The effect of anterior quadratus lumborum block on morphine consumption in minimally invasive colorectal surgery: a multicentre, double-blind, prospective randomised placebo-controlled trial

We investigated the efficacy and safety of a bilateral anterior quadratus lumborum block in patients undergoing minimally invasive colorectal surgery. This was a two-centre, double-blind, prospective, randomised, placebo-controlled trial including 150 patients undergoing laparoscopic colorectal surgery (left- or right hemicolectomy, sigmoidectomy) who were enrolled in the institutional abdominal enhanced recovery programme. Before induction of anaesthesia, patients received a bilateral anterior quadratus lumborum block in the left and right lateral decubitus position under ultrasound guidance and were allocated randomly to receive 30 ml of ropivacaine 0.375% (n = 75) or placebo (saline 0.9%) (n = 75) bilaterally. Postoperatively, all patients received multimodal intravenous analgesia including paracetamol, ketorolac and patient-controlled analgesia with morphine. The primary outcome was morphine consumption during the first 24 h after tracheal extubation. Secondary outcomes included severity of pain; presence and extent of sensory block; incidence of postoperative nausea and vomiting; and hospital duration of stay. We also investigated the need for, and dose of, rescue analgesia. Safety outcomes included the incidence of adverse events. Mean (SD) 24-hour morphine consumption was no different between patients allocated to ropivacaine and placebo (28.6 (22.3) mg vs. 28.4 (22.5) mg, p = 0.966, respectively). While a sensory block could be detected in significantly more patients allocated to the ropivacaine group, no differences were detected in pain scores or other secondary or safety endpoints. Patient satisfaction scores were high in both groups. In laparoscopic colorectal surgery, adding a bilateral anterior quadratus lumborum block to a standard multimodal analgesia regimen did not reduce opioid consumption or improve pain scores.

Attrition rate and predictors of a monitoring mHealth application in adolescents with obesity

BACKGROUND

Integrating mobile health (mHealth) into paediatric obesity treatment can provide opportunities for more personalized and lifetime treatment. However, high attrition rates pose a significant challenge. The current study attempts to better understand attrition by exploring (1) attrition rates of a monitoring mHealth application for usage over 14 days and (2) testing predictors of attrition in adolescents with obesity.

METHODS

Participants were 69 adolescents between 12 and 16 years old who engaged in a multidisciplinary obesity treatment centre (either outpatient or inpatient) in two countries (Belgium and France). To assess the attrition rates, frequency distributions were used. To test the predictors of attrition, zero-inflated negative binomial regression was performed.

RESULTS

Attrition rates were high, in the outpatient group, more than half of the participants (53.3%) used the app for only 0-7 days. In the inpatient group, this percentage was 24.1%. Only deficits in initiating (a component of executive functions) were a negative predictor of attrition, indicating that deficits in initiating lead to lower attrition rates.

CONCLUSIONS

This study provides evidence for high attrition rates in mHealth interventions for adolescents with obesity and was the first to investigate psychological predictors of attrition to an mHealth monitoring tool in adolescents with obesity in treatment. Findings regarding predictors of attrition should be approached with caution due to the small sample size.

A smartphone application as a personalized treatment tool for adolescents with overweight: an explorative qualitative study

BACKGROUND

The present study is the first step of a 3-year European project in which a tailored smartphone application will be developed and tested as a potential tool in the personalized treatment of children and adolescents with overweight.

METHODS

In this study, 10 focus groups (n = 48 participants) were conducted in Belgium, The Netherlands and France with adolescents with overweight (12-16 years; n = 30) and parents of adolescents with overweight (n = 18) to investigate their perceptions on (un)healthy behavior, the drivers of these behaviors, and the needs of an eHealth application for weight loss. A thorough thematic analysis was performed using Nvivo12.

RESULTS

Results show that adolescents with overweight have a well-articulated perspective on (un)healthy behavior and their needs. Parents underestimate their own influence on the (un)healthy behavior of their children and report difficulties in healthy lifestyle parenting, which makes their role as a coach rather ambiguous. Concerning the needs of an eHealth application, both parents and adolescents formulated some challenging expectations regarding the content and the format including information, a monitoring feature and features that increase participants' motivation to behave healthy. The results of this analysis will form the basis for designing a personalized eHealth application, which will be tested in a next phase.

CONCLUSION

We can conclude that adolescents have a well-articulated perspective on healthy and unhealthy behavior and their needs, whereby a new app could be of great help. It could function as a day-by-day diary and as a supportive coach.

