Postoperative Adjacent Segment Disease in Minimally Invasive Transforaminal Lumbar Interbody Fusion with Adjacent Laminectomy for Grade I-II Spondylolisthesis and Adjacent Spinal Stenosis

BACKGROUND AND OBJECTIVES

Studies have demonstrated increased risk of adjacent segment disease (ASD) after open fusion with adjacent-level laminectomy, with rates ranging from 16%-47%, potentially related to disruption of the posterior ligamentous complex. Minimally invasive surgical (MIS) approaches may offer a more durable result. We report institutional outcomes of simultaneous MIS transforaminal lumbar interbody fusion (MISTLIF) and adjacent-level laminectomy for patients with low grade spondylolisthesis and ASD.

METHODS

Retrospective analysis was performed on patients who underwent MISTLIF with adjacent level laminectomy to treat grade I-II spondylolisthesis with adjacent stenosis at a single institution from 2007-2022.

RESULTS

A total of 34 patients met criteria, with mean follow-up of 23.1 months. In total, 37 levels were fused and 45 laminectomies performed. In this group, 21 patients received a single level laminectomy and single-level MISTLIF, 10 patients received a 2-level laminectomy and single-level MISTLIF, 2 patients received a single-level laminectomy and 2-level MISTLIF, and 1 patient received a 2-level laminectomy and 2-level MISTLIF. Three (8.8%) patients experienced clinically significant postoperative ASD requiring reoperation. Three other patients required reoperation for other reasons. Multiple logistic regression did not reveal any association between development of ASD and surgical covariates.

CONCLUSION

MISTLIF with adjacent-level laminectomy demonstrated a favorable safety profile with rates of postoperative ASD lower than published rates after open fusion and on par with the published rates of ASD from MISTLIF alone. Future prospective studies may better elucidate the durability of adjacent-level laminectomies when performed alongside MISTLIF, but retrospective data suggests it is safe and durable.

Initiating a Magnetic Resonance-Guided Focused Ultrasound Program: Comprehensive Workflow and Lessons Learned from the Initial 116 Cases

INTRODUCTION

Magnetic resonance-guided focused ultrasound (MRgFUS) represents an incisionless treatment option for essential or parkinsonian tremor. The incisionless nature of this procedure has garnered interest from both patients and providers. As such, an increasing number of centers are initiating new MRgFUS programs, necessitating development of unique workflows to optimize patient care and safety. Herein, we describe establishment of a multi-disciplinary team, workflow processes, and outcomes for a new MRgFUS program.

METHODS

This is a single-academic center retrospective review of 116 consecutive patients treated for hand tremor between 2020 and 2022. MRgFUS team members, treatment workflow, and treatment logistics were reviewed and categorized. Tremor severity and adverse events were evaluated at baseline, 3, 6, and 12 months post-MRgFUS with the Clinical Rating Scale for Tremor Part B (CRST-B). Trends in outcome and treatment parameters over time were assessed. Workflow and technical modifications were noted.

RESULTS

The procedure, workflow, and team members remained consistent throughout all treatments. Technique modifications were attempted to reduce adverse events. A significant reduction in CRST-B score was achieved at 3 months (84.5%), 6 months (79.8%), and 12 months (72.2%) post-procedure (p < 0.0001). The most common post-procedure adverse events in the acute period (<1 day) were gait imbalance (61.1%), fatigue and/or lethargy (25.0%), dysarthria (23.2%), headache (20.4%), and lip/hand paresthesia (13.9%). By 12 months, the majority of adverse events had resolved with a residual 17.8% reporting gait imbalance, 2.2% dysarthria, and 8.9% lip/hand paresthesia. No significant trends in treatment parameters were found.

CONCLUSIONS

We demonstrate the feasibility of establishing an MRgFUS program with a relatively rapid increase in evaluation and treatment of patients while maintaining high standards of safety and quality. While efficacious and durable, adverse events occur and can be permanent in MRgFUS.

Internal Neurolysis for the Treatment of Trigeminal Neuralgia: A Systematic Review

INTRODUCTION

Trigeminal neuralgia (TN) remains a challenging disease with debilitating symptoms and variable efficacy in terms of treatment options. Microvascular decompression (MVD) with internal neurolysis (IN) is an alternative treatment that might benefit patients but has limited understanding. We performed a systematic review of IN for the treatment of TN.

