Meta-analysis of increased dose of inhaled steroid or addition of salmeterol in symptomatic asthma (MIASMA)

OBJECTIVE

To examine the benefits of adding salmeterol compared with increasing dose of inhaled corticosteroids.

DESIGN

Systematic review of randomised, double blind clinical trials. Independent data extraction and validation with summary data from study reports and manuscripts. Fixed and random effects analyses.

SETTING

EMBASE, Medline, and GlaxoWellcome internal clinical study registers.

MAIN OUTCOME MEASURES

Efficacy and exacerbations.

RESULTS

Among 2055 trials of treatment with salmeterol, there were nine parallel group trials of >/=12 weeks with 3685 symptomatic patients aged >/=12 years taking inhaled steroid in primary or secondary care. Compared with response to increased steroids, in patients receiving salmeterol morning peak expiratory flow was greater at three months (difference 22.4 (95% confidence interval 15.0 to 30.0) litre/min, P<0.001) and six months (27.7 (19.0 to 36.4) litre/min, P<0.001). Forced expiratory volume in one second (FEV(1)) was also increased at three months (0.10 (0.04 to 0.16) litres, P<0.001) and six months (0.08 (0.02 to 0.14) litres, P<0.01), as were mean percentage of days and nights without symptoms (three months: days-12% (9% to 15%), nights-5% (3% to 7%); six months: days-15% (12% to 18%), nights-5% (3% to 7%); all P<0.001) and mean percentage of days and nights without need for rescue treatment (three months: days-17% (14% to 20%), nights-9% (7% to 11%); six months: days-20% (17 to 23%), nights-8% (6% to 11%); all P<0.001). Fewer patients experienced any exacerbation with salmeterol (difference 2.73% (0.43% to 5.04%), P=0. 02), and the proportion of patients with moderate or severe exacerbations was also lower (2.42% (0.24% to 4.60%), P=0.03).

CONCLUSIONS

Addition of salmeterol in symptomatic patients aged 12 and over on low to moderate doses of inhaled steroid gives improved lung function and increased number of days and nights without symptoms or need for rescue treatment with no increase in exacerbations of any severity.

Changes in the glutathione status of plasma, liver and muscle following exhaustive exercise in rats

Our results show that following physical exercise to exhaustion, the levels of reduced glutathione are increased in the plasma, but decreased in both the liver and skeletal muscle of rats. Levels of glutathione disulfide are increased in all 3 tissues. Our results are consistent with a mechanism in which the liver may be dumping reduced glutathione into the plasma in an attempt to deliver it to those tissues that need it the most: in this case, skeletal muscle.

Recovery of drug-resistant influenza A virus during therapeutic use of rimantadine

The therapeutic activity of rimantadine and its relationship to the shedding of drug-resistant influenza A virus were assessed in two randomized, double-blind, placebo-controlled trials involving patients with laboratory-documented influenza A virus (H3N2 subtype) illness of 2 days' duration or less. In a family-based study, rimantadine treatment for 10 days (24 children and adults) was associated with significant decreases in the number of days to a 50% reduction in symptoms (mean difference, 2.5 days), days of fever (1.6 days), and days of restricted activity (1.5 days) compared with the results obtained with placebo-treated patients (32 children and adults). Drug-resistant virus was recovered from eight (33%) of the rimantadine recipients on day 5. No differences in patient demographics or illness severity at the time of enrollment in the study were apparent between those who shed resistant virus and those who did not. Illness resolution tended to be slower in those who shed resistant virus compared with that in those who did not. In a study of adults treated for 5 days (six treated with rimantadine, six treated with placebo), resistant virus was recovered in three rimantadine recipients by day 3 of treatment. The results indicate that drug-resistant influenza A virus (H3N2) can be recovered from rimantadine-treated children and adults as early as 2 days after starting treatment, but that rimantadine retains a net therapeutic benefit compared with that of placebo.

Further validation of the BILAG disease activity index in patients with systemic lupus erythematosus

OBJECTIVE

To examine the association among the BILAG disease activity index components and their relations with global assessments, health status, and laboratory tests with regard to the validity of the BILAG index.

METHODS

A cross sectional study of consecutive patients with systemic lupus erythematosus (SLE) attending a specialist lupus outpatient clinic between July 1994 and February 1995. The internal consistency of the British Isles Lupus Assessment Group (BILAG) index-a disease activity assessment system for SLE patients, based on the principle of the physician's intention to treat-was examined using Cronbach's coefficient alpha. The association of the components of the BILAG index with health status as measured with the MOS Short Form 20 (SF-20), with patients' and doctors' global assessments of patient wellbeing and with laboratory tests was analysed with Spearman rank correlations.

