Safety and efficacy of a testosterone metered-dose transdermal spray for treating decreased sexual satisfaction in premenopausal women: a randomized trial

BACKGROUND

It is not known whether premenopausal women who report low sexual satisfaction and have low circulating testosterone levels will benefit from testosterone therapy.

OBJECTIVE

To evaluate the effects of exogenous testosterone in premenopausal women reporting diminished sexual function.

DESIGN

Randomized, double-blind, placebo-controlled, dose-ranging trial.

SETTING

6 Australian medical centers.

PATIENTS

261 women age 35 to 46 years who reported a decrease in satisfying sexual activity relative to their younger years and had a morning serum free testosterone level less than 3.8 pmol/L (<1.1 pg/mL).

INTERVENTION

3 different doses of testosterone administered by a metered-dose transdermal spray for 16 weeks or placebo.

MEASUREMENTS

The primary outcome was the mean number of self-reported satisfactory sexual events (SSEs) over 28 days at week 16. The frequency of SSEs, total number of sexual events (every 4 weeks), scores from the modified Sabbatsberg Sexual Self-Rating Scale and the Psychological General Well-Being Index, and safety variables were also measured.

RESULTS

The number of SSEs increased during the treatment period in the active treatment groups and the placebo group. The mean number of SSEs over 28 days at week 16 was statistically significantly greater for women treated with the intermediate dose of testosterone therapy (one 90-microL spray) than for women treated with placebo. The least-squares mean was 2.48 versus 1.70 SSEs, respectively (event rate ratio, 1.49 [95% CI, 1.01 to 2.18]; P = 0.04). The frequency of SSEs in women treated with low and high doses of testosterone did not differ from that in women who took placebo. The rate ratios based on the least-squares mean rates of SSEs during weeks 4 to 16 for each treatment group showed statistically significant or borderline significant increases in all testosterone groups compared with the placebo group. The rate ratios for the one 56-microL spray, one 90-microL spray, and two 90-microL sprays treatment groups were 1.34 (CI, 0.97 to 1.85; P = 0.081), 1.48 (CI, 1.07 to 2.06; P = 0.018), and 1.38 (CI, 1.00 to 1.92; P = 0.052), respectively. At week 16, 95% of women treated with the one 90-microL dose had a free testosterone level less than the upper limit of the reference range for women. The most frequently reported adverse event was hypertrichosis, which was dose-related and mostly confined to the application site. No clinically relevant changes in blood test values, serum biochemical variables, or vital signs occurred.

LIMITATION

The study duration was short, and the placebo effect was strong.

CONCLUSION

A daily 90-microL dose of transdermal testosterone improves self-reported sexual satisfaction for premenopausal women with reduced libido and low serum-free testosterone levels by a mean of 0.8 SSE per month. The rate of SSEs with higher and lower testosterone doses did not differ from that with placebo.

The older persons' assessment and liaison team 'OPAL': evaluation of comprehensive geriatric assessment in acute medical inpatients

BACKGROUND

Reducing hospital length of stay (LOS) in older acute medical inpatients is a key productivity measure. Evidence-based predictors of greater LOS may be targeted through Comprehensive Geriatric Assessment (CGA).

OBJECTIVE

Evaluate a novel service model for CGA screening of older acute medical inpatients linked to geriatric intervention.

SETTING

Urban teaching hospital.

SUBJECTS

Acute medical inpatients aged 70+ years.

INTERVENTION

Multidisciplinary CGA screening of all acute medical admissions aged 70+ years leading to (a) rapid transfer to geriatric wards or (b) case-management on general medical wards by Older Persons Assessment and Liaison team (OPAL).

METHODS

Prospective pre-post comparison with statistical adjustment for baseline factors, and use of national benchmarking LOS data. Pre-OPAL (n = 46) and post-OPAL (n = 49) cohorts were similarly identified as high-risk by the CGA screening tool, but only post-OPAL patients received the intervention.

RESULTS

Pre-OPAL, 0% fallers versus 92% post-OPAL were specifically assessed and/or referred to a falls service post-discharge. Management of delirium, chronic pain, constipation, and urinary incontinence similarly improved. Over twice as many patients were transferred to geriatric wards, with mean days from admission to transfer falling from 10 to 3. Mean LOS fell by 4 days post-OPAL. Only the OPAL intervention was associated with LOS (P = 0.023) in multiple linear regression including case-mix variables (e.g. age, function, 'geriatric giants'). Benchmarking data showed the LOS reduction to be greater than comparable hospitals.

CONCLUSION

CGA screening of acute medical inpatients leading to early geriatric intervention (ward-based case management, appropriate transfer to geriatric wards), improved clinical effectiveness and general hospital performance.

Factors affecting sexuality in older Australian women: sexual interest, sexual arousal, relationships and sexual distress in older Australian women

OBJECTIVE

To investigate the sexual behavior, sexual relationships, sexual satisfaction, sexual dysfunction and sexual distress in a population of older urban Australian women.

