A Comparison of Postoperative Outcomes between Unilateral and Bilateral Palatoplasty: Analysis of 2015-2020 Pediatric NSQIP Data

OBJECTIVE

We sought to identify differences in 30-day medical and surgical complications in unilateral versus bilateral palatoplasty.

DESIGN

The NSQIP-P 2015-2020 database was queried to identify cleft palate repairs using CPT codes. Cases were stratified as unilateral (Veau III) and bilateral (Veau IV) using ICD-9 and -10 codes.

SETTING

A nationally representative random sample.

PATIENTS/PARTICIPANTS

A total of 3791 cases were identified with 2608 undergoing unilateral repair and 1183 undergoing bilateral repair.

MAIN OUTCOMES/MEASURES

The postoperative outcomes of interest included surgical complications (surgical site infections, wound dehiscence), medical complications (pneumonia, urinary tract infection, seizure, cardiac arrest, bleeding/transfusions, systemic sepsis, unplanned intubation), readmission, and reoperation.

RESULTS

The bilateral cohort was older (696 days versus 619 days, P < .001) and had longer operative times (157.3 min versus 144.5 min, P < .001). The unilateral cohort had more comorbidities including developmental delay, structural CNS abnormalities, need for nutritional support, and bleeding disorders. The bilateral cohort had statistically significant higher occurrences of wound dehiscence (2.1% versus. 1.2%, P = .03) and readmission (3.2% versus 1.7%, P = .01). On multivariate analysis, bilateral cleft repair (OR: 1.83, CI: 1.176-2.840, P = .007) and ASA class 4 (OR: 13.1, CI 2.288- 62.586, P = .002) were associated with greater odds of readmission.

CONCLUSION

Patients who underwent bilateral cleft repair had a higher proportion of 30-day postoperative complications and a two-fold increased odds of readmission. While palatoplasty is generally regarded as a safe procedure in the pediatric population, identifying factors related to an increased risk of early postoperative complications can help surgical teams better manage high-risk individuals.

Transcervical Fibroid Ablation (TFA) in an Ambulatory Surgical Center Setting: Utility during the COVID-19 Pandemic

Study Objective

To describe the experience of TFA with the Sonata® system in the ambulatory surgicenter (ASC) setting, relative to current recommendations by medical societies for elective procedures during the COVID-19 pandemic.

Design

Prospective, longitudinal, multicenter controlled trial.

Setting

22 clinical sites in the US and Mexico.

Patients or Participants

147 premenopausal women between the ages of 25 and 50 with heavy menstrual bleeding secondary to nonpedunculated fibroids.

Interventions

Transcervical, intrauterine ultrasound-guided radiofrequency ablation with the Sonata system. Pain scores were recorded after each procedure using a scale from 0-10. Length of stay (LOS) was measured from procedure start through discharge.

Measurements and Main Results

Of 147 treated patients, 49 were treated in an ASC setting and 98 were treated in other outpatient settings. Fifty-five percent of patients treated in an ASC had general anesthesia and 45% had conscious sedation vs 48% and 52%, respectively for non-ASC population. Average number of fibroids treated per patient was 3.2±2.0 and 2.9±2.1 in ASC and non-ASC, respectively. Mean LOS was 2.1±0.9 hours vs. 2.8±1.3 hours for ASC and non-ASC patients, respectively. Mean procedure pain scores were 0±0% for the ASC patients (0.4±1.1 for non-ASC patients). Mean return to normal activity for patients treated in ASC was 1.7±1.4 days (2.4±2.5 for non-ASC patients). Mean 12-month improvements in SSS and HRQL scores were -34.8±23.9 and 48.6±26.2 points, respectively, in ASC patients (-30.4±19.3 and 41.0±23.0, respectively, in non-ASC patients).

Conclusion

Current surgical guidance during the COVID-19 pandemic encourages avoidance of endotracheal intubation when appropriate and minimizing exposure time for patients and staff. Transcervical Fibroid Ablation with the Sonata system is performed without pneumoperitoneum or a requirement for intubation, providing short LOS, minimal pain scores and improved outcomes while potentially reducing risk to healthcare personnel and patients alike.

Improved glycaemic control and treatment satisfaction with a simple wearable 3-day insulin delivery device among people with Type 2 diabetes

AIM

To evaluate the PAQ® (CeQur SA, Horw, Switzerland), a wearable 3-day insulin delivery device that provides set basal rates and bolus insulin on demand, in people with Type 2 diabetes.

METHOD

Adults with Type 2 diabetes with HbA1c concentrations ≥53 and ≤97 mmol/mol (7.0 and 11.0%) while treated with ≥2 insulin injections/day were enrolled in two single-arm studies comprising three periods: a baseline (insulin injections), a transition and a PAQ treatment period (12 weeks). Endpoints included HbA1c , seven-point self-monitored blood glucose, total daily dose of insulin and body weight. Safety was assessed according to examination, hypoglycaemic episodes and adverse device effects.

