A comparison of the lung deposition of budesonide from Easyhaler, Turbuhaler and pMDI plus spacer in asthmatic patients

Inhaled corticosteroids in pressurized metered does inhalers (pMDIs) are often delivered via a large volume spacer device, but these are bulky and inconvenient. Dry powder inhalers (DPIs) provide a highly portable and convenient propellant-free alternative to pMDIs for asthma maintenance therapy However, each DPI could have unique in vivo delivery characteristcs. In order to quantify the total and regional lung deposition of budesonide (200 microg) from (a) Easyhaler, (b) Turbuhaler and (c) pMDI plus Nebuhaler 750 ml spacer, a three-way randomized cross-over study was carried out in 12 mild to moderate asthmatic patients. Deposition was quantified by the imaging technique of gamma scintigraphy Optimal inhalation techniques were used throughout. Mean (SD) whole lung deposition (% metered dose) was similar for Easyhaler [18.5 (7.8) %] and Turbuhaler [21.8 (8.2) %], but was significantly higher for pMDI plus Nebuhaler [44.1 (10.0) %, P < 0.01]. The regional distribution patterns in the lungs were predominantly central for all three devices. Nebuhaler reduced oropharyngeal deposition significantly compared with the two DPIs. Easyhaler showed comparable deposition to Turbuhaler and hence drugs delivered by Easyhaler would be expected to have a similar clinical effect to those delivered by Turbuhaler in asthma maintenance therapy.

Psychosocial interventions for caregivers of people with dementia: a systematic review

The content of interventions for caregivers of dementia patients is highly varied. None of the reviews conducted to date have focused on evaluating the effects of the content of interventions exclusively for dementia caregivers, and this issue is not well understood. The purpose of this review was to first identify the type of components (e.g. education, counselling) that have been utilized in psychosocial/psycho-educational interventions for dementia caregivers, and to evaluate the success of the different components or combination of components in producing positive outcomes for dementia caregivers. Forty studies were included in the review. Approximately two-thirds of the interventions did not show improvements in any outcome measures. Among those studies, which did demonstrate improvements, the inclusion of social components (e.g. social support) or a combination of social and cognitive (e.g. problem solving) components seemed to be relatively effective. It is important to note, however, that these analyses were based on small numbers and the review was limited by a number of methodological issues (e.g. poor description of interventions). To advance our understanding of the efficacy of psychosocial interventions for caregivers of people with dementia, a more systematic approach is required. Intervention components need to be carefully contrasted in appropriately designed studies of sufficient size.

What do patients expect of psychiatric services? A systematic and critical review of empirical studies

The article reviews literature concerning patients' expectations of psychiatric care. Early research (pre-1980) is outlined, followed by a systematic review of 21 studies fulfilling specific inclusion criteria from 1980 onwards. Overall, patients expected to improve as a result of psychiatric treatment, and had higher expectations of the helpfulness of psychological and combined treatments than other interventions. Few studies considered expectations of the process of psychiatric care or determinants of expectations. The majority of studies focused on examining the relation between expectations and outcomes. There were indications that expectations of improvement were linked to clinical outcomes, although the relationship appeared to be complex. There was also some evidence that when expectations of the process of care were incongruent with the service provided, outcomes were poorer. The findings of studies in the systematic review were generally congruent with earlier work (pre-1980), although expectations of improvement appeared to be higher in the later studies. Interventions to prepare patients for what to expect were found to have beneficial effects on attendance, satisfaction and the accuracy of expectations about the process of psychiatric care. Future research should focus on developing valid and reliable measures for use in different settings, and on determining the mechanism by which expectations may relate to outcomes, including clinical outcomes, attendance and satisfaction.

Scintigraphic evaluation of lung deposition with a novel inhaler device

A gamma-scintigraphic study was carried out in 13 healthy individuals to compare the lung deposition of budesonide from a novel multidose dry powder inhaler (MDPI; Novolizer) with that from the Pulmicort Turbuhaler, and to assess the degree of flow rate dependence of the Novolizer. Median whole lung depositions for the Novolizer at peak inhaled flow rates of 90, 60 and 45 l/min were 32.0, 25.4 and 19.9% of the metered dose, respectively, compared with 21.4% for the Turbuhaler (peak inhaled flow rate 60 l/min). Patterns of regional lung deposition were similar for all four regimens. These data provided proof of concept in vivo for the novel MDPI device, and demonstrated that it delivers drug to the lungs efficiently. The deposition data enabled drug doses to be used in subsequent clinical trials comparing the Novolizer with the Turbuhaler to be predicted with confidence.