METHOD

In 2004, 474 women participating in the Longitudinal Assessment of Ageing in Women (LAW) Study completed a series of questionnaires about sexuality. They included the Short Personal Experiences Questionnaire (SPEQ), Relationship Assessment Scale (RAS), Female Sexual Distress Scale (FSDS), questions concerning past sexual abuse based on the Sex in Australia Study, and questions comparing present and past sexual interest and activity.

RESULTS

The percentage of women with partners ranged from 83.3% in the 40 - 49-year age group to 46.4% women in the 70 - 79-year age group. The sexual ability of partners diminished markedly with age, with only 4.8% of the partners using medication to enable erections. Only 2.5% of women reported low relationship satisfaction. The incidence of sexual distress was also low, being reported by only 5.7% of women. Younger women and women with partners had higher levels of distress than older women. Indifference to sexual frequency rose from 26.7% in women aged 40 - 49 years to 72.3% in the 70 - 79-year age group. Past sexual abuse was recalled by 22.7% of women and 11.6% recalled multiple episodes of abuse. Women who recalled abuse had lower scores for satisfaction with sexual frequency.

CONCLUSIONS

It appears from this study that there is a wide range of sexual experience amongst aging women, from never having had a sexual partner, to having solitary sex, to having a relationship with or without sex into the seventh decade. As women age, they experience a decrease in sexual activity, interest in sex, and distress about sex. This may be associated with the loss of intimate relationships as part of separation, divorce or bereavement. Decreased sexual activity with aging may be interpreted as a biological phenomenon (part of the aging process) or as sexual dysfunction, or it may be the result of adapting to changed circumstances.

[Semantic dementia, a many-worded disorder]

INTRODUCTION

Semantic dementia is a progressive, relatively selective disorder affecting the semantic system with involvement of the verbal and non-verbal functions. The clinical picture is well characterised despite the confusion that may be generated by the different ways of classifying it. AIM. To determine the clinical, neurolinguistic, imaging and pathological features of this progressive language disorder.

DEVELOPMENT

Evaluation of language reveals above all the existence of semantic paraphasias, disorders affecting the comprehension of isolated words and surface dyslexia. Flow of speech, complex syntactic comprehension and grammar are preserved. Both episodic and autobiographic memory are close to normality. Both the clinical signs and symptoms and imaging studies agree on the fact that the most heavily affected area is the anteroinferomedial region of the temporal lobe on a bilateral scale but with predominance of the left-hand side. Pathologically, in most cases positive intraneuronal ubiquitin inclusions are observed like those described in motor neuron diseases.

CONCLUSIONS

Semantic dementia constitutes a diagnosis challenge, mainly from the neuropsychological point of view. Further advances towards reaching a diagnosis would allow us to determine which area is mainly affected and, in the future, to find an effective treatment for this progressive, degenerative disorder.

Testosterone patch for the treatment of hypoactive sexual desire disorder in naturally menopausal women

OBJECTIVE

To evaluate the efficacy and safety of a testosterone patch for the treatment of women with hypoactive sexual desire disorder after natural menopause.

DESIGN

A multicenter, randomized, double-blind, placebo-controlled, parallel-group trial was conducted in naturally menopausal women with hypoactive sexual desire disorder receiving a stable dose of oral estrogen with or without progestin (N = 549). Women were randomized to receive testosterone 300 microg/day or placebo patches twice weekly for 24 weeks. The primary efficacy measure was change from baseline in frequency of total satisfying sexual activity over a 4-week period (weeks 21-24).

RESULTS

A total of 483 women (88%) were included in the primary analysis population (those with baseline sex hormone binding globulin levels < or = 160 nmol/L). The change from baseline in number of total satisfying sexual episodes was significantly greater for testosterone compared with placebo (participants with baseline sex hormone binding globulin levels < or = 160 nmol/L, mean change of 2.1 +/- 0.28 versus 0.5 +/- 0.23 episodes/4 weeks; P < 0.0001; intent-to-treat population, mean change from baseline of 1.9 +/- 0.26 versus 0.5 +/- 0.21 episodes/4 weeks, P < 0.0001). Testosterone also produced statistically significant improvements compared with placebo in all secondary efficacy measures, including sexual desire and personal distress. The testosterone patch was well tolerated.

CONCLUSIONS

Testosterone patch treatment increased the frequency of satisfying sexual activity and sexual desire, decreased personal distress, and was well tolerated in naturally menopausal women with hypoactive sexual desire disorder.

A Prospective Analysis of Fenestrated Endovascular Grafting: Intermediate-term Outcomes

PURPOSE

To assess the intermediate-term outcomes following fenestrated grafting for juxtarenal aneurysms.

MATERIALS AND METHODS

A prospective trial was conducted on patients with short proximal necks, who were considered to be high-risk for open repair and unacceptable for conventional endovascular repair. Devices were designed from reconstructed CT data. Follow-up studies included CT, duplex ultrasound, and KUB and occurred at hospital discharge, 1, 6, and 12 months and annually thereafter.

