, and possibly by effects of disease activity.

Shared learning for community based maternity care

In order to ensure the best quality of maternity care midwives and doctors must work closely together but unfortunately the necessary interdisciplinary cooperation and respect has not always been present. This paper suggests that the benefits claimed for interprofessional education, which remain largely untested in maternity care, are being put forward as a panacea for earlier difficulties. It outlines some of the initiatives currently taking place. Material ripe for shared learning is identified and it is suggested that shared teaching in addition to shared learning for midwifery and medical students and for midwives and doctors should be the norm. Learners may then eventually provide shared care based on both their shared learning experiences and also on the role model of shared teaching. Such a major change would require considerable political will, including a shift in funding. There is some evidence that the necessary political will is developing and this may be given more emphasis by the need for teaching to follow care as the NHS becomes more primary-care led.

Operation Red Box: a pilot project of needle and syringe drop boxes for injection drug users in East Baltimore

We assessed the acceptability and the use of a community-based needle and syringe disposal project designed to serve injection drug users. In June 1996, three surplus U.S. mail collection boxes were painted red and used as syringe and needle drop boxes in locations with high drug use in East Baltimore. Acceptance of the drop boxes was measured by focus groups of residents, drug users, and police, held before and after project implementation. Use was measured by weekly counts of needles recovered from the red boxes. A sample of all deposited needles was randomly chosen for needle washing and subsequent HIV antibody testing. Community impact was measured by systematic surveys of needles discarded on public sidewalks, in areas with and areas without drop boxes. Before implementation, members of focus groups expressed concerns that drop boxes could convey mixed messages to youth (e.g., seeming to condone drug use), might result in increased loitering, and could further community stigmatization. After project implementation, all focus groups expressed support of project expansion. In the first 10 months, 2971 needles were collected. Of 156 needles tested, 10.9% were positive for HIV antibody. Needle counts on the street showed no significant change in red box areas compared with control areas. In this pilot project, red boxes were accepted by the community and drug users. Police officers also used the boxes to dispose of confiscated needles. Although limited in the number of drop boxes and follow-up time, this pilot project shows promise as a community-based method of safe needle disposal.

The impact of early and late shift changeovers on sleep, health, and well-being in 8- and 12-hour shift systems

The effects on industrial shift workers of the timing of the changeover from the night to morning shift and of the length of the shift were examined. Two groups changed over at 6 a.m. and worked either 8-hr or 12-hr shift systems; the other 2 groups changed over at 7 a.m., working either 8- or 12-hr systems. Night sleeps between consecutive shifts that started at 6 a.m. were shorter and more disrupted than those starting at 7 a.m. Day sleeps following night shifts that finished at 6 a.m. were longer and less disrupted than those finishing at 7 a.m. Early starts were associated with poorer psychological and physical health. These effects of changeover time are considered in relation to the circadian rhythms in sleep duration and propensity. Although several measures favored 12-hr shifts, physical health indicators appeared to favor 8-hr systems, especially in combination with late changeovers. However, the observed effects of shift length on chronic outcome measures are somewhat inconsistent with previous research findings.

Data for diagnosis, monitoring and treatment in indigenous health: the case of cervical cancer

Deficiencies in the availability and quality of data on the health status of indigenous Australians have long been recognised. For cervical cancer, data demonstrate a 2-5 fold greater incidence rate and an 8-10 fold greater mortality rate for Indigenous women compared to non-Indigenous Australians. However, incidence and mortality data are only available for some states and there is little or no information available on the geographic or social distribution of risk, or the reasons for risk differentials. There are also little or no data on the utilisation of, or preferences for, screening services. Thus, while there is clearly a need for a cervical cancer control program specifically to target Indigenous women, current data are inadequate to inform planning and implementation, and current systems are inadequate to monitor effectiveness. This situation is the result of insufficient research and inadequate attention to recording of Indigenous status in routine data systems and applies to a greater or lesser extent across the spectrum of health of Indigenous Australians. Health workers across the spectrum in mainstream and Indigenous medical services have a shared responsibility for improving the availability and quality of data and ensuring the appropriate use of information necessary to achieve and monitor improvements in service delivery and health status of Indigenous people.

Nursing assessment and intervention for adult hemodialysis patients: application of Roy's Adaptation Model

A comprehensive assessment tool and intervention typology for adult hemodialysis patients, based on the Roy Adaptation Model, is presented. The Roy model is reviewed, and examples from the assessment tool and intervention typology are presented. A case study illustrates application of the tool and typology to nephrology nursing. Comparison of the tool and typology with the ANNA Standards of Clinical Practice revealed that the Roy Adaptation Model includes additional important aspects of nephrology nursing practice.