RESULTS

A total of 28 adults were enrolled (age 63 ± 7 years, 86% men, BMI 32.3 ± 4.3kg/m2 , Type 2 diabetes duration 17 ± 8 years, HbA1c 70 ± 12 mmol/mol (8.6 ± 1.1%), total daily insulin dose 58.7 ± 20.7 U), of whom 24 completed the studies. When transitioned to PAQ, 75% of participants continued on the first basal rate selected. After 12 weeks of PAQ wear, significant improvements from baseline were seen [HbA1c -16 ± 9 mmol/mol (95% CI -20, -12) or -1.5 ± 0.9% (95% CI -1.8, -1.1) P<0.0001], and at all seven self-monitored blood glucose readings time points (P ≤0.03). Total daily insulin dose increased by 12.1 ± 19.5 U (95% CI 3.9, 20.4; P=0.0058), the number of meal time boluses increased by 0.9 ± 1.5/day (95% CI 0.3, 1.5; P=0.0081) and body weight remained stable. Six participants had mild to moderate catheter site reactions and one mild skin irritation occurred. No participant experienced severe hypoglycaemia.

CONCLUSIONS

Adults with Type 2 diabetes were safely transitioned from insulin injections to the PAQ and had significantly improved glycaemic control and treatment satisfaction with insulin therapy. (ClinicalTrials.gov identifiers: NCT02158078 & NCT02419859).

Early Posterior Vault Distraction Osteogenesis for the Treatment of Syndromic Craniosynostosis

Posterior cranial vault distraction (PCVD) has become an important modality in the management of complex craniosynostosis to increase intracranial volume and improve the cranial vault appearance. This technique can safely be performed as early as 3 months of age for the initial management of patients with complex craniosynostosis. A retrospective review was performed of all the patients with syndromic, multiple-suture synostosis treated with PCVD at Primary Children's Hospital in Salt Lake City, Utah, between 2012 and 2014. During this time period, a total of nine children with an average corrected age of 21.4 weeks were treated. Demographics, intraoperative data, and postoperative distraction data were collected. Occipital frontal head circumferences (OFCs) were recorded pre- and postdistraction, and at 3- and 6-month follow-up examinations. All patients had a substantial increase in head circumference with subjective improvement of the posterior calvarium shape. The average increase in OFC from preoperative to postdistraction was 4.9 cm. Only two significant postoperative complications were encountered, one hardware infection and one cerebrospinal fluid leak. PCVD is an effective procedure in the management of complex craniosynostosis and can be safely initiated very early in life.

Current knowledge of US metal and nonmetal miner health: Current and potential data sources for analysis of miner health status

Little is known about the current health status of US metal and nonmetal (MNM) miners, in part because no health surveillance systems exist for this population. The National Institute for Occupational Safety and Health (NIOSH) is developing a program to characterize burden of disease among MNM miners. This report discusses current knowledge and potential data sources of MNM miner health. Recent national surveys were analyzed, and literature specific to MNM miner health status was reviewed. No robust estimates of disease prevalence were identified, and national surveys did not provide information specific to MNM miners. Because substantial gaps exist in the understanding of MNM miners' current health status, NIOSH plans to develop a health surveillance program for this population to guide intervention efforts to reduce occupational and personal risks for chronic illness.

Importance of Postoperative Hydration and Lower Extremity Elevation in Preventing Deep Venous Thrombosis in Full Abdominoplasty: A Report on 450 Consecutive Cases Over a 37-Year Period

BACKGROUND

Abdominoplasty is a common plastic surgery procedure and has a higher rate of postoperative deep venous thrombosis (DVT) than any other such surgery. DVT prevention remains an important topic in the plastic surgery community. Many surgeons avoid DVT chemoprophylaxis, because they are concerned about the risk of postoperative bleeding.

OBJECTIVE

This study was performed in order to evaluate postoperative hydration and lower extremity elevation as two alternative methods of aiding DVT prevention after abdominoplasty.

METHODS

Preoperative, intraoperative, and postoperative measures were taken to monitor patient hydration via urine output and to ensure adequate hydration by providing intravenous fluids. In addition, measures were taken throughout these three phases to ensure adequate lower extremity elevation.

RESULTS

In a group of 450 consecutive full abdominoplasties from 1976 to 2013, the overall rate of patient DVT at 30 days following surgery was 0.22%.

CONCLUSIONS

Hydration and lower extremity elevation are innocuous and risk-free adjuncts that improve venous return from the legs and lessen the chance of postoperative DVT.

Pancraniosynostosis following endoscopic-assisted strip craniectomy for sagittal suture craniosynostosis in the setting of poor compliance with follow-up: a case report

Introduction

There is limited craniofacial literature on the complications of helmet therapy and controversy regarding the effects of inadequate orthotic helmet therapy. The authors present a case of inadvertently prolonged orthotic helmet therapy after endoscopic strip craniectomy for isolated sagittal synostosis.

