Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a condition associated with high morbidity, mortality and cost to the community. Patients often report symptomatic improvement with short-acting beta-2 agonists (SABA) and anticholinergic bronchodilator medications, and both are recommended in COPD guidelines. These medications have different mechanisms of action and therefore could have an additive effect when combined.

OBJECTIVES

To compare the relative efficacy and safety of regular long term use (at least four weeks) of ipratropium bromide and short- acting beta-2 agonist therapy in patients with stable COPD.

SEARCH STRATEGY

The Cochrane Airways Group Specialised Register of Trials was searched. Bibliographies were checked to identify relevant cross-references. Drug companies were contacted for relevant trial data. The searches are current to August 2005.

SELECTION CRITERIA

All randomised controlled trials comparing at least 4 weeks of treatment with an anticholinergic agent (ipratropium bromide) alone or in combination with a beta-2 agonist (short acting) versus the beta-2 agonist alone, delivered via metered dose inhaler or nebuliser, in non-asthmatic adult subjects with stable COPD.

DATA COLLECTION AND ANALYSIS

Data extraction and study quality assessment was performed independently by three reviewers. Authors of studies and relevant manufacturers were contacted if data were missing.

MAIN RESULTS

Eleven studies (3912 participants) met the inclusion criteria of the review. Small benefits of ipratropium over a short-acting beta-2 agonist were demonstrated on lung function outcomes. There were small benefits in favour of ipratropium on quality of life (HRQL), as well as a reduction in the requirement for oral steroids. Combination therapy with ipratropium plus a short-acting beta-2 agonist conferred benefits over a short-acting beta-2 agonist alone in terms of post-bronchodilator lung function. There was no significant benefit of combination therapy in subjective improvements in HRQL, but again there was a reduction in the requirement for oral steroids.

AUTHORS' CONCLUSIONS

The available data from the trials included in this review suggest that the advantage of regular long term use of ipratropium alone or in combination with a short-acting beta-2 agonist or over a beta-2 agonist alone are small, if the aim is to improve lung function, symptoms and exercise tolerance. Until further data are available, the strategy of providing a short-acting beta-2 agonist on a PRN basis, and then either continuing with the short-acting beta-2 agonist regularly or conducting an "n of 1" trial of regular beta-2 agonist or regular anticholinergic to determine the treatment that gives the best relief of symptoms (and continuing with it), would seem cost effective. This strategy does need formal evaluation. Patient preference is also important, as is the relative importance of avoiding the use of systemic corticosteroids.

Overland flow delivery of faecal bacteria to a headwater pastoral stream

AIMS

To quantify and derive statistical relationships with which to predict the delivery of faecal bacteria (Escherichia coli) to a pastoral stream, by overland flow.

METHODS AND RESULTS

A large-scale (1050 m2) rainfall simulator, located upon a steep (18 degrees) grazed hillside in New Zealand, was used to simulate 11 heavy rainfall events. Overland flow was generated and sampled throughout each event, before discharging to a headwater stream. The samples were subsequently analysed to determine the concentration of E. coli. Statistical analysis showed that the time elapsed since the last period of grazing was a statistically significant predictor of both the total number (load) and concentrations of E. coli in overland flow. Between 10(5) and 10(8)E. coli per m2 of hillside were delivered to the stream within overland flow during each event, and peak concentrations ranged between 10(3) and 10(7) most probable number per 100 ml.

CONCLUSIONS

Under heavy rainfall on steep pastoral land, overland flow can transport substantial levels of faecal bacteria to streams. Under such conditions, it is unlikely that vegetated buffer strips will be particularly effective at attenuating bacteria within overland flow.

SIGNIFICANCE AND IMPACT OF THE STUDY

This work has improved understanding of the importance of overland flow as a process contributing to the contamination of pastoral streams by faecal bacteria. In addition, the predictive relationships derived can be incorporated within catchment models.

Influence of family environment on language outcomes in children with myelomeningocele

BACKGROUND

Previously, our studies demonstrated language differences impacting academic performance among children with myelomeningocele and shunted hydrocephalus (MMSH). This follow-up study considers the environmental facilitators within families (achievement orientation, intellectual-cultural orientation, active recreational orientation, independence) among a cohort of children with MMSH and their relationship to language performance.

METHODS

Fifty-eight monolingual, English-speaking children (36 females; mean age: 10.1 years; age range: 7-16 years) with MMSH were evaluated. Exclusionary criteria were prior shunt infection; seizure or shunt malfunction within the previous 3 months; uncorrected visual or auditory impairments; prior diagnoses of mental retardation or attention deficit disorder. The Comprehensive Assessment of Spoken Language (CASL) and the Wechsler Abbreviated Scale of Intelligence (WASI) were administered individually to all participants. The CASL Measures four subsystems: lexical, syntactic, supralinguistic and pragmatic. Parents completed the Family Environment Scale (FES) questionnaire and provided background demographic information. Spearman correlation analyses and partial correlation analyses were performed.