METHODS

Studies from 2000 to 2021 that had assessed IN for TN were aggregated and independently reviewed.

RESULTS

A total of 520 patients in 12 studies were identified, with 384 who had undergone IN (mean age, 53.8 years; range, 46-61.4 years; mean follow-up, 36.5 months). Preoperative symptoms had been present for ∼55.0 months before treatment, and pain was predominantly in V2 and V3 (26.8%), followed by other distributions. Of the patients, 83.7% (range, 72%-93.8%) had had an excellent to good outcome (Barrow Neurological Institute pain scale score [BNI-PS], I-II). The pain outcomes at 1 year were excellent for 58%-78.4%, good or better for 77%-93.75%, and fair or better for 80%-93.75% of the patients. On average, facial numbness after IN was experienced by 96% of the patients. However, at follow-up, facial numbness remained in only 1.75%-10%. Most of the remaining numbness was not significantly distressing to the patients. Subgroup comparisons of IN versus recurrent MVD, IN versus radiofrequency ablation, the effects of IN in the absence of vascular compression, and IN with and without MVD were also evaluated.

CONCLUSIONS

IN represents a promising surgical intervention for TN in the absence of vascular compression and for potential cases of recurrence. Complications were limited in general but require further study.

Prediction of hematoma expansion in spontaneous intracerebral hemorrhage: Our institutional experience

BACKGROUND

Spontaneous intracerebral hemorrhage (sICH) is a disease process with high morbidity and mortality. In particular, hematoma expansion (HE) is a feared complication of sICH. With 15-40% of patients experiencing HE, it has become increasingly important to predict which sICH will remain stable and which will expand.

OBJECTIVE

With new treatment options being developed, it is becoming increasingly important to be able to predict which hemorrhages are at high versus low risk for expansion. The authors of this study hope to reexamine variables associated with hematoma expansion in hopes of generating newer data on risk factors for expansion.

METHODS

A retrospective analysis identified 334 patients who presented with sICH. The primary outcome was HE on follow up head CT. HE was defined as a greater than 33% increase or an absolute increase in 6 mL or more in overall volume between the two sets of CT images. Analysis was performed using unpaired t-test, Chi-square, and Fisher's exact tests, as appropriate.

RESULTS

Of the 334 patients, 247 (74.0%) did not experience an expansion of their ICH while 87 (26.0%) did. Multivariable logistic regression was performed demonstrating ICH score of 3 or greater (4.76 (95% CI 2.60-8.72, p < 0.001) , cortical location of the sICH (1.77 (95% CI 1.03-3.04, p = 0.038), and presence of a fluid level (6.46 (95% CI 2.28-18.3, p < 0.001) as significant predictors of HE.

CONCLUSIONS

Our study found that fluid-fluid levels on non-contrast CT, an ICH score 3 or greater, and lobar sICH were all more likely to expand.

Cranial Settling Causing Intracranial Hemorrhage Through Violation of the Skull Base by Cervical Spine Instrumentation

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory polyarthropathy that affects many synovial joints favoring the hands, knees, and vertebral articulations. Joint laxity manifests as subaxial instability, atlantoaxial instability, and cranial settling (CS).

CASE DESCRIPTION

A 70-year-old woman with past medical history of RA, Hashimoto's thyroiditis, osteoporosis, history of C1-2 fusion for instability 15 years prior, with subsequent revision cervicothoracic fusion for degeneration, and trauma 2 years prior presents with new onset headache, nausea, and vomiting of 36-hour duration. Neurologic examination was only notable for mild right dysmetria. Workup revealed acute hemorrhage in the posterior fossa with migration of the right rod implant and screw tulip, as a result of CS. The patient underwent occipital-cervical fusion with removal of the migratory hardware.

CONCLUSIONS

Intracranial rod migration and hemorrhage secondary to CS is a rare complication that must be brought to the attention of surgeons operating on patients with RA.