RESULTS

One hundred and nineteen patients were treated (2001-2005). Mean age and aneurysm size were 75 years and 65 mm, respectively, and 82% were male. A total of 302 visceral vessels were inferior to the fabric seal (a mean of 2.5 vessels per patient), with the most common design incorporating two renal arteries and the SMA (58%). All prostheses were implanted successfully without any acute visceral artery loss. The mean follow-up was 19 months (0-42 months). One patient died within 30 days of device implantation. Kaplan-Meier estimates of survival at 1, 12, 24, and 36 months are 0.99, 0.92, 0.83 and 0.79. There were no ruptures or conversions. Pre-discharge imaging noted 11 type I and type III endoleaks. The 30-day endoleak rate was 10% (all type II). Aneurysm sac size decreased (>5 mm) in 51, 79 and 77% at 6, 12 and 24 months, respectively. One patient had sac enlargement within the first year, associated with a persistent type II endoleak. In-stent stenoses occurred in 12 renal arteries and one SMA. Six renal arteries and the SMA stenosis were treated and two renal stenoses are awaiting treatment. Ten of 231 stented renal arteries occluded (three prior to discharge), one of which was recanalized. One component separation was treated with an extension at 2 years.

CONCLUSIONS

The placement of endovascular prostheses with graft material incorporating the visceral arteries is safe and appears to be effective at preventing rupture. Continued follow-up to assess the long-term benefit, aneurysm sac behavior and effect of stenting upon the visceral ostia remains critical.

A case of multiple cerebral abscesses due to infection with Cladophialophora bantiana

Cladophialophora bantiana is a highly neurotropic fungus which has been reported to cause a variety of infections in the immunocompromised and transplant populations. We describe a case of multiple cerebral abscesses caused by this dematiaceous fungus in a patient with probable Duncan's syndrome. The patient also had extensive extra-cerebral disease, which is unusual for infection with this organism. We discuss previously described cases of infection with Cladophialophora bantiana, and review the current and evolving treatment options.

Guidelines for the management of postmenopausal osteoporosis for GPs

BACKGROUND

Since the last series of guidelines on the management of osteoporosis from Osteoporosis Australia was published in Australian Family Physician (October 2002), there have been further advances in our understanding of the treatment involved in both the prevention of bone loss and the management of established osteoporosis.

OBJECTIVE

This article provides updated guidelines for the management of postmenopausal osteoporosis to assist general practitioners identify those women at risk, and reviews current treatment strategies.

DISCUSSION

Osteoporosis and its associated problems are major health concerns in Australia, especially with an aging population. While important principles of management are still considered to be maximising peak bone mass and preventing postmenopausal bone loss, new clinical trial data about drugs such as the bisphosphonates, raloxifene and oestrogen have recently become available and the relative role of various agents is gradually becoming clearer. The use of long term hormone therapy has mixed risks and benefits that requires individual patient counselling.

Primary Endovascular Repair of Juxtarenal Aneurysms with Fenestrated Endovascular Grafting

PURPOSE

To evaluate outcomes of an endovascular graft incorporating the visceral aortic segment with graft material in the setting of juxtarenal aneurysms.

MATERIALS AND METHODS

A prospective analysis of patients undergoing implantation of an endovascular device with graft material proximal to the renal arteries was conducted. All patients were deemed unacceptable candidates for open surgical repair and had proximal neck length=<10 mm, or =<15 mm with a compromising morphology (funnel or thrombus). Fenestrations were customized to accommodate aortic branch anatomy based upon CT and intravascular ultrasound data. Selective visceral ostia were treated with balloon expandable stents following endograft deployment. All patients were evaluated with CT, duplex ultrasound, and abdominal radiograph at discharge, 1, 6, 12 and 24 months.

RESULTS

A total of 32 patients were enrolled in the trial. Short proximal necks (3-10 mm) were present in 22, and 10 had necks 10-15 mm in length with concomitant angulation or thrombus compromising neck quality. Endograft design included bifurcated (30) and aortic tube (2) systems. A total of 83 visceral vessels were incorporated (mean of 2.6 per patient). These most commonly included both renal arteries and the SMA. All prostheses were implanted successfully without the acute loss of any visceral arteries. The mean follow-up was 9.2 months (range 0-24 months). One patient died within 30 days of device implantation and hypogastric bypass following the development of aspiration pneumonia. Three early (<30 days) and three late secondary interventions were performed. The 30-day endoleak rate was 6.5%. The aneurysm sac decreased greater than 5 mm in 58% of patients at 6 months and in 75% of patients at 12 months. One patient, with a persistent type II endoleak had 5 mm of sac growth over 12 months. Six patients had transient or permanent elevation of serum creatinine (>30% from baseline), with one requiring hemodialysis. Of the 83 vessels incorporated, three late stenoses (all successfully treated with an endovascular approach) and two renal occlusions were detected during follow-up. Three patients died of unrelated causes during the follow-up period.

CONCLUSIONS

The placement of endovascular prostheses with graft material incorporating the visceral arteries is technically feasible. The incidence of endoleaks is exceptionally low. It remains critical to follow the status of stented visceral vessels, and establish the long-term efficacy of this type of repair.

