Tamsulosin treatment of 19,365 patients with lower urinary tract symptoms: does co-morbidity alter tolerability?

PURPOSE

We compare the tolerability and blood pressure effects of 0.4 mg. tamsulosin once daily in patients with lower urinary symptoms suggestive of benign prostatic obstruction with or without concomitant disease and/or antihypertensive medication.

MATERIALS AND METHODS

Data from 2 open label, observational studies (study 1, 9,507 patients treated for 4 weeks and study 2, 9,858 patients treated for 12 weeks) were analyzed for global tolerability and effects on blood pressure stratifying for co-morbidity (none, diabetes, hypertension, other cardiovascular disease) and co-medication (diuretics, beta-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors).

RESULTS

Overall 90 and 95% of patients in studies 1 and 2, respectively, reported good or very good tolerability. While global tolerability was slightly reduced in patients with concomitant disease or some forms of medication (p < 0.05), it was rated as good or very good by more than 90 and 95% of patients even in those groups. In control patients, that is those with neither co-morbidity nor co-medication, the tamsulosin induced blood pressure reductions were similar to those previously reported for placebo treatment but were statistically significant (p < 0.05). Mean additional blood pressure reductions in patients with concomitant disease or medication were not more than 2 mm. Hg.

CONCLUSIONS

Tamsulosin is well tolerated and has marginal effects on blood pressure in the majority of patients. It largely maintains its good global tolerability and minimal blood pressure effects in patients with cardiovascular co-morbidity or diabetes, or those on co-medication with antihypertensive agents.

Tamsulosin treatment of 19,365 patients with lower urinary tract symptoms: does co-morbidity alter tolerability?

PURPOSE

We compare the tolerability and blood pressure effects of 0.4 mg. tamsulosin once daily in patients with lower urinary symptoms suggestive of benign prostatic obstruction with or without concomitant disease and/or antihypertensive medication.

MATERIALS AND METHODS

Data from 2 open label, observational studies (study 1, 9,507 patients treated for 4 weeks and study 2, 9,858 patients treated for 12 weeks) were analyzed for global tolerability and effects on blood pressure stratifying for co-morbidity (none, diabetes, hypertension, other cardiovascular disease) and co-medication (diuretics, beta-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors).

RESULTS

Overall 90 and 95% of patients in studies 1 and 2, respectively, reported good or very good tolerability. While global tolerability was slightly reduced in patients with concomitant disease or some forms of medication (p < 0.05), it was rated as good or very good by more than 90 and 95% of patients even in those groups. In control patients, that is those with neither co-morbidity nor co-medication, the tamsulosin induced blood pressure reductions were similar to those previously reported for placebo treatment but were statistically significant (p < 0.05). Mean additional blood pressure reductions in patients with concomitant disease or medication were not more than 2 mm. Hg.

CONCLUSIONS

Tamsulosin is well tolerated and has marginal effects on blood pressure in the majority of patients. It largely maintains its good global tolerability and minimal blood pressure effects in patients with cardiovascular co-morbidity or diabetes, or those on co-medication with antihypertensive agents.

Early carotid endarterectomy after non-disabling ischaemic stroke: adequate therapeutical option in selected patients

OBJECTIVE

To evaluate neurological outcome and long-term results of early carotid endarterectomy (CEA) after non-disabling stroke.

MATERIALS

Retrospective study between 1980 and 1995 of 56 patients undergoing CEA within 4 weeks of a transient (n = 15) or a permanent non-disabling (n = 41) ischaemic stroke.

METHODS

Analyses of preoperative cerebral CT imaging, neurological outcome (mod. Rankin-scale) and long-term results (life-table analyses according to Kaplan-Meier).