Go or no-go? An assessment of inhibitory control training using the GO/NO-GO task in adolescents

OBJECTIVE

Adolescence is a critical period for the onset of unhealthy eating habits. One important contributing factor is poor inhibitory control (IC), a cognitive skill that enables behavior regulation. IC training appears successful in countering unhealthy eating in adults, but evidence in adolescents is scarce. In addition, the mechanism of change from IC training remains unclear. Therefore, the present study aimed to assess changes in IC during a single session of IC training in adolescents. The effectiveness of the training was assessed by comparing the experimental group to a matched control group.

METHOD

A community sample of 57 adolescents between 10 and 18 years was recruited (M_age = 16.61, SD_age = 2.52, 73.7% girls, M_adj.BMI = 105.17, SD_adj.BMI = 18.81). IC was assessed before, during, and after the training using a GO/NO-GO task. Indices of IC were commission errors (CE; incorrectly responding on a no-go trial) and reaction time (RT) on go trials.

RESULTS

CE rates among adolescents who received the IC training were the highest during the training and decreased significantly after the training. However, there were no differences in CE before compared to after the training. No differences were found in RT before, during or after the training. In addition, compared to the control group, the experimental group showed no significant differences in either CE or RT before, during or after the training.

DISCUSSION

To the best of our knowledge, the present study is the first to assess changes in IC after an IC training in a community sample of adolescents. Results of this study further elucidate the complex role of IC in adolescents' unhealthy eating habits. Future studies should seek to corroborate these findings in a larger sample.

Guidelines for the safe clinical practice of peripheral nerve blocks in the adult patient

The Peripheral Nerve Block working group of the Belgian Association for Regional Anesthesia has revised and updated the “Clinical guidelines for the practice of peripheral nerve block in the adult” which were published in 2013.

Into the Wild, Out of the Woods: A Systematic Case Study on Facilitating Emotional Change

Cognitive and behavioral treatment programs for individuals who have committed sexual offenses (ISOs) have shown significant but small effect sizes. A growing body of research points toward the importance of difficulties in affect regulation (AR) as a risk factor for sexual recidivism. On this basis, it seems important to target difficulties in AR in treatment. The current systematic case study investigates the potential contribution of emotion-focused therapy (EFT) to changing problematic AR in ISOs. Kevin was a high-risk offender with a traumatic history who met the diagnostic criteria of pedophilic and borderline disorders, with serious AR difficulties. Self-report outcome measures, observation measures, and a biomarker were used to track changes in AR, psychological symptoms, and distress during baseline (Phase A); treatment as usual (Phase B); treatment with an EFT component added (Phase C); and follow-up (Phase A). Statistically significant change was found in AR, psychological symptoms, and distress during treatment (Phase B + C); however, it is not possible to attribute these changes causally to EFT. An examination of the qualitative process data provides deeper insights into how the client reacted to specific EFT interventions. Verbatim clinical vignettes are included to clarify key interventions, hindrances, and mechanisms of change. This study provides preliminary support for the role of therapy to facilitate emotional change in ISOs.

Combined spatial and retrospective analysis of fluoroalkyl chemicals in fluvial sediments reveal changes in levels and patterns over the last 40 years

Bed sediments and a dated sediment core were collected upstream and downstream from the city of Lyon (France) to assess the spatial and temporal trends of contamination by per- and polyfluoroalkyl substances (PFASs) in this section of the Rhône River. Upstream from Lyon, concentrations of total PFASs (ΣPFASs) in sediments are low (between 0.19 and 2.6 ng g^-1 dry weight - dw), being characterized by a high proportion of perfluorooctane sulfonate (PFOS). Downstream from Lyon, and also from a fluoropolymer manufacturing plant, ΣPFASs concentrations reach 48.7 ng g^-1 dw. A gradual decrease of concentrations is reported at the coring site further downstream (38 km). Based on a dated sediment core, the temporal evolution of PFASs is reconstructed from 1984 to 2013. Prior to 1987, ΣPFASs concentrations were low (≤2 ng g^-1 dw), increasing to a maximum of 51 ng g^-1 dw in the 1990s and then decreasing from 2002 to the present day (∼10 ng g^-1 dw). In terms of the PFAS pattern, the proportion of perfluoroalkyl sulfonic acids (PFSAs) has remained stable since the 1980s (∼10%), whereas large variations are reported for carboxylic acids (PFCAs). Long chain- (C > 8) PFCAs characterized by an even number of perfluorinated carbons represent about 74% of the total PFAS load until 2005. However, from 2005 to 2013, the relative contribution of long chain- (C > 8) PFCAs with an odd number of perfluorinated carbons reaches 80%. Such changes in the PFAS pattern likely highlight a major shift in the industrial production process. This spatial and retrospective study provides valuable insights into the long-term contamination patterns of PFAS chemicals in river basins impacted by both urban and industrial activities.