Case presentation

A two-month-old Caucasian baby underwent uncomplicated endoscopic-assisted strip craniectomy to treat synostosis of the sagittal suture and was fitted for an orthotic helmet two weeks postoperatively. He presented to the craniofacial clinic eight weeks postoperatively with occipital flattening and increased posterior vault height, so the helmet was refitted. During the next 18 months, the helmet was used inconsistently without follow-up. Upon re-presentation, the patient had developed pansynostosis, requiring a subsequent open total cranial vault reconstruction for correction for this secondary deformity.

Conclusions

Although it remains unclear whether postoperative development of pansynostosis is the result of prolonged helmeting or the consequence of progressive synostotic disease, this report highlights the importance of parent education and judicious scheduled follow-up for the avoidance of potential helmet therapy complications.

A comparison of twice-daily exenatide and biphasic insulin aspart in patients with type 2 diabetes who were suboptimally controlled with sulfonylurea and metformin: a non-inferiority study

AIMS/HYPOTHESIS

The aim of this 52-week, open-label, non-inferiority trial was to compare the safety and efficacy of exenatide (an incretin mimetic) with that of biphasic insulin aspart.

MATERIALS AND METHODS

Patients on metformin and a sulfonylurea were randomised to exenatide (n = 253; 5 microg twice daily for 4 weeks, 10 microg thereafter) or biphasic insulin aspart (n = 248; twice-daily doses titrated for optimal glucose control), while continuing with metformin and sulfonylurea treatment.

RESULTS

Glycaemic control achieved with exenatide was non-inferior to that achieved with biphasic insulin aspart (mean+/-SEM, HbA(1c) change: exenatide -1.04 +/- 0.07%, biphasic insulin aspart -0.89 +/- 0.06%; difference -0.15 [95% CI -0.32 to 0.01]%). Exenatide-treated patients lost weight, while patients treated with biphasic insulin aspart gained weight [between-group difference -5.4 (95% CI -5.9 to -5.0) kg]. Both treatments reduced fasting serum glucose (exenatide -1.8 +/- 0.2 mmol/l, p < 0.001; biphasic insulin aspart -1.7 +/- 0.2 mmol/l, p < 0.001). Greater reductions in postprandial glucose excursions following morning (p < 0.001), midday (p = 0.002) and evening meals (p < 0.001) were observed with exenatide. The withdrawal rate was 21.3% (54/253) for exenatide and 10.1% (25/248) for biphasic insulin aspart. Nausea (33% incidence, 3.5% discontinuation) was the most common adverse event observed with exenatide.

CONCLUSIONS/INTERPRETATION

Exenatide treatment resulted in HbA(1c) reduction similar to biphasic insulin aspart and provided better postprandial glycaemic control, making it a potential alternative for the treatment of type 2 diabetes. Treatment with biphasic insulin aspart was associated with weight gain and lower risk of adverse gastrointestinal events. Although the availability of glucose-lowering agents associated with weight reduction may be considered a therapeutic advance, the long-term implications of progressive weight reduction observed with exenatide have yet to be defined.

Long-term effects of pioglitazone and metformin on insulin sensitivity in patients with Type 2 diabetes mellitus

AIM

Despite their comparable glycaemic effects in patients with Type 2 diabetes mellitus (T2DM), pioglitazone and metformin may have different effects on insulin sensitivity because they have different mechanisms of action. We studied the changes in insulin sensitivity, as assessed by the Quantitative Insulin Sensitivity Check Index (QUICKI), in patients with T2DM who used metformin or pioglitazone as monotherapy or in combination therapy with sulphonylurea.

METHODS

Data in this report are from two multicentre, randomized, double-blind, double-dummy studies conducted in Europe (monotherapy) or in Europe and Canada (combination therapy study). Patients were randomized to 52 weeks of treatment consisting of a 12-week forced titration period and a 40-week maintenance period. HbA(1c), fasting plasma glucose (FPG) and fasting serum insulin (FSI) were quantified from a single blood sample at weeks 0, 8, 16, 24, 32, 42 and 52. Insulin sensitivity was assessed with QUICKI, which is calculated from FSI and fasting blood glucose (FBG) concentrations using the formula 1/(log(10) FSI + log(10) FBG). Time course effects of the treatments were compared by repeated measures analysis of covariance.

RESULTS

As monotherapy, pioglitazone and metformin increased QUICKI compared with baseline (baseline vs. end point [mean +/- sem]; pioglitazone [0.303 +/- 0.001 vs. 0.321 +/- 0.001; P < 0.001] and metformin [0.304 +/- 0.001 vs. 0.315 +/- 0.001; P < 0.001]). Pioglitazone increased insulin sensitivity more than metformin from week 4 through week 52. There were significant increases in QUICKI from baseline in both combination therapy groups (baseline vs. end point; pioglitazone + sulphonylurea [0.305 +/- 0.001 vs. 0.319 +/- 0.001; P < 0.001] and metformin + sulphonylurea [0.306 +/- 0.001 vs. 0.317 +/- 0.001; P < 0.001]). Overall, pioglitazone + sulphonylurea significantly increased insulin sensitivity more than metformin + sulphonylurea.