Developing standardized titles to classify the adverse events in 7,418 cranial and spinal neurosurgical procedures

BACKGROUND

Neurosurgical procedures are life- and function-saving but carry a risk of adverse events (AE) which can cause permanent neurologic deficits. Unfortunately, there is lack of clearly defined AEs associated with given procedures, and their reporting is non-uniform and often arbitrary. However, with an increasing number of neurosurgical procedures performed, there is a need for standardization of AEs for systematic tracking. Such a system would establish a baseline for future quality improvement strategies.

OBJECTIVE

To review our institutional AEs and devise standardized titles specific to the spine, tumor, functional, and vascular neurosurgery divisions.

METHODS

A review of prospective monthly-reported morbidity and mortality (M&M) conference data within the Department of Neurological Surgery was conducted from January 2017 to December 2019. An AE was defined as any mortality, an "unintended and undesirable diagnostic or therapeutic event", "an event that prolongs the patient's hospital stay", or an outcome with permanent or transient neurologic deficit.

RESULTS

A total of 1096 AEs from 7418 total procedures (14.8 %) were identified. Of those, 418 (5.6 %) were in cerebrovascular, 249 (3.4 %) were in neuro-oncology and 429 (5.8 %) were in the spine & functional divisions. The most common AEs across all divisions were infection (17 %), hemorrhage (11 %) and cerebrospinal fluid (CSF) leak (7.8 %). Other AEs were indirectly related to the neurosurgical procedure, such as deep vein thrombosis or pulmonary embolism (2.7 %), or pneumothorax (0.3 %).

CONCLUSION

This work illustrates standardized AEs can be implemented universally across the spectrum of neurological surgery. Standardization can help identify recurring AE patterns through better tracking.

Internal Neurolysis with and without Microvascular Decompression for Trigeminal Neuralgia: Case Series

OBJECTIVE

Microvascular decompression (MVD) has remained the first-line surgical treatment of trigeminal neuralgia when an offending vessel can be identified that is causing neurovascular compression. However, patients without neurovascular compression can either develop trigeminal neuralgia or recurrence after MVD. In addition, patients with venous and less severe arterial compression have been shown to have reduced efficacy after MVD. Internal neurolysis is a surgical technique used to separate the fascicles of the trigeminal nerve and might be a good option for patients with trigeminal neuralgia but without vascular compression.

METHODS

A retrospective, institutional review board-approved medical record review was performed of adult patients with trigeminal neuralgia who had undergone internal neurolysis. The search resulted in 32 patients who had been treated from 2016 to 2019. The Barrow Neurological Institute (BNI) pain intensity scale and hypesthesia scale (HS) were used to determine the outcomes.

RESULTS

The average follow-up was 20 months (range, 3-40 months). The postoperative outcomes showed a BNI pain intensity scale score of I for 50%, with excellent control in 56%, successful control in 78%, adequate control in 94%, and poor control in 6%. Significantly more patients without previous treatment had had successful pain control (95% vs. 54%). Six patients (19%) experienced pain recurrence and were significantly more likely to experience pain recurrence compared with patients without a previous procedure (39% vs. 5%). The overall BNI-HS score postoperatively was I for 28%, II for 69%, and III for 3%.

CONCLUSIONS

Internal neurolysis with and without MVD has shown efficacy in treating trigeminal neuralgia in carefully selected patients.

Changes in the structure and ultrastructure of the intestine of Spadella cephaloptera (Chaetognatha) during feeding and starvation experiments

Ultrastructural changes in the intestinal epithelium of fed and starved specimens of Spadella cephaloptera are described. Animals were maintained in a circulating natural sea water system and fed with Artemia salina nauplii. After a period of acclimation, they were individually isolated, deprived of food for 24 h and submitted to controlled feeding experiments. The absorption develop in the intestinal absorptive cells (A-cells) 5 min after the ingestion of prey and consist in the formation of endocytotic vesicles and endosome-like vacuoles. During the following steps up to 10 h, a second type of digestive vacuole containing electron-dense material, and probably corresponding to a lysosome-like compartment, appears. Throughout this time, the vacuoles progressively arrange in columns, the youngest at the top and the oldest at the bottom of the A-cells. In addition, large lipid inclusions appear in the apical cytoplasm. The ultrastructural changes of the intestinal secretory cells (S-cells) is less marked, but the number of granules largely diminishes during the first 30 min after the ingestion of prey. In starved specimens, major changes in A-cells occur between the sixth and tenth day of starvation and consist in the increase of endosome-like vacuoles. Lysosome-like vacuoles containing dense material are not observed. At the same time, necrosis features are evident in S-cells. After 30 days of starvation, necrosis features are observed in the totality of the intestinal epithelium and the specimens die few days later.