The role of apolipoprotein E in cognitive decline after cardiac operation

BACKGROUND

Recently, Tardiff and colleagues have suggested that the presence of the apolipoprotein E, epsilon4 allele was associated with increased likelihood of cognitive decline after coronary artery bypass grafting. The objective of the current study was to replicate this earlier work using an increased sample size. The increased sample also enabled an analysis by individual genotype in cognitive decline after coronary artery bypass grafting.

METHODS

Apolipoprotein E genotyping was performed on 111 individuals undergoing coronary artery bypass grafting. Each participant underwent a battery of nine neuropsychological tests before operation and 4 to 7 weeks after operation.

RESULTS

Cognitive decline, assessed by both continuous Z change scores and two categoric measures of cognitive deficit, was not significantly associated with either individual apolipoprotein E genotypes or categorization by the presence or absence of the epsilon4 allele. The examination of potential moderating factors did not alter this finding.

CONCLUSIONS

This study suggests that the epsilon4 allele is not associated with cognitive decline in the weeks after coronary artery bypass grafting.

Regulation of steroid sulphatase expression and activity in breast cancer

Steroid sulphatase (STS) catalyzes the conversion of oestrone sulphate (E1S) to oestrone (E1) and its action in breast tumours makes a major contribution to in situ oestrogen production in this tissue. Although expression of STS mRNA and STS activity are increased in malignant breast tissues compared with that in non-malignant tissues, little is known about the regulation of its expression or activity. In the present study we have used a RT-PCR technique to investigate the regulation of STS mRNA expression in cultured breast tissue fibroblasts and MCF-7 cells. STS mRNA expression was readily detectable in fibroblasts derived from breast tissue proximal to tumours, breast tumour tissue and reduction mammoplasty tissue. For two pre-menopausal subjects, STS mRNA expression was similar in proximal and tumour fibroblasts whereas for a third, post-menopausal subject, expression in breast tumour fibroblasts was 2.4-fold that in proximal fibroblasts. The cytokine tumour necrosis factor alpha (TNFalpha) or the STS inhibitor, 2-methoxyoestrone-3-O-sulphamate, had no effect on STS mRNA expression in fibroblasts. STS mRNA was detectable in MCF-7 cells but neither TNFalpha nor interleukin 6 (IL-6) affected its expression. Transient transfection of COS-1 and MCF-7 cells with a STS cDNA lacking STS 5' and 3' sequences increased activity 17-fold and 2-fold, respectively. TNFalpha plus IL-6 increased STS activity in mock transfected MCF-7 cells and further increased STS activity in transfected MCF-7 cells. This indicates that activation can occur independently of STS promoter and enhancer elements. In conjunction with the lack of regulation of STS mRNA it suggest that TNFalpha and IL-6 may increase STS activity via a post-translational modification of the enzyme or by increasing substrate availability.

Regional lung deposition of a technetium 99m-labeled formulation of mometasone furoate administered by hydrofluoroalkane 227 metered-dose inhaler

BACKGROUND

A new inhaled suspension formulation of mometasone furoate (MF), a potent corticosteroid with minimal systemic availability, has been developed for the treatment of asthma. This formulation is delivered by metered-dose inhaler (MDI) using the nonchlorofluorocarbon propellant hydrofluoroalkane 227 (HFA-227).

OBJECTIVE

The primary goal of this study was to determine the respiratory tract deposition of this formulation of MF. A secondary objective was to measure plasma concentrations of MF and a putative metabolite, 6-X-OH MF, to determine the systemic exposure to corticosteroid.

METHODS

This was a single-dose, open-label study in which 200 microg of technetium 99m (99mTc)-radiolabeled MF was administered to patients with asthma. Gamma scintigraphy was used to quantify lung, oropharyngeal, stomach, and MDI mouthpiece deposition patterns of MF.