Defining the sports medicine specialist in the United Kingdom: a Delphi study

OBJECTIVE

To define the role and responsibilities of the sports medicine specialist using a recognised research technique.

METHODS

A Delphi technique was employed using anonymous postal questionnaires sent to a random sample of 300 members of the British Association of Sport and Exercise Medicine. The questionnaire of 300 putative attributes was developed in a pilot study and the Delphi technique used allowed participants to modify their responses according to the responses of other participants.

RESULTS

There was a 53% response to both rounds of the study with 75.6% of the respondents being male, 39% having a higher qualification in sports medicine, and 45.6% being general practitioners. Some 86.3% strongly agreed that sport and exercise medicine should be a recognised speciality and 90% strongly agreed that it should be available on the National Health Service (NHS). The most important specialist attributes were orthopaedic and soft tissue medicine (83.6% strongly agreed) and emergency medical management (79.7% strongly agreed). More than 75% of respondents did not agree that either research or personal playing experience were relevant.

CONCLUSION

Sports and exercise medicine is an evolving speciality in the United Kingdom. We believe this is the first systematic attempt to define the role and responsibilities of the sports medicine specialist and the findings are of relevance to the future development of a career pathway.

Unusual stab injury of the spinal cord

OBJECTIVE

To report an unusual penetrating stab injury of the spinal cord.

DESIGN

Case report of a 13-year-old boy who sustained cervical trauma following an accident while playing.

SETTING

Spinal Cord Injuries Unit, Musgrave Park Hospital, Belfast, UK.

CASE REPORT

Mechanism of injury was by a spear-like electric fence post entering the neck. Initial neurological examination revealed tetraplegia with C4 sensory level. Magnetic resonance imaging (MRI) of spinal cord demonstrates the penetrating injury.

CONCLUSION

No ligamentous instability was demonstrated. In the absence of this, the penetrating injury by a short blade thrown at speed was felt to be responsible for the subsequent injury and resulting outcome at discharge of C4 American Spinal Injury Association (ASIA) grade D tetraplegia.

Anti-arrhythmic actions of polyunsaturated fatty acids in cardiac muscle exerted via the sarcoplasmic reticulum

Cardiac arrhythmias can be triggered from ischaemic cardiac muscle due to the damage inflicted on individual myocytes. During an ischaemic episode free fatty acids accumulate in the ischaemic tissue. The importance of these fatty acids lies in the apparent ability of some classes of fatty acid to protect against cardiac arrhythmias. As cardiac sudden death is a likely cause of death in patients who have suffered an initial ischaemic insult, protection against such arrhythmias may be of crucial importance. The following review discusses how this protection may be produced, dealing specifically with changes in electrophysiological properties of cells and intracellular calcium regulation.

Quality assessment of genetic markers used for therapy stratification

PURPOSE

Therapy stratification based on genetic markers is becoming increasingly important, which makes commitment to the highest possible reliability of the involved markers mandatory. In neuroblastic tumors, amplification of the MYCN gene is an unequivocal marker that indicates aggressive tumor behavior and is consequently used for therapy stratification. To guarantee reliable and standardized quality of genetic features, a quality-assessment study was initiated by the European Neuroblastoma Quality Assessment (ENQUA; connected to International Society of Pediatric Oncology) Group.

MATERIALS AND METHODS

One hundred thirty-seven coded specimens from 17 tumors were analyzed in 11 European national/regional reference laboratories using molecular techniques, in situ hybridization, and flow and image cytometry. Tumor samples with divergent results were re-evaluated.

RESULTS

Three hundred fifty-two investigations were performed, which resulted in 23 divergent findings, 17 of which were judged as errors after re-evaluation. MYCN analyses determined by Southern blot and in situ hybridization led to 3.7% and 4% of errors, respectively. Tumor cell content was not indicated in 32% of the samples, and 11% of seemingly correct MYCN results were based on the investigation of normal cells (eg, Schwann cells). Thirty-eight investigations were considered nonassessable.

CONCLUSION

This study demonstrated the importance of revealing the difficulties and limitations for each technique and problems in interpreting results, which are crucial for therapeutic decisions. Moreover, it led to the formulation of guidelines that are applicable to all kinds of tumors and that contain the standardization of techniques, including the exact determination of the tumor cell content. Finally, the group has developed a common terminology for molecular-genetic results.

Gaining insight: who benefits from residential, integrated treatment for people with dual diagnoses?

This retrospective study examines 18-month outcomes for 38 participants in an urban, residential integrated treatment (IT) program, and whether residents experienced different treatment benefits. Informed by an ACT team approach, the program emphasized harm reduction and motivational interventions. The design is naturalistic, and outcomes are self-comparisons over time reported in the aggregate. Repeated measurements with three standardized scales tracked stage of treatment and extent of alcohol and drug use. Outcomes analyses reveal advancements in stage of treatment and significant reductions in use of alcohol and drugs. Participants also worked more and were hospitalized less.

Guidelines for the treatment of postmenopausal osteoporosis for general practitioners

BACKGROUND

Osteoporosis Australia has been committed to the education of general practitioners and the community with a series of updated guidelines on the management of osteoporosis. Since the last series was published in Australian Family Physician (August 2000), there have been further advances in our understanding of the treatments involved in both prevention of bone loss and the management of established osteoporosis.

