Adrenal suppression among asthmatic children receiving chronic therapy with inhaled corticosteroid with and without spacer device

BACKGROUND

Inhaled corticosteroids have become a first-line treatment for chronic asthma. It has been shown that inhaled corticosteroids can have a measurable effect on the hypothalamic-pituitary-adrenal axis in asthmatic children.

OBJECTIVE

To investigate the prevalence of adrenal suppression among asthmatic children receiving chronic therapy with low to moderate doses (up to 1000 micrograms) of inhaled beclomethasone dipropionate via a metered dose inhaler (MDI) and via MDI attached to a spacer device (MDI-spacer).

METHODS

The study included 39 asthmatic children currently undergoing therapy; 24 received beclomethasone dipropionate by MDI attached to a spacer, and 15 directly by MDI. All the patients had been treated for at least 4 months. Another 21 children were normal controls. The 24-hour urinary free cortisol excretion was measured to evaluate hypothalamic-pituitary-adrenal axis function.

RESULTS

Seven of 15 (47%) patients from the MDI group had reduced 24 hour-urinary free cortisol excretion and 2 of 24 (8%) in the MDI-spacer group (P = .006). The mean 24-hour urinary free cortisol excretion of the MDI group was 0.0185 +/- 0.0089 microgram/gram creatinine, and the MDI-spacer and the control groups were, 0.0290 +/- 0.0138 microgram/gram creatinine and 0.0270 +/- 0.0118 microgram/gram creatinine, respectively, (P = 0.37, f = 3.51 ANOVA).

CONCLUSION

Chronic inhalation of low to moderate doses of corticosteroids is associated with adrenal suppression in some asthmatic children. This side effect is more common among patients inhaling directly from the MDI and is less frequent when a large volume spacer is attached to the MDI.

Effect of thromboxane A2 blockade on clinical outcome and restenosis after successful coronary angioplasty. Multi-Hospital Eastern Atlantic Restenosis Trial (M-HEART II)

BACKGROUND

Antithromboxane therapy with aspirin reduces acute procedural complications of coronary angioplasty (PTCA) but has not been shown to prevent restenosis. The effect of chronic aspirin therapy on long-term clinical events after PTCA is unknown, and the utility of more specific antithromboxane agents is uncertain. The goal of this study was to assess the effects of aspirin (a nonselective inhibitor of thromboxane A2 synthesis) and sulotroban (a selective blocker of the thromboxane A2 receptor) on late clinical events and restenosis after PTCA.

METHODS AND RESULTS

Patients (n = 752) were randomly assigned to aspirin (325 mg daily), sulotroban (800 mg QID), or placebo, started within 6 hours before PTCA and continued for 6 months. The primary outcome was clinical failure at 6 months after successful PTCA, defined as (1) death, (2) myocardial infarction, or (3) restenosis associated with recurrent angina or need for repeat revascularization. Neither active treatment differed significantly from placebo in the rate of angiographic restenosis: 39% (73 of 188) in the aspirin-assigned group, 53% (100 of 189) in the sulotroban group, and 43% (85 of 196) in the placebo group. In contrast, aspirin therapy significantly improved clinical outcome in comparison to placebo (P = .046) and sulotroban (P = .006). Clinical failure occurred in 30% (49 of 162) of the aspirin group, 44% (73 of 166) of the sulotroban group, and 41% (71 of 175) of the placebo group. Myocardial infarction was significantly reduced by antithromboxane therapy: 1.2% in the aspirin group, 1.8% in the sulotroban group, and 5.7% in the placebo group (P = .030).

CONCLUSIONS

Thromboxane A2 blockade protects against late ischemic events after angioplasty even though angiographic restenosis is not significantly reduced. While both aspirin and sulotroban prevent the occurrence of myocardial infarction, overall clinical outcome appears superior for aspirin compared with sulotroban. Therefore, aspirin should be continued for at least 6 months after coronary angioplasty.

