Losartan: a study of pharmacovigilance data on 14,522 patients

The objective of this study was to undertake a post- marketing safety surveillance study of losartan, the first specific angiotensin-II receptor antagonist to be marketed in England. It is a non-interventional observational cohort study using the technique of prescription-event monitoring. Subjects who took part in the study were from 14 522 patients treated by general practitioners in England. We recorded adverse drug reactions, adverse events, reasons for stopping the drug, pregnancies and deaths. The results were that general practitioners considered the drug to have been effective in 85.9% of the patients evaluated for effectiveness. Dizziness, malaise, lassitude, nausea, cough and headache were among the most frequently reported adverse drug reactions, reasons for stopping the drug and events of highest incidence density. None of the deaths that occurred were attributed to losartan and no serious unexpected adverse reactions or interactions were identified. In conclusion losartan has an acceptable safety profile and the study confirms the safety information given in the current Summary of Product characteristics for losartan.

Oral contraceptives and myocardial infarction: results of the MICA case-control study

OBJECTIVES

To determine the association between myocardial infarction and use of different types of oral contraception in young women.

DESIGN

Community based case-control study. Data from interviews and general practice records.

SETTING

England, Scotland, and Wales.

PARTICIPANTS

Cases (n=448) were recruited from women aged between 16 and 44 who had suffered an incident myocardial infarction between 1 October 1993 and 16 October 1995. Controls (n=1728) were women without a diagnosis of myocardial infarction matched for age and general practice.

MAIN OUTCOME MEASURES

Odds ratios for myocardial infarction in current users of all combined oral contraceptives stratified by their progestagen content compared with non-users; current users of third generation versus second generation oral contraceptives.

RESULTS

The adjusted odds ratio for myocardial infarction was 1.40 (95% confidence interval 0.78 to 2. 52) for all combined oral contraceptive users, 1.10 (0.52 to 2.30) for second generation users, and 1.96 (0.87 to 4.39) for third generation users. Subgroup analysis by progestagen content did not show any significant difference from 1, and there was no effect of duration of use. The adjusted odds ratio for third generation users versus second generation users was 1.78 (0.66 to 4.83). 87% of cases were not exposed to an oral contraceptive, and 88% had clinical cardiovascular risk factors or were smokers, or both. Smoking was strongly associated with myocardial infarction: adjusted odds ratio 12.5 (7.29 to 21.5) for smoking 20 or more cigarettes a day.

CONCLUSIONS

There was no significant association between the use of oral contraceptives and myocardial infarction. The modest and non-significant point estimates for this association have wide confidence intervals. There was no significant difference between second and third generation products.

The Drosophila melanogaster Suppressor of deltex gene, a regulator of the Notch receptor signaling pathway, is an E3 class ubiquitin ligase

During development, the Notch receptor regulates many cell fate decisions by a signaling pathway that has been conserved during evolution. One positive regulator of Notch is Deltex, a cytoplasmic, zinc finger domain protein, which binds to the intracellular domain of Notch. Phenotypes resulting from mutations in deltex resemble loss-of-function Notch phenotypes and are suppressed by the mutation Suppressor of deltex [Su(dx)]. Homozygous Su(dx) mutations result in wing-vein phenotypes and interact genetically with Notch pathway genes. We have previously defined Su(dx) genetically as a negative regulator of Notch signaling. Here we present the molecular identification of the Su(dx) gene product. Su(dx) belongs to a family of E3 ubiquitin ligase proteins containing membrane-targeting C2 domains and WW domains that mediate protein-protein interactions through recognition of proline-rich peptide sequences. We have identified a seven-codon deletion in a Su(dx) mutant allele and we show that expression of Su(dx) cDNA rescues Su(dx) mutant phenotypes. Overexpression of Su(dx) also results in ectopic vein differentiation, wing margin loss, and wing growth phenotypes and enhances the phenotypes of loss-of-function mutations in Notch, evidence that supports the conclusion that Su(dx) has a role in the downregulation of Notch signaling.

Nicorandil and diabetes: a nested case-control study to examine a signal generated by prescription-event monitoring

OBJECTIVE

To investigate a signal generated by an observational cohort study that treatment with the potassium channel opener drug, nicorandil, is associated with an increased incidence of diabetes mellitus (DM).