RESULTS

Eleven patients, aged 21 to 47 years, with a history of asthma were enrolled in and completed the study. The mean (+/- SD) whole lung deposition of MF was 13.9%+/-5.7% of the metered (ex-valve) dose. The central lung zone received 5.3%+/-2.8% of the dose; the intermediate zone received 4.7%+/-1.9%; and peripheral lung deposition was 4.0%+/-1.5%. The mean (+/- SD) ratio of peripheral to central lung deposition was 0.8+/-0.2. Oropharyngeal deposition was 79.1%+/-8.7% of the ex-valve dose, with 6.3%+/-7.8% deposited on the MDI mouthpiece and 0.7%+/-0.5% exhaled. The majority of plasma samples taken for analysis of MF and 6-13-OH MF concentrations were below the limit of quantification (50 pg/mL) in all patients after inhalation of 200 microg 99mTc-labeled ME CONCLUSION: The lung deposition of MF when administered via HFA-227 MDI is comparable to the 10 to 20% lung deposition seen with other corticosteroid suspension for- mulations administered by MDI that have demonstrated effectiveness in the treatment of asthma.

Human lung deposition data: the bridge between in vitro and clinical evaluations for inhaled drug products?

Regulatory dossiers for new inhaled drug products generally contain in vitro data, which assess delivered dose and particle size distribution, together with clinical efficacy and safety data. Human lung deposition data may be generated using radionuclide imaging techniques or appropriate pharmacokinetic methods, and can act as a 'bridge' via which a seamless transition can be made between in vitro testing in the laboratory and efficacy/safety testing in the clinic. By enabling informed decisions to be made about the evaluation of new devices or formulations in man, lung deposition data permit a long and expensive clinical trials programme to be commenced with much greater certainty of a successful outcome. Human lung deposition data should be considered for supplementing the information required for regulatory dossiers.

Cerebral microembolism detected by transcranial Doppler during cardiac procedures

BACKGROUND AND PURPOSE

Cerebral embolism with clinical sequelae may rarely complicate cardioversion and cardiac catheterization. Transcranial Doppler sonography has recently been introduced to monitor microemboli entering the middle cerebral artery in cardiac and carotid surgery. We therefore used this technique to evaluate the risk of asymptomatic embolism during common cardiac procedures.

METHODS

Patients were monitored by transcranial Doppler while undergoing direct current cardioversion (n=15) and cardiac catheterization (n=17).

RESULTS

Microemboli were detected in all patients having cardiac catheterization but in only 1 patient after cardioversion.

CONCLUSIONS

Microembolism occurred frequently during cardiac catheterization and rarely during cardioversion. It is not yet known whether this has clinical relevance.

Pulmonary drug delivery from the Taifun dry powder inhaler is relatively independent of the patient's inspiratory effort

The Taifun dry powder inhaler (Leiras OY, Turku, Finland) is a breath-actuated, multidose device, each metered dose containing 200 micrograms of budesonide. A two-way randomized crossover gamma scintigraphic study was performed in 10 asthmatic patients to determine the in vivo deposition pattern of budesonide inhaled from the Taifun. In vitro radiolabelling validation studies demonstrated that the radiolabel could be used as an accurate marker to assess in vivo drug deposition. Patients used either maximal inspiratory effort (targeted peak inhalation flow 30 L/min) or submaximal inspiratory effort (targeted peak inhalation flow 15 L/min) on each study day. Mean (S.D.) whole lung deposition (% of metered dose) was 34.3 (5.8)% and 29.6 (5.9)% for the two inhalation flows. The intersubject coefficient of variation in lung deposition was less than 20% on both study days. Drug was deposited uniformly across the central, intermediate, and peripheral lung regions for maximal and submaximal inspiratory efforts. The study suggests that the Taifun is a superior drug delivery device compared with many other inhalers, in terms of the amount of drug deposited in the lungs, the reproducibility of the lung dose, and the relative flow--independence of lung deposition.