CONCLUSION

Pioglitazone differed from metformin in its effects on insulin sensitivity despite both drugs having comparable glycaemic effects.

Pioglitazone elicits long-term improvements in insulin sensitivity in patients with type 2 diabetes: comparisons with gliclazide-based regimens

AIMS/HYPOTHESIS

Recent studies have demonstrated that pioglitazone (PIO) has beneficial effects on insulin sensitivity compared with placebo in patients with type 2 diabetes. The effects of PIO and gliclazide (GLIC)-based therapy on insulin sensitivity have not previously been directly compared. This analysis aimed to compare the effects of 52 weeks of treatment with PIO (30-45 mg/day) and GLIC (80-320 mg/day), both titrated to maximum tolerable doses, as monotherapy or in combination with metformin (MET), on insulin sensitivity and lipid parameters known to be related to insulin sensitivity in patients with type 2 diabetes.

METHODS

We performed an analysis of 1,880 patients with inadequately controlled type 2 diabetes (HbA1c 7.5-11.0%) who were participants in two parallel-group, double-blind, double-dummy, randomised, multicentre, clinical trials. Measures of insulin sensitivity and lipids were assessed.

RESULTS

The PIO- and GLIC-based regimens produced similar levels of glycaemic control (HbA1c). In both trials, insulin sensitivity as assessed using the homeostasis model assessment was improved in patients receiving PIO, but decreased in those receiving GLIC (mean change, baseline to endpoint: PIO 15.5, GLIC -15.6; p<0.001 and PIO+MET 18.9, GLIC+MET -5.3; p<0.001). Improvements in the atherogenic index of plasma (mean change: PIO -0.17, GLIC -0.08; p<0.001 and PIO+MET -0.17, GLIC+MET -0.02; p<0.001), triglycerides (mean change, mmol/l: PIO+MET -0.62, GLIC+MET -0.22; p<0.001) and NEFA (mean change, mmol/l: PIO+MET -0.12, GLIC+MET-0.05; p<0.001) were greater in PIO-treated patients than in patients receiving GLIC.

CONCLUSIONS/INTERPRETATION

The PIO-based regimens resulted in improved insulin sensitivity and more favourable insulin sensitivity-related lipid profiles compared with the GLIC-based regimens. These benefits may be important in the management of cardiovascular risk in patients with type 2 diabetes.

Sustained effects of pioglitazone vs. glibenclamide on insulin sensitivity, glycaemic control, and lipid profiles in patients with Type 2 diabetes

AIMS

This study compared the effects of 52 weeks' treatment with pioglitazone, a thiazolidinedione that reduces insulin resistance, and glibenclamide, on insulin sensitivity, glycaemic control, and lipids in patients with Type 2 diabetes.

METHODS

Patients with Type 2 diabetes were randomized to receive either pioglitazone (initially 30 mg QD, n = 91) or micronized glibenclamide (initially 1.75 mg QD, n = 109) as monotherapy. Doses were titrated (to 45 mg for pioglitazone and 10.5 mg for glibenclamide) to achieve glycaemic targets during the next 12 weeks: fasting blood glucose of < or = 7 mmol/l and 1-h postprandial blood glucose of < or = 10 mmol/l. Patients were maintained on the titrated dose for 40 weeks.

RESULTS

Pioglitazone significantly increased insulin sensitivity compared with glibenclamide, as assessed by homeostasis model assessment (17.0% vs. -13.0%; P < 0.001), quantitative insulin sensitivity check index (0.011 vs. -0.007; P < 0.001) and fasting serum insulin (-1.3 pmol/l vs. 23.8 pmol/l; P = 0.007). The glibenclamide group had significantly lower HbA1c than the pioglitazone group after 12 weeks of therapy (7.8% vs. 8.3%, P = 0.015), but significantly higher HbA1c after 52 weeks of therapy (7.8% vs. 7.2%, P = 0.001). Pioglitazone significantly (vs. glibenclamide) increased mean HDL-C (P < 0.001), decreased mean triglycerides (P = 0.019), and decreased mean atherogenic index of plasma (AIP; P = 0.001) and mean total cholesterol/HDL-C (P = 0.004), without significantly elevating mean total cholesterol or mean LDL-C compared with glibenclamide. CONCLUSIONS These data suggest that the effects of pioglitazone are more sustained than those of glibenclamide for improving insulin sensitivity in patients with Type 2 diabetes, and that 52 weeks' treatment with pioglitazone has favourable effects on glycaemic control and lipoprotein profile.