RESULTS

Incidence of early CEA increased from 1.7% (27 out of 1636) in the period 1980-1993 to 7.8% (29 out of 374) between 1994 and 1995. CEA was indicated after a neurological plateau phase was established (median interval 14 days). Fifty-seven per cent of the CEA patients had a minor ischaemic infarction (area < 2 cm), 18% showed a large territorial ischaemic infarction (area 2-5 cm) in cerebral CT imaging. Two patients deteriorated postoperatively (minor stroke rate 4%) but no major stroke or death occurred. Life-table probability of stroke-free survival (mean follow-up 42.7 months) was 94%, 90% and 84%, respectively, after 1, 2 and 5 years. Kaplan-Meier survival rates were 96%, 91% and 86% after 1, 2 and 5 years.

CONCLUSIONS

Early CEA after non-disabling stroke is a safe procedure in selected patients.

[Widening mediastinum after blunt thoracic trauma: an unexpected differential diagnosis]

We report our experience concerning a young, white, healthy woman who had a typical blunt chest injury caused by a severe car accident. We had to evaluate and differentiate the initial roentgenographic post-traumatic mediastinal enlargement in order definitely to exclude a suspected covered rupture of the thoracic aorta or the heart caused by this high-velocity deceleration trauma. The difficulties encountered are critically discussed with regard to the unexpected primary thymoma that was diagnosed postoperatively. The diagnostic algorithm in blunt chest injury is also discussed. The controversy about the classification and management options of primary thymic tumors is also presented.

Cefuroxime resistance in Klebsiella pneumoniae. Susceptibility to cefotaxime and ceftazidime despite production of ESBLs

The production of beta-lactamases, the outer membrane protein (OMP) patterns, some clinical impacts and the prevalence of resistance among cefuroxime-resistant Danish clinical isolates of Klebsiella pneumoniae were investigated. Fifteen resistant and five susceptible strains were collected from 14 patients during 1991-1994. Isolates from five patients produced extended-spectrum beta-lactamases (ESBLs). Cefuroxime resistance was accompanied by a 10-fold elevation of ciprofloxacin minimal inhibitory concentration (MIC), and for some isolates by an alteration of the OMP pattern. The relationship between alterations of the OMP patterns and cross-resistance to ciprofloxacin and the other antibiotics tested was not universal. Ten of the cefuroxime-resistant strains had elevated MICs of cefotaxime or ceftazidime, but the MICs were still below the breakpoint for susceptibility. The MICs of imipenem were not affected. Nosocomial infection or long-term colonization with resistant strains may be of importance since five patients were not treated with cefuroxime prior to isolation of the resistant strain, and all patients had either serious diseases or stayed at the hospital for a long period of time. The prevalence of cefuroxime and ciprofloxacin resistance among clinical isolates from Copenhagen county during 1990-1995 was 8.3% and 7.5%, respectively, but higher for urinary tract specimens. A greater consumption of cefuroxime as compared to cefotaxime and ceftazidime in this study, as seen generally in Denmark, indicated that ESBLs produced by the investigated strains of K. pneumoniae may be selected with cefuroxime.

Morphometry and classification in abdominal aortic aneurysms: patient selection for endovascular and open surgery

PURPOSE

To evaluate the anatomic morphology of abdominal aortic aneurysms (AAAs) and compose a classification system to facilitate patient selection for endovascular graft (EVG) repair.

METHODS

Data on 242 consecutive AAA patients evaluated on a nonemergent basis in a 3.5-year period to July 1996 were prospectively entered into a registry. Patients were examined using sequential intravenous spiral computed tomographic angiography and intraarterial digital subtraction angiography. The data collected and analyzed included: diameters of the supra- and infrarenal aorta, aneurysm, aortoiliac bifurcation, and iliac arteries; lengths of the proximal neck, distal cuff, and aneurysm; degrees of iliac artery tortuosity; and occlusion of the visceral, renal, or iliac arteries.