The influence of propofol and sevoflurane on intestinal motility during laparoscopic surgery

BACKGROUND

Volatile anaesthetics have an influence on small bowel peristalsis during laparoscopic surgery. A recent study concluded that desflurane increased intestinal motility compared to sevoflurane. Hence, a desflurane-based anaesthesia protocol may reduce surgical exposure during intestinal suturing or stapling due to small bowel hyperperistalsis. The effect of propofol on intestinal motility is not well studied. We tested the hypothesis that a propofol-remifentanil anaesthesia increases intestinal contractions in comparison with a sevoflurane-remifentanil anaesthesia.

METHODS

Patients scheduled for laparoscopic gastric bypass surgery were randomized in this single blind randomized controlled trial to receive remifentanil combined with sevoflurane or propofol (ISRCTN 12921661). Bispectral index monitoring was used to guide depth of anaesthesia. Visual observation of peristaltic waves was performed during 1 min at the planned site of the jejunostomy. Statistical analysis was performed using Wilcoxon two-sample test.

RESULTS

After obtaining written informed consent 50 patients were included. Groups were similar for demographic variables, and depth of anaesthesia during the observations. The median number of peristaltic waves was lower in the sevoflurane-remifentanil group compared to the propofol-remifentanil group (0 vs. 6, P < 0.001).

CONCLUSION

Propofol-remifentanil increases intestinal motility compared with sevoflurane-remifentanil during laparoscopic gastric bypass surgery. A sevoflurane-based protocol can help to avoid disturbing peristalsis.

Dynamics of metallic contaminants at a basin scale--Spatial and temporal reconstruction from four sediment cores (Loire fluvial system, France)

From the 19th century, the Loire basin (France) presents potentially pollutant activities such as mining and heavy industries. This paper shows spatio-temporal distribution of trace elements in sediments at a basin-scale, based on a comparison of archived temporal signals recorded in four sedimentary cores. Anthropogenic sources contributing to sediment contamination are also characterized, using geochemical signatures recorded in river bank sediments of the most industrialized tributaries. This study highlights upstream-downstream differences concerning recorded contamination phases in terms of spatial influence and temporality of archiving processes. Such differences were related to (i) various spatial influences of contamination sources and (ii) polluted sediments dispersion controlled by transport capacity of metal-carrier phases and hydrosedimentary dynamics.

Storage and source of polycyclic aromatic hydrocarbons in sediments downstream of a major coal district in France

During the 20th century, the local economy of the Upper Loire Basin (ULB) was essentially based on industrial coal mining extraction. One of the major French coal districts with associated urban/industrial activities and numerous coking/gas plants were developed in the Ondaine-Furan subbasins, two tributaries of the upper Loire main stream. To determine the compositional assemblage, the level and the potential sources of contamination, the historical sedimentary chronicle of the 16 US EPA priority polycyclic aromatic hydrocarbons (PAHs) has been investigated. PAH concentrations were determined using gas chromatography/mass spectrometry (GC/MS) in a dated core, sampled in the Villerest flood-control reservoir located downstream of the Ondaine-Furan corridor (OFC). The most contaminated sediments were deposited prior to 1983 (Σ16PAHs ca. 4429-13,348 ng/g) and during flood events (Σ16PAHs ca. 6380 ng/g - 1996 flood; 5360 ng/g - 2003 flood; 6075 ng/g - 2008 flood), especially in medium and high molecular weight PAHs. Among them, typical pyrogenic PAHs such as FLT, PYR, BbF and BaP were prevalent in most of the core samples. In addition, some PAHs last decade data is available from the Loire Bretagne Water Agency and were analyzed using high-performance liquid chromatography with postcolumn fluorescence derivatization (HPLC/FLD). These results confirm that the most highly contaminated sediments were found downstream of OFC (Σ16PAHs ca. 2264-7460 ng/g). According to the observed molecular distribution, PAHs are originated largely from high-temperature pyrolytic processes. Major sources of pyrogenic PAHs have been emphasized by calculation of specific ratios and by comparison to reported data. Atmospheric deposition of urban and industrial areas, wood combustion and degraded coal tar derived from former factories of coking/gas plants seem to be the major pyrogenic sources. Specifically, particular solid transport conditions that can occur during major flood events lead us to emphasize weathering of former contamination sources, such as more preserved coal tar.

