Oral treatments for fungal infections of the skin of the foot

BACKGROUND

About 15% of the population have fungal infections of the feet (tinea pedis or athlete's foot). Whilst there are many clinical presentations of tinea pedis the most common are between the toes (interdigital) and on the soles, heels and sides of the foot (plantar) which is known as moccasin foot. Once acquired the infection can spread to other sites including the nails, which can be a source of reinfection. Oral therapy is usually used for chronic conditions or when topical treatment has failed.

OBJECTIVES

To assess the effects and costs of oral treatments for fungal infections of the skin of the foot (tinea pedis).

SEARCH STRATEGY

Randomised controlled trials were identified from MEDLINE, EMBASE and CINAHL from the beginning of these databases to January 2000. We also searched the Cochrane Controlled trials Register (Cochrane Library issue 1, 2000) the Science Citation Index, BIOSIS, CAB-Health, Health star and Economic databases. Bibliographies were searched, podiatry journals hand searched and the pharmaceutical industry and schools of podiatry contacted.

SELECTION CRITERIA

Randomised controlled trials including participants who have a clinically diagnosed tinea pedis, confirmed by microscopy and growth of dermatophytes in culture.

DATA COLLECTION AND ANALYSIS

Study selection was done by two independent reviewers. Methodological quality assessment and data collection was also assessed by two independent reviewers.

MAIN RESULTS

Twelve trials, involving 700 participants, were included. The two trials comparing terbinafine and griseofulvin produced a pooled risk difference of 52% (95% confidence intervals 33% to 71%) in favour of terbinafine's ability to cure infection. No significant difference was detected between terbinafine and itraconazole; fluconazole and either itraconazole and ketoconazole; or between griseofulvin and ketoconazole, although the trials were generally small. Two trials showed that terbinafine and itraconazole were effective compared with placebo. Adverse effects were reported for all drugs, with gastrointestinal effects most commonly reported.

REVIEWER'S CONCLUSIONS

The evidence suggests that terbinafine is more effective than griseofulvin and that terbinafine and itraconazole are more effective than no treatment.

A prospective controlled study of the effect of intramural uterine fibroids on the outcome of assisted conception

BACKGROUND

Although uterine fibroids occur in 30% of women and are associated with a degree of subfertility, the effect of intramural fibroids on the outcome of IVF or ICSI treatment has not been prospectively studied.

METHODS

Data were prospectively collected on 434 women undergoing IVF/ICSI in the assisted conception unit of an inner London teaching hospital. Patients were assessed for the presence of fibroids by transvaginal ultrasound and hysterosonography or hysteroscopy where appropriate.

RESULTS

During the study period, 112 women with (study), and 322 women without (controls), intramural fibroids were treated. Patients were similar regarding the cause and duration of their infertility, number of previous treatments, and basal serum FSH concentration. Women in the study group were on average 2 years older (36.4 versus 34.6 years; P < 0.01). There was no significant difference in the duration of ovarian stimulation or gonadotrophin requirement, number of follicles developed, oocytes collected, embryos available for transfer or replaced. When analysing only women with intramural fibroids of < or =5 cm in size (n = 106) pregnancy, implantation and ongoing pregnancy rates were significantly reduced: 23.3, 11.9 and 15.1 respectively compared with 34.1, 20.2 and 28.3% in the control group (P = 0.016, P = 0.018 and P = 0.003). The mean size of the largest fibroids was 2.3 cm (90% range 2.1-2.5 cm). Logistic regression analysis demonstrated that the presence of intramural fibroids was one of the significant variables affecting the chance of an ongoing pregnancy, even after controlling for the number of embryos available for replacement and increasing age, particularly age > or =40 years, odds ratio 0.46 (CI 0.24-0.88; P = 0.019).

CONCLUSION

This study demonstrated that an intramural fibroid halves the chances of an ongoing pregnancy following assisted conception.