Phase II trial of 2-chlorodeoxyadenosine in patients with relapsed/refractory acute myeloid leukemia: a study of the Eastern Cooperative Oncology Group (ECOG), E5995

2-Chlorodeoxyadenosine (2-CdA) is a purine analog which has anti-leukemic activity in phase II trials in pediatric acute myeloid leukemia (AML) patients. An adult phase I trial suggested possible similar activity although neurotoxicity at higher doses was seen. We conducted a phase II trial of 2-CdA in patients with relapsed or refractory AML. 2-CdA was administered by continuous intravenous infusion at a dose of 17 mg/m(2) per day x5 days. Patients not achieving aplasia by day 21 were eligible for a second course of therapy. Fifteen patients (nine relapsed and six refractory AML) were enrolled including seven men and eight women with a median age of 60 years and median ECOG PS of 1. There were five deaths on study due to infections (two), AML (two), or hepatic failure (one). The 2-CdA was well tolerated without severe nausea, vomiting or stomatitis (all <grade 2). No severe neurologic complications related to 2-CdA were seen. Grade 4 myelosuppression occurred in nearly all patients with prolonged periods of pancytopenia and BM hypoplasia seen in most. There were no complete responses, though bone marrow aplasia was achieved in eight patients. 2-CdA as a single agent, in the doses used in this study, is ineffective therapy for relapsed or refractory AML.

Tourette's syndrome in patients referred for allergy evaluation

BACKGROUND

Tourette's syndrome is a relatively common disorder that may present as a spectrum that can include both motor and behavioral features.

METHODS

We report four patients referred to allergists to rule out atopy as a reason fro their presumed respiratory symptoms who were subsequently found to have Tourette's syndrome. A review of the literature was also performed using Medline.

RESULTS

The symptoms of Tourette's syndrome may overlap those associated with allergy involving the respiratory tract. There is little published information on the association of Tourette's syndrome with atopy.

CONCLUSIONS

Allergists should be aware of Tourette's syndrome and the variable clinical spectrum of this disorder as Tourette's syndrome patients may be referred prior to the diagnosis of Tourette's syndrome.

Budesonide aqueous nasal spray and pressurized metered dose inhaler in the treatment of adult patients with seasonal allergic rhinitis

Budesonide, a topical corticosteroid used in the treatment of seasonal allergic rhinitis, can be administered to the nose as an aerosol via a pressurized metered dose inhaler (pMDI) or as a metered nasal pump spray. Studies have shown that about 64% (256 micrograms) of a nominal dose of 400 micrograms budesonide pMDI preparation is delivered to the patient compared with 100% of the nominal dose of the pump spray. The present study was undertaken to assess the efficacy and safety of budesonide delivered via a nasal pMDI twice daily (Rhinocort pMDI, at 400 micrograms/day) with an aqueous suspension of budesonide delivered via a metered nasal pump spray once daily (Rhinocort Aqua, at 256 micrograms/day or 400 micrograms/day). The multicenter, double-blind, randomized, placebo-controlled, parallel-group study was conducted in 318 patients (154 men, 164 women; aged 12-67 years) with ragweed-induced seasonal allergic rhinitis. A 1-week baseline period was followed by a 3-week treatment. Nasal symptoms were recorded by the patients, adverse events were noted, an overall evaluation of treatment efficacy was made, and urine cortisol and creatinine levels were measured. Substantial or total control of symptoms was achieved in 83.8% of patients treated with 256 micrograms of aqueous budesonide, 76.3% with 400 micrograms of aqueous budesonide, and 80.8% with 400 micrograms of budesonide pMDI; these were all significantly different (p < 0.001) compared with placebo (23.4% of patients). There were no significant differences in the 24-hour urine cortisol levels between the groups and there were few, infrequent adverse events, similar between the groups and resolved completely on discontinuation of treatment. It was concluded that budesonide, given once daily as 256 micrograms or 400 micrograms in an aqueous suspension or twice daily as 400 micrograms in a pMDI provides good alleviation of the symptoms of seasonal allergic rhinitis with no significant risk of suppression of urine cortisol.