OBJECTIVE

This article represents updated guidelines for the treatment of postmenopausal osteoporosis to assist GPs identify those women at risk and to review current treatment strategies.

DISCUSSION

Osteoporosis and its associated problems are major health concerns in Australia, especially with an aging population. While important principles of management are still considered to be maximising peak bone mass and preventing postmenopausal bone loss, new clinical trial data about drugs such as the bisphosphonates, raloxifene and oestrogen have recently become available and the relative role of various agents is gradually becoming clearer. The use of long term hormone replacement therapy has mixed risks and benefits that requires individual patient counselling.

Assessing the dietetic needs of different patient groups receiving enteral tube feeding in primary care

AIM

To examine the nature of all contacts between adult tube-fed patients and the dietetic service and to refine the current dietetic protocols to reflect the findings of the study with a view to improving patient care.

METHODS

All adult patients referred to the Community Nutrition and Dietetic Service within a 6-month period were included in the study. Using a proforma developed from a retrospective case-note analysis, data were collected on the complications that prompted more frequent contacts than the department protocol. Data were analysed using the Statistical Package for the Social Sciences.

RESULTS

The most common indication for home enteral feeding in this group of adult patients was a swallowing disorder resulting from a cerebrovascular accident (59.5%) followed by cancer (21.5%). There was a trend for cancer patients to need more intervention compared with those patients with other medical conditions. A significant difference was observed in the total contacts and telephone calls given to those patients in there own homes (P=0.019) and there was a trend towards more domicilary visits with this group.

CONCLUSIONS

The department protocols have been revised to include a planned review within 2-6 weeks of initial dietetic assessment in the community for those patients who were identified to have the greatest need. More intensive dietetic monitoring has clear implications for dietetic services in the community.

Sports medicine and the accident and emergency medicine specialist

BACKGROUND

Sport and exercise related injuries are responsible for about 5% of the workload in the accident and emergency (A&E) department, yet training in sports medicine is not a compulsory part of the curriculum for Higher Specialist Training.

AIM

To determine how A&E medicine consultants and specialist trainees view their role and skill requirements in relation to sports medicine.

METHOD

A modified Delphi study, consisting of two rounds of a postal questionnaire. Participants were invited to rate the importance of statements relating to the role and training of the A&E specialist in relation to sports injuries (six statements) and the need for knowledge and understanding of defined skills of importance in sports medicine (16 statements). VALUE OF RESEARCH: This provides a consensus of opinion on issues in sport and exercise medicine that have educational implications for A&E specialists, and should be considered in the curriculum for Higher Specialist Training. There is also the potential for improving the health care provision of A&E departments, to the exercising and sporting population.

Genetic insights into the neurodevelopmental hypothesis of schizophrenia

The original neurodevelopmental hypothesis of schizophrenia presented by D.R. Weinberger in 1987 focused on pathogenesis and did not address etiology. Available evidence indicates that genetic factors are the principal cause of schizophrenia. It is imperative that any pathogenetic model for schizophrenia takes into account what is now known about genetic mechanisms of illness. Recent advances in molecular genetics can provide insights into the neurodevelopmental expression of the illness and what future genetic discoveries are likely to contribute to our understanding of schizophrenia. In this article, we propose a genetic model of etiopathogenesis that is consistent both with a modified neurodevelopmental hypothesis and our current knowledge about schizophrenia and molecular genetics.

Daughters and mothers exercising together (DAMET): a 12-week pilot project designed to improve physical self-perception and increase recreational physical activity

This paper presents the results of a 12-week single-sex, family-based physical activity intervention grounded in Social Cognitive Theory. Mother/daughter pairs and triads (n = 20) attended physical activity and classroom sessions twice weekly. Physiological data (VO2peak, height, and weight), psychological data (physical self-perception profile subscale scores), information about physical activity participation (PAP, d x wk(-1)) and qualitative impressions (QI) of the program were collected pre- and post-intervention. PAP and QI were also collected 6-months after completing the intervention. Although no significant increases in physical activity were reported, significant improvements in perceived sport competence, physical condition, and strength and muscularity were reported over time. The social cognitive theory, as used to plan this physical activity intervention, offered a promising theoretical perspective for facilitating improved physical self-perception in adolescent girls and their mothers.

Nitinol stent insertion for post-pneumonectomy syndrome

Post-pneumonectomy syndrome is an unusual condition, that can occur a variable period of time after a patient has had a pneumonectomy. Management of this syndrome has been described using a number of different techniques, often with considerable mortality. We present a case report where this condition was treated successfully by insertion of an expandable Nitinol stent. This is the first time this technique has been described to treat this condition, and we feel it may be the procedure of choice in managing these patients.