METHODS

Nested case-control study within cohorts used for prescription-event monitoring.

RESULTS

The cohort study of nicorandil showed that there was a significant difference between the event rate for DM in the first month after starting nicorandil, compared to months 2-6 (difference in rates 1.93, 99% CI 0.7-3.1, per 1000 patient months of treatment). However, the adjusted odds ratio from the case-control study was 1.42 (95% CI 0.66-3.07) for incidence of newly diagnosed DM in nicorandil versus four comparator drugs.

CONCLUSIONS

The nested case-control study was used as a hypothesis-testing instrument for following up a signal of a possible drug reaction to nicorandil. It showed no evidence that nicorandil is associated with increased incidence of newly diagnosed DM.

Epstein-Barr virus in Hodgkin's disease: correlation of risk factors and disease characteristics with molecular evidence of viral infection

Risk factors suggestive of relatively late exposure to EBV have been consistently associated with Hodgkin's disease (HD) in younger adults. In addition, evidence of EBV infection has been found in the Reed-Sternberg cells themselves in about one-third to one-half of all HD cases. However, no study yet published has correlated these childhood social environment risk factors with the presence of EBV in Hodgkin's tumor cells. We examined whether EBV-positive HD occurs in those patients whose childhood environment would predispose them to relatively late exposure to EBV. The study population consisted of 102 cases of mixed cellularity (MC; n = 25) or nodular sclerosing (n = 77) HD. Samples that tested positive for either EBV-encoded RNA or latent membrane protein or both were considered EBV-positive. Of the 102 cases, 83 completed a questionnaire regarding childhood social environment. The association with EBV-positivity was estimated by the odds ratio (OR) with 95% confidence intervals (CI). Twenty-two percent of the cases were EBV-positive. These cases were more likely to be MC (OR, 6.2; CI, 2.3-16.3) and male (OR, 3.4; CI, 1.3-9.0). History of infectious mononucleosis (IM) was not predictive of EBV-positivity, with only 3 of 14 such patients being EBV-positive (P = 0.82). Contrary to our hypothesis, no association between EBV and childhood environment risk factors was identified. The association of EBV with MC histology and male gender agrees with previous reports. The most intriguing finding was the dissociation between IM history and EBV-positivity, in that almost all of the cases with a history of IM were EBV-negative.

Casemix: challenges for nursing care

An Australia-wide patient classification system for nursing is urgently needed as the health system attempts to develop benchmarks against which to measure and compare services. Standardised measures of demand for nursing care must be developed to allow appropriate reimbursement and to act as proxies for illness severity. Nurses need to identify the outcomes that measure the nursing contribution to episodes of care, and assist in developing outcome goals reflecting the efficacy of treatment and the quality of care. A system of measuring nursing requirements and costs of early discharge and coordinated care programs is required. It must be consistent with nursing classifications and hospital costing systems.

Melting graft-wound syndrome

Progressive epithelial loss (melting) from a previously well-taken graft, healed burn wound, or healed donor site is a significant problem in the treatment of patients with burn injuries. For many years, such epithelial loss was attributed to the growth of Streptococcus spp; however, we recently have encountered progressive epithelial melting without significant colonization or infection with Streptococcus spp. We retrospectively reviewed 1035 cases admitted from January 1994 to July 1996 and then collected data prospectively from 324 patients admitted to the University of Washington Burn Center from August 1996 to May 1997. Melting graft-wound syndrome developed in 29 patients. Swab wound cultures from these patients mainly grew Staphylococcus aureus, and none grew Streptococcus spp. All patients were treated with systemic antibiotics and local wound care. Twenty-seven patients healed spontaneously, but two underwent debridement and re-autografting to close the wounds. The melting graft-wound is a significant clinical problem, and its incidence appears to be increasing. The pathophysiology, clinical course, and treatment of the melting graft-wound syndrome are not well understood, and there is no description of it in the literature. This study describes the clinical features of the syndrome.