Sibling empathy and behavioural adjustment of children with chronic illness

This study investigated the relationship of healthy siblings' empathy to the psychosocial adjustment of children with a congenital heart disease (CHD) in 28 sibling dyads aged 3.5-11 years, as well as the perceived quality of sibling interactions, reported by mothers and children with illness. As in previous studies, children with CHD were reported to have more behaviour problems in the clinical range than either siblings or normative populations. On the basis of a task unconnected with illness issues, siblings were assigned to a high or low empathy group. Children with illness, but not their mothers, saw the siblings with high empathy more positively than those with low empathy. However, the adjustment of the children with illness did not differ between high and low empathy groups. Findings suggest the need to seek children's points of view when studying psychosocial effects of paediatric conditions.

Infant-mother attachment and nutrition in children with cystic fibrosis

The association between nutritional status (percentage of weight for height) and infant-mother relationship was studied over 4 years in 38 children diagnosed with cystic fibrosis in the first year of life. Infant-mother relationship was assessed in a standardized laboratory observation. Although they could not be distinguished medically from the others at the time of diagnosis, infants showing a specific form of insecure relationship with their mothers (insecure-avoidant) differed from the others in: (1) failure to improve in nutritional status in the first year; (2) continuing decline in weight for height in the first 3 years; and (3) significantly lower weight for height at 1, 2, and 3 years of age. These data suggest that attention to mother-infant relationships, particularly feeding interactions, may improve nutritional status in children with cystic fibrosis.

Influence of B2 receptor antagonists on bradykinin-induced vasodilation and edema formation in isolated rabbit hindlimbs

In search of new possibilities to prevent acute inflammatory vascular reaction, we examined the effect of two selective B2 receptor antagonists, CP 0127 ([Bissuccimidohexane (L-Cys6)-1] and HOE 140 (D-Arg[Hyp3, Thi5, D-Tic7, Oic8]BK), on changes in perfusion pressure and on edema formation caused by bradykinin (BK) in the isolated perfused rabbit hindlimbs. CP 0127 and HOE 140 were added to the perfusion fluid 2 min prior to the first BK-administration (5 x 10(-9) mol/l). A second BK-stimulation was performed after 30 minutes. The antagonists were tested in groups of 6 experiments each at concentrations of 10(-6) mol/l, 5 x 10(-9) mol/l and 10(-10) mol/l. CP 0127 was also tested in a concentration of 10(-8) mol/l. The application of BK resulted in an acute decrease of the mean arterial pressure and in a continual edema formation, reflected by an increase of organ weight (controls, n = 6). Pretreatment with CP 0127 as well as with HOE 140 attenuated dose-dependently the BK-induced vasodilation (p < 0.005) and edema formation. The current results indicate that CP 0127 and HOE 140 are able to reduce BK-induced effects on vascular tone and edema formation.

Behavioural inhibition, attachment and anxiety in children of mothers with anxiety disorders

OBJECTIVE

This study examined the relationship between behavioural inhibition, insecure mother-child attachment and evidence of anxiety in the offspring of mothers with anxiety disorders.

METHOD

Twenty children aged 18 to 59 months who were born to 18 mothers with diagnosed anxiety disorders were examined for behavioural inhibition (Kagan's measures) and mother-child attachment (Strange Situation Procedure). Child anxiety was assessed using DSM-III-R criteria and the Child Behavior Checklist (CBCL).

RESULTS

Sixty-five percent of the children were behaviourally inhibited. They showed more somatic problems and fewer destructive behaviours than those who were not inhibited. Eighty percent of the children were insecurely attached. They had higher CBCL internalizing scores than secure children and three of them met diagnostic criteria for anxiety disorders.

CONCLUSION

Though preliminary, this work suggests a need to identify children of anxious mothers as being at risk for anxiety, especially in the presence of inhibited temperament or attachment difficulties.

Variability in lesion depth on prone and supine CT scans of the chest: implications for the accuracy of transthoracic needle aspiration biopsy

Transthoracic needle biopsy of the lung is often performed fluoroscopically in the prone position; nodule depth measurements are made from accompanying computed tomographic (CT) scans performed supine. We evaluated the effect of prone and supine positioning on the effect of nodule depth as measured from the skin surface. Twenty consecutive patients having CT-guided biopsy performed in the prone position were assessed. Nodule depth from posterior skin surface to nodule was compared with prebiopsy supine CT scan. Nodules above the carina showed minimal change in depth. Those below the carina showed considerable variability, with depth changes < or = 4.0 cm. Awareness of the magnitude of the potential effect of patient position on lesion depth should be helpful in reducing the likelihood of false negative results in fluoroscopically guided biopsy.