RESULTS

Mean intelligence scores for the MMSH group: full scale IQ 92.2 (SD = 11.9). The CASL revealed statistically significant difficulty for supralinguistic and pragmatic (or social) language tasks. FES scores fell within the average range for the group. Spearman correlation and partial correlation analyses revealed statistically significant positive relationships for the FES 'intellectual-cultural orientation' variable and performance within the four language subsystems. Socio-economic status (SES) characteristics were analyzed and did not discriminate language performance when the intellectual-cultural orientation factor was taken into account.

CONCLUSION

The role of family facilitators on language skills in children with MMSH has not previously been described. The relationship between language performance and the families' value on intellectual/cultural activities seems both statistically and intuitively sound. Focused interest in the integration of family values and practices should assist developmental specialists in supporting families and children within their most natural environment.

Manifestations and outcome of extra-pulmonary tuberculosis: impact of human immunodeficiency virus co-infection

SETTING

Metropolitan New Orleans.

OBJECTIVE

To determine the impact of human immunodeficiency virus (HIV) co-infection on the manifestations and outcome of extra-pulmonary tuberculosis (EPTB).

DESIGN

Retrospective analysis of 136 patients diagnosed with EPTB between 1 January 1993 to 31 December 2001. Characteristics of EPTB were compared by HIV serostatus.

RESULTS

Of those tested for HIV (n = 87), 42.5% were seropositive. Except for a higher frequency of disseminated TB among co-infected persons, the manifestations, laboratory diagnostic yield and outcome of EPTB were similar between HIV-infected and non-infected persons. The overall fatality rate was 20%; HIV-infected patients had a three-fold higher mortality compared to non-infected persons. In multivariate logistic regression analysis, factors associated with death were: HIV-seropositive (adjusted odds ratio [aOR] 5.2, 95% CI 1.1-24.65) compared to HIV-seronegative, disseminated and meningeal compared to lymphatic disease (aOR 16.87, 95% CI 12.31-123.34), and lack of TB treatment compared to receipt of TB treatment (aOR 29.23, 95% CI 14.47-191.23).

CONCLUSION

Manifestations of EPTB were non-specific and did not differ between HIV-infected and non-infected persons. Severe disease, lack of TB treatment and HIV co-infection were associated withdeath. Approaches are needed to reduce EPTB morbidity and mortality, especially among HIV-infected persons.

Total elbow arthroplasty after previous resection of the radial head and synovectomy

We examined the effects of previous resection of the radial head and synovectomy on the outcome of subsequent total elbow arthroplasty in patients with rheumatoid arthritis.

Fifteen elbows with a history of resection and synovectomy were compared with a control group of patients who had elbow arthroplasty with an implant of the same design. The mean age in both groups was 63 years. In the study group, resection of the radial head and synovectomy had been undertaken at a mean of 8.9 years before arthroplasty. The mean radiological follow-up for the 13 available patients in the study group was 5.89 years (0.3 to 11.0) and in the control group was 6.6 years (2.2 to 12.6). There were no revisions in either group. The mean Mayo elbow performance score improved from 29 to 96 in the study group, with similar improvement in the control group (28 to 87). The study group had excellent results in 13 elbows and good results in two. The control group had excellent results in seven and good results in six.

Our experience indicates that previous resection of the radial head and synovectomy are not associated with an increased rate of revision following subsequent arthroplasty of the elbow. However, there was a higher rate of complication in the study group compared with the control group.

Total elbow arthroplasty after previous resection of the radial head and synovectomy

We examined the effects of previous resection of the radial head and synovectomy on the outcome of subsequent total elbow arthroplasty in patients with rheumatoid arthritis. Fifteen elbows with a history of resection and synovectomy were compared with a control group of patients who had elbow arthroplasty with an implant of the same design. The mean age in both groups was 63 years. In the study group, resection of the radial head and synovectomy had been undertaken at a mean of 8.9 years before arthroplasty. The mean radiological follow-up for the 13 available patients in the study group was 5.89 years (0.3 to 11.0) and in the control group was 6.6 years (2.2 to 12.6). There were no revisions in either group. The mean Mayo elbow performance score improved from 29 to 96 in the study group, with similar improvement in the control group (28 to 87). The study group had excellent results in 13 elbows and good results in two. The control group had excellent results in seven and good results in six. Our experience indicates that previous resection of the radial head and synovectomy are not associated with an increased rate of revision following subsequent arthroplasty of the elbow. However, there was a higher rate of complication in the study group compared with the control group.