The Unna 'sleeve': an effective postoperative dressing for pediatric arm burns

The goal of this study was to develop a postoperative plan for sheet grafts that would protect the graft, yet would also eliminate the need for daily wound care. Eleven pediatric patients (13 arms burns) who underwent excision and grafting were included in our study. The total area on the arm ranged from 1% to 5% total body surface area. All grafts were sheet grafts held in place with steri-strips or sutures. The grafts were covered with a layer of greasy gauze, followed by an Unna done paste dressing, and then an elastic bandage. The Unna "sleeve" remained in place for an average of 6 days (range, 3 to 10 days). In eight cases, a second Unna sleeve was applied and removed 6 to 7 days later. In all 13 cases, additional wound care for grafts was unnecessary, and patients did not require extended inpatient hospitalization. Graft take was 100% in all cases, and no reconstruction was required.

The Notch ligand, Jagged-1, influences the development of primitive hematopoietic precursor cells

We examined the expression of two members of the Notch family, Notch-1 and Notch-2, and one Notch ligand, Jagged-1, in hematopoietic cells. Both Notch-1 and Notch-2 were detected in murine marrow precursors (Lin-Sca-1+c-kit+). The Notch ligand, Jagged-1, was not detected in whole marrow or in precursors. However, Jagged-1 was seen in cultured primary murine fetal liver stroma, cultured primary murine bone marrow stroma, and in stromal cell lines. These results indicate a potential role for Notch-Notch ligand interactions in hematopoiesis. To further test this possibility, the effect of Jagged-1 on murine marrow precursor cells was assessed by coculturing sorted precursor cells (Lin-Sca-1+c-kit+) with a 3T3 cell layer that expressed human Jagged-1 or by incubating sorted precursors with beads coated with the purified extracellular domain of human Jagged-1 (Jagged-1(ext)). We found that Jagged-1, presented both on the cell surface and on beads, promoted a twofold to threefold increase in the formation of primitive precursor cell populations. These results suggest a potential use for Notch ligands in expanding precursor cell populations in vitro.

Reviews of units of care: combining practice, research and quality assurance

That nurses should base their practice on the best available knowledge is generally accepted by the profession. However, the operationalisation of this ideal if difficult for hard pressed clinicians. We believe that responsibility for assimilating current knowledge in a practical format belongs to all nurses working in an organisation. This paper describes a project where clinicians, administrators and academics have collaborated to rewrite standards of practice in a format that includes up to date evidence and practical measures for appraising outcomes. This work is a practical example of quality assurance activities serving to create opportunities for collaboration between nurses who have chosen to practice, teach, manage and/or research nursing.

Silipos neck wraps

Burns of the neck are a problem. Grafted anterior necks can result in disfiguring hypertrophic scar contractures and wrinkling of the graft. The development of contractures can be prevented by effective splinting as soon as possible after the burn and by following a continuous wearing schedule until scar maturation is complete. Traditional neck conformers do not allow free neck rotation and can lead to stiffness as a result of decreased mobility. We used Silipos neck wraps for 10 patients who had good range of motion in the neck and who required pressure only for flattening of grafts and wrinkle prevention. The neck wrap is user-friendly, low in cost, and easy to fabricate and custom-fit for individual patients.

The role of prescribing and referral bias in studies of the association between third generation oral contraceptives and increased risk of thromboembolism

Recently published papers have shown a slightly increased risk for venous thromboembolism (VTE) among users of third generation oral contraceptive pills (OC) as compared with users of second generation OC. The extra risk is small (about twofold) and could be explained possibly by biases introduced into the original case-control studies. This paper examines the possible role of prescribing bias (i.e. that doctors would prescribe third generation OC preferentially to women whom they knew to be at risk of VTE) and referral bias (i.e. that doctors would preferentially refer women on third generation OC to hospital for investigations of symptoms suggestive of VTE). A cross-sectional survey was carried out of 106 physicians, to record their attitude to the prescription of OC in certain risk situations. Each doctor then extracted data on OC prescription from approximately 12 patients under his care. A total of 1192 patients were included. Data collected related to known risk factors to which the patient was prone, and the type of OC that the woman was taking. The results from the doctors' attitudinal survey showed that third generation oral contraceptives seemed to be very popular among doctors in England and that they would prefer to prescribe third generation to second generation oral contraceptives in virtually all risk situations, and also in situations where there was no particular risk of VTE. The results from the patients' survey, however, did not correspond with the attitudinal survey, and there was no evidence of a systematic bias running through this sample of patients, associating third generation OC prescription with particular risk factors. The results from the doctors' attitudinal survey on referral did not show any evidence of potential bias towards referring patients on third generation OC to hospitals. Comparison of this survey with an equivalent survey done in Germany suggests that there may be different factors governing doctors' behaviour in Germany and England, with reference to choice of OC prescription.