A Val193Met mutation in GPIIIa results in a GPIIb/IIIa receptor with a constitutively high affinity for a small ligand

We have identified a patient designated as (GTa) with Glanzmann's Thrombasthenia (GT) diagnosed on the basis of a prolonged bleeding time and failure of the patient's platelets to aggregate. The number of glycoprotein (GP)IIb/IIIa receptors on the platelet surface was 37% of normal and those receptors displayed a defect in soluble fibrinogen binding. Nevertheless, GTa platelets showed increased adhesion to solid-phase fibrinogen and binding affinity for the RGD-mimetic (3)H-SC52012, a non-peptide GPIIb/IIIa antagonist. Dithiothreitol (DTT) and ADP enhanced the affinity for [(3)H]-SC52012 in normal platelets, but had little effect in GTa platelets. These findings suggested that GTa platelets were locked in an altered affinity state. Genetic analysis showed that GTa was a compound heterozygote for the GPIIIa gene. One allele showed a deletion at the 3' end of exon 3 resulting in a premature stop codon. The second GPIIIa allele had a G to A transition at nucleotide 577, resulting in a Val193Met substitution. HEK 293T cells transfected with mutant GPIIb/IIIaV193M bound [(3)H]-SC52012 with a higher affinity than wild-type GPIIb/IIIa, and this was not increased by DTT. The mutant receptor distinguishes between platelet adhesion and aggregation, and demonstrates the phenotype that may be expected when platelet aggregation alone is inhibited.

Improved asthma control with budesonide/formoterol in a single inhaler, compared with budesonide alone

Budesonide/formoterol in a single inhaler was compared with budesonide alone, and with concurrent administration of budesonide and formoterol from separate inhalers, in patients with asthma, not controlled with inhaled glucocorticosteroids alone. In this 12-week, double-blind, randomized, double-dummy study, 362 adult asthmatics (forced expiratory volume in one second 73.8% of predicted, inhaled glucocorticosteroid dose 960 microg x day(-1)) received single inhaler budesonide/formoterol (Symbicort Turbuhaler) 160/4.5 microg, two inhalations b.i.d., or corresponding treatment with budesonide, or budesonide plus formoterol via separate inhalers. There was a greater increase in morning peak expiratory flow (PEF) with single-inhaler (35.7 L x min(-1)) and separate-inhaler (32.0 L x min(-1)) budesonide and formoterol, compared with budesonide alone (0.2 L x min(-1); p<0.001, both comparisons); the effect was apparent after 1 day (p<0.001 versus budesonide, both comparisons). Similarly, evening PEF, use of rescue medication, total asthma symptom scores and percentage of symptom-free days improved more with both single inhaler and separate inhaler therapy than with budesonide alone, as did asthma control days (approximately 15% more, p<0.001 versus budesonide, both comparisons, with a marked increase in the first week). All treatments were well tolerated and the adverse event profile was similar in all three treatment groups. It is concluded that single inhaler therapy with budesonide and formoterol is a clinically effective and well-tolerated treatment for patients with asthma that is not fully controlled by inhaled glucocorticosteroids alone.

Corticosteroid induced osteoporosis. Guidelines for treatment

BACKGROUND

Last year, Australian Family Physician published 'Guidelines for Management of Postmenopausal Osteoporosis', which were developed by Osteoporosis Australia. Recently, significant advances in our understanding of the treatment of corticosteroid osteoporosis have occurred.

OBJECTIVE

The following guidelines, also developed by Osteoporosis Australia, and supported by the National Asthma Campaign, are to help general practitioners identify those patients at risk of this problem and to provide information about current treatment strategies.

DISCUSSION

Corticosteroids are widely used and effective agents for the control of many inflammatory diseases. Corticosteroid osteoporosis is a common problem associated with the long term high dose use of these medications.

Comprehensive genetic and histopathologic study reveals three types of neuroblastoma tumors

PURPOSE

To determine the relationship between multiple genetic features, tumor morphology, and prognosis in neuroblastoma.

PATIENTS AND METHODS

The genetic alterations and morphologic features that underpin three histopathologic risk classifications were analyzed in 108 neuroblastoma patients. Tumors were subdivided into four groups based on the three most frequent and prognostically significant genetic alterations (17q gain, 1p deletion, and MYCN amplification), and all other genetic, morphologic, and clinical data were analyzed with respect to these groups.

RESULTS

Our analyses identify three nonoverlapping tumor types with distinct genetic and morphologic features, defined here as types 1, 2, and 3. Type 1 tumors show none of the three significant genetic alterations and have good prognosis. Both type 2 (17q gain only or 17q gain and 1p del) and type 3 (17q gain, 1p del, and MYCN amplification) tumors progress. However, these tumor types are distinguished clinically by having significantly different median age at diagnosis and median progression-free survival (PFS). Multivariate analysis indicates that 17q gain is the only independent prognostic factor among all genetic, histopathologic, and clinical factors analyzed. Among histopathologic risk systems, the International Neuroblastoma Pathology Classification was the best predictor of PFS.

CONCLUSION

Our results indicate that specific combinations of genetic changes in neuroblastoma tumors contribute to distinct morphologic and clinical features. Furthermore, the identification of two genetically and morphologically distinct types of progressing tumors suggests that possibilities for different therapeutic regimens should be investigated.