Cohort studies of health effects among people exposed to estuarine waters: North Carolina, Virginia, and Maryland

A variety of human symptoms have been associated with exposure to the dinoflagellate Pfiesteria and have been grouped together into a syndrome termed "possible estuary-associated syndrome." Prospective cohort studies of health effects associated with exposure to estuarine waters that may contain Pfiesteria spp. and related organisms are in progress in North Carolina, Virginia, and Maryland. The three studies recruited cohorts of 118-238 subjects who work or engaged in recreation in estuary waters. Baseline health and neuropsychological evaluations are conducted, and study subjects are followed prospectively for 2-5 years with periodic assessments of health and performance on a battery of neuropsychological tests. Health symptoms and estuary water exposure are recorded by telephone interviews or diaries every 1-2 weeks. Water quality information, including measurements of Pfiesteria spp., is collected in the areas where the subjects are working. Because it is not possible to measure individual exposure to Pfiesteria or a toxin produced by this organism, these studies examine surrogate exposure measures (e.g., time spent in estuary waters, in a fish kill area, or in waters where Pfiesteria DNA was detected by molecular amplification). Preliminary analyses of the first 2 years (1998-2000) of data indicate that none of the three ongoing cohorts have detected adverse health effects. However, there have not been any reported fish kills associated with Pfiesteria since the studies began, so it is possible that none of the study subjects have been exposed to toxin-producing Pfiesteria spp.

Screening for HIV, hepatitis B and C infection in a population seeking assisted reproduction in an inner London hospital

The Human Fertilisation and Embryology Authority requires all sperm donors to be screened for human immunodeficiency virus (HIV), hepatitis B and C and their semen quarantined for six months. No guidelines exist for screening prior to in vitro fertilisation or intracytoplasmic sperm injection. We prospectively analysed the prevalence of these viruses in our patients. Screening detected one case of HIV (0.13%), four of hepatitis C (0.5%) and 14 new cases of hepatitis B (1.7%). The prevalence of hepatitis B and HIV in our antenatal population at this time was 1.4% and 0.8%, respectively. Knowledge allows measures to be taken to reduce the risk of transmission to partner, fetus, new born baby, or by cross-contamination during embryo cryostorage and enables couples to make an informed decision regarding proceeding with treatment. Detection of infection in one partner should no longer preclude fertility treatment.

Selectivity and sensitivity of intramuscular and transcutaneous electromyography electrodes

We evaluated the differences in selectivity and sensitivity of intramuscular fine-wire electrodes and transcutaneous electrodes in detecting dynamic electromyography (EMG) signals from extensor digitorum (EDC) and extensor carpi radialis (ECR) muscles during isolated EDC and ECR contractions in two able-bodied subjects. Intramuscular fine-wire electrodes differentiated EDC and ECR EMG activities better than transcutaneous electrodes, and intramuscular fine-wire electrodes recorded higher amplitude signals than transcutaneous electrodes. Data suggest that intramuscular fine-wire electrodes are more selective and sensitive than transcutaneous electrodes in detecting EMG signals from adjacent forearm muscles.

Extracts from "Clinical evidence": Athlete's foot and fungally infected toenails

Definition Athlete's foot is a cutaneous fungal infection that causes the skin to itch, flake, and fissure. Nail involvement is characterised by ungual thickening and discoloration.

Diagnostic and therapeutic advantages of hysteroscopic surgery in management of intrauterine lesions in postmenopausal women

STUDY OBJECTIVE

To determine the value of hysteroscopic surgery in the management of intrauterine lesions in postmenopausal women.

DESIGN

Descriptive study (Canadian Task Force classification II-2).

SETTING

Tertiary care university hospital. Patients. Fifty postmenopausal women, most with vaginal bleeding, all with intrauterine lesions (leiomyomas, polyps, adhesions) on hysteroscopy or ultrasound.

INTERVENTION

Hysteroscopic operations consisting of myomectomy, polypectomy, and adhesiolysis.

MEASUREMENTS AND MAIN RESULTS

Forty-seven procedures were completed successfully by hysteroscopy; partial myomectomies were performed in three women for large or deeply embedded leiomyomas. The only complication was one case of fluid overload. Median operating time was 20.0 minutes (range 5.0-60.0 min) and median postoperative hospital stay was zero days (range 0-2 days). Eight patients (16%) subsequently underwent hysterectomy, mostly for uterine malignancy or premalignancy. In two cases, the operative specimen included malignant elements that were not evident on preoperative endometrial biopsy. During mean follow-up of 33.1 months (range 6-72 mo), 95.2% of women without hysterectomy were free of symptoms.

