A NEW CORTICOID FOR TOPICAL THERAPY—Fluocinolone Acetonide

Sixty-seven patients with chronic and subacute cutaneous lesions of varying long duration that had previously been resistant to topical use of corticosteroid compounds were treated with a cream containing fluocinolone acetonide. To avoid subjective bias, only two classifications were used in appraising results: “complete clearing of treated lesions” and “not effective.”Forty-eight patients had complete clearing of the treated area. Results were best in atopic dermatitis, chronic eczematous dermatitis and nummular dermatitis. Granuloma annulare, dyshidrotic dermatitis of the palms and psoriasis were not affected.In some cases in which there were multiple lesions some of the lesions were treated with fluocinolone acetonide cream and some were treated concurrently with other corticoid ointments or with noncorticoid compounds, either bland or with active ingredients. Fluocinolone was effective in more than twice as many cases as the other agents.In some of the patients with chronic disease it was possible to greatly reduce or discontinue systemic steroid therapy after fluocinolone acetonide became available.No untoward effects were observed.     

Relation between insufficient response to antihypertensive treatment and poor compliance with treatment: a prospective case-control study

ObjectivesTo prospectively compare compliance with treatment in patients with hypertension responsive to treatment versus patients with treatment resistant hypertension.DesignProspective case-control study.SettingOutpatient department in a large city hospital in Switzerland, providing primary, secondary, and tertiary care.Participants110 consecutive medical outpatients with hypertension and taking stable treatment with at least two antihypertensive drugs for at least four weeks.ResultsComplete data were available for 103 patients, of whom 86 took ⩾80% of their prescribed doses (“compliant”) and 17 took <80% (“non-compliant”). Of the 49 patients with treatment resistant hypertension, 40 (82%) were compliant, while 46 (85%) of the 54 patients responsive to treatment were compliant.ConclusionNon-compliance with treatment was not more prevalent in patients with treatment resistant hypertension than in treatment responsive patients.

What is already known on this topic

For many patients with arterial hypertension, blood pressure cannot be adequately controlled despite treatment with antihypertensive drugsPatients'' poor compliance with treatment is often suggested as the reason for lack of response to antihypertensive drugs

What this study adds

When treatment compliance was monitored in hypertensive patients following stable treatment regimens, no difference in compliance was found between those with treatment resistant hypertension and those responsive to treatmentFactors other than patients'' compliance with treatment regimens should be examined to explain lack of response to antihypertensive drugs     

in Vitro Activity of Antimycotic Agents Determined by e-Test Method Against Vaginal Shape Candida Species

Vaginal candidiasis continues to be a common cause of vaginal discharge, pruritus and other local complaints in women worldwide. Although numerous antimycotic agents are available for the treatment of yeast vaginitis there is little comparative data on the in vitro activity of these drugs. The objectives of this study were to isolate and identify the Candida species in the vagina and anus of patients treated in a gynaecology clinic, as well as determine the susceptibility to azolic compounds measured by the E-test method. Vaginal and rectal swabs were collected from 80 adult non-pregnant patients, seen at a gynaecological clinic, aged 18–59 years, with sexual activity, with and without vaginitis. The swabs were processed by methods routinely used for the detection of pathogenic yeasts. The susceptibility of the isolates to fluconazole, ketoconazole and itraconazole, was measured by the agar diffusion method (E-test), using RPMI 1640 medium with 2% glucose and phosphate buffer. Candida species (33) strains were isolated from 17 patients at similar proportions from both anatomical sites, and 12 patients harboured 24 strains of C. albicans in the vaginal and rectal tracts. Twenty one percent of the strains of C. albicans were resistant to ketoconazole, 54% were resistant to itraconazole and 0% were resistant to fluconazole. The sensitivity of strains isolated from the two sites were similar, indicating that these are strains of the same phenotype. This revised version was published online in August 2006 with corrections to the Cover Date.     