Duplication of ATR inhibits MyoD, induces aneuploidy and eliminates radiation-induced G1 arrest

Chromosome 3q alterations occur frequently in many types of tumours. In a genetic screen for loci present in rhabdomyosarcomas, we identified an isochromosome 3q [i(3q)], which inhibits muscle differentiation when transferred into myoblasts. The i(3q) inhibits MyoD function, resulting in a non-differentiating phenotype. Furthermore, the i(3q) induces a 'cut' phenotype, abnormal centrosome amplification, aneuploidy and loss of G1 arrest following gamma-irradiation. Testing candidate genes within this region reveals that forced expression of ataxia-telangiectasia and rad3-related (ATR) results in a phenocopy of the i(3q). Thus, genetic alteration of ATR leads to loss of differentiation as well as cell-cycle abnormalities.

Predicting communicative competence at 2 and 3 years from pragmatic skills at 10 months

It is proposed that children play an important part in determining the kinds of linguistic experience they receive, influencing their language environment by means of early pragmatic communication. These early behaviours may also be predictive of later communicative competence. As a preliminary investigation into the wider implications of children's potential influence over their linguistic environment, a study was undertaken which looked at infant pragmatic signalling systems and joint engagement skills, to establish whether these early interactive behaviours might be related to children's subsequent communicative development. During the course of the study, the frequency and distribution of early pragmatic behaviours in a random sample of 145 10-month-old infants were investigated, and their subsequent language development followed up at ages 24 and 36 months. The study examined (a) the predictive validity of specific pragmatic behaviours at age 10 months for language development at age 24 months and (b) the specificity and stability of profiles of communicative disability at 2 and 3 years. A subset of behaviours was identified which would have correctly predicted 82.4% of children found to have communicative difficulties at 24 months and 85.4% of those who did not. Predictive language profiles drawn up at age 24 months were substantially confirmed when the children were reassessed at age 36 months. It is proposed that specific early communicative behaviours may be predictive of a child's subsequent linguistic development. Additionally, 2-year-old children will be exhibiting certain patterns of language acquisition which may be significant for subsequent linguistic development. Implications for intervention are discussed.

Work shift duration: a review comparing eight hour and 12 hour shift systems

OBJECTIVES

Shiftwork is now a major feature of working life across a broad range of industries. The features of the shift systems operated can impact on the wellbeing, performance, and sleep of shiftworkers. This paper reviews the current state of knowledge on one major characteristic of shift rotas-namely, shift duration. Evidence comparing the relative effects of eight hour and 12 hour shifts on fatigue and job performance, safety, sleep, and physical and psychological health are considered. At the organisational level, factors such as the mode of system implementation, attitudes towards shift rotas, sickness absence and turnover, overtime, and moonlighting are discussed.

METHODS

Manual and electronic searches of the shiftwork research literature were conducted to obtain information on comparisons between eight hour and 12 hour shifts.

RESULTS

The research findings are largely equivocal. The bulk of the evidence suggests few differences between eight and 12 hour shifts in the way they affect people. There may even be advantages to 12 hour shifts in terms of lower stress levels, better physical and psychological wellbeing, improved durations and quality of off duty sleep as well as improvements in family relations. On the negative side, the main concerns are fatigue and safety. It is noted that a 12 hour shift does not equate with being active for only 12 hours.

CONCLUSIONS

There can be considerable extension of the person's time awake either side of the shift. However, the effects of longer term exposure to extended work days have been relatively uncharted in any systematic way. Longitudinal comparative research into the chronic impact of the compressed working week is needed.

Proliferation signaling and activation of Shc, p21Ras, and Myc via tyrosine 764 of human granulocyte colony-stimulating factor receptor

The membrane-distal region of the cytoplasmic domain of human granulocyte colony-stimulating factor receptor (G-CSF-R) contains four conserved tyrosine residues: Y704, Y729, Y744, and Y764. Three of these (Y729, Y744, and Y764) are located in the C-terminal part of G-CSF-R, previously shown to be essential for induction of neutrophilic differentiation. To determine the role of the tyrosines in G-CSF-mediated responses, we constructed tyrosine-to-phenylalanine (Y-to-F) substitution mutants and expressed these in a differentiation competent subclone of 32D cells that lacks endogenous G-CSF-R. We show that all tyrosines can be substituted essentially without affecting the differentiation signaling properties of G-CSF-R. However, substitution of one specific tyrosine, ie, Y764, markedly influenced proliferation signaling as well as the timing of differentiation. 32D cells expressing wild-type (WT) G-CSF-R (or mutants Y704F, Y729F, or Y744F) proliferated in G-CSF-containing cultures until day 8 and then developed into mature neutrophils. In contrast, 32D/Y764F cells arrested in the G1 phase of the cell cycle within 24 hours and showed complete neutrophilic differentiation after 3 days of culture. This resulted in an average 30-fold reduction of neutrophil production as compared with the 32D/WT controls. Importantly, G-CSF-mediated activation of Shc, p21Ras and the induction of c-myc were severely reduced by substitution of Y764. These findings indicate that Y764 of G-CSF-R is crucial for maintaining the proliferation/differentiation balance during G-CSF-driven neutrophil development and suggest a role for multiple signaling mechanisms in maintaining this balance.

