A multicenter double-blind study of controlled-release physostigmine for the treatment of symptoms secondary to Alzheimer's disease. Physostigmine Study Group

OBJECTIVE

A multicenter trial to evaluate the efficacy of controlled-release physostigmine salicylate, a cholinesterase inhibitor, was conducted in 1,111 mild-to-moderate Alzheimer's disease (AD) subjects.

DESIGN

During dose titration, subjects received 18, 24, or 30 mg of physostigmine or placebo daily. After a 2-week washout period, 366 subjects with putative improvement were randomized to receive either placebo or their best dose of physostigmine in a 6-week double-blind trial. Nonresponding patients (439) were randomized to receive in a separate double-blind trial either placebo or their highest tolerated dose of physostigmine. The primary efficacy measures included the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS) and a Clinical Global Impression of Change (CGIC). Secondary measures included the Mini-Mental State Examination and two activities-of-daily-living scales.

RESULTS

At the end of the 6-week double-blind phase, physostigmine-treated patients scored 1.75 points higher than placebo-treated patients on the ADAS (p = 0.003) and 0.26 points higher on the CGIC (p = 0.012) in the intent-to-treat analysis. There was no significant improvement on the secondary outcome measures. Patients failing to respond to physostigmine during the dose titration phase failed to respond on any of the outcome measures during the double-blind period of re-exposure. Common adverse events included nausea, vomiting, diarrhea, and anorexia. There were no significant changes in liver function tests.

CONCLUSION

This study demonstrated statistically significant differences between physostigmine and placebo on both a performance-based cognitive functioning instrument and a clinician's global evaluation. The magnitude of the effect size was small and occurred only in the subset of patients who responded in the initial dose titration study period. Nevertheless, the results suggest that in a subset of patients, physostigmine can induce a degree of cognitive improvement over 6 weeks of treatment.

[Physiotherapy in chronic obstructive pulmonary disease: oscillatory breathing with flutter VRP1]

Chronic obstructive pulmonary disease (COPD) is characterized by sputum production and cough. It has been shown that mucus hypersecretion predisposes to recurrent bronchial infection and that reduction in airway secretions is associated with clinical improvement. Recently a new pipe-shaped device for chest physiotherapy, the flutter VRP1 ("VarioRaw:" Aubonne, Switzerland), was introduced in order to help clear bronchial hypersecretion. We determined the long-term efficacy of daily chest physiotherapy with the VRP1 in COPD and bronchial hypersecretion. 13 men and 7 women with COPD and sputum hypersecretion were studied; 10 were assigned to the physiotherapy group, and 10 to the control group getting sham therapy. After 3 months of physiotherapy, FVC, FEV1 and distance walked in 12 minutes increased in the treated group, but were almost unchanged in the sham-treated group. Arterial blood gases, the maximum voluntary ventilation, and respiratory rate at rest were unchanged in both groups. There was also an overall significant improvement in COPD symptoms in the physiotherapy group compared to baseline (p < 0.05). We conclude that long-term home physiotherapy with the flutter VRP1 is effective in COPD in improving airflow, functional ability and symptoms.

Learning from patients: a discharge planning improvement project

BACKGROUND

In 1991 Beth Israel Hospital (Boston) joined nine other hospitals in using the Picker/Commonwealth survey instrument to tap patients perceptions of their hospitalization experience. Beth Israel focused on one of the nine dimensions of the instrument-continuity and transition (discharge planning). FOUR WORK TEAMS: In 1992 four multidisciplinary work teams were formed-for cardiac surgical patients, stroke patients, patients on a medical unit, and patients on a medical and surgical unit. Each team conducted a patient/family discussion group, during which recently discharged patients and their families were asked about their preparation for discharge and asked for input on how to improve the process.

INTERVENTIONS

Each work team developed interventions on the basis of information specific to their patients. The cardiac work team, for example, developed interdisciplinary practice guidelines for patient care management for the entire postoperative period; the guidelines include a patient education component on what patients and families can expect during hospitalization.

OUTCOMES

Clinicians practice differently, inviting more patient feedback and other involvement in care, as a results of their involvement in the project. On the first annual patient survey, administered in 1994, only 6% of 1,179 randomly selected patients (versus 20% of the 100 patients first surveyed in 1993) indicated that they did not receive the information they needed to help themselves recover. CURRENT PROGRESS AND FUTURE DIRECTIONS: A standardized teaching packet containing material developed during the discharge planning improvement project is now distributed. In May 1995 the nursing department launched a patient and family learning center to better meet the health education needs of patients.