RESULTS

The 242 aneurysms could be easily grouped into three distinctive categories related to the extent of the aneurysmal disease. Type I AAAs (11.2%) had nondilated, thrombus-free infrarenal (15 mm) necks and distal (10 mm) cuffs appropriate for EVG anchoring. In type II and its subgroups (72.3%), a sufficient proximal neck was present, but the aneurysm extended into the iliac arteries; 56% of these were eligible for a bifurcated endograft. In type III (16.5%), a sufficient proximal neck was missing, independent of distal involvement. In all, 51.7% were good EVG candidates based on AAA morphology. Taking into consideration relevant concomitant vascular diseases, proximal iliac kinking, and iliac, renal, or visceral occlusive disease, only 30.2% of the population were potential candidates for an efficient and secure EVG repair using the devices currently available.

CONCLUSIONS

In contrast to classical open repair, detailed preoperative measurements are recommended for EVG planning. The use of liberal EVG indications may lead to a higher incidence of complications, whereas restrictive morphology-based selection criteria may offer excellent results.

Pedal bypass for limb-threatening ischaemia: an 11-year review

Fifty-six patients with limb-threatening ischaemia had pedal revascularization with either autologous vein (n = 39) or sequential composite graft with a 6-mm polytetrafluoroethylene prosthesis and autologous vein (n = 17); 75 per cent had gangrene and skin necrosis and 25 per cent had ischaemic rest pain alone. Twelve grafts occluded within the first week, and resulted in major amputation in eight patients after unsuccessful revision. Two patients required amputation for persistent ischaemia despite a patent bypass. One patient died from bowel perforation (2 per cent). In 47 (84 per cent) of the 56 patients limb and life were preserved. The primary patency rate after 1, 2 and 4 years was 65, 55 and 55 per cent respectively, the secondary patency rate was 71, 62 and 62 per cent, and cumulative limb salvage rates were 77, 71 and 66 per cent. Life-table survival rates during follow-up (median 25 (range 0-112) months) were 89, 78 and 52 per cent respectively after 1, 2 and 4 years. Thirteen of 21 patients who died during follow-up did not require major amputation. Pedal reconstruction with autologous vein provides limb salvage until death in nearly two-thirds of patients with critical limb ischaemia resulting from crural arterial occlusive disease.

Cefuroxime resistance in Escherichia coli. Resistance mechanisms and prevalence

In order to characterize cefuroxime resistance in Escherichia coli 22 clinical isolates were investigated for susceptibility to different beta-lactam antibiotics and ciprofloxacin. The production of beta-lactamases, the pattern of the major outer membrane proteins (OMPs), and the plasmid profiles were determined for these isolates. Ten of the isolates were resistant to ceftazidime, two to cefotaxime, and none was resistant to imipenem or ciprofloxacin. The dominating resistance mechanism was hyperproduction of the chromosomally encoded beta-lactamase to some extent accompanied by alterations of the OMP's. Two isolates with low ampicillin MIOs seemed solely to have alteration of the OMPs. None of the isolates produced plasmid-mediated extended-spectrum beta-lactamases. In addition, the prevalence of cefuroxime resistance was investigated. The prevalence as attained in 8704 clinical isolates of E. coli collected from Copenhagen County during a 5-year period (1990-1994) was 4.4%, but there was considerable variation among specimens from different sites of the body. Isolates from blood were much less resistant (2.5%) than isolates from the respiratory tract (9.7%).

Goldenhar, Möbius and hypoglossia-hypodactyly anomalies in a patient: syndrome or association?

The Möbius, Goldenhar and hypoglossia-hypodactyly anomalies are usually sporadic conditions with a recurrence risk of about 2%. The combination of Goldenhar and one or the two others is rare, whereas the concomitant occurrence of Möbius and hypoglossia-hypodactyly, and/or Poland, and/or Klippel-Feil anomaly is well known. Pathogenetically, vascular disruptions around the 4th embryonic week have been hypothesized. In vivo and pathological studies as well as animal models support this theory for all the above-mentioned combinations. Whether a preceding blastogenetic alteration is an influencing factor or a disorganization mutation, remains unclear. We describe a 3-year-old girl with bilateral anotia, epidermoid on the right eye, 6th and 7th nerve palsy, hypoglossia, left hypodactyly, and ventricular septal defect.