The decision support system for a therapeutic department physician as an example of Dr. Watson Type System

The System Analysis Guide (Sage) is decision support system intended for highly-skilled physicians. The SAGe estimates the effectiveness and adequacy of treatment delivered by physicians. The traditional technique was not suitable for the solution of such complex tasks, and, as a basic model, the technology of the Dr. Watson Type System (Dr.WTS) (S. Goldberg, L. Meshalkin, 1990) was selected. Dr.WTS creates an informational medium that promotes correct decision making by a specialist. With that end in view, it is necessary to: a) get all the necessary information for decision making; b) stimulate the user by production of a conflict situation for the given informational space; c) direct the user's reflections toward a correct decision; d) provide the user with an compelling motive for continuing to work with the Dr.WTS program. Similar methods are actively used for the organization of creative process conditions by psychologists, system analysis specialists, and for invention machines. A distinctive feature of the Dr.WTS is the presence of an inference engine. Though the decisions themselves are not offered, Dr.WTS creates the enumerated conditions on the basis of decision making algorithms together with the result of the specialists work. Another characteristic is the system self-tuning on the problem which is solved, not in invention machines, but by the concrete specialist. The SAGe is written in C++ on an Intel 386SX-based computer and consists of five subsystems: "Diagnostics," "Treatment Effectiveness," "Treatment Adequacy," "Integral assessment of patients in the department," and "Information import." The "Diagnostics" subsystem gives a physician the opportunity to assess all information about a patient from the point of view of compensating the organism's basic systems. The SAGe organizes the presentation of the information and notes the signs which are not used in the physician's diagnostic schema (as interpreted by the SAGe). The "Treatment Effectiveness" subsystem makes it possible to compare the state severity dynamics with the dynamics of treatment character and intensity. The physician has the possibility of including the dynamics of any quantitative or qualitative indices in the analysis. The SAGe proposes the dynamics of signs which, from its "point" of view, are the most important for the choice of treatment and assessment of treatment efficacy. The "Treatment Adequacy" subsystem gives the physician an opportunity to create an archive of his own a priori and a posteriori reflections about the treatment course, causes of a state aggravation, treatment ineffectiveness, non-coincidence of prognoses, etc. The SAGe reflects the basic dynamic information about a patient and the dynamics of a physician's reflections in the form of a flower growth picture. The SAGe, stressing various details of the picture according to its notions, gives a physician an opportunity to assess divergences between his reflections at different moments in time and between the real dynamics of a disease. Thus the physician receives a notion of harmony patient treatment which is close to the adequacy of notions. The SAGe's most important role, both for stimulating a physician's intellectual activity and for the work of decision-making algorithms, is played by demanding that the physician make independent short-term and long-term prognostic assessments of a disease's development. These prognostications are then compared with reality. At present, the SAGe has been passed for approbation to some of the physicians of Yekaterinburg and Peterburg. The next task in developing the SAGe is a full-volume realization of mechanisms for algorithmic self-tuning with a concrete user.

Performance on the internal medicine second-year residency in-training examination predicts the outcome of the ABIM certifying examination

For 223 residents from eight teaching hospitals, the results of the second-year in-training examination and the first-sitting certifying examination of the American Board of Internal Medicine were highly correlated. The results of the in-training examination can serve residents as an important measure of their preparedness for certification and can be useful in identifying the need for more intensive self-study strategies during the subsequent one and a half years.

Attachment in mothers with anxiety disorders and their children

OBJECTIVE

This study examined adult attachment in mothers diagnosed with anxiety disorders and child-mother attachment in their children.

METHOD

Eighteen mothers with Axis I anxiety disorders completed the Adult Attachment Interview and standardized questionnaires. These mothers and their preschool children (n = 20) then participated in the Strange Situation Procedure.

