Systemic bioavailability and potency of high-dose inhaled corticosteroids: a comparison of four inhaler devices and three drugs in healthy adult volunteers

OBJECTIVES

To compare the systemic bioavailability (assessed by cortisol suppression) of high-dose budesonide when given by four inhaler devices and orally. Also studied are the relative systemic potencies of three inhaled steroids (budesonide, fluticasone propionate, and beclomethasone dipropionate) when given by metered-dose inhaler (MDI) with a large volume spacer.

DESIGN

Double-blind, crossover, placebo-controlled trial.

PARTICIPANTS

Sixteen healthy, steroid-naive adult volunteers.

METHODS

On separate occasions, each subjects took 4 mg of budesonide through the following devices: MDI alone, MDI with 750-mL. spacer, dry-powder inhaler and nebulizer; 4 mg of budesonide was also taken orally to assess the effects of GI absorption. For the drug comparison, each subject took 4 mg of budesonide, fluticasone, and beclomethasone, and 2 mg of budesonide and fluticasone by MDI and spacer.

RESULTS

Greatest percent suppression (95% confidence interval) of 9:00 AM cortisol with budesonide was observed with MDI alone (73% [57 to 90]) and turbohaler (72% [58 to 86]) compared with MDI spacer (42% [22 to 64]) and oral administration (14% [+6- to -34]). Nebulized budesonide produced an insignificant rise in 9:00 AM cortisol level. The most suppressive drug (given by MDI spacer) was fluticasone at 4 mg (86% [82 to 91]) and at 2 mg (72% [59 to 85]). The least suppressive drug was budesonide at 4 mg (43% [22 to 64]) and at 2 mg (25% [3 to 47]). The effects of 4 mg of beclomethasone were intermediate (66% [49 to 82%]).

CONCLUSIONS

The choice of delivery device for administration of budesonide can lead to important differences in systemic bioavailability. Fluticasone has greater systemic potency than budesonide or beclomethasone when given at microgram equivalent dosage. The systemic potency ratio of fluticasone propionate to budesonide in normal human volunteers in the present study is similar to the therapeutic potency ratio of the drug in asthmatic patients (approximately 2:1).

A Motivational Message, External Barriers, and Mammography Utilization

Based on a theory of behavior, the interaction of a motivational message and external barriers on mammography utilization was tested. Participants (N = 101) had not had mammograms annually, and were identified from an urban clinic serving a disproportionally high percentage of indigent clients. Fifty-five percent were Caucasian; 45% were African-American. In an experimental design, half of the sample received a telephone discussion about rationale, feelings, and beliefs regarding mammograms, and half did not receive this contact. Four months later, nurses assessed women's recent mammography utilization and external barriers (e.g., affordability and accessibility). A logistic regression revealed an interaction between the intervention and barriers on postintervention mammography utilization (odds ratio: 2.12; p < 0.05). As proposed, the intervention was associated with a 64% rate of mammography utilization among women without barriers, but only a 26% rate among women with barriers. Not only should clinicians offer motivational messages about mammography, but also administrators should address external barriers to maximize mammography among socioeconomically disadvantaged groups.

Olanzapine in the long-term treatment of schizophrenia

The primary aim of the long-term treatment of patients with schizophrenia is to prevent relapse, which is costly both in psychological and economic terms. Although with conventional antipsychotic drugs relapse may occur despite compliance with maintenance regimens, the rate of relapse is reduced in compliant patients. However, this benefit is achieved at the cost of side-effects and the risk of developing tardive dyskinesia, even among patients who have taken these drugs for only a year or two. To provide the therapeutic benefits of maintenance medication without its drawbacks, intermittent dosing and long-term therapy with reduced doses of conventional medications have been explored. The atypical antipsychotic agent, olanzapine, has been shown to be effective maintenance medication and has an improved safety profile.

Engagement in breast cancer screening behaviors

PURPOSE/OBJECTIVES

To distinguish women who engaged in recommended breast cancer screening from those who did not.