Novel SCO2 mutation (G1521A) presenting as a spinal muscular atrophy type I phenotype

Rare cases of suspected spinal muscular atrophy (SMA) have been found to have cytochrome c oxidase (COX) deficiency. To date, four cases with SMA features have been reported in children with mutations in the synthesis of cytochrome oxidase 2 (SCO2) gene. We report a male neonate who was born hypotonic, with persistent lactic acidosis, spontaneous activity with EMG testing, development of respiratory distress in the first few hours of life, and died at 30 days of age with progressive cardiomyopathy. Testing for survival motor neurone (smn) and NAIP deletions were negative and a skeletal muscle biopsy showed neurogenic features with severe reductions of COX enzymatic and histochemical staining intensity. Post-mortem muscle, heart, and liver biopsies showed severe, moderate, and mild reductions in COX activity, respectively, with parallel findings in the protein content for the mitochondrial DNA (COII) and nuclear DNA (COIV) encoded subunits. DNA sequencing of exon 2 of the SCO2 gene revealed compound heterozygosity with mutations at G1541A (common mutation, E140K) and also at a novel site in the copper binding region (G1521A in the current case (converting a highly conserved cysteine to tyrosine [corrected] (C133Y) [corrected]); mother heterozygous for G1521A; and father heterozygous for G1541A). This case provides strong support that SCO2 mutations can result in neonatal hypotonia with an SMA 1 phenotype. SCO2 mutations should be screened in suspected SMA cases with normal smn mutation analysis and any one of; cardiomyopathy, lactic acidosis, or COX deficiency in muscle.

Airway inflammation, basement membrane thickening and bronchial hyperresponsiveness in asthma

BACKGROUND

There are few data in asthma relating airway physiology, inflammation and remodelling and the relative effects of inhaled corticosteroid (ICS) treatment on these parameters. A study of the relationships between spirometric indices, airway inflammation, airway remodelling, and bronchial hyperreactivity (BHR) before and after treatment with high dose inhaled fluticasone propionate (FP 750 microg bd) was performed in a group of patients with relatively mild but symptomatic asthma.

METHODS

A double blind, randomised, placebo controlled, parallel group study of inhaled FP was performed in 35 asthmatic patients. Bronchoalveolar lavage (BAL) and airway biopsy studies were carried out at baseline and after 3 and 12 months of treatment. Twenty two normal healthy non-asthmatic subjects acted as controls.

RESULTS

BAL fluid eosinophils, mast cells, and epithelial cells were significantly higher in asthmatic patients than in controls at baseline (p<0.01). Subepithelial reticular basement membrane (rbm) thickness was variable, but overall was increased in asthmatic patients compared with controls (p<0.01). Multiple regression analysis explained 40% of the variability in BHR, 21% related to rbm thickness, 11% to BAL epithelial cells, and 8% to BAL eosinophils. The longitudinal data corroborated the cross sectional model. Forced expiratory volume in 1 second improved after 3 months of treatment with FP with no further improvement at 12 months. PD(20) improved throughout the study. BAL inflammatory cells decreased following 3 months of treatment with no further improvement at 12 months (p<0.05 v placebo). Rbm thickness decreased in the FP group, but only after 12 months of treatment (mean change -1.9, 95% CI -3 to -0.7 microm; p<0.01 v. baseline, p<0.05 v. placebo). A third of the improvement in BHR with FP was associated with early changes in inflammation, but the more progressive and larger improvement was associated with the later improvement in airway remodelling.

CONCLUSION

Physiology, airway inflammation and remodelling in asthma are interrelated and improve with ICS. Changes are not temporally concordant, with prolonged treatment necessary for maximal benefit in remodelling and PD(20). Determining the appropriate dose of inhaled steroids only by reference to symptoms and lung function, as specified in current international guidelines, and even against indices of inflammation may be over simplistic. The results of this study support the need for early and long term intervention with ICS, even in patients with relatively mild asthma.

Decreased vascular glucose transporter expression and glucose uptake in DOCA-salt hypertension

OBJECTIVE

Because glucose uptake and metabolism can affect vascular smooth muscle cell function, we proposed that animals with hypertension might develop alterations in glucose transporter expression in vascular smooth muscle cells that were responsible for some of the vascular abnormalities characteristic of hypertension.

DESIGN AND METHOD

Male Sprague-Dawley rats (250-300 g) were left uni-nephrectomized and either implanted or not with deoxycorticosterone acetate (DOCA, 200 mg/kg) impregnated silastic. All animals were fed normal rat chow. The DOCA-implanted rats were given water supplemented to 1% NaCl and 0.2% KCl for 7, 14 or 28 days.

RESULTS

The insulin-response glucose transporter (GLUT4) polypeptide levels were depressed several-fold in aortae and carotid arteries from DOCA-salt hypertensive rats compared with sham rats. Uptake of the glucose analog, 2-deoxyglucose (2-DOG), was also reduced 53% in hypertensive compared with sham aortae. There were no changes in GLUT4 expression in other tissues in the DOCA-salt animals, nor were there significant changes in aortae from spontaneously hypertensive rat/stroke prone animals. As previously demonstrated, carotid arteries from DOCA-salt animals exhibited a significant increased contractile sensitivity to ergonovine. Inhibition of glucose metabolism with 2-DOG in sham arteries caused a marked enhancement of contractile responsiveness to ergonovine, whereas 2-DOG had no effect on the already enhanced contractility of DOCA-salt arteries, suggesting that reduction in glucose uptake and metabolism substantially increases the contractile response of DOCA-salt arteries.