Ethics, national sovereignty and the control of immigration

"This paper examines the debate as to whether migration is a basic human right or if the claims of outsiders are superseded by the principle of national sovereignty--the moral obligation of states to do the best for their own citizens. In evaluating migration and refugees it focuses on issues of open borders, migration selectivity, the capacity of sovereign states to control entry, the claims of refugees, the relationship between sovereignty and justifiable intervention, and the role of public opinion and morals throughout migration policies."

Inhaled budesonide therapy for patients with stable COPD

A significant minority of patients with COPD have favorable response to corticosteroid treatment. In addition, the benefit of corticosteroid treatment may be outweighed by the side effects. Long-term administration of inhaled steroids is a safe means of treatment. We hypothesized that treatment with high-dose inhaled budesonide would improve clinical symptoms and pulmonary function in subjects with COPD, and that the response to inhaled beta 2-agonist will serve to individualize steroid responders. We compared a 6-week course of 800 micrograms/d inhaled budesonide with placebo, separated by 4 weeks when no medication was taken, in a double-blind crossover trial, in 8 patients responding to inhaled beta 2-agonist, and in 22 nonresponders with stable COPD. In six of eight "responders to beta 2-agonist," there was a significant improvement in the FEV1 (defined as > or = 20%) following inhaled budesonide, as compared with placebo. In the 22 "nonresponders to beta 2-agonist," there was no significant improvement in the mean FEV1 (1.41 +/- 0.1 L before, and 1.61 +/- 0.1 L after treatment) with inhaled budesonide or placebo. Over the 6-week course of treatment by either budesonide or placebo, the nonresponders reported similar beta 2-agonist consumption (4.8 +/- 0.2 and 5.0 +/- 0.1 puffs per patient per day, respectively). However, there was a significant difference between the two periods of treatment in the responders as for the mean daily number of beta 2-agonist inhalations (2.4 +/- 0.1 in the budesonide period as compared with 5.3 +/- 0.1 in the placebo period; p < 0.005). We conclude that treatment with inhaled steroids improved spirometry data and inhaled beta 2-agonist consumption in about 25% of patients with stable COPD, and this rate is increased to about 75% in patients who respond to beta 2-agonist inhalation.

Long term clinical comparison of single versus twice daily administration of inhaled budesonide in moderate asthma

BACKGROUND

Inhaled steroids are widely used in the treatment of mild to moderate asthma. However, long term compliance with inhaled steroids is poor and administration of a single daily dose may improve compliance.

METHODS

A double blind, randomised study was performed to determine whether inhaled steroids given once daily at bedtime are as efficacious as a twice daily regimen in the long term maintenance of moderate asthmatic patients. Forty adults of mean age 37 years with moderate asthma (mean (SE) forced expiratory volume in one second (FEV1) 73.6 (1.4)% predicted, mean morning peak expiratory flow (PEF) 328 l/min) were randomised to receive either a twice daily dose (400 micrograms morning and bedtime) of inhaled budesonide (group A) or a once daily dose of 800 micrograms (group B) and were followed for a period of 12 months. Asthma symptom scores (assessed according to a modified Borg scale), inhaled beta 2 agonist consumption, and peak expiratory flow rates were recorded daily. Spirometry and airways responsiveness to methacholine (PC20) were measured at the end of each period of three months of treatment.

RESULTS

There was no difference between the two groups at baseline and during the follow up period in the PC20 for methacholine. However, a difference was seen between the two groups in the mean daily number of beta 2 agonist inhalations (1.4 (0.1) puffs/patient/day in group A v 2.3 (0.1) in group B), the PEF variability (episodes of decrease in PEF of > 20%) (0.22 (0.01) episodes/patient/day in group A v 0.40 (0.02) in group B), and for asthma symptom scores (0.30 (0.04) in group A v 0.42 (0.06) in group B) for the 12 month period of the study.

CONCLUSIONS

Although both regimens provide good clinical control, twice daily doses of 400 micrograms inhaled budesonide are more effective than a single dose of 800 micrograms at bedtime in the long term control of stable moderate asthma.

Visuoconstructive deficit following infarction in the right basal ganglia: a case report and some experimental data

Visuospatial disorders are typically described as a consequence of right hemisphere, cortical lesions. We report the case of a female with visuoconstructive deficits with an infarct in the right basal ganglia, with no evidence of visual field defect, hemi-inattention, or sensory or motor loss. Using a process approach to obtain additional quantitative data, we showed that her visuoconstructive disorder could not be attributed to a defect in visual perception, per se. All other aspects of her neuropsychologic skills were normal. These findings provide additional support for the role of subcortical structures in spatially-related motor function and for the utility of applying experimental techniques to clarify the nature of deficits.