DESIGN

Descriptive design, with quantitative measures.

SETTING

Urban, county hospital serving many low-income clients.

SAMPLE

119 women, age 51 to 80, who had not had mammograms in the last 13 months.

METHOD

Nurse-conducted telephone interviews that incorporated a modified Profile of Mood States, Attitudes Towards Mammography Scale, Barriers Scale, and reports of engagement in mammography and clinical breast exam (CBE) in the last 13 months and breast self-exam (BSE) practice in the last 3 months.

MAIN RESEARCH VARIABLES

Affect, beliefs, facilitators, and knowledge regarding screening; engagement in mammography, CBE, and BSE.

FINDINGS

In discriminant analyses of engagement in mammography and CBE, affect, barriers, prior history of breast problems, and race were significant variables. In discriminant analysis of BSE, history of breast biopsy, family history of breast cancer, beliefs about screening and cancer, prior instruction in BSE, and being single were significant variables.

CONCLUSIONS

Variables that discriminated between use and non-use of professional screening were different from those that discriminated between use and non-use of BSE.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can promote professional breast screening by addressing women's negative affect, prior breast concerns, and barriers, especially among Caucasians. Nurses can promote monthly BSE by supporting realistic beliefs about screening and cancer as well as by demonstrating BSE, especially among married women.

The loss of Peyton

Eclampsia, a convulsive disorder usually occurring near the end of pregnancy and more often than not occurring with primigravida mothers, represents a serious toxic condition that endangers the life of both the mother and child. Because of this possibility it is very important for women to receive prenatal care. Most obstetricians believe that the causes of eclampsia are unknown. However, midwives usually believe that good nutrition in combination with the reduction of stress prevents eclampsia. Eclampsia can be insidious and can present itself with little warning.

What are we teaching about lifting and transferring patients?

Lifting patients under the axilla has been found to be physically stressful for nurses and uncomfortable for patients. The goals of this study were to find out: how often educators teach this method and observe it in the clinical field; which assistive devices are used in teaching; and what authors of textbooks teach about the under-axilla method. A questionnaire was sent to 546 baccalaureate (BS) and associate (AD) degree programs; 358 educators responded and 337 responses were analyzed. Eighty-three percent of the educators teach the under-axilla method for in- and out-of-bed transfers; 94% observe it used in the clinical field. For lifting up in bed, 56% teach the under-axilla method; 86% observe it in the clinical field. When assistive devices are included in teaching, the hydraulic lift and gait belt are taught most often; less stressful and more comfortable devices are not taught or observed by most respondents. None of the authors of the 3 most frequently used textbooks describe the use of the under-axilla method; authors of 2 textbooks state patients should not have pressure placed on the axilla area.

First isolation of Trichophyton fischeri in the United States

A 49-year-old male with Pneumocystis carinii pneumonia was seen at Bellevue Hospital in New York, N.Y. Sputum samples yielded cultures of Candida lusitaniae, Mycobacterium avium, and a filamentous fungus, Trichophyton fischeri. T. fischeri is a nonpathogenic fungus which resembles the dermatophyte Trichophyton rubrum. This is the first record of the species from U.S. sources. This case exemplifies the ecological differences between T. fischeri and T. rubrum and illustrates how correct identification of the former species can minimize diagnostic confusion. The two species are distinguished from each other by the type of growth on Casamino Acids-erythritol-albumin agar and by micromorphological differences.

Effects of clozapine on auditory event-related potentials in schizophrenia

BACKGROUND

Schizophrenia is associated with cognitive deficits that are an intrinsic component of the disorder. Clozapine is an atypical antipsychotic that is superior to typical agents in the treatment of positive symptoms. The degree to which clozapine ameliorates cognitive deficits, however, is still controversial. Mismatch negativity (MMN), N200 (N2), and P300 (P3) are cognitive event-related potentials (ERPs) that index preattentive (MMN) and attention-dependent information processing (N2, P3) and provide a measure of cognitive deficits associated with schizophrenia. In schizophrenic patients deficient generation of MMN, N2, and P3 has been observed, suggesting impairments of discrete stages of information processing.