CONCLUSION

Hysteroscopic surgery is an effective and safe option for postmenopausal women with intrauterine lesions. It allows the correct diagnosis to be made, reduces the need for major and unnecessary surgery, and is therapeutic in most patients. (J Am Assoc Gynecol Laparosc 8(1):87-91, 2001)

Preliminary evaluation of an abstinence-based program for 7th grade students from a small rural school district

The purpose of this study was to investigate the effects of an abstinence-based program designed for 7th grade students (n = 59) from a rural school district. Analysis suggested that after the program more students intended to avoid having sex before marriage but no change was noted for knowledge, attitudes, and self-efficacy.

Phase I trial of concurrent tirapazamine, cisplatin, and radiotherapy in patients with advanced head and neck cancer

PURPOSE

To determine the maximum-tolerated dose of tirapazamine when combined with cisplatin and radiation in patients with T3/4 and/or N2/3 squamous cell carcinoma of the head and neck.

PATIENTS AND METHODS

The starting schedule was conventionally fractionated radiotherapy (70 Gy in 7 weeks) with concomitant cisplatin 75 mg/m2 and tirapazamine 290 mg/m2 (before cisplatin) in weeks 1, 4, and 7 and tirapazamine alone 160 mg/m2 three times a week in weeks 2, 3, 5, and 6. Positron emission tomography scans for tumor hypoxia (18F misonidazole) were performed before and during radiotherapy.

RESULTS

We treated 16 patients with predominantly oropharyngeal primary tumors, including 10 patients with T4 or N3 disease. Febrile neutropenia occurred toward the end of radiotherapy in three out of six patients treated on the initial dose level. Two of these patients also developed grade 4 acute radiation reactions. Another 10 patients were treated with the same doses, but the week 5 and week 6 tirapazamine doses were omitted. This resulted in less neutropenia and only one dose-limiting toxicity (DLT) (febrile neutropenia), and eight out of 10 patients completed treatment without any dose omissions. In these 10 patients, the acute radiation toxicities were not obviously enhanced compared with chemoradiotherapy regimens using concurrent platinum and fluorouracil. 18F misonidazole scans detected hypoxia in 14 of 15 patients at baseline, with only one patient having detectable hypoxia at the end of treatment. With a median follow-up of 2.7 years, the 3-year failure-free survival rate was 69% (SE, 12%), the 3-year local progression-free rate was 88% (SE, 8%), and the 3-year overall survival rate was 69% (SE, 12%).

CONCLUSION

DLT was due unexpectedly to febrile neutropenia, which could be overcome by omitting tirapazamine in weeks 5 and 6. The combination of tirapazamine, cisplatin, and radiotherapy resulted in remarkably good and durable clinical responses in patients with very advanced head and neck cancers. It warrants further investigation.

A complication of infrarenal arterial conduit following orthotopic liver transplant

BACKGROUND

Thrombosis of the arterial inflow to a transplanted liver graft frequently leads to graft necrosis, and retransplantation is required.

CASE OUTLINE

A 41-year-old man underwent orthotopic liver retransplantation. Arterial inflow to the graft was provided by an infrarenal arterial conduit. On day 14 he developed thrombosis of the conduit due to herniation of the jejunum between the conduit and the transverse mesocolon. Reduction of the herniated bowel and thrombectomy of the graft was initially successful, but he subsequently developed necrosis of segments II-V (diagnosed on computed tomography, CT). These segments were then resected, and thereafter his graft functioned well over the next 7 years.

DISCUSSION

The potential space between an infrarenal arterial conduit and the transverse mesocolon must be eliminated to prevent incarceration of the intestine following liver transplantation. Early diagnosis of arterial thrombosis may allow revascularisation of the liver graft, but subsequent CT scanning is essential to assess the viability of the graft. Segmental graft necrosis may be managed by liver resection with good long-term results.