A comparison of crossover versus parallel-group design in the evaluation of analgesic efficacy after molar extraction

This study compares the analgesic effects of two standard combinations (Empirin with codeine versus Mersyndol) and placebo as measured by crossover versus parallel-group design. The analgesic results obtained with three groups of 12 to 13 crossed over subjects with two extractions divided into six subgroups of five to seven subjects for each sequence were qualitatively the same and statistically at least as strong as those obtained by analysis of parallel groups of 38 to 42 extractions per group. By both methods the analgesics were statistically significantly more effective than placebo. The difference between the two products was not statistically significant, although the score for Mersyndol was somewhat better by both methods of study. The crossover data did not allow judgments concerning side effects in spite of its greater efficiency in quantifying pain relief.

[Structure and process components of trauma care services in emergency departments]

Increasing attention is being paid by staffs of hospitals and directors of our national health agencies to providing emergency medical services for trauma care. The results of a nationwide survey documenting the structure and process components of trauma care in all 24 acute care hospitals in Israel are presented. Although these hospitals provide 24-hour trauma service, there are no formal guidelines for required resources in emergency departments. The results show extreme interhospital variation in physical structure of trauma services and in manpower, protocols and critical resource. However, it is evident that the main focus for intervention in the quality of initial trauma care in hospitals in Israel, is to establish and implement organizational standards.

Inspiratory muscle training during treatment with corticosteroids in humans

In a previous study performed by us, functional alterations in the inspiratory muscles were evaluated in patients receiving corticosteroids for diseases other than respiratory. We have shown that patients who received high-dose steroids for several weeks developed inspiratory muscle weakness that was reversible following withdrawal of the drug treatment. The present study was designed to evaluate the ability of specific inspiratory muscle training (SIMT) to prevent the effects of a therapeutic dosage of corticosteroids on inspiratory muscle function in patients receiving the drug for diseases other than pulmonary, with no underlying respiratory or muscular disease. Twelve patients, 5 men and 7 women, with ages ranging from 19 to 41 years, who received corticosteroids for diseases other than respiratory were recruited into two groups: 6 patients were assigned to the control group and got sham training and 6 patients received SIMT while receiving corticosteroids in a single-blind group-comparative trial. In both groups, there was no difference between the post-treatment and pretreatment values as regard to the FEV1/FVC relationship. However, in the control group but not in the training group, there was a small but significant decrease, from 99.2 +/- 3.0 to 94.3 +/- 2.8 (mean +/- SEM, p < 0.01) in FEV1 (percent of predicted normal values) and from 103.5 +/- 4.0 to 88.7 +/- 3.1 (p < 0.001) in the FVC, following treatment. All subjects had normal inspiratory muscle strength, as expressed by the maximal inspiratory mouth pressure (PImax) at residual volume, and inspiratory muscle endurance as expressed by the relationship between peak pressure and the PImax before treatment. Following administration of corticosteroids, there was a gradual decrease in both inspiratory muscle strength (from 117.5 +/- 9.4 to 80.5 +/- 3.3 cm H2O, p < 0.005) and endurance (from 82.7 +/- 2.6 to 40.2 +/- 1.7%, p < 0.001) in the control group. On the contrary, despite corticosteroid therapy, there were no significant changes in the inspiratory muscle function in the patients whose inspiratory muscles were specifically trained. We conclude that corticosteroids have a significant deteriorating effect on respiratory muscle function in humans. This weakness is preventable by using SIMT during corticosteroid treatment.

The effects of age on the pharmacokinetics and biotransformation of theophylline in vivo and in vitro in the Mongolian gerbil (Meriones unguiculatus)