Phase I and pharmacokinetic study of GI147211, a water-soluble camptothecin analogue, administered for five consecutive days every three weeks

GI1147211 is a 7-substituted 10,11-ethylenedioxy-20(S)-camptothecin analogue that inhibits the nuclear enzyme topoisomerase I. In this Phase I and pharmacological study, 24 patients with advanced solid malignancies received a total of 72 courses of GI147211 as a 30-min infusion daily for 5 consecutive days, at doses ranging from 0.3 to 1.75 mg/m2/day. Severe neutropenia precluded dose escalation above 1.5 mg/m2/day in minimally pretreated patients, and both severe neutropenia and thrombocytopenia were dose limiting in heavily pretreated patients at doses above 1.0 mg/m2/day. These doses are, therefore, recommended for subsequent Phase II evaluations of GI147211 in patients with comparable prior therapy. Nonhematological toxicities, including nausea, vomiting, fatigue, and anorexia, were mild to moderate. The disposition of GI147211 in blood was described by a linear three-compartment model, with renal elimination accounting for only 11% of drug distribution. No relationship was observed between the pharmacological exposure to GI147211 and effects on neutrophils; however, patients who developed dose-limiting myelosuppression did experience greater exposure to both the lactone and total forms of the drug. The hydrolysis kinetics of GI147211 revealed not only a shift of the drug to the inactive carboxylate form in human serum albumin but also stabilization of the lactone in erythrocytes, perhaps accounting for the observed lactone:total area under the concentration-time curve ratio of 0.27. These results indicate that GI147211 exhibits predictable toxicities and that further studies are warranted to determine the distinct role of this compound among currently available camptothecin analogues.

The practice of general internal medicine by subspecialists

To determine the proportion of specialists in internal medicine at a university medical center practicing general internal medicine in addition to their specialty, full-time and voluntary faculty were asked to complete a questionnaire concerning their practice patterns. In addition, the directories of two of the largest managed-care groups in the area were reviewed to identify physicians who were also faculty members, to determine whether faculty in these directories self-identified as general internists. Excluding those with primary research appointments, 303 faculty in the Department of Medicine were asked to participate. Of these, 187 (62%) responded, of whom 86 (46%) were full-time and 101 (54%) voluntary faculty. Of the respondents, 183 (98%) were either board certified (152; 81%) or board eligible (31; 17%) in a subspecialty. Both general internal medicine and specialty medicine were practiced by 116 (65%), with full-time faculty being more likely to have solely subspecialty practices (P < .001). The majority of faculty (150; 80%) participated in managed care. A review of directories of two managed-care groups revealed that 100 (87%) of the 115 faculty with appointments within subspecialty divisions of the Department of Medicine were listed as general internists. Subspecialists in internal medicine already spend considerable time practicing general medicine and are increasingly willing to identify themselves as generalists. Unless this is recognized, the future need for generalists may be overestimated considerably.

An empirical study of the psychodynamics of suicide

This paper presents results from an empirical study of four key psychodynamic concepts (self-directed aggression, object loss, ego functioning disturbance, pathological object relations) of suicidal behavior. The sample consists of hospitalized psychiatric patients following a suicide attempt (attempters: n = 52) and demographically similar hospitalized psychiatric patients with no history of suicidal behavior (controls: n = 47). The study was designed to ascertain whether attempters differed from matched psychiatric control patients on the four psychodynamic constructs hypothesized to be associated with suicide. It was predicted that attempters would manifest higher levels of depression and self-targeted anger, a more significant history of loss, less adaptive defenses, and more primitive object representations. Results strongly supported an object-relational view of suicidal behavior. In addition, support for the loss hypothesis was found in the identification of one specific constellation of losses. Namely, attempters were significantly more likely to report a history of childhood loss combined with a recent loss in adulthood than were their nonattempter counterparts. Limited support was provided for the other two hypotheses in differentiating suicidal from nonsuicidal severely ill psychiatric patients. This unexpected finding is examined and suggestions are made for the refinement and greater specification of psychodynamic theories regarding the etiology of suicidal behavior, with the aim of differentiating individuals prone to such action from those with similar psychopathology and dynamic issues who do not actually attempt suicide. Limitations of the study are discussed and implications of the findings for the theory and treatment of suicidal behavior are offered.

Can Oxford heal itself?

The fast-growing HMO was hammered on Wall Street after revealing its massive computer problems. Those foul-ups are being fixed, but now comes the hard part--reclaiming the trust of stunned shareholders and outraged doctors.