A randomised controlled trial of intravenous dexamethasone combined with interscalene brachial plexus blockade for shoulder surgery

We recruited patients scheduled for shoulder rotator cuff repair or subacromial decompression under general anaesthesia and interscalene brachial plexus blockade (30 ml ropivacaine 0.5%). We allocated 240 participants into four groups of 60 that were given pre-operative saline 0.9% or dexamethasone 1.25 mg, 2.5 mg or 10 mg, intravenously. We recorded outcomes for 48 h. The median (IQR [range]) time to first postoperative analgesic request after saline was 12.2 (11.0-14.1 [1.8-48]) h, which was extended by intravenous dexamethasone 2.5 mg and 10 mg to 17.4 (14.9-21.5 [7.2-48]) h, p < 0.0001, and 20.1 (17.2-24.3 [1.3-48]) h, p < 0.0001, respectively, but not by dexamethasone 1.25 mg, 14.0 (12.1-17.7 [2.1-48]) h, p = 0.05. Postoperative analgesia was given sooner after rotator cuff repair than subacromial decompression, hazard ratio (95% CI) 2.2 (1.6-3.0), p < 0.0001, but later in older participants, hazard ratio (95% CI) 0.98 (0.97-0.99) per year, p < 0.0001.

Influence of fluvial environments on sediment archiving processes and temporal pollutant dynamics (Upper Loire River, France)

Floodplains are often cored to build long-term pollutant trends at the basin scale. To highlight the influences of depositional environments on archiving processes, aggradation rates, archived trace element signals and vertical redistribution processes, two floodplain cores were sampled near in two different environments of the Upper Loire River (France): (i) a river bank ridge and (ii) a paleochannel connected by its downstream end. The base of the river bank core is composed of sandy sediments from the end of the Little Ice Age (late 18th century). This composition corresponds to a proximal floodplain aggradation (<50 m from the river channel) and delimits successive depositional steps related to progressive disconnection degree dynamism. This temporal evolution of depositional environments is associated with mineralogical sorting and variable natural trace element signals, even in the <63-μm fraction. The paleochannel core and upper part of the river bank core are composed of fine-grained sediments that settled in the distal floodplain. In this distal floodplain environment, the aggradation rate depends on the topography and connection degree to the river channel. The temporal dynamics of anthropogenic trace element enrichments recorded in the distal floodplain are initially synchronous and present similar levels. Although the river bank core shows general temporal trends, the paleochannel core has a better resolution for short-time variations of trace element signals. After local water depth regulation began in the early 1930s, differences of connection degree were enhanced between the two cores. Therefore, large trace element signal divergences are recorded across the floodplain. The paleochannel core shows important temporal variations of enrichment levels from the 1930s to the coring date. However, the river bank core has no significant temporal variations of trace element enrichments and lower contamination levels because of a lower deposition of contaminated sediments and a pedogenetic trace elements redistribution.

I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study

BACKGROUND

Interscalene brachial plexus block (ISB) provides excellent, but time-limited analgesia. Dexamethasone added to local anaesthetics prolongs the duration of a single-shot ISB. However, systemic glucocorticoids also improve postoperative analgesia. The hypothesis was tested that perineural and i.v. dexamethasone would have an equivalent effect on prolonging analgesic duration of an ISB.

METHODS

We performed a prospective, double blind, randomized, placebo-controlled study. Patients presenting for arthroscopic shoulder surgery with an ISB were randomized into three groups: ropivacaine 0.5% (R); ropivacaine 0.5% and dexamethasone 10 mg (RD); and ropivacaine 0.5% with i.v. dexamethasone 10 mg (RDiv). The primary outcome was the duration of analgesia, defined as the time between performance of the block and the first analgesic request. Standard hypothesis tests (t-test, Mann-Whitney U-test) were used to compare treatment groups. The primary outcome was analysed by Kaplan-Meier survival analysis with a log-rank test and Cox's proportional hazards regression.

RESULTS

One hundred and fifty patients were included after obtaining ethical committee approval and patient informed consent. The median time of a sensory block was equivalent for perineural and i.v. dexamethasone: 1405 min (IQR 1015-1710) and 1275 min (IQR 1095-2035) for RD and RDiv, respectively. There was a significant difference between the ropivacaine group: 757 min (IQR 635-910) and the dexamethasone groups (P<0.0001).