The effect of post maturational aging on the in vivo disposition of theophylline was examined in the Mongolian gerbils (Meriones unguiculatus) aged 30-39 (old), 12-18 (middle-aged) and 3 (young) months following a 20 mg/kg i.p. dose. Biotransformation of theophylline was also examined in liver microsomes from non-induced and 3-methylcholanthrene induced gerbils. Analysis of theophylline plasma kinetics showed decreased clearance, increased half-life and increased volume of distribution in old vs. young animals. Clearance to the 1,3-dimethyluric acid metabolite was similar for all age groups, while clearance to the 1-methyluric acid metabolite was significantly lower in the middle-aged group compared to that of young and old gerbils. Urinary recovery of 1-methylurate was increased in old vs. young and middle-aged animals while recovery of theophylline was decreased. 3-Methylcholanthrene induction resulted in decreased recovery of theophylline and increased recovery of 1,3-dimethylurate and 1-methylurate in young and middle-aged gerbils compared to non-induced controls. Decreased microsomal protein content was observed in old vs. young and middle-aged gerbils and an age-related decrease in cytochrome P-450 content (nmol P-450/g liver) was also observed. The rate of dimethylurate formation was decreased 37% in microsomes from old vs. young and middle-aged gerbils. 3-Methylcholanthrene administration resulted in a 2- and 1.5-fold increase in the rate of 1,3-dimethylurate formation in young and middle-aged gerbils, respectively. The results of these experiments indicate that the Mongolian gerbil may be useful for the study of the biochemical mechanisms underlying age-related changes in the biotransformation and kinetics of theophylline.

Automated reconstruction of endoscopic images of the esophagus

Endoscopic devices distort the image of a region under examination. Previous work has shown that there are computational methods which can precisely reconstruct planar structures in a model of the esophagus and that reconstruction in human subjects is operator independent. The purpose of this report is to show that much of the process can be automated and to provide additional evidence that the reconstruction is both accurate and reproducible.

[Effect of corticosteroids on inspiratory muscle function]

Functional alteration in inspiratory muscles was evaluated in patients receiving corticosteroids for nonrespiratory diseases. Inspiratory muscle strength, as expressed by maximal inspiratory mouth pressure (PImax), and inspiratory muscle endurance (PmPeak/PImax), determined with a pressure threshold breathing device, were evaluated in 8 patients with normal pulmonary and inspiratory muscle function. There was a gradual decrease in both inspiratory muscle strength and endurance when corticosteroids were given. Tapered decrease in steroid dosage resulted in marked improvement in both strength and endurance, and the improvement was even more significant 6 months later. We also evaluated the ability of specific inspiratory muscle training to prevent the effects of therapeutic corticosteroids on inspiratory muscle function in 6 patients, as compared to 6 control patients who received sham training. Following corticosteroids there was a gradual decrease in both inspiratory muscle strength and endurance in those getting sham training. However, there was no significant change in inspiratory muscle function in those getting inspiratory muscle training. We conclude that corticosteroids result in significant deterioration in respiratory muscle function. This weakness is reversible by tapering steroid dosage, but can be prevented by specific inspiratory muscle training during corticosteroid treatment.

Conjunctival orbital cyst

A 61-year-old woman had gradual onset of ptosis and painless proptosis of her left eye of 1-year duration. Orbital computed tomography (CT) showed a well-circumscribed superior nasal orbital tumor with uniform density. The mass was removed by anterior orbitotomy and histopathologically diagnosed as a conjunctival cyst. Recent reports have increased awareness of this entity. This case typifies findings of conjunctival orbital cysts. These cysts should be considered when a differential diagnosis is formulated for orbital tumors with a similar presentation.

Esophageal balloon cytology and subsequent risk of esophageal and gastric-cardia cancer in a high-risk Chinese population

Linxian, China has some of the highest rates of esophageal/gastric cardia cancer in the world. In 1983, esophageal balloon cytology screening was performed in 3 communes in northern Linxian. Of the participants, 10,066 with no evidence of cancer were followed prospectively for 7 1/2 years to evaluate the ability of the initial cytologic diagnoses to identify individuals at increased risk for developing cancer of the esophagus or gastric cardia. A total of 747 incident cases of esophageal or cardia cancer and 322 deaths due to these tumors were identified during the follow-up period and used in this analysis. The risks for esophageal or cardia cancer incidence and mortality increased in parallel with the presumed severity of the 1983 Chinese cytologic diagnoses. After adjusting for potential confounding factors, relative risks for esophageal or cardia cancer incidence, by initial cytologic diagnosis, were normal = 1.00 (reference), hyperplasia = 1.25, dysplasia 1 = 2.20, dysplasia 2 = 4.22 and near-cancer = 5.96. Our results suggest that esophageal balloon cytology, as performed and interpreted in Linxian in 1983, successfully identified individuals at increased risk for developing cancer of the esophagus or gastric cardia.

The airway in the obstetrical patient

Airway management of the parturient has serious implications for the anesthetist. Meticulous patient evaluation and preparation is essential. A management plan that can be implemented in the event of failed intubation should be familiar to all anesthetists who are involved in obstetrical anesthesia.