RESULTS

133 female and eight male patients, age 20.1 to 88.7 years (mean 41.1, SD 12.5), were included. With few exceptions, the components of the BILAG index which reflect disease activity in different organ systems were not associated with each other. With the exception of the mucocutaneous component, we found a significant relation between all components of BILAG and global assessment of patient wellbeing, health status, erythrocyte sedimentation rate, or serum C3 level.

CONCLUSIONS

The study confirms the validity of all but the mucocutaneous component of the BILAG index. However, disease activity in different organ systems in SLE does not follow a common pattern. Thus the individual BILAG components should be used rather than the total BILAG score as a primary endpoint in clinical and epidemiological studies. To capture the total effect of SLE on an individual measures of disease activity, damage, and health status are all needed.

Severe depletion in liver glutathione during physical exercise

Physical exercise at submaximal levels in rats results in a progressive depletion of liver glutathione to about 20% of the levels found in sedentary controls which persists for several hours following the cessation of exercise. Skeletal muscle appears to be spared this severe depletion phenomenon. The levels of plasma glutathione show a transient increase at the beginning of the exercise bout followed by a linear decrease with increased running time of the animals. These results may be particularly relevant when attempting to understand the effects of physical exercise on a large number of cellular and organismal functions that are known or suspected to depend critically on the glutathione status of the liver.

Costs and cost effectiveness of cardiovascular screening and intervention: the British family heart study

OBJECTIVE

To measure costs and cost effectiveness of the British family heart study cardiovascular screening and intervention programme.

DESIGN

Cost effectiveness analysis of randomised controlled trial. Clinical and resource use data taken from trial and unit cost data from external estimates.

SETTING

13 general practices across Britain.

SUBJECTS

4185 men aged 40-59 and their 2827 partners.

INTERVENTION

Nurse led programme using a family centered approach, with follow up according to degree of risk.

MAIN OUTCOME MEASURES

Cost of the programme it self; overall short term cost to NHS; cost per 1% reduction in coronary risk at one year.

RESULTS

Estimated cost of putting the programme into practice for one year was 63 pounds per person (95% confidence interval 60 pounds to 65 pounds). The overall short term cost to the health service was 77 pounds per man (29 pounds to 124 pounds) but only 13 pounds per woman (-48 pounds to 74 pounds), owing to differences in utilisation of other health service resources. The cost per 1% reduction in risk was 5.08 pounds per man (5.92 pounds including broader health service costs) and 5.78 pounds per woman (1.28 pounds taking into account wider health service savings).

CONCLUSIONS

The direct cost of the programme to a four partner practice of 7500 patients would be approximately 58,000 pounds. Annually, 8300 pounds would currently be paid to a practice of this size working to the maximum target on the health promotion bands, plus any additional reimbursement of practice staff salaries for which the practice qualified. The broader short term costs to the NHS may augment these costs for men but offset them considerably for women.

The fall and rise of Andean cutaneous leishmaniasis: transient impact of the DDT campaign in Peru

A retrospective analysis was carried out on census data collected from house-to-house surveys during 1991-1992 in 4 areas endemic for Andean cutaneous leishmaniasis (uta) in the Department of Lima, Peru. Major changes in mean annual incidence in susceptible persons have taken place in these sites during the last 60 years. In particular, there is strong support for the hypothesis that, from the 1950s to the 1970s, the transmission rate was temporarily suppressed, largely as a by-product of the DDT house spraying campaign against malaria. These results are consistent with (i) anecdotal evidence, contemporary with the spraying campaign, and (ii) the official Ministry of Health records for the annual number of uta cases in the Departments of Lima and Ancash.

Cigarette smoking, polyunsaturated fats, and coronary heart disease

The relation between smoking habit and diet was investigated in 910 men and women. Diet was assessed by a self-administered food frequency questionnaire. After adjustment for age, sex, and occupational group, smokers had a substantially higher saturated fat (SFA) intake and much lower polyunsaturated fat (PUFA), principally due to a lower linoleic acid (LA) intake, resulting in a lower P:S ratio compared with never smokers, and these dietary differences remained after adjustment for alcohol consumption, BMI, and energy intake. Smokers also had different food choices obtaining more PUFA from saturated fat products such as dairy foods, lard, and ordinary margarine, and less from concentrated sources such as PUFA margarines and vegetable oils than nonsmokers. The food choices of cigarette smokers leading to a higher SFA and lower PUFA intakes may partly explain their increased risk of coronary heart disease.