METHODS

This study investigates the effects of clozapine treatment on MMN, N2, and P3 generation. Patients were recruited from a haloperidol-controlled, double-blind treatment study of clozapine in chronic schizophrenia. ERPs were obtained at the beginning of the study and after 9 weeks (4 patients) and 16 weeks (13 patients) of treatment.

RESULTS

Clozapine treatment was associated with a significant increase of P3 amplitude, which was not observed in the haloperidol group; however, clozapine treatment did not affect deficits in MMN and N2.

CONCLUSIONS

These findings suggest that clozapine--in contrast to conventional antipsychotics--improves electrophysiological measures of attention-dependent information processing, but does not ameliorate preattentive deficits.

Apoptosis in esophageal cancer following induction chemoradiotherapy

BACKGROUND

The poor survival of patients with esophageal cancer following esophagectomy has led to intense investigation into combined modality therapy. Based on results from clinical trials examining chemoradiotherapy alone without surgery, resection has come under increased scrutiny and its necessity as a component of a multimodal approach has been questioned. In this study, we examined whether residual tumor cells in esophagectomy specimens following induction chemoradiotherapy are viable and, therefore, provide putative evidence for the appropriateness of esophagectomy.

MATERIALS AND METHODS

Between August 1991 and January 1995, 46 patients were entered into an induction chemoradiotherapy trial consisting of 5-fluorouracil, cisplatin, alpha-interferon, and concurrent external beam radiotherapy followed by esophagectomy. Response was determined histologically and apoptosis assessed with a terminal deoxytransferase assay system. p53 status was determined by immunohistochemistry and mutational analysis.

RESULTS

Thirty-eight patients underwent esophagectomy, 33 of whom had either a complete (n = 10) or partial (n = 23) response. None of the 28 patients with residual tumor in the resected specimen had 100% apoptotic cells and the vast majority of specimens had less than a 10% apoptotic rate. The percentage of apoptotic cells did correlate with tumor differentiation but not with histologic type nor presence of p53 mutations.

CONCLUSIONS

These data suggest that resection following upfront chemoradiotherapy is a necessary component of a multimodality approach to esophageal cancer and will ultimately provide superior local-regional control to a nonsurgical approach.

Somatic cell cloned transgenic bovine neurons for transplantation in parkinsonian rats

Parkinson's disease symptoms can be improved by transplanting fetal dopamine cells into the putamen of parkinsonian patients. Because the supply of human donor tissue is limited and variable, an alternative and genetically modifiable non-human source of tissue would be valuable. We have generated cloned transgenic bovine embryos, 42% of which developed beyond 40 days. Dopamine cells collected from the ventral mesencephalon of the cloned fetuses 42 to 50 days post-conception survived transplantation into immunosuppressed parkinsonian rats and cells from cloned and wild-type embryos improved motor performance. Somatic cell cloning can efficiently produce transgenic animal tissue for treating parkinsonism.

Essential role of induced nitric oxide in the initiation of the inflammatory response after hemorrhagic shock

Resuscitation from hemorrhagic shock induces profound changes in the physiologic processes of many tissues and activates inflammatory cascades that include the activation of stress transcriptional factors and upregulation of cytokine synthesis. This process is accompanied by acute organ damage (e.g., lungs and liver). We have previously demonstrated that the inducible nitric oxide synthase (iNOS) is expressed during hemorrhagic shock. We postulated that nitric oxide production from iNOS would participate in proinflammatory signaling. Using the iNOS inhibitor N6-(iminoethyl)-L-lysine or iNOS knockout mice we found that the activation of the transcriptional factors nuclear factor kappaB and signal transducer and activator of transcription 3 and increases in IL-6 and G-CSF messenger RNA levels in the lungs and livers measured 4 h after resuscitation from hemorrhagic shock were iNOS dependent. Furthermore, iNOS inhibition resulted in a marked reduction of lung and liver injury produced by hemorrhagic shock. Thus, induced nitric oxide is essential for the upregulation of the inflammatory response in resuscitated hemorrhagic shock and participates in end organ damage under these conditions.