Once daily mometasone furoate aqueous nasal spray is as effective as twice daily beclomethasone dipropionate for treating perennial allergic rhinitis patients

BACKGROUND

Perennial allergic rhinitis is chronic and persistent, may lead to a constellation of secondary complaints including sinusitis, mouth-breathing, and some symptoms resembling a permanent cold, and often requires constant medical intervention. Well-tolerated nasal corticosteroids, alone or in combination with antihistamines, have been found to be very effective in treating this condition.

OBJECTIVE

To compare the effectiveness and tolerability of mometasone furoate aqueous suspension, a new once daily nasal spray, to placebo vehicle and to beclomethasone dipropionate, administered twice daily, in patients with perennial allergic rhinitis.

METHODS

This was a randomized, double-blind, placebo-controlled, double-dummy, parallel group study, in 427 patients age 12 years and older at 24 centers in Canada and Europe. Patients allergic to at least one perennial allergen, confirmed by medical history, skin testing, and adequate symptomatology were eligible to receive one of the following regimens for 3 months: mometasone furoate, 200 micrograms only daily; beclomethasone dipropionate, 200 micrograms twice daily (400 micrograms total dose); or placebo vehicle control. The primary efficacy variable was the change from baseline in total AM plus PM diary nasal symptom score over the first 15 days of treatment.

RESULTS

Three hundred eighty-seven patients were valid for efficacy. For the primary efficacy variable, mometasone furoate was significantly (P < or = .01) more effective than placebo and was indistinguishable from beclomethasone dipropionate. Similar trends were seen among individual symptoms, physician symptom evaluations, and therapeutic response. There was no evidence of tachyphylaxis. All treatments were well tolerated.

CONCLUSIONS

Mometasone furoate nasal spray adequately controls symptoms of perennial allergic rhinitis, offers the advantage of once daily treatment, and is well tolerated.

Decoupling spatial and temporal processes for clinical analyzers

The separation of time and space in processing a sample greatly simplifies the design of automation for clinical testing. The efficient spatial arrangement of analytical units and sample manipulators has become a more complex task because of the degree of automation required on today's state-of-the-art analyzer. Minimization of sample volume and the reduction of overall analyzer size further complicate the design problem. We report the development of a proprietary method of decoupling the temporal and spatial elements required for analysis of samples. This process is based on number theory and can be used to optimize the distance between the physical processing stations while allowing these same stations to operate on samples over a substantial range of times. The technique is versatile and can also be used when it is desirable to sequentially move groups of items from location to location.

Decoupling spatial and temporal processes for clinical analyzers

The separation of time and space in processing a sample greatly simplifies the design of automation for clinical testing. The efficient spatial arrangement of analytical units and sample manipulators has become a more complex task because of the degree of automation required on today's state-of-the-art analyzer. Minimization of sample volume and the reduction of overall analyzer size further complicate the design problem. We report the development of a proprietary method of decoupling the temporal and spatial elements required for analysis of samples. This process is based on number theory and can be used to optimize the distance between the physical processing stations while allowing these same stations to operate on samples over a substantial range of times. The technique is versatile and can also be used when it is desirable to sequentially move groups of items from location to location.

Comparative study of SCH 434 and CTM-D in the treatment of seasonal allergic rhinitis

The efficacy and safety of an extended-release combination of loratadine plus pseudoephedrine sulfate (SCH 434) was compared with that of a tablet containing chlorpheniramine maleate plus pseudoephedrine sulfate (CTM-D) in 131 patients with symptomatic seasonal allergic rhinitis. Patients were randomly assigned to receive either SCH 434 (loratadine 5 mg and pseudoephedrine sulfate 120 mg) or CTM-D (chlorpheniramine maleate 12 mg and pseudoephedrine sulfate 120 mg) twice daily for 2 weeks. Evaluations were made after 3, 7, and 14 days of treatment. Demographics (age, race, sex, and duration of seasonal allergic rhinitis) and baseline total symptom scores were comparable between groups. Both combination products were effective in relieving the symptoms of allergic rhinitis. Improvement in total symptom scores was 54% on day 3 and 65% on day 14 in the SCH 434 group versus 57% on day 3 and 64% on day 14 in the CTM-D group. Individual symptom scores (nasal discharge, stuffiness, nasal itching, sneezing, and ocular symptoms) responded similarly. A smaller proportion of patients in the SCH 434 group reported side effects, especially dry mouth (7% vs 19%, P = 0.07), fatigue (6% vs 25%, P < 0.01), and sedation (7% vs 22%, P < 0.03). In conclusion, the combination of loratadine plus pseudoephedrine sulfate was equally as effective as a classic antihistamine (chlorpheniramine maleate) plus pseudoephedrine sulfate but had a lower incidence of side effects.

