[Evaluation of the handicap and the quality of life in spinal cord injuries: study in a population of 58 patients living at home]

GOAL

The main purpose of this study was to identify objective factors (social and economic status, impairments, functional limitations) contributing to the subjective quality of life of subjects presenting with residual neurological deficits from a traumatic spinal cord injury (SCI) and living at home.

SUBJECTS AND METHOD

This is a cross-sectional descriptive study of a sample of SCI patients followed at a Physical Medicine and Rehabilitation facility. After informed consent was obtained, a clinical and functional examination was conducted and questionnaires were filled out by the subjects. The following parameters were assessed: impairments (sensory and motor ASIA scores), disability (Barthel Index and Functional Independence Measure), and quality of life (Reintegration to Normal Living Index and Nottingham Health Profile).

RESULTS

Fifty-eight subjects completed the study (mean age 41.38 +/-13.55 years and mean delay from onset 6.24 +/- 6.06 years). There was a strong significant correlation between the level of quality of life and the current age, the age at the time of the accident and the disability level, particularly for the dimensions of physical independence, social integration and mobility.

CONCLUSION

Our results are consistent with published data, which identify age as a determining factor of quality of life after SCI. Our review of the literature indicated that time from onset influences quality of life. Longitudinal studies, taking into account the levels of social participation, are needed to better understand the impact of time on quality of life after SCI.

Amino acids: analytical aspects

This workshop was organized as a direct response to concerns and queries raised by laboratory personnel, both in Europe and in the United States, about the imminent withdrawal of Beckman Coulter from the amino acid analysis market. The topics covered included external quality control schemes, standard operating procedures for amino acid analysis and instrumentation, both from a user's perspective and that of the company representatives. There was a discussion panel of all speakers following the presentations.

In vitro activity of quinupristin/dalfopristin in comparison with five antibiotics against worldwide clinical isolates of staphylococci

OBJECTIVE

To evaluate the in vitro activity of quinupristin/dalfopristin (Q/D), a streptogramin combination, in comparison with five antibiotics against worldwide clinical isolates of staphylococci.

METHODS

A multicenter in vitro study was performed using the E test during a period of 3 months (April to June) in 1997 on fresh, clinically significant, non repetitive strains of staphylococci from patients hospitalized in 23 different hospitals in 18 countries tested.

RESULTS

A total of 2132 staphylococcal isolates including methicillin resistant (MR), methicillin susceptible (MS) S. aureus (1003 MS, 462 MR), S. epidermidis (169 MS, 251 MR), S. haemolyticus (28 MS, 46 MR), S. hominis (28 MS, 16 MR), and coagulase negative staphylococci (86 MS, 43 MR) were analyzed. Q/D was highly active against all species tested. MIC90 (mg/L) ranged from 0.5 to 2 depending on the species. Strains had MIC < or = 1 mg/L in 97.6%. For S. aureus, S. epidermidis, S. hominis and other coagulase-negative staphylococci no differences in MIC90 were observed for MS or MR. One dilution difference was observed for S. haemolyticus, which overall was the less susceptible species. Erythromycin resistance was observed among 57- 87% of MR-strains and was lower among MS-strains (18-56%). Erythromycin resistance had no or little influence on MIC of Q/D. In comparison to vancomycin, Q/D was two to four times more active.

CONCLUSIONS

The streptogramin combination Q/D showed an excellent in vitro activity against all staphylococcal species tested regardless of the resistance pattern to other drug classes, particularly resistance to methicillin. Q/D was two to four times more active than vancomycin and MIC values varied from 0.5-2 according to the species. The synergy of Q/D was well conserved in macrolide-resistant strains.

Lidocaine plus ropivacaine versus lidocaine plus bupivacaine for peribulbar anesthesia by single medical injection

This study was designed to compare the effects of ropivacaine and bupivacaine, each combined with lidocaine, during peribulbar anesthesia by single medial injection for cataract surgery. One hundred patients were included and randomly divided into two groups of 50, given a mixture of 50% bupivacaine (0.5%) and 50% lidocaine (2%) or 50% ropivacaine (1%) and 50% lidocaine (2%), and 25 U hyaluronidase per mL with each combination. After the first injection, patients given ropivacaine exhibited significantly better akinesia than those given bupivacaine, and significantly fewer were reinjected (19/50 vs 31/50). Among the patients reinjected, peroperative akinesia and analgesia proved satisfactory in both groups. We observed three cases of diplopia caused by retraction of the internal rectus muscle and two cases of moderate ptosis after superonasal reinjection. Hemodynamic profiles were similar in the two groups, and no major side effects were noted during the observation. One percent ropivacaine may be a more appropriate agent than 0.5% bupivacaine for peribulbar anesthesia by single medial injection.