RESULTS

All mothers were classified as nonautonomous with respect to attachment, with 78% judged unresolved. When those judged unresolved were reassigned to their alternate categories, the proportion of nonautonomous mothers was 61%. Eighty percent of the children were classified as insecurely attached, with 65% judged disorganized. When those judged disorganized were reassigned to their alternate categories, the proportion of insecurely attached children was 55%. Sixty-five percent of the children matched their mother's attachment classification. Mothers of securely attached children reported fewer recent life events, fewer depressive symptoms, and a greater sense of parenting competence than mothers of insecurely attached children.

CONCLUSIONS

These results suggest that attachment measures can be applied to anxious populations. The high rate of insecurity among offspring of anxious mothers indicates a need for longitudinal studies of these children.

Comparison of coronary angiographic findings during the first six hours of non-Q-wave and Q-wave myocardial infarction

The angiographic features of non-Q-wave acute myocardial infarction (AMI) soon after symptom onset have not been previously reported. Accordingly, this study reviewed the coronary angiographic findings of 86 patients with AMI studied within 6 hours of symptom onset: 58 had Q-wave and 28 had non-Q-wave AMI. Patients with Q-wave and non-Q-wave AMI were comparable in terms of clinical characteristics, frequency of 1-vessel disease, and infarct-related artery location. Thrombus was observed in 49 patients (84%) with Q-wave AMI versus 12 (43%) with non-Q-wave AMI (p = 0.0002). Whereas complete occlusion of the infarct-related artery was present in 53 patients (91%) with Q-wave AMI, total coronary occlusion was present in only 11 (39%) with non-Q-wave AMI (p = 0.0001). Collaterals to occluded infarct arteries were seen in 10 patients (19%) with Q-wave AMI versus 5 (45%) with non-Q-wave AMI (p = 0.06). Residual perfusion of the infarct artery by either anterograde or collateral flow was typical of patients with non-Q-wave AMI (22 of 28, 79%) but was uncommon in those with Q-wave AMI (15 of 58, 26%) (p = 0.0001). Thus, coronary angiography performed within 6 hours of symptom onset demonstrates important differences between Q-wave and non-Q-wave AMI. Non-Q-wave AMI is characterized by partial perfusion of the infarct-related artery by either anterograde or collateral flow, and a lower incidence of thrombus than Q-wave AMI.(ABSTRACT TRUNCATED AT 250 WORDS)

Cadaverine as a putative component of oral malodor

Whereas previous studies have shown correlations between volatile sulphur compounds (VSC) and bad breath levels, it is probable that other compounds found in the oral cavity may contribute to oral malodor. In the present investigation, the possibility that diamines (cadaverine and putrescine) are associated with oral malodor parameters was assessed. Saliva samples from 52 subjects were analyzed for cadaverine and putrescine by HPLC. Oral malodor of whole mouth, tongue, and saliva of the subjects was recorded by an experienced judge on a continuous 10-cm scale; peak and steady-state VSC intraoral levels were measured by the Interscan 1170 sulphide monitor. Log-transformed VSC and diamine levels were compared with odor judge measurements by Pearson analysis and stepwise forward multiple regression. Putrescine scores were not significantly associated with odor judge parameters or with VSC levels (p > 0.1). However, highly significant correlations (p < or = 0.003) were found between cadaverine levels and all three odor judge assessments. In contrast, associations between cadaverine and VSC measurements were non-significant. In an attempt to correlate odor judge results in terms of both VSC and diamines, we carried out stepwise forward multiple regression. Results showed that VSC and cadaverine both factor significantly in explaining each of the odor judge measurements, with multiple r values ranging from 0.545 (p = 0.0002) to 0.604 (p < 0.0001). The results suggest that cadaverine levels are associated with oral malodor, and that this association may be independent of VSC.

Pneumothorax during fluoroscopic biopsy: effect on nodule depth

Transthoracic needle aspiration biopsy of lung nodules is often performed under fluoroscopic guidance after measurement of lesion depth on preliminary computed tomography (CT) scans is obtained. We evaluated the change in depth of nodules in 10 patients in whom pneumothorax developed during CT-guided biopsy. We observed that nodule depth changed by an amount equal to the size of the pneumothorax. Awareness of the potential effect of pneumothorax on lesion depth should be helpful in reducing the likelihood of false-negative results with CT-assisted fluoroscopic biopsy when only single-plane fluoroscopy is available.