Tuberculosis: A Challenge to the General Practitioner

Of 157 patients dying of tuberculosis in Ontario (1960) 132 (87.4%) suffered from the pulmonary form of the disease (incidence 2.6 per 100,000). In the same year, 1632 of 1847, or 88.3%, active new cases reported had the pulmonary type and 183 additional cases were reported without details as to type of disease. Thus, in 1960, a total of 2030 new cases of tuberculosis were reported in Ontario.Of 1367 patients with pulmonary tuberculosis (reinfection type), 357 (26.1%) had “far advanced” disease and 613 (44.8%) had “moderately advanced” disease.This high percentage of patients with “moderately advanced” to “far advanced” disease at the time of diagnosis constitutes the real challenge to physicians in private practice, who made the diagnosis in 45% of cases.Emergence of resistant strains of bacteria increases the urgency of prompt diagnosis and treatment. The most vulnerable population segment is the 15-30 year age-group, many of whom are negative intracutaneous reactors. A high index of suspicion is necessary, particularly in certain segments of the population with a high incidence of infection, combined with a careful history, meticulous physical examination, intracutaneous tests, chest and other radiographs, and appropriate bacteriological studies.     

Economic Analysis of the Impact of Overseas and Domestic Treatment and Screening Options for Intestinal Helminth Infection among US-Bound Refugees from Asia

BackgroundMany U.S.-bound refugees travel from countries where intestinal parasites (hookworm, Trichuris trichuria, Ascaris lumbricoides, and Strongyloides stercoralis) are endemic. These infections are rare in the United States and may be underdiagnosed or misdiagnosed, leading to potentially serious consequences. This evaluation examined the costs and benefits of combinations of overseas presumptive treatment of parasitic diseases vs. domestic screening/treating vs. no program.MethodsAn economic decision tree model terminating in Markov processes was developed to estimate the cost and health impacts of four interventions on an annual cohort of 27,700 U.S.-bound Asian refugees: 1) “No Program,” 2) U.S. “Domestic Screening and Treatment,” 3) “Overseas Albendazole and Ivermectin” presumptive treatment, and 4) “Overseas Albendazole and Domestic Screening for Strongyloides”. Markov transition state models were used to estimate long-term effects of parasitic infections. Health outcome measures (four parasites) included outpatient cases, hospitalizations, deaths, life years, and quality-adjusted life years (QALYs).ResultsThe “No Program” option is the least expensive ($165,923 per cohort) and least effective option (145 outpatient cases, 4.0 hospitalizations, and 0.67 deaths discounted over a 60-year period for a one-year cohort). The “Overseas Albendazole and Ivermectin” option ($418,824) is less expensive than “Domestic Screening and Treatment” ($3,832,572) or “Overseas Albendazole and Domestic Screening for Strongyloides” ($2,182,483). According to the model outcomes, the most effective treatment option is “Overseas Albendazole and Ivermectin,” which reduces outpatient cases, deaths and hospitalization by around 80% at an estimated net cost of $458,718 per death averted, or $2,219/$24,036 per QALY/life year gained relative to “No Program”.DiscussionOverseas presumptive treatment for U.S.-bound refugees is a cost-effective intervention that is less expensive and at least as effective as domestic screening and treatment programs. The addition of ivermectin to albendazole reduces the prevalence of chronic strongyloidiasis and the probability of rare, but potentially fatal, disseminated strongyloidiasis.     

Benzoyl Peroxide and Sulfur: Foundation for Acne Management

One hundred and thirteen consecutive patients with acne were studied by qualified dermatologists during a trial of topical 10% benzoyl peroxide and 2%-5% sulfur cream. The results were considered “good” to “excellent” in both office and clinic situations. The method was remarkably free of undesirable side effects. The program has been adopted as a standard acne regimen at the dermatology clinic of the Royal Victoria Hospital, Montreal.     