The psychotherapy of a male anorectic

The author describes the way in which a male anorexic patient came to be understood in once-weekly psychotherapy. The findings are similar to recent psychoanalytic ones about female anorectics, but add that he was preoccupied with display and that there was an erotised transference in the oral mode. Of two major themes, the first was a food obsession; the food was felt concretely to be the mother as in a symbolic equation, and the conflict about eating represented a wish for and fear of fusion with her. The second major theme concerned exhibition; the self, as seen in two screen memories, was felt to be uncomfortably on show. Meanwhile the patient was preoccupied with a self-displaying maternal object, which was prominent in the transference. This perception of the object served as a defence against envy, although the defensive aspect may have been added to by an actual experience of a mother who functioned operatively, giving food rather than loving attention. The patient employed primary-process thinking defensively against self-object differentiation, which would have excited further awareness both of envy and of the real deficiencies of his primary objects. The author raises the possibility that the anorexia functioned as a perversion, binding and organising the core complex about fusion.

Clinical governance in action. Part 9. Teamworking

Part 9 of our series on clinical governance describes how a group of people from different disciplines can be transformed into an effective working team.

Towards a safe future

Creating a 'safety culture' requires an open approach to encourage analysis of deeper, systemic factors which may be causing serious failures. The NHS is setting systems in place which will work to end the most common and preventable errors.

Designing, specifying and evaluating a new repeat prescribing process for UK general practice

Research carried out on repeat prescribing indicates the low quality of repeat medication management. This paper reports on the project methodology, some initial results and ongoing work on the UK NHS Repeat Prescribing Project currently under way in the North East of England aimed at developing an intervention to improve the quality of repeat prescribing.

Antioxidant prevention of Heinz body formation and oxidative injury in cats

OBJECTIVE

To determine the effectiveness of 3 antioxidants in preventing Heinz body anemia in cats.

DESIGN

Prospective study.

ANIMALS

44 specific-pathogen-free healthy cats.

PROCEDURE

Cats were housed individually, divided randomly into 4 groups, and given the following orally every 12 hours: empty gelcaps (control cats), N-acetylcysteine (NAC, 100 mg/kg of body weight), vitamin E (d,l-alpha-tocopherol; 400 IU), or ascorbate (250 mg). After 2 weeks, Heinz bodies were induced by dietary onion powder (OP; 1% or 3% of dry matter) or propylene glycol (PG, 8% wt/vol in drinking water) for an additional 3 weeks. Intake of treated water or food was recorded daily. Body weight, PCV, Heinz body and reticulocyte percentages, reduced glutathione concentration, and total antioxidant status were measured twice weekly in all cats.

RESULTS

Heinz body percentage and degree of anemia did not differ significantly among cats receiving antioxidants and control cats except in cats that ingested water containing PG, in which antioxidant supplementation was associated with a decrease in water intake. Of cats that were fed a diet that contained OP, cats that received NAC had significantly higher reduced glutathione concentrations, compared with other cats in the experiment. Total antioxidant status did not consistently correlate with antioxidant supplementation or type of oxidant administered (ie, OP or PG).

CONCLUSIONS AND CLINICAL RELEVANCE

Although the effect of antioxidant supplementation on Heinz body anemia in cats was minimal, antioxidants may have subclinical biochemical effects such as GSH sparing that may be important against milder forms of oxidative stress.

Genetic counselling for schizophrenia in the era of molecular genetics

OBJECTIVE

To review the role of genetic counselling for individuals with psychiatric illnesses.

METHOD

Using schizophrenia as an example and including updated information about a genetic subtype (22q deletion syndrome), we discuss the value of the genetic counselling process in psychiatry, with support from the literature and our clinical experience.

RESULTS

Genetic counselling, the process through which knowledge about the genetics of illnesses is shared, provides information on the inheritance of illnesses and their recurrence risks; addresses the concerns of patients, their families, and their health care providers; and supports patients and their families dealing with these illnesses. For comprehensive medical management, this service should be available to all individuals with schizophrenia and their families.

CONCLUSIONS

New findings in the genetics of psychiatric illness may have important clinical implications for patients and their families.

Clinical governance: its origins and its foundations

This article from the NHS Clinical Governance Support Team (NCGST) outlines the development of quality concerns since the NHS was founded in 1948. It traces the development of clinical governance as a means of achieving continuous quality improvement and describes what the implementation of clinical governance means for patients and professionals. It analyses features of the cultural shift necessary to underpin quality improvement initiatives and describes with practical examples the constituents of the culture necessary for successful clinical governance. Future articles in this series will address other issues around clinical governance and will explain the model being followed by delegates to the NCGST's Clinical Governance Development Programme as they implement clinical governance "on the ground".