Scintigraphic comparison of budesonide deposition from two dry powder inhalers

Chlorofluorocarbons (CFCs), used in metered dose inhalers (MDIs), have been identified as being deleterious to the environment leading to a ban on their production. Dry powder inhalers (DPIs) are a widely used alternative to MDIs. One disadvantage of DPIs is that in vivo lung deposition can be influenced by the patient's inspiratory flow rate. The ASTA Medica multi-dose dry powder inhaler (AM-MDPI) has been designed to offer low resistance on inhalation, so that asthmatic patients can achieve inhaled flow rates of approximately 90 L x min(-1). The aim of the study was to evaluate the in vivo deposition of budesonide from the AM-MDPI at different flow rates and to compare this with delivery from a Turbuhaler DPI at a high flow rate. The study was a scintigraphic, randomized, crossover study in which 13 healthy volunteers inhaled a single 200 microg dose of radiolabelled budesonide on four separate occasions with a minimum 44-h washout period between dosings. At the lowest flow rate of 54 L x min(-1), comparable to that for the Turbuhaler (58 L x min(-1)), a similar percentage of the metered dose was delivered to the lung (AM-MDPI median 19.9%; Turbuhaler median 21.4%). At high flow rate (peak inspiratory flow rate 99 L x min(-1)) the AM-MDPI delivered significantly more drug to the lung (median 32.1% of metered dose) than at 65 L x min(-1) or 54 L x min(-1) (median 25.0% and 19.9% of metered dose, respectively), thus demonstrating flow rate dependence. The pattern of regional lung deposition from the AM-MDPI was similar for all three inhalation manoeuvres. It was concluded that the ASTA Medica multi-dose dry powder inhaler achieves at least as much deposition of budesonide in the lungs as a Turbuhaler when used at similar inspiratory flow rates.

Acute psychological stress and the propensity to ventricular arrhythmias; evidence for a linking mechanism

AIMS

This study was designed to test the hypothesis that acute psychological stress is capable of inducing an increase in the dispersion of repolarization in patients with underlying coronary artery disease.

METHODS AND RESULTS

Twenty four patients undergoing elective coronary angiography were studied, 17 with significant coronary artery disease and seven with normal coronary arteries. Following coronary angiography they were subjected to a series of timed cognitive tests, well known to induce acute psychological stress. An individual's perception of stress was assessed by visual analogue scales. Serial ECGs were recorded during the cognitive tests and QT, QRS and JT intervals measured from which QT, QRS and JT dispersion were calculated. Psychological stress was reported by the seven patients with normal coronaries and 14 of the 17 with coronary artery disease. In patients who experienced stress a marked increase in QT dispersion, reflecting JT dispersion, was observed in those with coronary artery disease (F=22.4, P=0.0001) but not in those without. At baseline there was no difference in QT dispersion between those with and without coronary artery disease (27-57 ms, 17-53 ms, P > or = 0.5).

CONCLUSION

Acute psychological stress induces an increase in QT dispersion in patients with underlying coronary artery disease due to changes in JT dispersion (rather than QRS dispersion). This suggests that psychological stress modifies the dispersion of repolarization through ischaemia related changes in action potential duration.

Can lung deposition data act as a surrogate for the clinical response to inhaled asthma drugs?

Studies involving the direct measurement of clinical response to inhaled asthma drugs, especially inhaled corticosteroids, may be very difficult to conduct. However, the deposition of drug in the lungs may be considered as a measure of local bioavailability, and may be quantified by radionuclide imaging techniques, or for some drugs by pharmacokinetic methods. This paper reviews evidence for considering lung deposition data as a surrogate for the clinical response to inhaled asthma drugs, based mainly upon a series of case histories. The appropriate use of lung deposition data in regulatory packages, especially to document the equivalence or comparability of two products, offers the possibility of significant time saving in the drug development process, and hence a faster drug development programme for inhaled asthma products.

Cofactor competition between the ligand-bound oestrogen receptor and an intron 1 enhancer leads to oestrogen repression of ERBB2 expression in breast cancer

Overexpression of the ERBB2 proto-oncogene in breast tumours, which occurs in 25-30% of patients, correlates with poor prognosis. In oestrogen receptor (ER) positive breast epithelial cells oestrogens reduce ERBB2 mRNA and protein levels, an effect that is reversed in the presence of anti-oestrogens such as tamoxifen and ICI 182780. Our previous studies have shown that the major effect of oestrogen on ERBB2 expression is at the level of transcription and that this is mediated through a region within the ERBB2 first intron which can act as an oestrogen-suppressible enhancer in ER positive breast cells. In vitro footprinting of the smallest DNA fragment that retained full activity revealed four transcription factor binding sites. We report here that two of these sites are recognized by AP-2 proteins and the other two are bound by a variety of bZIP factors, including CREB and ATFI, with a major complex containing ATFa/ JunD. However, by using ER mutants it is clear that repression occurs essentially off the DNA. Indeed, the essential domain of the ER responsible for repression of the ERBB2 enhancer is a region termed AF2 which is required for the ligand-dependent association of non-DNA binding cofactors. We further demonstrate that one of these ER cofactors, SRC-1, can relieve oestrogen repression of the ERBB2 enhancer and conclude that these data fit with a model whereby the ER and the ERBB2 enhancer compete for this limiting, non-DNA binding cofactor. Thus, in oestrogenic conditions SRC-1 preferentially binds to the ER which effectively sequesters it thereby reducing enhancer activity, but in antioestrogenic media the cofactor is released from the ER and is therefore available to activate the ERBB2 enhancer.