A VM 26-based regimen for patients with previously untreated non-Hodgkin lymphoma. Prolonged disease-free survival in patients younger than 60 years of age: a phase II trial of the eastern Cooperative Oncology Group

BACKGROUND

The epidophyllotoxin VM 26 has been shown to have single-agent activity in patients with diffuse aggressive lymphoma. In an attempt to determine its activity in combination with other agents known to be effective in lymphoma, a Phase II trial of a novel chemotherapy regimen was conducted.

METHODS

Forty-two patients with Stages II, III, and IV diffuse aggressive lymphoma were treated with teniposide, doxorubicin, prednisone, cyclophosphamide, vincristine, and bleomycin (PA Ten-CPOB) as part of a Phase II trial of the Eastern Cooperative Oncology Group. Fifty-five percent of patients had Stage IV disease, 21% Stage III, and 24% Stage II.

RESULTS

The overall complete response rate was 64%. Of the 27 patients who had complete response, 19 (70% [45% of the entire group]) are still alive without disease (median follow-up, 5.7 years). No patient had a follow-up time of less than 5 years. On examination of factors that were predictive of survival and relapse, it was found that age younger than 60 years was predictive of long-term survival, as 76% of patients younger than 60 years of age were alive without disease. Forty patients were evaluable for toxicity. There were four (10%) early deaths, and six patients (15%) had Grade 4 hematologic toxicity.

CONCLUSIONS

This alternating combination chemotherapy regimen (PA Ten-CPOB) results in a complete response rate comparable to what has been reported previously in the literature, but 45% of patients in this series demonstrated long-term disease-free survival. When patients younger than 60 years of age with follow-up times of at least 5 years were considered, disease-free survival was 76%.

Comparison of chlorambucil and prednisone versus cyclophosphamide, vincristine, and prednisone as initial treatment for chronic lymphocytic leukemia: long-term follow-up of an Eastern Cooperative Oncology Group randomized clinical trial

The Eastern Cooperative Oncology Group (ECOG) conducted a study in which patients with advanced chronic lymphocytic leukemia (CLL) were randomized between a regimen consisting of chlorambucil (30 mg/m2 orally day 1) and prednisone (80 mg orally days 1 to 5) (C + P) administered every 2 weeks and a more intensive regimen of cyclosphosphamide (300 mg/m2 orally days 1 to 5), vincristine (1.4 mg/m2 intravenously [IV] day 1), and prednisone (100 mg/m2 orally days 1 to 5) (CVP) given every 3 weeks. Treatment was continued for up to 18 months to maximal response. Of the 122 eligible patients, 60 received C + P, while 62 received CVP. With a median follow-up of 7 years, there were no significant differences in survival (4.8 v 3.9 years, P = .12), complete remission (CR) rate (25% v 23%; P = .83), or duration of response (2.0 v 1.9 years; P = .78) between C + P and CVP. Toxicity was modest despite the prolonged treatment. The long median survival of 4.1 years for stage III and IV patients is superior to that usually reported. This could stem from continuing treatment to maximal response rather than an increase in intensity of therapy. These results are comparable to those reported with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) therapy by other investigators. The data suggest that intermittent C + P administered to maximal response continues to be the standard treatment approach for advanced CLL.

A double-blind, placebo-controlled trial of fluvoxamine versus imipramine in outpatients with major depression

The authors employed a double-blind, placebo-controlled design to investigate the effectiveness of fluvoxamine versus imipramine in 54 outpatients with moderate major depression. Fluvoxamine proved superior to placebo but not to imipramine on the Hamilton Rating Scale for Depression and the Montgomery and Asberg Depression Rating Scale. Nausea and hyperarousal were the most common side effects in the fluvoxamine-treated patients.