CONCLUSIONS

Alterations in glucose uptake and metabolism in vascular smooth muscle cells may participate in the contractile abnormalities characteristic of certain forms of hypertension.

Cefaclor af versus amoxycillin/clavulanate in acute bacterial exacerbations of chronic bronchitis: a randomised multicentre study

Cefaclor and amoxycillin/clavulanate are active against Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis and Staphylococcus aureus--pathogens commonly associated with acute exacerbations of chronic bronchitis (AECB). This randomised, parallel-group, single-blind, multicentre study investigated the comparative efficacy and safety of 7-day treatment regimens of cefaclor AF (750 mg b.d. [n = 73]) and amoxycillin/clavulanate (875/125 mg b.d. [n = 72]) in AECB. A favourable clinical response was obtained in 95.9% of patients on cefaclor AF and 97.2% of patients on amoxycillin/clavulanate. There were no statistically significant differences between the groups for improvement in clinical response measured by pulmonary peak expiratory flow (PPEF), or for common symptoms associated with AECB. Both agents were well tolerated, with no statistically significant differences in overall safety; however, nausea and vomiting, and abdominal pain, the most frequently occurring adverse events in the amoxycillin/clavulanate group, were not reported in the cefaclor group. In conclusion, cefaclor AF and amoxycillin/clavulanate have similar efficacy and safety profiles in the treatment of AECB.

Hypoxemia and hypercapnia during exercise and sleep in patients with cystic fibrosis

BACKGROUND

In patients with cystic fibrosis (CF), it has been proposed that hypoxemia and hypercapnia occur during episodes of stress, such as exercise and sleep, and that respiratory muscle weakness because of malnutrition may be responsible.

METHODS

Pulmonary function, respiratory muscle strength, and nutrition were assessed and correlated with the degree of hypoxemia and hypercapnia during exercise and sleep in 14 patients with CF and 8 control subjects.

RESULTS

Despite no differences in maximum static inspiratory pressure (PImax) between the two groups, the CF group developed more severe hypoxemia (minimum oxyhemoglobin saturation [SpO2], 89 +/- 5% vs 96 +/- 2%; p < 0.001) and hypercapnia (maximum transcutaneous CO2 tension [PtcCO2], 43 +/- 6 vs 33 +/- 7 mm Hg; p < 0.01) during exercise. Similarly, during sleep, the CF group developed greater hypoxemia (minimum SpO2, 82 +/- 8% vs 91 +/- 2%; p < 0.005), although CO2 levels were not significantly different (maximum PtcCO2, 48 +/- 7 vs 50 +/- 2 mm Hg). Within the CF group, exercise-related hypoxemia and hypercapnia did not correlate with FEV1, residual volume/total lung capacity ratio (RV/TLC), PImax, or body mass index (BMI). Hypoxemia and hypercapnia during sleep correlated with markers of gas trapping (RV vs minimum arterial oxygen saturation [r = -0.654; p < 0.05]), RV vs maximum PtcCO2 (r = 0.878; p < 0.001), and RV/TLC vs maximum PtcCO2 (r = 0.790; p < 0.01) but not with PImax or BMI.

CONCLUSION

Patients with moderately severe CF develop hypoxemia and hypercapnia during exercise and sleep to a greater extent than healthy subjects with similar respiratory muscle strength and nutritional status. Neither respiratory muscle weakness nor malnutrition are necessary to develop hypoxemia or hypercapnia during exercise or sleep.

Loracarbef versus clarithromycin in children with acute otitis media with effusion

Two multicenter, randomized, single-masked, parallel-group studies compared loracarbef and clarithromycin with regard to efficacy, tolerability, and patient acceptance. Three hundred thirty-four children aged 6 months to 3 years with acute otitis media with effusion received loracarbef (15 mg/kg) or clarithromycin (7.5 mg/kg) orally twice daily for 10 days. Patients were assessed for the presence of the diagnostic signs and symptoms of otitis media with effusion by physical examination and pneumatic otoscopy at 48 hours pretreatment, 3 to 5 days after initiation of treatment, 0 to 3 days after the final dose (posttreatment), and 14 to 21 days later (termination). Symptoms were assigned numeric values. Symptomatic response was assessed at the posttherapy and termination visits. Tolerability was determined by assessing adverse events, and a patient acceptance survey was completed by each patient's caregiver. The combined results of these 2 studies showed that the efficacy and tolerability of loracarbef were comparable to those of clarithromycin. Adverse events were reported by 46.4% of loracarbef patients and 41.0% of clarithromycin patients, with no statistically significant difference between groups. In the intent-to-treat analysis, 57.9% of loracarbef patients were cured at the termination of the study, compared with 55.7% of clarithromycin patients. Improvement was seen in 4.1% of loracarbef patients and 2.7% of clarithromycin patients. Results of the patient acceptance survey showed a clear preference for loracarbef over clarithromycin. Difficulties with administration of treatment were reported by 36.3% of clarithromycin caregivers, compared with 7.8% of loracarbef caregivers (P < 0.001). A desire to stop treatment was reported by 23.8% of clarithromycin caregivers, compared with 7.8% of loracarbef caregivers (P < 0.001). Taste and texture issues were most frequently cited as reasons for nonacceptance.