Kicking footedness and movement discrimination by elite australian rules footballers

Kicking a football accurately with a certain velocity over a desired distance is dependent upon the speed of the kicking foot and the quality of contact between the foot and ball. Control of the swinging lower leg is critical to these factors and the overall performance of the kick, and this was assessed in 20 Australian Football League players. Assessment of movement extent discrimination of the swinging leg was made while standing on the other leg. An automated device accurately set a stop plate to five different positions and each subject was asked to swing the leg to the plate, and make a non-visual judgment of the movement extent. Forty forward and forty backward swings of each leg were assessed, and based on a subject's responses, non-parametric signal detection analysis resulted in a movement extent discrimination score. For left leg performance, coach ratings of overall kicking ability were correlated with movement discrimination ability. Left-foot kickers (0.83) had a higher movement discrimination score than right-foot kickers (0.77), and had a significantly higher score on their dominant side, whereas right-footers had no left-right side difference. Rating of kicking ability by coaches also reflected this difference between the dominant leg performance of left- and right-footers. These data showed left-foot kickers to have higher movement discrimination ability with their dominant leg, and this may be related to their on-field kicking ability.

Prehospital use of adenosine by ambulance services in the Netherlands: Daily practice, literature overview and practical recommendations

BACKGROUND

The prehospital use of adenosine in the treatment of supraventricular arrhythmias has recently been implemented in standard ambulance care. However, establishing the origin and nature of the arrhythmia with certainty is an absolute requirement for using adenosine.

METHODS

The ability of the ambulance nurse to predict supraventricular arrhythmias and the necessity of prehospital treatment of arrhythmias in general was evaluated. To do this, cardiologists at the Academic Medical Centre of Amsterdam were consulted and a literature search by means of an electronic search in Pubmed was performed. The search was complemented by a second survey concerning antagonists of adenosine using the keywords: adenosine and theophylline. Moreover, the Ambulance Nurse textbook, the National Protocol for Ambulance Care as well as the explanatory memorandum to the protocol were consulted.

RESULTS

No strong indication for the prehospital use of adenosine was found, while detrimental effects of the drug can occur. There is no literature showing the ability of ambulance staff to correctly interpret complex cardiac arrhythmias in the Netherlands; the current ambulance protocol does not prevent an incorrect choice of therapy and medication.

CONCLUSION

It is strongly advised against using antiarrhythmic medication for the treatment of tachycardias in a prehospital setting if this treatment can be postponed to the hospital environment.

Football boot insoles and sensitivity to extent of ankle inversion movement

BACKGROUND

The capacity of the plantar sole of the foot to convey information about foot position is reduced by conventional smooth boot insoles, compared with barefoot surface contact.

OBJECTIVE

To test the hypothesis that movement discrimination may be restored by inserting textured replacement insoles, achieved by changing footwear conditions and measuring the accuracy of judgments of the extent of ankle inversion movement.

METHODS

An automated testing device, the ankle movement extent discrimination apparatus (AMEDA), developed to assess active ankle function in weight bearing without a balance demand, was used to test the effects of sole inserts in soccer boots. Seventeen elite soccer players, the members of the 2000 Australian Women's soccer squad (34 ankles), took part in the study. Subjects were randomly allocated to start testing in: bare feet, their own football boots, own football boot and replacement insole, and on the left or right side. Subjects underwent six 50 trial blocks, in which they completed all footwear conditions. The sole inserts were cut to size for each foot from textured rubber "finger profile" sheeting.

RESULTS

Movement discrimination scores were significantly worse when subjects wore their football boots and socks, compared with barefoot data collected at the same time. The substitution of textured insoles for conventional smooth insoles in the football boots was found to restore movement discrimination to barefoot levels.

CONCLUSIONS

The lower active movement discrimination scores of athletes when wearing football boots with smooth insoles suggest that the insole is one aspect of football boot and sport shoe design that could be modified to provide the sensory feedback needed for accurate foot positioning.

Monocytes are a rheologically heterogeneous population of cells

The effect of increased adhesiveness and decreased deformability of leukocytes following activation can have a profound effect on flow through the microcirculation. Measurement of leukocyte deformability is therefore an important tool in the study of the pathology of vascular diseases. Although much work has been done on the rheological properties of lymphocytes and granulocytes, there is little information available on the larger mononuclear cells, the monocytes. To investigate monocyte rheology, attempts were made to purify monocytes by a variety of methods. Purified monocytes were then filtered through 5 microm polycarbonate filters, with flow profiles (change in volume with time) recorded over 300 seconds. The profiles were analysed by least squares fitting to an appropriate mathematical model. Analysis of filtration data demonstrated 3 distinct sub-populations of monocytes with differing rheological properties. Other workers have characterised monocytes into defined subsets on the basis of their size, phagocytic ability or expression of cell surface markers. The definition of monocytes into defined rheological subsets is a new and useful addition to these studies.