Potential for meeting clinician information requirements in an intensive care unit (ICU) via the web

OBJECTIVE

A web interface allows ICU-oriented information to be accessed from other patient care areas and clinical applications, optimizing information integration in the hospital. In preparation for installation of a web-enabled bedside patient charting application, we attempted to maximize the percentage of our ICU-information requirements that could be met via the web and designed a web interface for accessing this information.

DESIGN

A comprehensive inventory of the information needs of our ICU was made by taking an inventory of existing paper and electronic documents, manuals, handouts, patient chart elements, and clinician communication about patients. We then designed a web site, created web-based prototype applications, and linked to hospital web applications.

MEASUREMENTS

Before and after implementation of the web site, each category of requirements that were identified were marked as available, partially available, or unavailable via the web.

RESULTS

After implementation of the ICU web site, 56.3% of identified information category requirements (+18.3%) were available via the web, 23.9% were partially available (+4.2%) and 19.8% were still unavailable (-22.5%). Implementation of the web-enabled bedside charting application would increase the percentage of information categories available via the web to 73.2% (+16.9%) and 18.3% of required information would be partially web-accessible.

CONCLUSIONS

The majority of information required by clinicians in an ICU can be made accessible via the web if a systematic approach is taken to identify needs and to develop or link to applications and web pages to meet these needs.

Studies of the surgical scrub

BACKGROUND

To evaluate the effectiveness of various scrub techniques in reducing bacterial skin flora, the present study was developed in three stages.

METHODS

Each stage involved fingertip bacterial colony counts measured before, immediately after and 30 min after a variety of handwashing techniques using 10% povidone iodine solution. The first compared 1, 2 or 3 non-timed washes from fingertips to elbows in 10 volunteers. The second compared two volunteers scrubbing for equal durations with or without friction rubbing, while the third involved 15 volunteers who each scrubbed for different time intervals.

RESULTS

The first stage showed that a single wash episode failed to provide lasting bacterial colony count reductions on fingertip cultures. The second showed that enduring colony count reductions occur whether friction rubbing of the hands was used or not, and the third showed that a 30 s wash was as effective as washing for longer periods in reducing fingertip flora.

CONCLUSIONS

These findings suggest that prolonged vigorous pre-operative scrubbing is unnecessary, although more than a cursory wash is required to produce lasting fingertip antisepsis.

HEPES inhibits contractile responses of canine basilar artery

N-2-hydroxyethylpiperazine-N'-2-ethanesulphonic acid (HEPES) is a commonly-used buffer. This study determined the effect of HEPES on contractility of the dog basilar artery and tested the hypothesis that HEPES inhibits vasoconstriction of isolated arterial segments by generating H2O2. Rings of dog basilar artery with or without endothelium were suspended under isometric tension and contracted with KCl, serotonin, or prostaglandin F2 alpha (PGF2 alpha) in bicarbonate or HEPES buffer. Addition of HEPES, 30 mmol l-1, before or after contraction with KCl, serotonin or PGF2 alpha significantly decreased maximal tension in rings with or without endothelium. Preincubation with HEPES buffer, 10 mmol l-1, significantly decreased maximal contractions to each agonist in rings with endothelium and to KCl and serotonin in rings without endothelium. HEPES, 30 mmol l-1, noncompetitively inhibited concentration-contraction curves to increasing concentrations of each agonist in rings with or without endothelium. Inhibition by HEPES was completely reversible with washing. The inhibitory effects of HEPES on responses to each agonist in rings with endothelium were significantly less in the dark or after coincubation with catalase. Unlike HEPES, effects of H2O2 were endothelium-dependent in that H2O2 caused contractions in rings with endothelium and relaxations in rings without endothelium. 5-(N,N'-dimethyl)-amiloride and 4,4'-diisothiocyanataostilbene-2,2'-disulfonic acid did not affect contractility in this preparation. These results show that HEPES exerts significant inhibitory effects on arterial smooth muscle contractility. The mechanism does not involve endothelium-dependent relaxation, effects on chloride channels or the sodium-hydrogen exchanger or generation of H2O2 by HEPES in the light.