Vertebral arteries and neck rotation: Doppler velocimeter interexaminer reliability

The purpose of this study was to test the interexaminer reliability of Doppler ultrasound (US) velocimeter examination of vertebral arteries during contralateral cervical rotation. Vertebral arteries from 20 adults were insonated using a bidirectional Doppler velocimeter at the suboccipital portal (standard technique) and C2 transverse process level (new technique) during contralateral cervical rotation. The data obtained by two examiners, regarding persistence or major reduction in Doppler signals, were compared. There was 93% agreement between the data from the two examiners, and the kappa score was 0.78 at p = 0.05. These results provide evidence to support the interexaminer reliability of bidirectional Doppler velocimeter examination for the purpose of assessing the effects of contralateral rotation on vertebral artery blood flow.

Blood flow velocity using transcranial Doppler velocimetry in the middle and anterior cerebral arteries: correlation with sample volume depth

The baseline transcranial Doppler studies of the middle (MCA) and anterior cerebral (ACA) arteries of 135 patients were retrospectively reviewed. 3312 data points were classified according to gender, vessel, mean blood flow velocity (MBFV), systolic blood flow velocity (SBFV), diastolic blood flow velocity (DBFV) and sample volume depth (SVD). The flow velocities at each depth were averaged, and plotted against acquisition depth. The male MCA yielded a correlation coefficient (r), between MBFV and SVD of 0.999. For the female MCA, r = 0.986. For the ACA, male, r = 0.911, and female, r = 0.894. All other data showed r values >/= 0.563, with 11 of 12 r values >/= 0.808. These data suggest that BFV reduces with SVD in a highly predictable way for the MCA and ACA, from which expected BFV values may be estimated at any given SVD.

Nonoperative management of dens fracture nonunion in elderly patients without myelopathy

STUDY DESIGN

A retrospective review of elderly patients treated without surgery for chronic mobile nonunions of the odontoid process. Patients were observed on an annual basis with clinical examinations and flexion/extensions plain film radiographs.

OBJECTIVES

To evaluate the clinical and radiographic results of elderly patients without myelopathy treated without surgery for dens fracture nonunion.

SUMMARY OF BACKGROUND DATA

Because of the risk of progressive myelopathy or sudden neurologic injury, many surgeons recommend operative stabilization for patients with mobile dens nonunions who are able to withstand an operation. There is, however, a lack of information about the radiographic and neurologic progression of dens nonunions. Although a less aggressive surgical approach has been recommended by some authors for elderly or medically compromised patients with acute fractures, long-term follow-up evaluation of patients with resulting nonunions has not been reported.

METHODS

A series of elderly patients with chronic, unstable, dens nonunions without myelopathy were treated with a nonoperative treatment protocol. Patients were informed of the nature of their lesion, including the risk of acute or chronic spinal cord injury and the options for operative treatment. Patients were evaluated yearly for clinical and radiographic progression. No intervention to slow progression of atlantoaxial instability was undertaken.

RESULTS

None of the patients developed myelopathic symptoms during the follow-up period, and no patient experienced more than a 1 mm radiographic increase in atlantoaxial excursion. None of the reported patients had less than 14 mm available for the spinal cord in either flexion or extension at the start of clinical monitoring.

CONCLUSIONS

Although further follow-up evaluation is needed, the authors believe on the basis of this review that this treatment protocol may be considered for patients who are poor candidates for surgical fusion.

Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks

BACKGROUND

Atrial fibrillation (AF) carries an increased risk of stroke; antiplatelet agents are proven effective for stroke prevention in other settings.

OBJECTIVES

The objective of this review was to determine the efficacy and safety of antiplatelet therapy for prevention of stroke in patients with chronic non-valvular AF.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Specialised Register of Trials, MEDLINE database (June 1999), and the database of the Antithrombotic Trialists Collaboration, as well as reference lists of relevant articles.

SELECTION CRITERIA

All randomized trials comparing antiplatelet therapies to placebo in patients with non-valvular AF and no history of transient ischemic attack (TIA) or stroke.

DATA COLLECTION AND ANALYSIS

Trials for inclusion were independently selected by two reviewers who also extracted each outcome and double-checked the data. The Peto method was used for combining odds ratios. All analysis were, as far as possible, "intention-to-treat". Since the published results of two trials included 3-8% of participants with prior stroke or TIA, unpublished results excluding these participants were obtained from the Atrial Fibrillation Investigators.