Insecticide Mixtures Could Enhance the Toxicity of Insecticides in a Resistant Dairy Population of Musca domestica L

House flies, Musca domestica L., are important pests of dairy operations worldwide, with the ability to adapt wide range of environmental conditions. There are a number of insecticides used for their management, but development of resistance is a serious problem. Insecticide mixtures could enhance the toxicity of insecticides in resistant insect pests, thus resulting as a potential resistance management tool. The toxicity of bifenthrin, cypermethrin, deltamethrin, chlorpyrifos, profenofos, emamectin benzoate and fipronil were assessed separately, and in mixtures against house flies. A field-collected population was significantly resistant to all the insecticides under investigation when compared with a laboratory susceptible strain. Most of the insecticide mixtures like one pyrethroid with other compounds evaluated under two conditions (1∶1-“A” and LC₅₀: LC₅₀-“B”) significantly increased the toxicity of pyrethroids in the field population. Under both conditions, the combination indices of pyrethroids with other compounds, in most of the cases, were significantly below 1, suggesting synergism. The enzyme inhibitors, PBO and DEF, when used in combination with insecticides against the resistant population, toxicities of bifenthrin, cypermethrin, deltamethrin and emamectin were significantly increased, suggesting esterase and monooxygenase based resistance mechanism. The toxicities of bifenthrin, cypermethrin and deltamethrin in the resistant population of house flies could be enhanced by the combination with chlorpyrifos, profenofos, emamectin and fipronil. The findings of the present study might have practical significance for resistance management in house flies.     

The Probability of Death Following a Fracture of the Hip

All patients 45 years of age and over admitted with fractures of the hip to hospitals in the Atlantic Health Region of Nova Scotia were followed up over a two-year period. Actuarial methods were used to estimate survivorship from the date of fracture in 202 patients.Over-all, it was estimated that only 63.8% would be alive by one year post-fracture. This is 70% of the survival rate expected in the general population of corresponding age and sex. The period of greatest mortality was within the first 12 weeks. Patients surviving to one year could be considered “cured”, for after that their survivorship was at least as favourable as that of the “normal” population.Mortality was greatest in males in those 75 years of age and over and especially in patients who were relatively immobilized prior to their fracture. In this “dependent” group the relative survival ratio at one year was only 38%.     

Erythropoietic Protoporphyria IV. Protection from Sunlight

Dihydroxyacetone and lawsone, in a vanishing cream base, applied to the skin was found to protect patients with erythropoietic protoporphyria against sunlight. The use of the same ingredients in a 50% isopropyl alcohol/water solution did not induce adequate light protection. The chemically induced ultraviolet light filter in the stratum corneum allowed these patients to change their lives from an “indoor” to an “outdoor” environment.     

Incidence of Uraemia and Requirements for Maintenance Haemodialysis

The biochemistry laboratory records of a 400-bed general hospital serving a population of about 120,000 showed that during the three-year period 1966-8 inclusive 487 patients had at some stage during their admission a blood urea of 100 mg/100 ml or more. Ninety per cent. were aged 50 or over, 79% were 60 or over, and 52% were 70 or over.The case notes of all patients with renal failure admitted during 1966 and 1967 were examined together with those of patients under 60 admitted during 1968. Three observers agreed about the most likely cause of the renal failure in 90% of patients whose case notes were available, or 74% of the total. The raised blood urea was thought to be due to “prerenal” factors in 60% of the patients, to acute tubular necrosis in 80%, to obstructive uropathy in 12%, and to “intrinsic” renal disease in 20%. Renal failure precipitated by such factors as cardiac failure, chest infections, cerebrovascular accidents, and shock was particularly common in old people.The hospital survey and replies to a questionnaire sent to all general practitioners in the area suggest that in the three-year period 14 patients may have been suitable for treatment by maintenance haemodialysis or renal transplantation. This represents a rate of about 39 per million per year under the age of 60 and 28 per million per year under 50.     