Use of gamma scintigraphy to evaluate the performance of new inhalers

Many new inhaler devices and formulations involving pressurized metered dose inhaler (pMDI), dry powder inhaler (DPI), and liquid spray technologies are currently being developed. Some of these novel drug delivery products deposit a greater percentage of the drug dose in the lungs than a conventional chlorofluorocarbon (CFC)-based pressurized aerosol, hence providing better drug targeting to the required site of drug action. The noninvasive imaging technique of gamma scintigraphy provides an accurate quantification of the amount of drug deposited in the lungs from inhaler devices together with an assessment of deposition in different lung regions. Respimat (Boehringer Ingelheim, Ingelheim am Rhein, Germany) is a novel liquid spray "soft mist inhaler" that more than doubles deposition in the lungs compared with a pMDI and reduces oropharyngeal deposition, thus providing a degree of drug targeting comparable to that from a spacer device. These data suggest that Respimat should be a valuable addition to the range of devices available for inhalation therapy.

What do patients want and do we want to know? A review of patients' requests of psychiatric services

OBJECTIVE

A systematic review was conducted of the literature concerning patients' requests of psychiatric care in order to identify the types of requests patients make, psychiatrists' perceptions of their patients' requests, and the relationship between requests and the outcome of care.

METHOD

A total of 28 published original articles which fulfilled specific inclusion criteria were reviewed.

RESULTS

The studies showed that there are certain core requests that patients make irrespective of the type of service attended. Patients mainly request psychological approaches, and the most common requests are for 'clarification', 'psychological expertise' and 'psychodynamic insight'. There is evidence that patients normally feel inhibited about making requests, and that psychiatrists often fail to identify what their patients want.

CONCLUSION

The majority of patients attending psychiatric services have requests which they will express when encouraged to do so, but little is known about the relationship between patients' requests and the outcome of care. Recommendations are made for future research.

Pharmacoscintigraphic evaluation of lung deposition of inhaled zanamivir in healthy volunteers

OBJECTIVE

The objective of this study was to determine the sites of zanamivir deposition in the respiratory tract and the pharmacokinetics of zanamivir after oral inhalation from the Diskhaler device and from a prototype of a novel breath-activated device.

DESIGN

This was a 2-period block-randomised study in which participants inhaled zanamivir from a Diskhaler and/or the prototype device on separate days.

STUDY PARTICIPANTS

13 healthy volunteers (5 men and 8 women) aged 20 to 42 years (mean age 29 years) and weighing 54.0 to 94.0 kg (mean bodyweight 69.2 kg) entered the study.

INTERVENTIONS

Participants were given dry powder zanamivir 10 mg formulated with 99mTc from the Diskhaler or the prototype device on separate days. Scintigraphic images of the chest and oropharynx were recorded. Blood samples for determination of serum zanamivir and urine for excretion studies were taken up to 8 hours after drug administration. Safety was evaluated by monitoring lung function tests, adverse events and laboratory parameters.

RESULTS

Orally inhaled zanamivir was well tolerated, as demonstrated by lung function tests. A mean of 13.2% (n = 11) of the 10 mg dose from the Diskhaler was deposited in the bronchi and lungs. The deposition pattern varied between individuals, showing a preferentially central deposition pattern in some and a uniform distribution pattern in others. The major deposition site was the oropharynx (mean 77.6%), with a mean of 1.2% deposited on the trachea and a mean of 3.2% retained in the blister. Similar data were obtained with the prototype device. Inhalation of zanamivir gave a broad peak of systemic absorption with mean maximum serum concentrations of approximately 30 to 40 micrograms/L after 1.5 hours. The rate and extent of absorption were similar irrespective of inhalation device. Less than 5% of drug was excreted unchanged in urine within 8 hours of inhalation, confirming the low bioavailability of zanamivir after pulmonary delivery. A significant correlation existed between systemic exposure and peripheral lung deposition.