MAIN RESULTS

Among 1680 participants without prior stroke/TIA, randomized to aspirin (N = 838) or placebo in two trials, aspirin was associated with nonsignificantly lower risks of ischemic stroke (OR = 0.71, CI 95% 0. 46 - 1.10), all stroke (OR = 0.70, CI 95% 0.45 - 1.08) all disabling/fatal stroke (OR =0.88, CI 95% 0.48 - 1.58) and the constellation of stroke, MI or vascular death (OR = 0.76, CI 95% 0. 54 - 1.05 ). Considering all randomized participants including those with prior stroke or TIA, reductions in these events by aspirin were consistently smaller and marginally statistically significant: ischemic stroke (OR = 0.77, CI 95% 0.60-1.00), all stroke (OR = 0.76, CI 95% 0.61 - 0.93), all disabling/fatal stroke (OR = 0.87, CI 95% 0.64 - 1.19) and the combined outcome (OR = 0.79, CI 95% 0.64 - 0. 99). No increase in major hemorrhage was seen, but the number of hemorrhagic events was small.

REVIEWER'S CONCLUSIONS

Considering all randomized data, aspirin modestly (by about 20%) reduces stroke and major vascular events in nonvalvular AF. For primary prevention among AF patients with an average stroke rate of 4.5%/year, about 10 strokes would be prevented yearly for every 1000 given aspirin.

Oral anticoagulants for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks

BACKGROUND

Non-valvular atrial fibrillation (AF) is associated with an increased risk of stroke.

OBJECTIVES

The objective of this review was to characterize the efficacy and safety of oral anticoagulation (OAC) with vitamin K antagonists for the primary prevention of stroke in patients with chronic AF.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Specialised Register of Trials (June 1999), MEDLINE database, and the database of the Antithrombotic Trialists Collaboration, as well as reference lists of relevant articles.

SELECTION CRITERIA

All randomized controlled trials comparing the value of OAC versus control in patients with non-valvular chronic atrial fibrillation and no history of transient ischemic attack (TIA) or stroke.

DATA COLLECTION AND ANALYSIS

Trials for inclusion were independently selected by two reviewers who also extracted each outcome and double-checked the data. The Peto method was used for combining odds ratios. All analysis were, as far as possible, "intention-to-treat". Since the published results of four trials included 3-8% of participants with prior stroke or TIA, unpublished results excluding these participants were obtained from the Atrial Fibrillation Investigators.

MAIN RESULTS

Of 2313 participants without prior cerebral ischemia from five trials, about half (n = 1154) were randomized to adjusted-dose OAC with an estimated mean INRs ranging between 2.0-2.6 during 1.5 years/participant average follow-up. Participant features and study quality were similar between trials. OAC was associated with large, highly statistically significant reductions in ischemic stroke (OR = 0.34, 95% CI 0.23 - 0.52), all stroke (OR = 0.39, 95% CI 0.26 - 0. 59), all disabling or fatal stroke (OR = 0.47, 95% CI 0.28 - 0.80), and the combined endpoint of all stroke, MI or vascular death (OR = 0.56, 95% CI 0.42 - 0.76). The observed rates of intracranial and extracranial hemorrhage not significantly increased by OAC therapy, but confidence intervals were wide.

REVIEWER'S CONCLUSIONS

Adjusted-dose OAC (achieved INRs between 2-3) reduces stroke as well as disabling/fatal stroke for patients with nonvalvular AF, and these benefits were not substantially offset by increased bleeding among participants in randomized clinical trials. Limitations include relatively short follow-up and imprecise estimates of bleeding risks from these selected participants. For primary prevention in AF patients who have an average stroke rate of 4%/year, about 25 strokes and about 12 disabling fatal strokes would be prevented yearly for every 1000 given OAC.