CONCLUSION

We wish to emphasize the aetiological relevance of vascular disruptions in this previously unreported combination of Möbius, Goldenhar and hypoglossia-hypodactyly anomalies. The concurrence of anomalies in this patient represents an association and not a pleiotropic syndrome.

The impact of disease pattern, surgical management, and individual surgeons on the risk for relaparotomy for recurrent Crohn's disease

OBJECTIVE

The authors provide a multivariate analysis of a large single-center experience with limited surgery for Crohn's disease.

SUMMARY BACKGROUND DATA

During the past decade, the aim of surgery for Crohn's disease has shifted from radical operation, achieving inflammation-free margins of resection, to "minimal surgery," intended to remove just grossly inflamed tissue or performing strictureplasties.

METHODS

Seven hundred ninety-three cases of resection and/or strictureplasty in 689 individuals with histologically verified Crohn's disease were followed for a mean period of 50 months (range, 5-166 months). Two different end points were analyzed: 1) any relaparotomy for recurrent (or persistent) Crohn's disease and 2) relaparotomy for site-specific recurrence. More than 30 variables of patient/disease characteristics and surgical management were included in a proportional hazard model.

RESULTS

Five parameters were associated independently with the risk for relaparotomy: increased risk coincided with young age at onset of disease, involvement of jejunum, enterocutaneous fistula, or performed strictureplasty, and decreased risk followed ileocecal resection. Site-specific risks of reoperation were calculated on the basis of 1260 intestinal resections or anastomoses performed in these patients. Young age at onset, duodenal and jejunal involvement, presence of enterocutaneous or perianal fistula, and a single surgeon (of 23) were associated significantly with increased risk of regional recurrence but not strictureplasty or inflammation at margins of resection.

CONCLUSIONS

Limited surgery for Crohn's disease is not associated with increased risk of regional recurrence requiring reoperation. However, patients with juvenile onset, proximal small bowel disease, and some types of fistulae are at a considerable risk of experiencing early surgical recurrence.

[Prospective preoperative morphometry of abdominal aortic aneurysms: selective patient management for endovascular surgery]

The objective of this prospective clinical investigation of 205 elective abdominal aortic aneurysm (AAA) patients over a 3-year period. 1993-1995, was both to evaluate the morphology and aortic dimensions of AAA as a management decision for patient selection for endovascular grafting and to correctly plan the custom-made TPEG size and shape prior to the procedure.

[Infrarenal abdominal aortic aneurysm: morphological classification as decision aid for therapeutic procedures]

This clinical trial aimed to prospectively investigate the morphological structure of infrarenal abdominal aortic aneurysms (AAA) to establish a valid dataset in the preoperative assessment supporting either the conventional or endovascular (TPEG) surgical approach. Regarding both the general feasibility testing and safe TPEG placing, all the anatomic AAA data must already be measured preprocedurally, due to the necessity for conversion as a frequent consequence of an intraprocedural failure. Between January 1993 and June 1995, all the patients (n = 159) admitted for elective AAA repair, were prospectively analysed. Graded on the basis of these measurements we developed a new AAA classification system supporting the kind of the surgical procedure (standard) approach vs. TPEG). Three different types of AAA were clearly defined. Due to morphological AAA criteria, 86 out of 159 patients (54.1%) might be suitable for TPEG (Type I, IIA and IIB). An infrarenal (proximal) neck < 15 mm, an infrarenal aortic diameter > 24 mm or an extension of the aneurysm to the iliac bifurcation are considered to be exclusion criteria for TPEG placement. In consideration of relevant co-morbidities (e.g. renal artery stenosis, SMA occlusion, iliac occlusive disease, simultaneous operations) only 43 out 159 patients (27.1%) were good candidates for TPEG. In general, smaller AAA are more appropriate for TPEG repair due to better proximal and distal fixation. As a consequence, indication criteria for AAA repair must not be expanded to smaller AAA.