Effect of non-attenders on the potential of a primary care programme to reduce cardiovascular risk in the population. Family Heart Study Group

OBJECTIVES

To determine the feasibility of enrolling non-attenders of a population based cardiovascular risk reduction programme (the British family heart study) into a further, similar programme and to assess the effect of non-attendance on the effectiveness of the programme.

DESIGN

Follow up of non-attenders by practice nurses, including home visits if necessary, to administer questionnaires and obtain physiological measurements.

SETTING

Eight general practices across England, Scotland, and Wales.

SUBJECTS

Non-attenders in a cardiovascular risk factor screening and intervention programme compared with attenders.

MAIN OUTCOME MEASURES

Number of non-attenders enrolled; sociodemographic characteristics; personal and family history of coronary heart disease; cardiovascular risk factors; and total coronary risk score.

RESULTS

Data were collected from 106 (17%) of the 608 non-attending families (99 men and 42 women). Of the 543 non-attending families from five practices that attempted complete follow up, 256 had moved away or died. Only 76 were eventually enrolled into the study. The prevalence of coronary heart disease and a family history of coronary heart disease were similar among non-attenders and attenders as were the individual coronary risk factors studied except smoking. Women non-attenders were more likely to be current cigarette smokers than attenders (15/42 v 202/948, P = 0.02).

CONCLUSIONS

The intensive follow up of non-attenders resulted in real intervention opportunities in only a small number. Since the effect of any intervention in a population is reduced by non-attendance audit of preventive medical programmes aimed at the population should allow for the effect of non-attenders on the overall results.

The relationship between CDC light-trap and human-bait catches of endophagic sandflies (Diptera: Psychodidae) in the Peruvian Andes

A study was carried out in the Peruvian Andes to test the suitability of CDC light traps for monitoring changes in the human-landing rate of endophagic phlebotomine sandflies, following house-spraying with pyrethroid insecticide. On four pairs of consecutive nights, sandflies were caught inside eight sprayed and eight unsprayed houses, either by human bait or by CDC light traps. The sandflies collected were Lutzomyia verrucarum (97%) and Lu.peruensis (3%), both probable vectors of Leishmania peruviana, and the species composition was unaffected by house-spraying. A non-linear relationship was detected between light-trap and human-bait catches, but the relationship did not diverge significantly from linearity within the range of sandfly abundance found in most houses in the endemic area (i.e. between 3 and 200 sandflies/house-night), and did not differ significantly between sprayed and unsprayed houses. However, light trap catches had a significantly lower proportion of blood-fed females in sprayed than in unsprayed houses, probably due to an insecticidal effect on post-blood-feeding behaviour. The proportion of Lu. verrucarum was significantly higher in light trap than in human bait catches, indicating that Lu.peruensis is either more anthropophilic or less phototropic than Lu.verrucarum.

Clinical effectiveness on an acute in-patient psychiatric unit

The paper outlines a model for addressing clinical effectiveness, and an illustration of how this is practically implemented through team working in a multidisciplinary in-patient environment. This is particularly relevant given the number of recent reports that highlight the need to develop and invest in the in-patient services. The difficulty in implementing evidence-based practice for mental health interventions is also addressed and initiatives being developed to enable a realistic approach in such an environment are described. The paper describes a structure and a process, using examples from audit, research and other initiatives particular to the unit, in providing accessible evidence based interventions for ward based staff, and improved clinical effectiveness generally.

Frequency and recency effects on response biasing in a pseudo-perceptual task

The pseudo-recognition technique provides an ingenious method of evaluating the influence of response biasing variables. This study tests the effects of recency on low and medium frequency words using the pseudo-recognition procedure. It was found that under short recency conditions the thresholds of medium and low frequency words did not differ, while under longer recency conditions the low frequency words had significantly lower thresholds than medium frequency words.

Notas acerca de xenófitos detectados en Cataluña, España

Estas notas incluyen seis especies, entre ellas tres gramíneas: Axonopus compressus, Dactyloctenium aegyptium y Megathyrsus maximus, la crucífera Lepidium densiflorum, la pequeña compuesta anual Soliva sessilis y la trepadora Aristolochia sempervirens (Aristolochiaceae), todas ellas presentes en o alrededor de la ciudad de Barcelona, Cataluña (nordeste de España). Forman parte de la creciente flora alóctona de la región. Algunas han sido citadas con anterioridad en la península, pero son novedades para Cataluña, mientras que otras parecen constituir nuevas citas para la Península Ibérica.