Beneficial Effect of Isoniazid Preventive Therapy and Antiretroviral Therapy on the Incidence of Tuberculosis in People Living with HIV in Ethiopia

Background

IPT with or without concomitant administration of ART is a proven intervention to prevent tuberculosis among PLHIV. However, there are few data on the routine implementation of this intervention and its effectiveness in settings with limited resources.

Objectives

To measure the level of uptake and effectiveness of IPT in reducing tuberculosis incidence in a cohort of PLHIV enrolled into HIV care between 2007 and 2010 in five hospitals in southern Ethiopia.

Methods

A retrospective cohort analysis of electronic patient database was done. The independent effects of no intervention, “IPT-only,” “IPT-before-ART,” “IPT-and-ART started simultaneously,” “ART-only,” and “IPT-after-ART” on TB incidence were measured. Cox-proportional hazards regression was used to assess association of treatment categories with TB incidence.

Results

Of 7,097 patients, 867 were excluded because they were transferred-in; a further 823 (12%) were excluded from the study because they were either identified to have TB through screening (292 patients) or were on TB treatment (531). Among the remaining 5,407 patients observed, IPT had been initiated for 39% of eligible patients. Children, male sex, advanced disease, and those in Pre-ART were less likely to be initiated on IPT. The overall TB incidence was 2.6 per 100 person-years. As compared to those with no intervention, use of “IPT-only” (aHR = 0.36, 95% CI = 0.19–0.66) and “ART-only” (aHR = 0.32, 95% CI = 0.24–0.43) were associated with significant reduction in TB incidence rate. Combining ART and IPT had a more profound effect. Starting IPT-before-ART (aHR = 0.18, 95% CI = 0.08–0.42) or simultaneously with ART (aHR = 0.20, 95% CI = 0.10–0.42) provided further reduction of TB at ∼80%.

Conclusions

IPT was found to be effective in reducing TB incidence, independently and with concomitant ART, under programme conditions in resource-limited settings. The level of IPT provision and effectiveness in reducing TB was encouraging in the study setting. Scaling up and strengthening IPT service in addition to ART can have beneficial effect in reducing TB burden among PLHIV in settings with high TB/HIV burden.     

Psychiatric Illness in General Practice: A Detailed Study Using a New Method of Case Identification

A self-administered questionary (the General Health Questionnaire) aimed at detecting current psychiatric disturbance was given to 553 consecutive attenders to a general practitioner''s surgery. A sample of 200 of these patients was given an independent assessment of their mental state by a psychiatrist using a standardized psychiatric interview. Over 90% of the patients were correctly classified as “well” or “ill” by the questionary, and the correlation between questionary score and the clinical assessment of severity of disturbance was found to be +0·80.The “conspicuous psychiatric morbidity” of a suburban general practice assessed by a general practitioner who was himself a psychiatrist and validated against independent psychiatric assessment was found to be 20%. “Hidden psychiatric morbidity” was found to account for one-third of all disturbed patients. These patients were similar to patients with “conspicuous illnesses” in terms both of degree of disturbance and the course of their illnesses at six-month follow-up, but were distinguished by their attitude to their illness and by usually presenting a physical symptom to the general practitioner.When 87 patients who had been assessed as psychiatric cases at the index consultation were called back for follow-up six months later, two-thirds of them were functioning in the normal range. Frequency of attendance at the surgery in the six months following index consultation was found to have only a modest relationship to severity of psychiatric disturbance.It is argued that minor affective illnesses and physical complaints often accompany each other and usually have a good prognosis.     

Acute Myocardial Infarction in Doncaster. II—Delays in Admission and Survival

The speed of admission of patients with suspected acute myocardial infarction was observed over a period of 12 months during which a “no refusal” coronary care scheme was functioning, with emphasis on minimizing delay. During the same period the duration of survival of cases diagnosed as coronary thrombosis by the coroner''s pathologist was measured. Comparison of the two series shows that 75% to 80% of the coroner''s cases had died before the median time of notification of the general practitioner by those patients referred to hospital.We argue that the provision of mobile coronary care on request from general practitioners is unlikely to have an appreciable effect in preventing deaths from acute myocardial infarction outside hospital.     