[Carotid TEA and perioperative thrombolysis: a new concept in therapy of acute ischemic stroke]

In seven carotid-related acute hemispheric strokes with simultaneous embolic occlusion of the middle cerebral artery thrombolysis with urocinase or rt-PA was performed preoperatively (n = 3) or intraoperatively (n = 4) after carotid endarterectomy. Four patients recovered totally, three patients showed a remarkable improvement and were able to walk postoperatively. The combination of carotid endarterectomy and thrombolysis (simultaneous or staged) is a new option in the emergency treatment of an acute carotid-related stroke and should be evaluated in prospective interdisciplinary studies.

Experience with ileostomy and colostomy in Crohn's disease

This study involved 746 patients with Crohn's disease treated surgically within a 13-year interval in whom 227 stomas (159 primary, 68 secondary) were created. The main indication (64 per cent) for primary stoma was severe perianal or genital fistulous disease. Revisional surgery for stomal complications was more common following colostomy than ileostomy (31 versus 5 per cent, P < 0.01). Twenty years after the first symptoms of Crohn's disease the cumulative risks of receiving any stoma or a permanent stoma were 41 and 14 per cent respectively. Four parameters were shown by proportional hazards analysis to be independently associated with the risk for any stoma as well as a permanent one; increased risk coincided with rectal inflammation, perianal fistula or abscess, and absence of small intestinal involvement. In addition, long-standing symptomatic disease before the first surgical intervention reduced the risk of a permanent stoma. The long-term chances of closure following temporary stoma were 75 per cent when used for anastomotic protection or avoidance, 79 per cent after postoperative complications, and 40 per cent for perianal or genital fistulas or for rectal inflammation or stenosis. Rectal disease and perianal fistula were the only independent predictors of a low possibility of stoma closure during follow-up.

[Endovascular reconstruction of infrarenal abdominal aortic aneurysm]

Animal experiments in the 80's demonstrated the feasibility of the concept first inaugurated by Dotter in 1969 of the endovascular implantation of a stent-graft prosthesis for the treatment of abdominal aortic aneurysm. In September 1990 Parodi was the first to treat a patient with an AAA using the implantation of a TPEG (transluminal placed endovascular stented graft). The rapid development of a variety of different devices can be observed since resulting in about 400 such prosthesis being implanted world wide for the treatment of AAA. The experience accumulated so far shows that severe complications can be avoided if morphology-based criteria are considered for the various treatment options (AAA classification type I, type IIa-c, type III). Despite considerable lethal incidents, technical mishaps and severe complications to date, the potential of TPEG for a structured approach to the treatment of AAA has to be evaluated. Prerequisites are 1) a competent team based on a close mutual cooperation of vascular surgeons and interventional radiologists, 2) a careful selection of patients, 3) TPEG to be performed in especially equipped operation theatres permitting the immediate application of conventional surgery if necessary, and 4) the implantation to be performed as a clinical study with flawless documentation of the procedure and follow-up.

[Gentamycin resistant Enterobacteriaceae at a neonatal care unit]

A case of septicaemia in a seven-day-old infant with a gentamicin-resistant strain of Enterobacter cloacae prompted an epidemiological survey in a neonatal unit. Another 18 patients harboured gentamicin-resistant Enterobacteriaceae without symptoms. Control of the outbreak was achieved by cohort nursing, strict hygiene and reduction of aminoglycoside consumption by 50%. Efficiency of the measures was monitored by weekly faecal samples from all patients. All strains produced the aminoglycoside modifying enzyme AAC(3)II. The resistance was plasmid-mediated.