CONCLUSIONS

The local concentrations of zanamivir that result from oral inhalation via the Diskhaler are estimated to be > 10 mumol/L throughout the respiratory tract, well in excess of the concentrations observed to inhibit influenza virus neuraminidases by 50% (0.64 to 7.9 nmol/L). Similar deposition data were obtained with the Diskhaler and the prototype device, which was consequently not developed further. Pharmacoscintigraphy was confirmed as being a reliable technique for measuring zanamivir deposition in the respiratory tract.

Improved targeting of beclomethasone diproprionate (250 micrograms metered dose inhaler) to the lungs of asthmatics with the Spacehaler

The Spacehaler (Evans Medical Ltd, Leatherhead, U.K.) is a new, compact, inhaler device containing the same aerosol canister as a conventional metered dose inhaler (MDI). However, the design of the Spacehaler has been shown to reduce the velocity of the aerosol, thus reducing the proportion of non-respirable particles delivered to the patient. This study compared radioaerosol deposition patterns following inhalation of 250 micrograms of beclomethasone dipropionate from the Spacehaler and a conventional MDI (Beclazone, Norton Health Care, Harlow, U.K.). After rigorous in vitro validation of the radiolabelling technique, 12 asthmatic subjects (seven men aged 20-69 years, mean baseline FEV1 2.59 1 (SD 0.55 1) received one dose of 99mTc-labelled beclomethasone dipropionate 250 micrograms via either a Spacehaler or MDI on each of two study days in a randomized cross-over manner. All subjects had been taught the required inhalation technique before the dose was administered. Inhalation details were recorded using a spirometer connected in series with the device. Lung and oropharyngeal depositions were measured by gamma scintigraphy. The mean percentage of the metered dose deposited in the lungs was 23.0% (SD 8.3%) for the Spacehaler and 12.8% (SD 6.8%) for the MDI (P < 0.01). However, there was no significant difference in the distribution patterns within the lungs between the two devices. Oropharyngeal deposition was significantly lower (P < 0.01) for the Spacehaler than for the MDI [mean (SD) 27.9% (16.4%) and 73.6% (8.7%), respectively] whilst the percentage of the metered dose remaining on the Spacehaler actuator was significantly greater than that on the MDI actuator [mean (SD) 48.0% (11.8%) and 12.4% (8.5%) respectively, P < 0.01]. There was evidence from the inhalation recordings that some patients experienced the 'cold Freon effect' whilst using the metered dose inhaler which may have contributed to the lower lung deposition seen with this device. This study demonstrates that the proportion of a 250 micrograms dose of beclomethasone dipropionate that is delivered to the lungs is significantly greater with the Spacehaler than the MDI. The Spacehaler also reduces the proportion of the does that is deposited in the oropharynx to less than half that observed with the MDI, and reduces the total dose of drug received by the patient.

A longitudinal study of anticardiolipin antibody levels and cognitive functioning in systemic lupus erythematosus

OBJECTIVE

To determine the relationship between persistently raised anticardiolipin antibody (aCL) levels and neuropsychological performance in patients with systemic lupus erythematosus (SLE).

METHODS

Forty-five patients with SLE underwent a detailed neuropsychological assessment on 2 occasions 12-18 months apart. Serum samples stored since the time of previous assessments as well as samples obtained 6 months to 2 years before the first neuropsychological assessment were tested for IgG aCL levels. Patients were divided into 4 groups according to the number of times their aCL levels were elevated (never, once, twice, 3 times). A wide-ranging battery of new neuropsychological tests was utilized, and the results were compared with double-stranded DNA (dsDNA) antibody levels, C3 levels, and results of magnetic resonance imaging (MRI).