Inter-series differences in the restenosis rate of Palmaz-Schatz coronary stent placement: differences in demographics and post-procedure lumen diameter

Restenosis rates following Palmaz-Schatz stenting vary between 13 and 36%. To determine whether the nearly three-fold interseries difference in restenosis rates reflects systematic factors (demographic and procedural variables such as post-treatment lumen diameter) rather than random variation, we pooled 486 lesions treated with the Palmaz-Schatz coronary stent in the U.S. Multicenter Registry (n = 259) with the single-center Beth Israel Hospital experience (n = 227) and analyzed the combined series using a continuous geometric model of restenosis. A greater proportion of lesions (66 vs. 50%; P < 0.001) in the Multicenter cohort represented restenosis after a prior intervention. The Multicenter experience also showed a smaller minimum lumen diameter following stent placement (2.61 vs. 3.43 mm; P < 0.001), higher post-stent percent stenosis (16 vs. -2%; P < 0.001), and less acute gain (1.79 vs. 2.67 mm; P < 0.001) than lesions treated in the Beth Israel cohort. At 6-month follow-up, the angiographic restenosis rate (> or = 50% diameter stenosis) was significantly higher in the Multicenter group (35 vs. 27%; P = 0.05), despite the development of less absolute late loss (0.96 vs. 1.32 mm; P < 0.001). Multivariable modeling, however, showed that the only independent predictors of restenosis were a post-procedure lumen diameter < 2.80 mm (odds ratio = 1.57; P = 0.04), diabetes mellitus (odds ratio = 3.55; P < 0.001), and prior restenosis (odds ratio = 1.84; P = 0.008).(ABSTRACT TRUNCATED AT 250 WORDS)

Quality of toddler-mother attachment in children with Down syndrome: limits to interpretation of strange situation behavior

Researchers studying social-emotional development have argued that primary attachment relationships, established by the end of the first year of life, are important organizing factors that influence the trajectory of development throughout childhood. Central to this argument is a dimension of "attachment security," along which attachments differ. For normally developing infants and toddlers, attachment security is assessed using the Ainsworth Strange Situation. However, it is not clear that this procedure is appropriate for evaluating attachment security in atypical populations. In this report, 3 samples of children with Down Syndrome (total N = 138) were assessed using the Strange Situation. The procedures were scored according to traditional protocols. Although the 3 samples differed with respect to chronological and developmental age, they showed basic similarity with respect to attachment variables. However, developmentally younger children were more difficult to classify using the standard scoring rules. Scores and classifications for the sample were compared to scores from a sample of normally developing children tested at about 12 months of age. Significant differences with respect to the distributions of cases to classification categories and with respect to the interactive scale scores suggest that the Strange Situation may be measuring different aspects of behavior for children with Down Syndrome, even when they are tested at similar developmental age levels.

Mobilization of peripheral blood stem cells by subcutaneous injections of yeast-derived granulocyte macrophage colony stimulating factor: a phase I-II study

A phase I-II study was conducted in 15 patients to determine the tolerability, efficacy and optimal dose of s.c. yeast-derived granulocyte-macrophage colony stimulating factor (GM-CSF) for mobilization of peripheral blood stem cells (PBSC). PBSC were measured by the colony forming unit granulocyte-macrophage (CFU-GM) and burst forming unit erythroid (BFU-E) in vitro colony assays and CD34 flow cytometric analysis. GM-CSF was administered for 12 days as a single daily s.c. injection at 125 micrograms/M2 (n = 3), 250 micrograms/M2 (n = 3), 375 micrograms/M2 (n = 6) and 500 micrograms/M2 (n = 3). At these doses, sustained serum GM-CSF levels of approximately 100-400 pg/ml were observed for at least six hours. Most (97.2% or 175/180) of the planned GM-CSF doses were administered with no serious adverse effects at any of the dose levels. Three leukapheresis procedures were performed before and then after 8, 10 and 12 doses of s.c. GM-CSF. Compared with basal leukapheresis collections, s.c. GM-CSF mobilized leukapheresis collections yielded greater numbers of total white blood cells ([WBC] 15/15 patients or 100%, p < 0.001) mononuclear cells ([MNC] 8/15 patients or 53%, p = 0.55), CFU-GM (11/15 patients or 73%, p = 0.037), BFU-E (9/15 patients or 60%, p = 0.13) and CD34+ cells (6/15 patients or 40%, p = 0.15). The in vitro CFU-GM were augmented approximately two to tenfold in GM-CSF mobilized collections with no clear dose effects from 125-500/micrograms/M2. However, in vivo engraftment time to absolute neutrophil count (ANC) 500/mm3 correlated strongly with GM-CSF PBSC mobilizing dose (r2 = 0.99). We conclude that s.c. yeast-derived GM-CSF is a simple, effective and tolerable method for mobilization of PBSC.