The 1997 Clinical Research Award. Health outcome for burn survivors

Little is known concerning health outcome for patients who survive burn injuries, and how their health outcome compares with that of other medical populations. Such information is important given that the current direction of health care policy decision making is toward outcomes-driven decision models. We compared the health status of 91 patients 1 month after severe burn injury with the published reports of the health status of 39 medical comparison samples, and two reports of health status for the general population. Additionally, we collected longitudinal data on a subsample of our surviving patients with burn injuries at 1 year. Our findings suggest that people who survive a severe burn experience a stable and relatively good health status after their injury compared with other medical samples. However, their health status remains worse than that of the general population over time. Further, people who survive a major burn indicate that the areas of vocational and psychosocial functioning are often the most troublesome for them.

Comparison of pain control medication in three age groups of elderly patients

There are no published reports of burn pain management in the elderly population. To assess the range of requirement and use of opioids among elderly patients with burns of different age categories, a retrospective review of 89 consecutive admissions of patients over 55 years of age (January 1995 through July 1996) was conducted. Complete data were available on 44 patients with a burn mean total body surface area of 17.2%. Patient ages ranged from 55 to 92 years. Individuals were divided into three age categories: Group I (55 to 65) n = 20; Group II (66 to 75) n = 14; and Group III (76 to 92) n = 10. Use of commonly prescribed opioids for procedural pain and breakthrough pain were evaluated. We compared the opioid equivalents of medications prescribed versus the actual amount administered. Paired t tests comparing minimum amount of medication ordered with that given revealed Group I patients received significantly more procedural medication than the minimum prescribed (t = 3.88, p = 0.001), and that Group III patients were given significantly less as needed medication than the minimum prescribed (t = 2.58, p < 0.05).

Do increased levels of drug abuse treatment lead to fewer drug-related problems?

It has been argued that increased levels of treatment for drug abuse are effective in reducing the levels of drug problems. During the 1980s in Ontario levels of treatment increased considerably. More treatment facilities were opened, and the number of drug abuse cases increased by a factor of about seven. It was expected that drug-related problems (mortality, morbidity, and convictions) would decrease, as happened for alcohol problems when alcohol treatment levels increased. However, the results were inconsistent. Hospital separations for drug problems decreased in the late 1970s and then increased in the 1980s. However, deaths from drug psychoses and drug dependency showed an opposite trend. Convictions for cocaine offences increased while those for narcotics, LSD, and hallucinogenic drugs showed a substantial decline from the early 1980s to the present. Significant negative correlations (suggestive of a beneficial impact) were found between treatment rates and three drug-problem measures (deaths rates from drug psychoses and drug dependence, other drug-related deaths, and convictions under the Food and Drug Act); however, a significant positive correlation was found between treatment rates and Narcotic Control Act convictions. Thus, although some of the predicted negative relationships between treatment rates and drug problems were observed, the correlations did not provide a consistent picture of the effects of increased drug treatment. More research is needed to identify better indicators of drug problems and monitor the factors that influence them.

Residual myocardial damage following electrical injuries

It is unknown to what degree electrical injury causes cardiac muscle damage. We used standard clinical methods and varying combinations of 201Tl scintigraphy (TI), 123I-metaiodobenzylguanidine scintigraphy, echocardiography, 99mTc-RBC angiography, and coronary catheterization to evaluate five patients with high-tension electrical injuries for cardiac damage. The first follow-up examination was performed within 2 months of injury, and the second follow-up was performed more than 6 months after the first follow-up. Electrocardiographic abnormalities were observed in two patients in the acute stage, but no abnormality was detected in the follow-up period. Myocardial perfusion abnormalities were found in all cases with Tl. The degree of injury indicated by Tl was more severe than that indicated by 123I-metaiodobenzylguanidine scintigraphy. Moreover, Tl showed progression of injury in all cases. These preliminary findings must now be confirmed and verified in a larger group of patients.