RESULTS

Analysis of variance revealed that the group with persistently elevated aCL levels performed less well than the other groups. At the first neuropsychological assessment, poorer performance by this group was noted for letter cancellation (P = 0.02), trail making task B (P = 0.04), and digit span (P = 0.03). At the second assessment, letter cancellation (P = 0.01), trail making task A (P = 0.03), trail making task B (P = 0.01), word fluency (P = 0.01), and reaction time (P = 0.05) were impaired. In contrast, no significant differences in neuropsychological test results were identified with respect to DNA antibody or C3 levels. MRI abnormalities were associated with both persistent elevation of aCL levels and low C3 levels.

CONCLUSION

Levels of IgG aCL that were persistently elevated over a 2-3-year period (as opposed to never or occasionally elevated) were associated with significantly poorer performance in cognitive function by patients with SLE. Tasks requiring speed of attention and concentration appear to be particularly affected.

Impact of Carotid Endarterectomy upon Cognitive Functioning

BACKGROUND AND PURPOSE

The extent to which carotid endarterectomy (CEA) influences cognitive functioning has been the subject of a number of studies often with conflicting conclusions. This paper systematically reviews the literature in an attempt to clarify this issue.

RESULTS

Although the majority of studies (16/28) reported an improvement in cognition after surgery, a substantial minority (12/28) found no change. Studies before 1984 tended to report an improvement, while later studies tended to report no change in cognition. Cognitive improvement was also more likely the longer the time interval between CEA and assessment. The studies were found to differ on many methodological factors, e.g. sample size, type of patient and control group, severity and side of carotid stenosis, the range of cognitive tests and timing of postoperative assessment.

CONCLUSION

Given the conflicting findings, and the methodological issues, it is not possible to draw a clear conclusion regarding the impact of carotid endarterectomy upon cognition. Future research which pays attention to these methodological factors is needed in order to adequately resolve the current debate.

Influence of HIV positive status on sexual behavior among males

OBJECTIVE

To compare HIV seronegative (HIV-) and HIV seropositive (HIV+) males in terms of sexual behavior with female and male partners of different types.

METHOD

Cross-sectional study. From August 1994 to February 1995, a sample of 236 respondents (150 HIV- and 86 HIV+) recruited from public health centers in the State of S. Paulo (Brazil), answered a questionnaire, including questions on demographic aspects, HIV and AIDS related knowledge, sexual orientation, use of alcohol and other drugs, sexual behavior with regular and casual female and male partners, and perceived risk of HIV infection. Sexual behavior with regular and casual female and male partners within the previous three months, was investigated.

RESULTS

A lower proportion of HIV+ engaged in sexual contact with regular female partners (p < .01) and in vaginal intercourse with this type of partner (p < .01). A lower proportion of HIV+ engaged in overall sexual activity (p < .001) and reported lower frequency of penetrative sexual practices (p < .05). A high level of condom use with female and male partners was identified with no significant differences being found between the two serostatus groups. Some risky sexual behavior was identified, however, especially with regular partners, suggesting that some men were continuing to practice unsafe sex.

CONCLUSIONS

The high level of condom use identified suggests that safer sex advice has been taken up. Condom use was not universal, however, and some men continue to place themselves at risk, especially with regular partners. Prevention programs should strive not only to encourage HIV- to practice safer sex, but also to encourage HIV+ to do so in order to prevent further transmission of the virus.

Neuroprotection of the brain during cardiopulmonary bypass: a randomized trial of remacemide during coronary artery bypass in 171 patients

BACKGROUND AND PURPOSE

Neuropsychological impairment may follow coronary artery bypass surgery as a result of peroperative cerebral microembolism. The hypothesis that remacemide, an NMDA receptor antagonist, would provide protection against such ischemic damage has been tested in a randomized trial.

METHODS

One hundred seventy-one patients undergoing coronary artery bypass surgery by a single cardiothoracic surgical team were randomized to receive remacemide (up to 150 mg every 6 hours) or placebo from 4 days before to 5 days after their bypass procedure. Peroperative monitoring included an estimate of the number of microembolic events detected by transcranial Doppler ultrasonography of the middle cerebral artery. A battery of 9 neuropsychological tests was administered before and 8 weeks after surgery.

RESULTS

The proportion of patients showing a decline in performance of 1 SD or more in 2 or more tests was reduced in the treated group (9% versus 12%), but this was not statistically significant. On the other hand, overall postoperative change (reflecting learning ability in addition to reduced deficits) was more favorable in the remacemide group, which demonstrated significantly greater improvement in a global z score (P=0.028) and changes in 3 individual tests (P<0.05). The 2 patient groups were well matched, including for the burden of microembolic events.