A comparison of oral procaterol and albuterol in reversible airflow obstruction

The efficacy and safety of orally administered procaterol hydrochloride, a potent beta 2-adrenergic bronchodilator, was compared with that of albuterol in an eight-center, double-blind study conducted in 223 patients with mild to moderate, reversible bronchial airway obstruction. After a 1-wk placebo washout period, patients were administered either procaterol 0.05 mg twice daily for 2 wk followed by 0.10 mg twice daily for 10 wk or albuterol 2 mg three times a day for 2 wk followed by 4 mg three times a day for 10 wk. Spirometry determinations 1.5 h postdose showed consistently greater percent improvements from predose in FVC, FEV1, and FEF25-75 with procaterol than with albuterol at Weeks 1, 2, 4, 8, and 12. Treatment differences were statistically significant (alpha = 0.05) after 2 wk, 2 months, and 3 months of treatment. Bronchodilatation was evident 0.5 h after dosing and peaked at 1.5 to 3 h postdose for both treatments. The duration of action (i.e., time until spirometry determinations were lower than those at 0.5 h postdose) was at least 5 h after procaterol but only 3 h after albuterol. There was no evidence of tolerance with continued procaterol treatment, whereas a diminished duration of response to albuterol was observed with long-term treatment. Tremor was reported statistically more frequently in patients receiving procaterol than in those receiving albuterol (alpha = 0.05); the frequencies of other adverse events were similar for the two groups. No statistically significant treatment differences were noted for asthma symptoms, global evaluations, ECG results, vital signs, or clinical laboratory measurements.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative tolerability of two formulations of Rhinalar (flunisolide) nasal spray in patients with seasonal allergic rhinitis

This double-blind, randomized, crossover study compared the incidence of nasal burning and stinging, as well as overall tolerability of the currently marketed formulation of Rhinalar (original formulation) to a new formulation of Rhinalar containing less propylene glycol. In addition, patient and investigator subjective evaluations were used to compare the effectiveness of the test medications in controlling the nasal symptoms of seasonal allergic rhinitis. A total of 122 patients were enrolled in this 4-week trial. Each patient received one formulation of Rhinalar for 2 weeks and then crossed over to receive the alternate formulation for an additional 2 weeks. Eighteen patients withdrew from the trial prematurely. Ten patients were lost to follow-up and eight withdrew due to side effects and/or inadequate therapeutic response. Statistical comparisons of patient evaluations of nasal burning and stinging with the two formulations of Rhinalar showed a very significant difference in terms of severity (P less than .001), duration (P less than .001), and tolerability (P = .006) in favour of the new formulation. A reduction in severity of throat irritation with the new formulation was also shown to be statistically significant (P = .006). Nausea, headache, and other side effects including watery eyes, taste perversion, and runny nose were seldom reported with either test medication. Both formulations were shown to be equally effective in relieving the nasal symptoms of seasonal allergic rhinitis. The considerable reduction in nasal burning and stinging and throat irritation with the new formulation of Rhinalar was shown to enhance patient acceptability and may lead to better compliance.

Symptom utilization in strategic therapy

Five techniques of symptom utilization have been presented in an interactional strategic approach. They are: utilization of peers, utilization of the desire to grow up, utilization of personal ambition and future expectations, utilization of an antagonistic relationship, and utilization of sibling rivalry. Emphasis is placed on helping the therapist develop a way of thinking to approach difficult problems.

Clinical trials designed to evaluate therapeutic preferences

We present an experimental design for the evaluation of therapeutic preferences among well established similar modes of therapy. The measure of the degree of preference is based on clinical decisions to continue or discontinue the current treatment at each patient visit. Such a trial simulates decision-making in ordinary clinical practice, while adhering to the scientific principles of experimental design, and it alleviates some of the ethical problems inherent in randomized allocation of a treatment for a period of fixed length in conventional control trials. We discuss the design and methods of analysis and illustrate their application with data from a trial comparing three alternative drug treatments for chronic asthma. Such clinical trials provide a mechanism for examining concordance between the relative efficacy of treatments predicted from conventional controlled clinical trials and their ultimate performance in ordinary clinical practice, expressed in terms of therapeutic preferences.