Sublingual gland involvement in systemic Wegener's granulomatosis: a case report

Wegener's granulomatosis is a systemic vasculitis characterized by necrosis, granulomatosis and inflammation. The usual targets are extra-oral, although salivary gland involvement has been recognized, usually confined to parotid and submandibular glands. A case report is presented of sublingual gland presentation, confirmed on biopsy, which proceeded to systemic involvement. Some evidence suggests that salivary gland involvement, if recognized, may lead to an early diagnosis and the potential for earlier therapeutic intervention.

Changes in endothelial, leucocyte and platelet markers following contrast medium injection during angiography in patients with peripheral artery disease

Peripheral artery angiography, a common diagnostic procedure, may cause early and late adverse reactions, such as anaphylaxis, thrombosis and possible progression of the underlying arterial disease. To test the hypothesis that radiographic contrast medium may contribute to these events by adversely affecting the endothelium, leucocytes and/or platelets, 19 subjects undergoing angiography for the investigation and/or treatment of lower limb atherosclerosis were recruited. Blood was obtained from the external iliac vein before, and at serial intervals after, the injection of radiographic contrast medium into the ipsilateral femoral artery for diagnostic use. Markers of endothelial cell injury (von Willebrand factor (vWf)), platelet activation (soluble P-selectin) and leucocyte activation (neutrophil elastase and soluble L-selectin) were measured in citrated plasma. Soluble intercellular adhesion molecule-1 (sICAM-1) and thromboxane B(2), which are non-specific markers of inflammation, were also measured. Compared with the sample prior to angiography, levels of soluble L-selectin and sICAM-1 were reduced (p<0.02) immediately after passage of the last bolus of contrast medium. 15 min later, levels returned to normal but the level of vWf had increased (p<0.02). After 30 min, only levels of thromboxane B(2) were increased (p<0.05). The following day both vWf (p<0.01) and soluble P-selectin (p<0.05) were increased. These data point to both early and late effects of contrast medium on markers of endothelial, platelet and leucocyte function.

Normative data for passive ankle plantarflexion--dorsiflexion flexibility

OBJECTIVE

To describe the normal distribution parameters for measures of passive ankle plantarflexion-dorsiflexion flexibility obtained from a large sample of able-bodied young adult subjects.

DESIGN

Seven variables were assessed and descriptive analyses were conducted.

BACKGROUND

While assessment of plantarflexion-dorsiflexion flexibility is an important component of a clinical examination of plantarflexion contracture, there is limited normative data available that can be used as a reference for clinical decision-making.

METHODS

Data were collected from 300 able-bodied male and female subjects aged between 15 and 34 years. Both ankles were measured. Load-displacement curves were collected using a manually controlled instrumented footplate. Six variables were extracted from these curves: passive torque at zero and 10 deg, passive stiffness at zero and 10 deg, and two coefficients from an equation fitted to the curve (i.e., k and b). The seventh variable, passive dorsiflexion range of motion, was quantified using a clinical procedure.

RESULTS

Flexibility variables did not differ between the left and right ankles, nor between the dominant and non-dominant legs. All variables were normally distributed. These distributions can, therefore, be adequately described using their mean and standard deviation values.

CONCLUSIONS

This study has substantially increased the available database on plantarflexion-dorsiflexion flexibility and forms the basis of norm-referenced clinical tests.

A sensitive, single-tube assay to measure the enzymatic activities of influenza RNA polymerase and other poly(A) polymerases: application to kinetic and inhibitor analysis

We describe a fast and robust new assay format to measure poly(A) polymerase (PAP) activity in a microtiter plate format. The new assay principle uses only natural nucleotide triphosphates and avoids a labour-intensive filtration step. A coupled enzymatic system combining PAP and reverse transcriptase forms the basis of the assay. The PAP generates a poly(A) tail on a RNA substrate and the reverse transcriptase is used to quantify the polyadenylated RNA by extension of a biotinylated oligo-dT primer. We demonstrate the principle of the assay using influenza virus RNA polymerase and yeast PAP as examples. A specific increase in the K(m) value for ATP and the observation of burst kinetics in the polyadenylation dependent, but not in the polyadenylation independent, assay suggest that a rate limiting step of influenza polymerase activity occurs after transcription elongation. Yeast PAP was used to validate the assay as an example of a template independent PAP. The new yeast PAP assay was approximately 100-fold more sensitive than the conventional TCA precipitation assay for yeast PAP, but the kinetic analysis of the PAP reaction gave similar results in both assays. The two enzymes show important differences with respect to inhibition by 3'-deoxy-ATP. Whereas the K(i) value for 3'-deoxy-ATP (105-117 microM) is similar to the K(m) value for ATP (186 microM) in the case of influenza RNA polymerase, the K(i) value for 3'-deoxy-ATP (0.4-0.6 microM) is approximately 100-fold lower than the K(m) value for ATP (50 microM) in the case of yeast PAP.