Five-day dirithromycin therapy is as effective as seven-day erythromycin therapy for acute exacerbations of chronic bronchitis

In a meta-analysis of two identically designed, well-controlled, randomized, double-blind clinical trials, we compared 5 days of dirithromycin with 7 days of erythromycin for acute exacerbations of chronic bronchitis. Five hundred and thirty-one patients were randomized to receive dirithromycin (500 mg od) for 5 days and 526 patients were randomized to receive erythromycin (250 mg qid) for 7 days. Clinical and bacteriological responses were assessed 3-5 days after therapy and at termination from the study. Adverse events were collected from both groups and compared with each other, before and after treatment. Of the 690 patients clinically appraisable at the post-therapy visit, 298 (84.2%) dirithromycin-treated patients and 270 (80.4%) erythromycin-treated patients showed a favourable response. At termination, 273 (77.1%) dirithromycin-treated patients and 243 (72.3%) erythromycin-treated patients showed a favourable response. The microbiological cure was equivalent in the two groups (75% of dirithromycin-treated patients and 74.1% of erythromycin-treated patients showed a favourable response at termination). After therapy, dirithromycin was as effective as erythromycin in eradicating Streptococcus pneumoniae (77.8% vs 90.9%), Haemophilus influenzae (71.7% vs 72.2%), Moraxella catarrhalis (93.3% vs 88.9%) and Staphylococcus aureus (81.8% vs 82.1%). Although not statistically significant, fewer dirithromycin-treated patients reported adverse events than did erythromycin-treated patients. Nausea (6.8% vs 7.8%), headache (7.3% vs 8.2%) and diarrhoea (6.6% vs 9.5%) were the most frequently reported adverse events in both groups. In the treatment of acute exacerbations of chronic bronchitis, 5 days of dirithromycin is as effective as 7 days of erythromycin.

Use of predictive probabilities in phase II and phase III clinical trials

Predictive probability is particularly useful in aiding a decision-making process related to drug development. This is especially true for decisions occurring as the result of interim analyses of clinical trials. Examples of clinical trial applications of Bayesian predictive probability and the use of the beta-binomial distribution are described.

Comparison of cefaclor and cefuroxime axetil in the treatment of acute otitis media with effusion in children who failed amoxicillin therapy

This trial compared the efficacy and safety of a 10-day treatment course of cefaclor and cefuroxime axetil in the treatment of acute otitis media with effusion in children who failed therapy with amoxicillin. This was an investigator-blind, randomized, parallel treatment group study. To be included, patients must have received treatment with a standard clinical regimen of amoxicillin for at least 48 hours and not more than 10 days, with the last dose within 72 hours of randomization. Patients who met the entry criteria were randomly assigned to one of two antibiotic treatment groups. Cefaclor and cefuroxime axetil suspensions were administered twice daily for a total daily dose of 40 mg/kg and 30 mg/kg, respectively. Physical examination, pneumatic otoscopy and tympanogram were performed to evaluate efficacy to therapy. Therapeutic equivalence was established by ruling out a difference (cefaclor minus cefuroxime axetil) of 15% in percentages of clinical success (cure plus improvement). Safety evaluation was performed by assessment of clinical adverse events. In the intent-to-treat analysis post-therapy (1-6 days after completion of therapy), 96 of 104 (92.3%) cefaclor-treated patients had clinical success compared to 90 of 101 (89.1%) cefuroxime axetil patients. The 95% confidence limits on the difference between proportions of favorable outcomes (cefaclor minus cefuroxime axetil) was from -4.8% to +11.2%. At termination of the study (day 10-16 after completion of therapy), 86 of 104 (82.7%) cefaclor patients and 84 of 101 (83.2%) cefuroxime axetil patients had favorable clinical outcomes (95% confidence interval: -10.8% to +9.9%). Thirty-two (30.8%) of the 104 patients in the cefaclor treatment group reported at least one adverse event, with rhinitis reported in 9 (8.7%) patients and cough increased in 7 (6.7%) patients. Thirty-six (35.6%) of the 101 patients in the cefuroxime axetil treatment group reported at least one event, with diarrhea reported in 11 (10.9%) of patients and rhinitis in 10 (9.9%) patients. Cefaclor and cefuroxime axetil were equally effective in the treatment of patients with acute otitis media with effusion who had failed therapy with amoxicillin. Significantly fewer patients treated with cefaclor reported diarrhea, which is the most frequently reported adverse event in children treated with antibiotics for this disease.