IMPLICATIONS

One percent ropivacaine may be a more appropriate agent than 0.5% bupivacaine for peribulbar anesthesia by single medial injection. Combined with lidocaine, it provides better akinesia and similar analgesia.

What have been the strategies for the registration, positioning and control of medical information for intramuscular artemether?

At the beginning of the 1990s the Chinese Authorities and Rhone-Poulenc Rorer signed an agreement to develop intramuscular (i.m.) artemether (Paluther) and to market the product in the malaria endemic countries. This accord ushered in an exemplary period of co-operation between an international pharmaceutical group and its Chinese partners, the WHO (especially TDR), the Wellcome Trust, and several university research departments. The challenge was to complement the Asian development (to Western standards of Good Manufacturing Practices, Good Laboratory Practices, and Good Clinical Practices) of a molecule which was already used on an everyday basis in East Asia and by Chinese medical missions in Africa. The implementation of Good Manufacturing Practice was the priority for Rhone-Poulenc Rorer in order to ensure the pharmaceutical quality of Paluther. New preclinical and clinical studies confirmed the importance of the drug in the curative treatment of severe malaria due to Plasmodium falciparum, or when resistance to other antimalarial drugs is suspected. The outcome of these new trials was the recognition that i.m. artemether is at least as efficient as quinine. The results of the current development of Paluther have been presented at several international congresses and the latest clinical trials were published in the New England Journal of Medicine in July 1996. The neurotoxicity observed in animals after long term administration of high and repeated dosages has never been reported in human subjects. I.m. artemether was listed in the WHO List of Essential Drugs in December 1995, and the product has now been registered in more than 40 malaria endemic countries. Authorization for use of Paluther in hospitals in France and in several other European countries was granted in 1996.

Inclusive dielectron cross sections in p + p and p + d interactions at beam energies from 1.04 to 4.88 GeV

Measurements of dielectron production in p + p and p + d collisions with beamkinetic energies from 1.04 to 4.88 GeV are presented. The differential cross section is presented as a function of invariant pair mass, transverse momentum, and rapidity. The shapes of the mass spectra and their evolution with beam energy provide information about the relative importance of the various dielectron production mechanisms in this energy regime. The p + d to p + p ratio of the dielectron yield is also presented as a function of invariant pair mass, transverse momentum, and rapidity. The shapes of the transverse momentum and rapidity spectra from the p + d and p + p systems are found to be similar to one another for each of the beam energies studied. The beam energy dependence of the integrated cross sections is also presented.

Preoperative color-Doppler assessment of vascularisation of the rectus abdominis: anatomic basis of breast reconstruction with a transverse rectus abdominis myocutaneous flap--a prospective study

The unipedicled TRAM flap is an useful alternative to breast reconstruction after mastectomy in patients who refuse mammary implants. There is however the risk of unpredictable partial skin necrosis even after rigorous surgical procedures. Certain authors have proposed color flow doppler assessment before reconstructive surgery better to identify the vascular network and optimise patient selection. We performed a prospective study in 20 outpatients in order to compare preoperative assessment of the blood supply to the abdominal flap with the operative findings. An Ultramark 9 HDI (Advanced Technology Laboratories) equipped with a high frequency (10 Mhz) linear probe was used to measure blood flow and vessel caliber in the epigastric a. and perforating vessels (localisation, number; peak flow). Despite three limiting factors (anatomic, technical, morphologic) the results obtained in this series could be used to determine the indications for a TRAM flap.