[Resistance of gram-negative bacteria to beta-lactams, aminoglycosides and quinolones]

Antibiotic treatment of infections has traditionally been restrictive, in that use of broad-spectrum antibiotics has been avoided as far as possible. A change in therapeutic principles has occurred in recent years for example with respect to treatment of patients that are immunocompromised, suffering from multiple traumas, recovering from major surgery or have implanted foreign bodies. The use of antibiotics has become more complicated, as one more frequently has to consider the possibility of development of antibiotic resistance in different bacterial species because of long-term treatment regimes in such patients. However, it is important to avoid the spread of broad-spectrum antibiotic regimes such as those for neutropenic patients to less vulnerable patient groups, where narrow-spectrum therapy is usually sufficient. In later years an increased resistance to broad-spectrum antibiotics among enterobacteria has been described abroad. Resistance mechanisms for the most commonly used intravenous antibiotics (beta-lactams, aminoglycosides and quinolones) are described. Resistance mechanisms for the individual antibiotics, cross-resistance and the most important epidemiological aspects are discussed. It is suggested that surveillance of antibiotic use and development of resistance as well as identification of resistance mechanisms be increasingly used so as to continuously ensure optimum treatment regimes.

[Resistant gram-negative bacteria at seven intensive care units in Denmark]

A prospective study on the prevalence of resistance to 16 antibiotics in 704 Gram-negative bacteria isolated from seven intensive care units was undertaken in 1990. A microtitre panel carrying 16 antibiotics was used for susceptibility testing. The study revealed minor differences in resistance between the participating centres. The overall resistance was relatively low in Denmark, but there was increased resistance among E. coli from intensive care units compared to E. coli isolates from bloodcultures collected in 1988. At one centre the susceptibility of P. aeruginosa to gentamicin was slightly lower than at other centres, indicating a minor outbreak during the collection period. P. aeruginosa and Enterobacteriaceae with inducible production of beta-lactamases showed cross-resistance between penicillins and cephalosporins, but not between penicillin/cephalosporins and imipenem gentamicin or ciprofloxacin. The resistance among the repeated isolates of inducible Enterobacteriaceae was slightly higher than among the initial isolates indicating acquisition of resistance or selection of resistant mutants.

Antibodies against chromosomal beta-lactamase

A murine monoclonal anti-chromosomal beta-lactamase antibody was developed and an immunoblotting technique was used to study the presence of serum and sputum antibodies against Pseudomonas aeruginosa chromosomal group 1 beta-lactamase in patients with cystic fibrosis (CF). The serum antibody response was studied with serum samples collected in 1992 from 56 CF patients in a cross-sectional study and with serum samples from 18 CF patients in a longitudinal study. Anti-beta-lactamase immunoglobulin G antibodies were present in all of the serum samples from the patients with chronic bronchopulmonary P. aeruginosa infection (CF + P) but in none of the CF patients with no or intermittent P. aeruginosa infection. Anti-beta-lactamase antibodies were present in serum from CF + P patients after six antipseudomonal courses (median) and correlated with infection with a beta-lactam-resistant strain of P. aeruginosa. The sputum antibody response and the beta-lactamase activity in sputum samples from 14 of the CF + P patients were also studied. beta-lactamase antibodies were present in 10 of these samples. P. aeruginosa strains isolated from these samples were partially derepressed, producing group 1 cephalosporinase. We found a wide range of chromosomal beta-lactamase activity in the sputum samples, with no correlation with basal or induced activity of beta-lactamase expression. The presence of anti-beta-lactamase antibodies in endobronchial sputum could be an important factor in the defense against the infection. On the other hand, immune complexes between the beta-lactamase and corresponding antibodies could play a role in the pathogenesis of bronchopulmonary injury in CF by mediating hyperimmune reactions.

Resistance characteristics of blood culture isolates of Enterobacter cloacae with special reference to beta-lactamases and relation to preceding antimicrobial therapy