US-guided puncture of the internal jugular vein: complications and anatomic considerations

PURPOSE

To examine success and complication rates for ultrasound (US)-guided cannulation of the internal jugular vein (IJV) in comparison with blind techniques and to present the variations in anatomy of the IJV.

MATERIALS AND METHODS

Data were prospectively collected for 869 cases of sonographically guided cannulation of the IJV. In all cases, the side of the puncture, procedural success or failure, and any immediate complications were recorded. In 764 (88%) cases, the number of passes required and whether a single- or double-wall puncture was used were recorded. In 690 (79%) cases, IJV diameter and depth were recorded, while its relationship to the common carotid artery (CCA) was noted in 659 (76%) cases.

RESULTS

Cannulation was successful in 868 (99.9%) cases. Complications occurred in 20 (2.3%) cases. Eighty-seven percent of cannulations were achieved with one pass and 83% with a single-wall puncture. Success at first pass was significantly correlated with right-sided puncture and the diameter of the IJV. In 5.5% of cases, the IJV lay medial to the CCA, making successful cannulation with use of the landmark technique unlikely.

CONCLUSIONS

US-guided cannulation of the IJV is superior to blind techniques, increasing the success rate and incidence of first pass cannulation and reducing the incidence of complications.

The effects on asthmatics of exposure to a conventional water-based and a volatile organic compound-free paint

The water-based paints now frequently used for house painting still contain small amounts of volatile organic compounds (VOCs), with the potential to exacerbate symptoms of asthma. Because of these potential problems and environmental concerns, some manufacturers have produced paints with no VOC content. We wished to compare the effects on asthmatics of conventional water-based paint and the new VOC-free paint. Seventeen asthmatics were recruited on the basis of having previously reported exacerbation of symptoms by paint or other odours. Each undertook a standard painting task with identically coloured conventional acrylic and VOC-free paints in a double-blind, crossover study. Respiratory symptoms, lung function, and airway responsiveness were measured at each visit. A significant increase in reported "wheeze" was detected during use of conventional paint (p<0.01), but not with the new paint. There was also a significantly greater increase in reported "breathlessness" whilst using conventional paint than with the new paint (p<0.05). In contrast, lung function measurements showed a small but significant increase during the use of both paints (p<0.05). There was no significant change in airway responsiveness after use of either paint. The new paint appears to be less likely to cause a worsening of respiratory symptoms than conventional acrylic paint, although this difference is not reflected in measurements of lung function or airway responsiveness. Although the benefit conferred in the majority of asthmatics is probably modest, there may be some patients with an increased sensitivity to paint odour, who would derive a useful symptomatic benefit from using the VOC-free paint.

The effects on asthmatics of exposure to a conventional water-based and a volatile organic compound-free paint

The water-based paints now frequently used for house painting still contain small amounts of volatile organic compounds (VOCs), with the potential to exacerbate symptoms of asthma. Because of these potential problems and environmental concerns, some manufacturers have produced paints with no VOC content. We wished to compare the effects on asthmatics of conventional water-based paint and the new VOC-free paint. Seventeen asthmatics were recruited on the basis of having previously reported exacerbation of symptoms by paint or other odours. Each undertook a standard painting task with identically coloured conventional acrylic and VOC-free paints in a double-blind, crossover study. Respiratory symptoms, lung function, and airway responsiveness were measured at each visit. A significant increase in reported "wheeze" was detected during use of conventional paint (p<0.01), but not with the new paint. There was also a significantly greater increase in reported "breathlessness" whilst using conventional paint than with the new paint (p<0.05). In contrast, lung function measurements showed a small but significant increase during the use of both paints (p<0.05). There was no significant change in airway responsiveness after use of either paint. The new paint appears to be less likely to cause a worsening of respiratory symptoms than conventional acrylic paint, although this difference is not reflected in measurements of lung function or airway responsiveness. Although the benefit conferred in the majority of asthmatics is probably modest, there may be some patients with an increased sensitivity to paint odour, who would derive a useful symptomatic benefit from using the VOC-free paint.

Rett syndrome studies of natural history and search for a genetic marker

The commonly held notion that Rett syndrome (RS) is a neurodegenerative disorder with normal early development was examined by an epidemiological survey and review of medical records and serial neurological and development evaluations. In some subjects, deviance from normal development was evident from the perinatal period, and gradually became more prominent with age. These findings are convincing when seen in conjunction with a reduction in velocity of brain growth, as early as 2-4 months of life, well before the recognition of gross neurological deficits. Neurodevelopmental evaluations provide no indication that there is progressive loss of adaptive behaviors, or communication skills to indicate a neurodegenerative process. Taken together with the known neuropathological and neurochemical changes in RS brain we hypothesize that RS is a neurodevelopmental disorder, which has a genetic basis, and affects subsets of neurons and their connections during a period of vigorous brain growth, when synapse formation and pruning are at a peak. Studies of mitochondrial (mt) DNA in brain to understand the genetic mechanisms underlying matrilineal inheritance in the few familial cases, and mt structural and enzyme deficiencies have been unrevealing to date.