The view of the pharmaceutical industry

Rhône-Poulenc Rorer has committed itself to the development of artemether because we believe the drug will be of considerable benefit to sufferers from severe falciparum malaria, and because it is a stable, effective and economical compound that can be given by intramuscular injection. The quality of the pharmaceutical product meets international regulatory standards. Artemether is unlikely to yield big profits, but we believe that major pharmaceutical companies have a responsibility to develop such much-needed products. To develop this project further, we will need the assistance of academic institutions, research organizations and international bodies.

Hyperhomocysteinaemia: a risk factor for extracranial carotid artery atherosclerosis

Hyperhomocysteinemia arising from impaired methionine metabolism, and usually due to a deficiency of cystathionine beta-synthase is a significant and independent risk factor for symptomatic vascular disease. It is not known if hyperhomocysteinemia in apparently healthy asymptomatic subjects is associated with atherosclerosis and whether such a relationship is independent of conventional risk factors. The prevalence of asymptomatic extracranial carotid artery atherosclerosis was determined by duplex ultrasound examination in 25 obligate heterozygotes with respect for cystathionine beta-synthase deficiency (whose children were known to be homozygous for this genetic defect) and in 21 controls. Hyperhomocysteinemia was determined by a standard methionine-loading test and conventional risk factors were also recorded. Twelve of 25 obligate heterozygotes and 8 of 21 normal controls had evidence of extracranial carotid artery atherosclerosis. Hyperhomocysteinemia as a genetic trait was not a significant risk marker, but the actual homocysteine level was associated with an increased risk of carotid disease. After adjustment for the effects of other significant risk factors, the odds ratio of hyperhomocysteinemia for carotid disease was 1.038 per unit increase in homocysteine level (P = 0.03). Hyperhomocysteinemia is a weak risk factor for asymptomatic extracranial carotid atherosclerosis and the relative risk associated with this genetic trait is less than that observed in a study of patients presenting with clinical manifestations of vascular disease.

Comparative bioavailability study of cefixime administered as tablets or aqueous solution

The relative bioavailability of cefixime was studied in 24 healthy male volunteers, with each subject receiving a single 400mg dose of cefixime administered as an aqueous solution, a 400mg tablet and two 200mg tablets, in a randomised crossover sequence. Serum and urine samples were analysed using high-performance liquid chromatography. Peak cefixime levels were achieved 3 hours after administration of the solution vs 4 hours for the 2 tablet formulations; however, the extent of absorption was only slightly improved with the solution (by 14 and 7% compared with the 1 x 400 and 2 x 200mg tablets, respectively). The 400mg and 2 x 200mg tablets were found to be bioequivalent. The pharmacokinetic profile of the 400mg cefixime tablet (mean maximum plasma concentrations of 4.4 mg/L at 4 hours, area under the concentration-time curve of 34.4 mg/L.h, and apparent terminal elimination half-life of 3.7 hours) supports the clinical evaluation of a 400mg once-daily dosage regimen for cefixime.

[Cefixime, the first oral third-generation cephalosporin]

In the early 1980's parenteral third generation cephalosporins changed the hospital use of antibiotics. The MICs of these cephalosporins are several dozen times lower than those of first or second generation cephalosporins for Enterobacteriaceae and they are much more beta-lactamase stable than second generation cephalosporins. After years of research, is has finally been possible to develop orally active compounds possessing the same antibacterial activity as parenteral third generation cephalosporins, either through the use of prodrugs, or by modifying the molecular structure of drugs. Cefixime is an example of the latter. The vinyl group at the 3-position of the cephem nucleus is responsible for the intestinal absorption of the intact molecule, primarily by a carrier-mediated transport mechanism. The aminothiazole ring and the R-oxyimino group on the side-chain at the 7-position are associated with an antibacterial activity similar to that of third generation cephalosporins. Thousands of adults have been treated by cefixime for lower respiratory tract, ear-nose-throat and urinary tract infections, showing that cefixime is a safe and effective antimicrobial agent. The major clinical indications for cefixime in adults are bronchial and pulmonary infections, acute otitis or sinusitis, acute pyelonephritis with no underlying uropathy, and complicated or uncomplicated lower urinary tract infections excluding prostatitis. In all cases, the dosage is 200 mg b.i.d.