Development of Multidrug Resistant Tuberculosis in Bangladesh: A Case-Control Study on Risk Factors

Objective

To determine the risk factors for developing multidrug resistant tuberculosis in Bangladesh.

Methods

This case-control study was set in central, district and sub-district level hospitals of rural and urban Bangladesh. Included were 250 multidrug resistant tuberculosis (MDR-TB) patients as cases and 750 drug susceptible tuberculosis patients as controls. We recruited cases from all three government hospitals treating MDR-TB in Bangladesh during the study period. Controls were selected randomly from those local treatment units that had referred the cases. Information was collected through face-to-face interviews and record reviews. Unadjusted and multivariable logistic regression were used to analyse the data.

Results

Previous treatment history was shown to be the major contributing factor to MDR-TB in univariate analysis. After adjusting for other factors in multivariable analysis, age group “18–25” (OR 1.77, CI 1.07–2.93) and “26–45” (OR 1.72, CI 1.12–2.66), some level of education (OR 1.94, CI 1.32–2.85), service and business as occupation (OR 2.88, CI 1.29–6.44; OR 3.71, CI 1.59–8.66, respectively), smoking history (OR 1.58, CI 0.99–2.5), and type 2 diabetes (OR 2.56 CI 1.51–4.34) were associated with MDR-TB. Previous treatment was not included in the multivariable analysis as it was correlated with multiple predictors.

Conclusion

Previous tuberculosis treatment was found to be the major risk factor for MDR-TB. This study also identified age 18 to 45 years, some education up to secondary level, service and business as occupation, past smoking status, and type 2 diabetes as comorbid illness as risk factors. National Tuberculosis programme should address these risk factors in MDR-TB control strategy. The integration of MDR-TB control activities with diabetes and tobacco control programmes is needed in Bangladesh.     

复方黄柏液联合夫西地酸软膏及西替利嗪 治疗面部糖皮质激素依赖性皮炎疗效观察

目的观察复方黄柏液联合夫西地酸软膏及西替利嗪治疗面部糖皮质激素依赖性皮炎（以下简称为面部激素性皮炎）的疗效。方法采用随机对照观察方法对108例面部激素性皮炎患者分成治疗组和对照组。治疗组使用复方黄柏液（湿敷）联合夫西地酸软膏（外用）,对照组用3%的硼酸溶液湿敷及维生素B6软膏外用;两组均口服西替利嗪片。2周为1个疗程,治疗2个疗程。结果治疗组有效率为80.77%;对照组有效率为56.86%。两组有效率比较差异有统计学意义（χ^2=7.16,P〈0.05）。结论复方黄柏液联合夫西地酸软膏及西替利嗪治疗面部激素性皮炎疗效好,无明显不良反应。     

CARCINOMA OF THE CERVIX

Studies by eminent surgeons to reevaluate the place of radical operations in the treatment of carcinoma of the cervix—now that extensive procedures have become less hazardous—apparently have led to confusion in some minds as to choice between surgical and radiation therapy. Pending outcome of the studies, general employment of surgical treatment is unwarranted. Radiation is the treatment of choice in most cases, particularly if the lesion is in an early stage, although radical operation is indicated in certain rare early cases in which delivery of an effective dose of radiation to involved areas is technically difficult. Elsewise it appears at present that operation should be used only in cases of stages III or IV carcinoma—in which results by either means of treatment are poor.One hundred and seven patients were treated with a combination of x-ray and radium irradiation. X-ray was used first to reduce the hazard of implanting the radium. The “five-year arrest” rates were as follows: For 22 patients with stage I lesion, 70 per cent; for 31 with stage II, 55.7 per cent; 33 with stage III, 39.7 per cent; 21 with stage IV, 0. Eighteen patients with diagnosis of carcinoma of the cervix who had had subtotal hysterectomy were treated. The stage of the disease could not be determined. In this group the five-year arrest rate was 52 per cent.     