CONCLUSIONS

This is the first study to show statistically significant drug-based neuroprotection during cardiac surgery. In addition to offering improvement in cerebral outcome for such at-risk patients, it supports the hypothesis that drugs acting on the excitotoxic mechanism of ischemic cerebral damage can be effective in humans.

Evidence of CNS impairment in HIV infection: clinical, neuropsychological, EEG, and MRI/MRS study

OBJECTIVES

To identify by clinical examination, EEG, MRI, and proton spectroscopy, and neuropsychological assessment the prevalence of signs of CNS involvement in patients infected with HIV, and to relate such findings to the evidence of immunosuppression.

METHODS

The design was a cross sectional analysis of a cohort of male patients with infected HIV with an AIDS defining diagnosis or low CD4 count (<350), and seropositive asymptomatic subjects, both groups being followed up in a longitudinal study. Control groups consisted of seronegative subjects from the same genitourinary medicine clinics.

RESULTS

This report sets out the cross sectional findings at the seventh visit in the longitudinal study. Patients with AIDS had more signs of neurological dysfunction, poorer performance on a neuropsychological test battery, were more likely to have an abnormal EEG, and to have abnormalities on MRI. They more often had cerebral atrophy, abnormal appearing white matter, and abnormal relaxometry and spectroscopy. There was little evidence of abnormality in seropositive people who had a CD4 count >350 compared with seronegative people from a similar background.

CONCLUSIONS

Detailed testing failed to disclose significant CNS impairment without immunosuppression in men infected with HIV. Findings from MRI and magnetic resonance spectroscopy (MRS) correlated with those of the neurological examination and neuropsychological assessment. A combination of such assessments offers a simple surrogate for studies of CNS involvement in HIV disease.

Lung deposition of fenoterol and flunisolide delivered using a novel device for inhaled medicines: comparison of RESPIMAT with conventional metered-dose inhalers with and without spacer devices

STUDY OBJECTIVES

To compare lung deposition of fenoterol or flunisolide administered from a novel, multidose inhalation device delivering liquid droplets (RESPIMAT; Boehringer Ingelheim Ltd; Bracknell, UK) or from conventional metered-dose inhalers (MDIs) with and without spacers.

DESIGN

Two randomized, three-way crossover studies.

SETTING

Clinical research laboratory.

PARTICIPANTS

Healthy, nonsmoking volunteers.

INTERVENTIONS

In one study, radiolabeled aerosols of fenoterol from the RESPIMAT device and from a conventional MDI with or without an Aerochamber spacer (Trudell Medical; London, Ontario Canada). In the second study, radiolabeled aerosols of flunisolide from a RESPIMAT device, from a RESPIMAT device modified by inclusion of a baffle/impactor in the mouthpiece, and from a conventional MDI with an Inhacort spacer (Boehringer Ingelheim; Ingelheim, Germany).

MEASUREMENTS AND RESULTS

Assessment of the deposition of fenoterol or flunisolide in the lung and oropharynx using gamma scintigraphy. Safety was assessed based on reported adverse effects and spirometry (FEV1, FVC, and peak expiratory flow rate) to detect any paradoxical bronchoconstriction. The RESPIMAT device delivered significantly more fenoterol to the lungs than either an MDI alone or an MDI with Aerochamber (39.2% vs 11.0% and 9.9% of metered dose, respectively; p<0.01). Oropharyngeal deposition of fenoterol from the new device was lower than that from the MDI (37.1% vs 71.7%, respectively; p<0.01). The RESPIMAT device deposited significantly more flunisolide in the lungs compared with MDI plus spacer (44.6% vs 26.4%, respectively; p<0.01), while resulting in similar oropharyngeal deposition (26.2% vs 31.2%, respectively). Introduction of a baffle into the RESPIMAT system reduced lung deposition of flunisolide to 29.5%, and oropharyngeal deposition to 7.8% (p<0.01).

CONCLUSION

The RESPIMAT device may prove to be an effective alternative to MDIs for the administration of inhaled bronchodilators and corticosteroids. The high lung deposition and low oropharyngeal deposition may lead to improved efficacy and tolerability of inhaled medications, especially corticosteroids.