[Oogenesis in Centropages typicus (Copepoda, Calanoida)]

We carried out a complete study of oogenesis in Centropages typicus using structural, ultrastructural and cytochemical data. The usual stages of oogenesis, i.e. germinative phase, premeiosis, primary and secondary vitellogenesis, were found. The latter two stages were the most typical. Primary vitellogenesis consisted of endogenous yolk accumulations; these substances, probably of lipoprotein or lipoglycoprotein nature, were produced at the granular endoplasmic reticulum level and then stocked in the reticulum cavities. During secondary vitellogenesis, endogenous yolk production continued, but we mainly observed the development of exogenous yolk accumulation (lipid droplets and protein globules) in the ooplasm. These accumulations resulted from the fusion of very numerous pinocytotic vesicles arising from the oolemma and containing substances probably brought to the oocytes by the hemolymph. The effect of various proteases on the vitellus globules caused a more or less marked digestion of their contents, tending to prove their protein nature. The end of vitellogenesis was marked by the appearance of vacuolar formations with dense lamellae which could correspond to cortical granules.

Usefulness of the serum ferritin concentration in the detection of iron deficiency in a general hospital

The efficacy of measuring the transferrin saturation and the serum ferritin concentration to detect iron deficiency was determined under routine conditions in a general hospital. The tests were performed on 100 adult patients who consecutively underwent bone marrow aspiration for the appraisal of a wide range of clinical conditions. The absence of stainable reticuloendothelial iron in smears of the aspirate was used as the benchmark of iron deficiency. Of the 86 patients who were anemic 19 lacked hemosiderin in the bone marrow. The percentage of patients with iron deficiency who were correctly classified by the tests (i.e., the tests' sensitivity) was 84% for the transferrin saturation and 79% for the serum ferritin concentration, and the percentage of patients free of iron deficiency who were correctly classified by the tests (i.e., the tests' specificity) was 63% and 96% respectively. The predictive value of an abnormal (positive) result for the detection of iron deficiency was 39% for the transferrin saturation and 83% for the serum ferritin concentration, whereas the predictive value of a normal or high (negative) result for the exclusion of iron deficiency was 93% and 94% respectively. Measurement of the serum ferritin concentration was superior to measurement of the transferrin saturation only in its specificity. The former is of particular value in clinical settings where the prevalence of iron deficiency is low and conditions that increase the serum ferritin concentration out of proportion to the size of the body iron stores are infrequent.

Studies on the midgut of Centropages typicus (copepod, calanoid). I. Structural and Ultrastructural Data

From a structural study of the midgut of Centropages typicus, three main zones presenting different cellular associations may be defined. The ultrastructural study carried out allows us to distinguish several cell types. The four principal cell categories (E, R, F and B) show a more or less marked resemblance with those identified in the Malacostraceans, especially in the hepatopancreas of Decapods. The three types R, F and B, which are subdivided according to their localization (R and R') or their developing stages (F1, F2; B1 to B5), are recognized by the following characteristics: R-cells with smooth endoplasmic reticulum and high microvilli (zones I and III); F-cells with rough endoplasmic reticulum and short or spherical microvilli (zones I and II); B-cells with a large vacuolar apparatus made up of lysosome-like dense bodies associated with vacuoles originating from pinocytosis (zone II). From the comparisons of morphological, ultrastructural and histochemical results concerning Centropages typicus with author's data, we propose and discuss these functions for the three principal cell types: synthesis and secretion of pre-digestive enzymes (F1 and F2-cells); enzyme synthesis, intracellular digestion and extrusion (B1 to B5-cells); absorption (R and R'-cells).

Quantitative osmotic fragility and disease states: a preliminary study

The Kalmedic D-3 Fragiligraph was used to obtain both cumulative and derivative osmotic fragility data. Several instrumental modifications and several procedural changes combined to make the data more reproducible and more easily obtained. An analytical expression employing but two parameters was found to give excellent fits for the cumulative data, and when differentiated, reproduced the experimental derivative data equally well. The curve fitting procedure used is given in detail. Data obtained on a limited number of subjects with beta-thalassemia or multiple sclerosis are presented. The interpretation of these data by techniques common to the literature is compared with the procedure developed in this paper.