Topical treatments for fungal infections of the skin and nails of the foot

OBJECTIVES

The objective of this review is to identify and evaluate the evidence of efficacy for topical treatments for fungal infections of the skin and nails of the human foot. To establish the effectiveness of topical treatments in achieving a cured condition and in preventing recurrence

SEARCH STRATEGY

Randomised controlled trials were identified from the MEDLINE, EMBASE and CINHAL databases, from the beginning of these databases to December 1997. Also we screened the Cochrane Controlled Trials Register, the Science Citation Index BIOSIS, CAB - Health, Healthstar and Economic databases. References and unpublished studies were searched, podiatry journals handsearched and the pharmaceutical industry contacted.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) using participants who have mycologically diagnosed fungal infections of the skin and nails of the human foot are included in the analysis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently summarised the included trials and appraised their quality of reporting using a structured data extraction tool which assessed 12 quality criteria.

MAIN RESULTS

Of 126 trials identified in 121 papers, 72 met the inclusion criteria. Placebo-controlled trials yielded the following pooled relative risks of failure to cure (RRFC) for skin infections: allylamines 0.30 (95% confidence interval 0.23 to 0.37); azoles 0.53 (0.42 to 0.68); undecenoic acid 0.28 (0.11 to 0.74); tolnaftate 0.46 (0.17 to 1.22). Though meta-analysis of 11 trials comparing allylamines and azoles showed an RRFC of 0.88 (0.78 to 0.99) in favour of allylamines, there was evidence of language bias. Seven English language reports favoured allylamines (RRFC = 0.79; 0.68 to 0.93) but four foreign language reports showed no difference between the two drugs (RRFC = 1.00; 0.90 to 1.12). The two trials of nail infections did not provide any evidence of benefit for topical treatments compared with placebo.

CONCLUSIONS

In placebo-controlled trials allylamines, azoles and undecenoic acid were efficacious. There are sufficient comparative trials to judge relative efficacy only between allylamines and azoles. Allylamines cure slightly more infections than azoles but are much more expensive. The most cost-effective strategy is first to treat with azoles or undecenoic acid and to use allylamines only if that fails.

Health complaints related to pesticide stored at a public health clinic

Employees at a health center in Georgia were concerned that symptoms experienced by some employees were related to pesticide exposure at the center. Malathion and DDT, used for mosquito control from 1969 to 1981, had been stored and handled at the center's first floor. We surveyed 117 (91%) of 129 employees to determine whether reported symptoms were associated with pesticide exposure. We performed environmental sampling for pesticides. We analyzed serum samples for 17 chlorinated pesticides, and urine samples for malathion. We found that 37% of the participants had reported a diagnosis of sinusitis and 24% of bronchitis since working at the health center. Frequently reported symptoms were eye irritation (44%) and headache (68%). DDT and malathion were found at levels of 2.4 and 11%, respectively, in bulk samples from the loading dock of the building. Multivariate analysis of responses to the questionnaire showed that the perception of odors, inadequate air flow, and length of employment were significantly associated with the employees' health complaints. Pesticide concentrations in employees' serum and urine samples were not associated with any health complaint. The health complaints reported by the employees at the health center were precipitated by both environmental and psychological factors. The epidemiology and laboratory components of this study highlight the importance of obtaining biological measurements in episodes of perceived environmental exposure.

[Surgical treatment of the ruptured achilles tendon.]

The article deals with the issues of the rupture of Achilles tendon with a focus on its surgical treatment. On the group of 42 patients operated on between 1994 and 1999 with the average follow-up of 3 years and 9 months the authors analyze the epidemiology of this injury, i. e. its incidence by sex, age, causes etc. They also examine the influence of the presence of pretrauma complaints and the associated diseases. The results reflect both the subjective condition and the objective finding. Satisfaction of patients is expressed by a scale of seven subgroups. Achieved were 64,2 points out of the maximum number of 85. Clinical examination is focused mainly on the assessment of the standing on the toes or plan-tiflexion,Thompson test, range of motion and the presence of potential postoperative muscular hypotrophy. In the conclusion the authors discuss the influence of immobilization of the knee joint after the surgery on the strength of the regenerated tendon and mainly on the healing of the tendon in elongation which corresponds with the above mentioned clinical tests. Reduced plantiflexion was recorded in 26,2 % and the positive Thompson test in 21,4 % patients treated after the surgery by a foot-knee plaster fixation applied for 6 weeks. Key words: rupture of Achilles tendon, surgical treatment, results.