Aspirin “resistance” and risk of cardiovascular morbidity: systematic review and meta-analysis

Objective To determine if there is a relation between aspirin “resistance” and clinical outcomes in patients with cardiovascular disease.Design Systematic review and meta-analysis.Data source Electronic literature search without language restrictions of four databases and hand search of bibliographies for other relevant articles.Review methods Inclusion criteria included a test for platelet responsiveness and clinical outcomes. Aspirin resistance was assessed, using a variety of platelet function assays.Results 20 studies totalling 2930 patients with cardiovascular disease were identified. Most studies used aspirin regimens, ranging from 75-325 mg daily, and six studies included adjunct antiplatelet therapy. Compliance was confirmed directly in 14 studies and by telephone or interviews in three. Information was insufficient to assess compliance in three studies. Overall, 810 patients (28%) were classified as aspirin resistant. A cardiovascular related event occurred in 41% of patients (odds ratio 3.85, 95% confidence interval 3.08 to 4.80), death in 5.7% (5.99, 2.28 to 15.72), and an acute coronary syndrome in 39.4% (4.06, 2.96 to 5.56). Aspirin resistant patients did not benefit from other antiplatelet treatment.Conclusion Patients who are resistant to aspirin are at a greater risk of clinically important cardiovascular morbidity long term than patients who are sensitive to aspirin.     

Candidal vaginitis in hormone-treated mice: Prevention by a chitin extract

In view of findings from previous studies that a chitin soluble extract (CSE) blocked adhesion of Candida albicans in vitro and in vivo and prevented thereby a short lived candidal infection in naive mice, we attempted in the present study to block by CSE the development of a persistent infection, induced in hormone-treated animals. Continuous oestrus phase was obtained in mice by repeated weekly subcutaneous injections with estradiol benzoate. Intravaginal inoculation of the hormone-treated mice with 10⁷–10¹⁰ C. albicans cells induced a persistent candidal infection. Fifty three mice were pretreated intravaginally prior to inoculation of C, albicans with 2.5, 5.0 or 10 mg/mouse of a CSE cream and followed up for development of infection in comparison to 30 untreated animals. Twenty four hrs post fungus inoculation the infection rate among the CSE treated mice was 11–23% VS 84% among the controls; the rate increased a week later to 97% among the controls VS 41–50% among the CSE treated. Administering the CSE to the mice prior — and post-yeast inoculation (37 mice), led to increased efficacy of the treatment. The data, indicating that CSE is an effective measure for preventing persistent candidal vaginitis, may open the way to consider a similar approach for prophylaxis of vaginitis in human susceptible populations.     

Methadone

Methadone and acetylmethadol, although possessing almost all of morphine''s pharmacological properties, differ from other morphine-like drugs in their longer action, more gradual and less intense withdrawal syndrome, and blockade of euphoric effect of other opiates in addicts. A high percentage of patients maintained on methadone are better able to hold employment or to be otherwise socially productive than when dependent on heroin or morphine.A review of published results and procedures used in methadone maintenance treatment programs for heroin dependence is presented. Former heroin addicts are usually maintained on 80 to 120 mg. (high dose) or 20 to 60 mg. (low dose) oral methadone daily. Some programs are reported to have produced 80% success (patients employed or otherwise socially productive). Selection of patients, availability of allied therapeutic and rehabilitative facilities, strict control of supply, record keeping and periodic evaluation are considered essential.Different criteria (“drug-free” vs. “socially productive”) for judging “success” of treatment of heroin-dependent persons by methadone maintenance and administrative problems in large-scale treatment programs constitute the principal aspects of controversy.