Infant age, context, and family system influences on the interactive behavior of mothers of infants with mental delay

Interactive behavior of 30 mothers of infants with mental delay and 30 comparison mothers and infants was examined in relation to child age (first and second year), context (feeding versus teaching), maternal characteristics (family stress, coping resources), and family social system (maternal education). Groups were compared from two perspectives: with infants matched on mental age (9 and 19 months MA), and on chronological age (8 and 18 months CA). Study mothers scored lower than comparison mothers during teaching but not during feeding in year 1 with both MA and CA match, but only with the CA match in year 2. Study infants scored lower than comparison infants in both contexts in year 1, but not in year 2. Groups did not differ on maternal or family measures. In year 1, group status, coping, and maternal education were predictive of mother interaction. In year 2, only maternal education was predictive. Results confirm the importance of type of match, context, and family system variables in understanding effects of child mental delay on maternal interactive behavior.

Phase II study of topotecan in patients with advanced non-small-cell lung cancer previously untreated with chemotherapy

PURPOSE

This study was designed to assess the anti-tumor activity of topotecan (TPT) in patients with advanced non-small-cell lung cancer (NSCLC) previously untreated with chemotherapy.

PATIENTS AND METHODS

Patients with stage IIIB or IV NSCLC with measurable disease in nonradiated fields were eligible. Other eligibility criteria were Zubrod performance status (PS) < or = 2 and adequate renal and liver function. TPT was administered at a dose of 1.5 mg/m2/d for 5 days over 30 minutes every 21 days. Of 48 registered patients, 40 were fully assessable. Nineteen patients had adenocarcinoma (AD), 14 squamous carcinoma (SCC), and seven poorly differentiated carcinoma.

RESULTS

Six patients (15%) achieved a partial remission (PR) (durations: 8, 14, 18, 28, 56, and 61 weeks) and four patients a minor response; 10 patients had stable disease and 20 patients progressive disease. The PR rate was 36% (five of 14 patients) in patients with SCC versus 4% (one of 26 patients) in those with other histologies (P = .014). The overall median survival time was 38 weeks and 30% of patients were alive at 1 year. Grade 3 to 4 granulocytopenia and thrombocytopenia occurred after 76% and 10% of courses administered, respectively. No grade 3 to 4 nonhematologic toxicities were observed. Grade 1 or 2 nonhematologic toxicities consisted of nausea (46% and 5%), vomiting (31% and 7%), and fatigue (53% and 16%).

CONCLUSION

TPT at the dose and schedule used has moderate antitumor activity in NSCLC; its activity is mostly limited to patients with SCC. TPT is well tolerated, with myelosuppression of short duration being the most common and limiting toxicity.

Analysis of the dual discrimination ability of the two-port photorefractive joint transform correlator

An all-optical joint transform correlator featuring two operative correlation planes(ports) with complementary performance is presented. We present the theory of operation, derive the input-output characteristics, and demonstrate computer simulations and experimental results. The two-port joint transform correlator is based on simultaneous use of two photorefractive wave-mixing architectures. The first port uses two-beam coupling, and the second port uses four-wave mixing. The performance of the two ports depends on an experimentally controlled beam intensity ratio and the photorefractive coupling coefficient. With appropriate selection of these parameters, the first port is capable of high discrimination, while simultaneously the second offers a low discrimination output. Our results show that the two-beam coupling port can achieve peak-to-noise and signal-to-noise ratio values better than the phase-only correlator, whereas the four-wave-mixing port performs similarly to the classical joint transform correlator. This leads to a potential application in which the correlator could be set up so that in one port a general class is detected (interclass) and, in the other, the specific item in a class is detected (intraclass).