Especies del grupo Intravaginal de <em>Festuca</em> L. sección <em>Festuca</em> en los pisos basal y montano del nordeste de la Península Ibérica

Diferentes especies de Festuca morfológicamente afines crecen en gran parte del territorio objeto de esta reseña (tierras mediterráneas del nordeste de la Península Ibérica), a baja y mediana altitud. Excluyendo las especies de alta montaña, estas poblaciones se han estudiado aquí haciendo hincapié en Festuca grupo inops (F. gracilior), y se han tratado otras especies (F. lemanii en especial) que a veces complican la identificación de los miembros de dicho grupo, sobre todo cuando solapan sus distribuciones. Se comenta la aplicación del binomen F. inops De Not. a algunas poblaciones ibéricas del grupo F. inops. Nuevas citas de F. tarraconensis, F. occitanica, F. michaelis y F. heteroidea amplían la distribución de estos taxones dentro de la Península Ibérica.

<em>Youngia japonica</em> (L.) DC. (Compositae), recently detected in Barcelona

Se cita por vez primera en la península ibérica Youngia japonica, recientemente introducida en una zona ajardinada de Barcelona. Desde la primera observación la especie ha permanecido en el mismo lugar sin expandirse, pero reapareciendo los años posteriores. Se sugiere su posible introducción como contaminante de semillas o plantas de Zoysia, utilizada como alternativa de los céspedes de grama.

Antiphospholipid antibodies, haemostatic variables and thrombosis--a survey of 144 patients

Several clotting abnormalities have been put forth to explain the thrombotic tendency of the antiphospholipid syndrome, but a possible role for fibrinogen and von Willebrand factor has been poorly investigated. The present cross-sectional retrospective study evaluated the relationship of IgG anticardiolipin antibodies, lupus anticoagulants, fibrinogen and von Willebrand factor with the occurrence of arterial and venous thromboses in patients with antiphospholipid antibodies. Among the clotting assays for the detection of lupus anticoagulant, dilute Russell's viper venom time correlated with a history of venous thrombosis more strongly than activated partial thromboplastin time (p < 0.0002 vs p < 0.009) and was the only test which correlated with a history of arterial thrombosis (p < 0.01), also at low levels of IgG anticardiolipin antibodies (p = 0.003). By regression analysis, and after correction for confounders, serum levels of IgG anticardiolipin antibodies were found to be positively associated with the number of venous events (p < 0.001). Plasma levels of fibrinogen and von Willebrand factor were associated with each other (p < 0.0001; r: 0.48) and with the occurrence of arterial and venous thromboses (p < 0.001). Moreover, plasma levels of fibrinogen and von Willebrand factor in thrombotic patients with antiphospholipid antibodies were significantly higher than those of a control group of thrombotic patients who suffered thrombosis for other reasons (p < 0.0001 and p = 0.0008 respectively). Titres of IgG anticardiolipin antibodies correlated with plasma levels of von Willebrand factor (p < 0.0001; r: 0.42).(ABSTRACT TRUNCATED AT 250 WORDS)

Functional disability and end organ damage in patients with systemic lupus erythematosus (SLE), SLE and Sjögren's syndrome (SS), and primary SS

OBJECTIVE

To determine the accumulated end organ damage and health status in patients with SS and to compare with patients with SLE (with or without SS).

METHODS

Thirty-seven patients with primary SS were studied and compared with 120 patients with SLE and 21 patients with SLE and SS. The Medical Outcome Survey Short Form 20 with an additional question for fatigue was used to assess health status. The SLICC/ACR damage index with a supplementary oral section was used to assess end organ damage. For statistical analysis, logistic regression analysis, Fisher's exact test, and Kruskal-Wallis rank tests were applied.

RESULTS

Patients in all 3 groups had reduced quality of life with respect to all aspects of functional status and well being. There was no difference between the groups. In the primary SS group, the greatest damage was in the oral section (62% of patients). The patients with SLE and SS had the greatest renal, peripheral vascular, and musculoskeletal damage (24, 19, 38% of patients, respectively) followed by the SLE group. Ocular damage was more common in the primary SS group, but that was due to older age in this group. Malignancy was most common in the primary SS group (11%). Other organ damage scores did not differ between groups.

CONCLUSION

End organ damage is uncommon in primary SS (with the exception of oral damage), but the degree of functional ability is as great as in SLE.