Low sodium inotropy is accompanied by diastolic Ca2+ gain and systolic loss in isolated guinea-pig ventricular myocytes

We measured sarcolemmal Ca2+ fluxes responsible for the positive inotropic effects of solutions with reduced Na+ concentration in voltage-clamped guinea-pig ventricular myocytes; intracellular Ca2+ concentration ([Ca2+]i) was measured with Indo-1. Reduction of external Na+ concentration by 50 % (to 67 mM) produced an increase in systolic [Ca2+]i accompanied by a decrease in Ca2+ entry via the L-type Ca2+ current. With reduced Na+ concentration, there was an initial decrease in the Na+-Ca2+ exchange current on repolarization followed by an increase to greater than control. We attribute this initial decrease to a decrease in the Na+ gradient and the subsequent increase to a fall in intracellular Na+ concentration and increase in systolic [Ca2+]i. The decreased L-type Ca2+ current and increased Ca2+ efflux on Na+-Ca2+ exchange resulted in a calculated systolic loss of Ca2+. The calculated systolic loss of Ca2+ was accompanied by a measured increase in sarcoplasmic reticulum (SR) Ca2+ content. Reduction of the external Na+ concentration also produced an outward shift of holding current which was blocked by Ni2+. This is taken to represent Ca2+ influx via Na+-Ca2+ exchange. When diastolic influx is taken into account, the observed gain in SR Ca2+ content can be predicted. The measurements show that, in reduced Na+, much of the entry of Ca2+ into the cell occurs during diastole (via Na+-Ca2+ exchange) rather than in systole (via the L-type Ca2+ current).

Alpha1-antitrypsin deficiency: biological answers to clinical questions

Alpha1-antitrypsin (alpha1AT) deficiency is a common lethal hereditary disorder of white persons of European descent. The condition is characterized by reduced serum levels of alpha1AT, a 52-kDa glycoprotein synthesized chiefly in the liver and, to a lesser extent, by macrophages and neutrophils. Alpha1AT acts as an antiprotease and is the physiological inhibitor of neutrophil serine proteases such as neutrophil elastase cathepsin G and proteinase 3. The clinical manifestations of alpha1AT deficiency occur chiefly in the lung, with a high risk of emphysema occurring by the third or fourth decade of life. Cigarette smoking accelerates the development of emphysema in persons with alpha1AT deficiency. There is also an increased risk of liver disease in alpha1AT deficiency, which occurs mostly in childhood. In this review, we will define further the diagnosis of alpha1AT deficiency and its clinical manifestations and describe the therapeutic strategies that are currently being developed to treat the hepatic and pulmonary disease associated with this condition.

MYCN amplification and 17q in neuroblastoma: evidence for structural association

MYCN oncogene amplification in neuroblastoma is statistically associated with gain of chromosome segment 17q21-qter. In neuroblastoma cell lines and primary tumors with MYCN amplification in the form of homogeneously staining regions (hsrs), juxtaposition of chromosome 17 material with MYCN sequences has occasionally been reported, raising the possibility of a physical affinity between MYCN and chromosome arm 17q. We used FISH to test for association between chromosome 17 segments and MYCN in eight neuroblastoma cell lines and two neuroblastoma primary tumors known to include hsrs. Evidence of an association was found in the chromosomes of both primary tumors; in one, a MYCN hsr was inserted into a structurally abnormal chromosome 17, in the other, an hsr in 16p was shown to be flanked by 17 material. In cell line NCG, hsrs in 4q and 16p were flanked by 17q material. These observations confirm the juxtaposition of 17q material with MYCN sequences in some neuroblastomas, and imply that there may be a physical or functional relationship between these two features in MYCN amplified neuroblastoma.

17q gain in neuroblastoma predicts adverse clinical outcome. U.K. Cancer Cytogenetics Group and the U.K. Children's Cancer Study Group

BACKGROUND

It is now recognized that gain of chromosome 17 material is the most frequent genetic abnormality of neuroblastoma cells. Several studies have linked 17q gain with known adverse prognostic factors: patient age >1 year, advanced stage disease, deletion of chromosome arm 1 p, and amplification of the MYCN oncogene. We sought to further investigate the clinical and prognostic associations of chromosome 17 status in relation to other well-established predictive factors.

PROCEDURE

In a collaborative study by UK cytogenetics centres, we compiled a series of 104 neuroblastoma tumours for which the status of chromosome 17 was confidently defined by cytogenetics, metaphase or interphase FISH, or CGH analysis. The results were correlated with data on 1p and MYCN, and with centrally collated clinical and survival information.

RESULTS

Gain of 17q (i.e., unbalanced gain of segment 17q21-qter) was found in 66.3% of tumours, while 33.7% showed a '17q normal' status (i.e., no gain at all, or gain of whole chromosome 17 relative to ploidy). Gain of 17q was strongly associated with advanced stage disease, patient age >1 year, 1p deletion, and MYCN amplification (all P< 0.01). In univariate analysis, 17q gain was a significant predictor of adverse outcome (projected 5 year relapse-free survival 15.6% compared to 75.2% in cases lacking this feature in tumour cells; (P < 0.0001). In multivariate analysis, 17q gain was more strongly associated with adverse outcome than was either stage (Stage 4 vs other combined) or 1p status.

CONCLUSION

We conclude that gain of chromosome segment 17q21-qter is of great biological and clinical importance in neuroblastoma, and that its detection at diagnosis should be a priority.