[Pharmacokinetics of cefixime in healthy volunteers after a single oral administration of 200 mg]

The antibacterial activity of cefixime is identical with that of parenteral third generation cephalosporins. Its kinetics were studied in 24 healthy male volunteers who received one single 200 mg tablet. Cmax was 3.25 mg/l and Tmax was 4 h. After 12 hours, serum concentrations were still as high as 0.70 mg/l. Half-life was 3.3 h and urinary excretion was not predominant. Thus, cefixime was characterized by its relatively long serum half-life as compared with other cephalosporins. Despite some degree of individual variations, serum and urine concentrations of the antibiotic remained for 12 hours above the MIC of susceptible pathogens.

[Pulmonary diffusion of cefixime in man]

We measured the concentrations of cefixime in the human lung in vivo in order to evaluate indirectly the effectiveness of this antibiotic in the treatment of pulmonary infections. Twenty-three patients undergoing lung surgery entered the study and received cefixime either 200 mg 12-hourly (4 times) or 400 mg every 24 hours (twice). Blood samples and tissue specimens were collected simultaneously during surgery 4 or 8 hours after the last dose. Cefixime concentrations were measured by HPLC. The penetration of cefixime in both normal and neoplastic lung tissue was significant. Four or 8 hours after a 200 or 400 mg oral dose, lung concentrations were higher than the MIC90 values for sensitive strains and therefore consistent with effective therapeutic activity. The pharmacokinetics of cefixime in blood and in lung tissue suggest that pulmonary infections could be treated with a 400 mg dose once a day.

[Effect of hepatic failure upon the pharmacokinetics of cefixime]

Modifications of cefixime kinetics due to severe impairment of liver function were determined in 9 cirrhotic patients. Cefixime was administered as a single dose of 200 mg and levels were measured by HPLC. Maximum serum concentrations and area-under-the-curves of serum concentrations were not modified. The time for maximum serum concentration was delayed and the cefixime half-life in serum was prolonged, as a reflect of increased volume of distribution resulting from ascites and hypoalbuminemia. Renal clearance increased in these patients, possibly because of reduced extra-renal clearance. No metabolite was detected in serum or urine. Modifications of cefixime kinetics resulting from impaired hepatic function were modest and did not require specific dosage adjustment.

[Comparative study of 2 dosage regimens of cefixime in the treatment of otorhinolaryngeal or bronchial infections]

A double-blind comparative study of cefixime (400 mg/day), given either as a single daily dose, or in two divided doses, was carried out in collaboration with 54 general practitioners. This study was mainly directed towards tolerance assessment. 431 patients with upper and lower respiratory tract infection were included. In terms of tolerance, 89 per cent of patients showed no side-effect and the tolerance was deemed satisfactory in 90.3 per cent of the cases by the investigators, without any statistically significant difference between both groups. Roughly, the most frequent side-effects were gastrointestinal reactions, such as diarrhea or stool changes (4.0 per cent), gastralgia (1.9 per cent), nausea and/or vomiting (1.6 per cent). In terms of effectiveness, after an average of 8.8 +/- 0.1 days of treatment, 94.4 per cent of assessable patients were improved or cured. Once again, there was no statistical difference between both groups. Cefixime effectiveness and safety are comparable with both modes of administration.

[In vitro comparative bactericidal effect of cefotaxime and cefixime in a kinetic model]

The bactericidal activity of cefotaxime against Escherichia coli, Klebsiella pneumoniae and Serratia marcescens, was compared with that of cefixime in an in vitro model simulating the human pharmacokinetics of these antibiotics. Kinetic parameters in this model were T1/2 = 1.3 h and Cmax = 45 mg/l for cefotaxime; T1/2 = 3.5 h and Cmax = 5 or 3.5 mg/l for cefixime. These parameters mimicked those obtained after a 1 g intravenous infusion of cefotaxime and an oral uptake of 0.4 or 0.2 g of cefixime, respectively. Both antibiotics demonstrated a strong bactericidal activity. Against Escherichia coli, the bactericidal effect of cefotaxime was slightly more rapid and more prolonged than that of cefixime: -5 log10 CFU/ml over 4 h vs -3 log10 CFU/ml over 8 h respectively. Against Klebsiella pneumoniae and Serratia marcescens, both drugs exhibited similar bactericidal activity despite different dosages and routes of administration: -2 to -3 log10 CFU/ml over 4 h.