Resistance characteristics of 53 blood culture isolates of E. cloacae were examined and correlated with antimicrobial treatment preceding bacteraemia. Resistance patterns of 22 antimicrobial agents, presence of resistant mutants, and inducibility of beta-lactamase were investigated; furthermore, population analysis and investigation of beta-lactamase production of selected isolates were performed. Thirty-two isolates (60%) were resistant to cephalothin and/or cefoxitin and/or ampicillin, and 14 isolates (26%) had further resistance characteristics, 7 of the 14 being resistant to non-beta-lactam antibiotics. All ampicillin-susceptible and 76% of cefotaxime-susceptible isolates had resistant mutants in the zone of inhibition when high inoculum was used. All isolates investigated had inducible chromosomal beta-lactamases, and, in addition, two isolates had an enzyme corresponding with TEM-1. Correlation of resistance patterns and antimicrobial treatment preceding bacteraemia showed that treatment with a third-generation cephalosporin was associated with beta-lactam multiresistance. In conclusion, susceptibility testing of beta-lactam antibiotics of Enterobacter must be interpreted with caution and monotherapy with an extended-spectrum cephalosporin should be avoided unless presence of resistant mutants and inducibility of beta-lactamase can be excluded.

[Mexiletine in treatment of painful diabetic neuropathy]

The objective of this double-blind placebo controlled multicenter study was to prove the efficacy of mexiletine in painful diabetic neuropathy. Treatment was provided for in three dosages. For pain measurements a visual analogue scale (VAS) and McGill's verbal rating scale were chosen. 95 patients were included. A global assessment of the VAS showed no differences in treatment. The total evaluation (PRIT = Pain Rating Index Total) of the McGill scale just failed the level of significance. More specific exploratory evaluation of subclasses of the McGill scale, representing different qualities of pain, gave remarkable differences between mexiletine and placebo. According to types of complaints an evaluation showed substantial advantages of the mexiletine treatment with both the VAS and the McGill scale. There is strong evidence that particularly patients with stabbing or burning pain, heat sensations or formication will benefit most by mexiletine therapy. Concerning the dosage, a medium regimen of 450 mg per day seems to be appropriate in this indication. With an increase in dosage the efficacy does not rise proportionally. Mexiletine proved a very safe therapy with negligible side effects at the medium dose range, even less than placebo. There were no cardiovascular side effects. Further investigations should pay more attention to the variety of the complaints and include the quality of life.

Respiratory effects and tolerability of Mr 2264 Cl. A new opiate partial agonist in comparison with morphine and placebo

In this double-blind, randomised, placebo-controlled cross-over study the respiratory effects of M(r) 2264 Cl 2 x 5 mg i.v., a new partial opiate receptor agonist, were investigated and compared with the respiratory effects of morphine 2 x 10 mg i.v. and placebo. As primary end-points, the slope of the rebreathing curve (dV'/dPCO2ET) and V55 (ventilation at PCO2ET = 55 mm Hg) were determined by Read's rebreathing method. The incidence of adverse events was also documented and compared. The respiratory depression after the intravenous administration of 5 mg and 10 mg M(r) 2264 Cl was comparable to the decreased sensitivity of the respiratory centre after the 20 mg morphine i.v. In contrast to morphine, a ceiling effect of M(r) 2264 Cl was found. The tolerability of M(r) 2264 Cl was comparable to that of morphine.

Efficacy and safety of two different galenic formulations of a transdermal clonidine system in the treatment of hypertension

The efficacy and safety of two different galenic formulations of transdermal clonidine systems were compared in 905 patients with mild to moderate essential hypertension during a 12 weeks observation period. 449 patients were treated with the matrix controlled clonidine transdermal (C-TD) system and 456 patients with the membrane controlled clonidine system (C-TTS). The mean blood pressure was reduced from 168/102 mmHg to 146/87 mmHg in the C-TD and from 169/102 mmHg to 148/88 mmHg in the C-TTS group. There was no difference in the response rate. The pattern of systemic side-effects appeared to correspond to those seen during oral clonidine treatment but with a lower frequency and intensity. The C-TD patch improved skin tolerability and the drop-out rate due to skin reactions was 2.2 times lower compared with the C-TTS group. Local skin reactions led to withdrawal in 35 of 449 C-TD treated and in 79 of 456 C-TTS treated patients. In conclusion, the improved carrier system for the transdermal clonidine treatment reduced local side-effects which in turn may further enhance acceptability and compliance in treated patients.