Dose-related efficacy and bleeding complications of double-chain tissue plasminogen activator in acute myocardial infarction. The Wellcome Tissue Plasminogen Activator Study Group

Although the efficacy of recombinant tissue-type plasminogen activator (rt-PA) in acute myocardial infarction has been demonstrated, little formal dose-ranging information is available. This study examined the use of duteplase, the double-chain rt-PA subsequently used in the Third International Study of Infarct Survival, in a multicenter trial of 267 patients with evolving acute myocardial infarction assigned to receive 1 of 6 weight-adjusted doses. The primary end point was infarct vessel patency after 90 minutes of drug infusion. Patency was defined as Thrombolysis in Myocardial Infarction trial grade 2 or 3 perfusion, and was determined by an independent core laboratory masked to treatment assignment. Patency was present in 48% of patients receiving the lowest dose range and 78% of those receiving the highest, with an association between thrombolytic dose and patency (p = 0.009). The frequency of serious bleeding complications also correlated with the total dose of rt-PA infused (p = 0.003). Bleeding complications were primarily related to instrumentation; blood loss requiring transfusion or otherwise deemed clinically significant occurred in 12% of patients (central nervous system hemorrhage occurred in 1.1%). Thus, higher doses of rt-PA are associated both with increased efficacy and increased risk of serious bleeding complications. Weight-adjusted dosing may provide an optimal risk-benefit ratio for thrombolysis during acute myocardial infarction.

Restenosis after placement of Palmaz-Schatz stents in native coronary arteries. Initial results of a multicenter experience

BACKGROUND

Several metallic intracoronary stents are currently undergoing preliminary evaluation to ascertain potential benefit as means to reduce the 30-40% incidence of restenosis after balloon angioplasty.

METHODS AND RESULTS

To determine the incidence and correlates of restenosis after placement of Palmaz-Schatz stents in native coronary arteries in the first group of patients selected for this procedure, clinical and quantitative angiographic data from 206 consecutive patients (221 stenoses) with successful stent placement (diameter stenosis < 50%) were analyzed. Six patients (2.9%) had thrombosis-mediated stent closure within 1 month after stent placement and were excluded from long-term angiographic follow-up. One hundred eighty-one (91%) of the remaining 200 patients had angiography at 5.8 +/- 2.1 months. Patients with and without follow-up did not differ in any baseline characteristic; in particular, history of restenosis at the site stented (73% versus 65%), placement of multiple overlapping stents (17% versus 20%), and mean poststent diameter stenosis (16 +/- 12% versus 14 +/- 12%). The overall incidence of restenosis (diameter stenosis > or = 50% at follow-up) in this group at high risk for restenosis was 36% (95% confidence interval, 29-43%) on a per-stenosis basis. The incidence of restenosis when a single stent was placed was 30% (95% confidence interval, 23-37%). Risk was dependent upon a history of restenosis (present versus absent 36% versus 16%, p = 0.02) and upon whether or not a poststent stenosis < or = 0% was achieved (6% versus 33%, p = 0.02). When multiple overlapping stents were placed, restenosis occurred at 64% of sites, and placement of multiple stents was discouraged during the later phases of this study as these results became apparent.

CONCLUSIONS

Although multiple stents appear to yield a poor long-term result, placement of single stents may offer a benefit compared with standard coronary angioplasty, particularly if an excellent angiographic result can be obtained in patients without prior restenosis. Further randomized trials in such patients are needed.