Reversal of megaduodenum and duodenal dysmotility associated with improvement in nutritional status in primary anorexia nervosa

Anorexia nervosa is considered one type of eating disorder that may result in severe malnutrition. Patients with this disorder commonly complain of postprandial nausea, abdominal pain, and distension. We describe the radiologic and motility abnormalities associated with anorexia nervosa in a 21-year-old female. Barium gastrointestinal series demonstrated marked dilation of the duodenum, with prolongation of intestinal transit. A 4-hr fasting gastroduodenal motility study showed no propagating migrating motor complexes (MMC). Prolonged, but nonpropagating, bursts of high-amplitude phasic and tonic contractions were seen in the duodenum. In contrast, antral contractions were of low amplitude and esophageal motor function was normal. Metoclopramide and edrophonium caused an increase in gastroduodenal motor activity, but increased contractions were not associated with symptoms. Following a renutrition program that raised the patient's weight from 64 to 80% of her ideal body weight, the radiographic abnormalities and gastrointestinal dysmotility resolved completely. These observations suggest that anorexia-associated gastrointestinal motor dysfunctions are a consequence, not the cause of the generalized protein-calorie malnutrition associated with anorexia nervosa. The facts that motility in different parts of the gut is affected to different degrees and that gastric and duodenal muscle responds normally to exogenous stimulation argue against a generalized myogenic dysfunction and, rather, point to a reversible dysfunction of neural regulation.

Concepts of "tissue PO2" in relation to O2 delivery

Resistance to O2 diffusion is reflected in the difference in pO2 between O2 reservoirs of hemoglobin (Hb) and myoglobin. The very low normal myocyte pO2 (less than one torr but adequate for optimal oxidative ATP synthesis) compared to venous pO2 indicates that blood does not achieve equilibrium with tissue during its passage through capillaries. In the lung, diffusion rate of O2 from alveolus to capillary is normally sufficient to achieve essential equilibrium. However, system-wide capillary pathology and reduced Hb saturation has been observed with distal local ischemia. In peripheral vascular disease (PVD) patients, we found a mean arterial pO2 of 77 torr (normal over 90 torr). Classical concepts based on "tissue pO2" values derived from venous blood or oxygen electrodes inserted into tissue need re-evaluation. Readings of O2 electrodes moved through tissue range widely from intracapillary levels down toward intracellular levels and do not reflect the pO2 of any particular site. Intravenous pO2 is the result of residual O2 after incomplete diffusion out of capillaries during transit through a tissue, and is not an equilibrium value with some tissue pool. The effect of HbO2 p50 on oxygen release during the passage of blood through a capillary bed, generally judged on the basis of percentage percent saturation at "tissue pO2", should be judged on the basis of the change in pO2 (the diffusion driving force) associated with a particular degree of HbO2 saturation at a particular p50. The thesis that O2 diffusion rate is a major determinant of oxygen delivery is supported by pO2 responses to treatment of PVD that does not alter blood flow or p50.

The effect of corticosteroids on inspiratory muscle performance in humans

Functional alterations in the inspiratory muscles were evaluated in patients receiving corticosteroids for diseases other than respiratory. Inspiratory muscle strength, as expressed by the maximal inspiratory mouth pressure (PImax), and inspiratory muscle endurance (PmPeak/PImax), using a pressure threshold breathing device, were evaluated in eight patients with normal pulmonary and inspiratory muscle functions (two patients with rapidly progressive glomerulonephritis, two with glomerulonephritis with minimal changes, two with idiopathic thrombocytopenic purpura, and two with subacute thyroiditis). There was a gradual decrease in both inspiratory muscle strength and endurance following corticosteroid administration. After 8 weeks of treatment PmPeak/PImax decreased from 84.4 +/- 2.4 to 67.9 +/- 3.1 percent (p < 0.001), while inspiratory muscle strength dropped from 126.9 +/- 9.6 to 86.5 +/- 7.4 cm H2O (p < 0.005). Gradual steroid dosage tapering resulted in marked improvement in both strength and endurance; the inspiratory muscle strength rose significantly to 112.2 +/- 8.1 cm H2O (p < 0.0005) when steroid treatment was stopped, and even more significantly 6 months later (to 123.1 +/- 8.1 cm H2O [p < 0.0001]), and the PmPeak/PImax rose to 60.6 +/- 3.4 percent (p < 0.001) and to 74.7 +/- 3.2 percent (p < 0.0001), respectively. We conclude that corticosteroids have a significant deteriorating effect on respiratory muscle function in humans. This weakness is reversible while tapering steroid dosage. Steroid therapy should be reconsidered in patients with underlying lung disease.