CONCLUSIONS

I.V. dexamethasone is equivalent to perineural dexamethasone in prolonging the analgesic duration of a single-shot ISB with ropivacaine. As dexamethasone is not licensed for perineural use, clinicians should consider i.v. administration of dexamethasone to achieve an increased duration of ISB.

Alexithymia and interpersonal functioning:an extension of empirical research by using a dimensional approach for interpersonal style and the structured interview for alexithymia

Introduction

The concept of alexithymia refers to problems in experiencing and regulating affects; clinical study as well as empirical research suggests that alexithymia is related to cold and socially inhibited interpersonal functioning. However, empirical studies frequently use only self report questionnaires.

Objectives/aims

This study investigates the relation between alexithymia and self-reported interpersonal problems. By using an interview measure of alexithymia next to a questionnaire, we want to avoid artificially high correlations due to shared method variance and thus get a clearer picture of the link between alexithymia and interpersonal style. We hypothesize that alexithymia will be related to a cold, but not to a dominant or submissive interpersonal style.

Method

The Toronto Structured Interview for Alexithymia (TSIA) was administered by a trained researcher to 74 psychiatric inpatients, who also filled out the Toronto Alexithymia Scale (TAS-20) and the Inventory of Interpersonal Problems (IIP-64). Dimensional affiliation and dominance scores of the IIP-64 were computed and Pearson correlations between TSIA, TAS-20 and IIP-64 dimensional scores were calculated.

Results

As hypothesized, we observed no significant correlation between TSIA, TAS-20 and the dominance dimension of the IIP-64 and a significant correlation between the affiliation dimension and TSIA and TAS-20.

Conclusions

Our results support previous research and confirm that alexithymia is related to a cold interpersonal style. Since our findings converge for both measurements of alexithymia, the link between alexithymia and interpersonal style can not be explained by shared method variance. The measurement of only self-reported interpersonal problems is a limitation of this study.

P02 - 368 - Interactions between obsessive - compulsive symptoms and interpersonal profiles during short - term psychodynamic therapy

Introduction

An increasing amount of outcome research supports the efficacy of Short Term Psychodynamic Psychotherapy (STPP) for a wide range of psychological disorders, reporting effect sizes in meta-analyses between 0.50 and 1.40 (for review see Shedler, 2010). Mapping mechanisms of change in the STPP process can be considered the major challenge of STPP for the decades to come.

Objectives/aims

This study focuses on STPP with Obsessive-Compulsive (OC) patients and tests the hypothesis that the progressive elimination of OC symptoms throughout an STPP process is correlated to a parallel process of change at the level of interpersonal characteristics.

Method

Mixed quantitative-qualitative analyses of data of Short Term Psychodynamic Therapies with four OC patients are presented. Repeated Measures analyses are performed to study intra-subject associations between intensity of OC symptoms (measured by General Health Questionnaire, GHQ-12, and Obsessive-Compulsive Inventory, OCI-R) and interpersonal characteristics (measured by Inventory of Interpersonal Problems, IIP-32).

Results

Observed associations between evolutions in general interpersonal characteristics and general complaints were significant yet inconsistent across the patients. Qualitative analyses, however, revealed similarities on the level of specific interpersonal characteristics, in this respect that all patients struggled to escape the suffocating impact of parental figures and/or romantic partners.

Conclusions

Rather than elaborating a general interpersonal style (cfr. Desmet et al., 2008), the results suggest that a progressive elaboration of parent-child and partner relationships is a crucial characteristic of the STPP process with OC patients. Limitations of the study are the small sample size and the absence of contrast- and control groups.

Abolition of cost-sharing is pro-poor: evidence from Uganda

OBJECTIVE

To document the effects of the abolition of user fees on utilization of health services in Uganda with emphasis on poor and vulnerable groups.

METHODS

A longitudinal study using quantitative and qualitative methods was carried out in 106 health facilities across the country. Health records were reviewed to determine trends in overall utilization patterns and use among vulnerable groups. A modification of wealth ranking as defined by the Uganda Poverty Participatory Assessment Project was used to categorize households by socio-economic status in order to compare utilization by the poor against that of other socio-economic groups.

FINDINGS

There was a marked increase in utilization in all population groups that was fluctuating in nature. The increase in utilization varied from 26% in public referral facilities in 2001, rising to 55% in 2002 compared with 2000. The corresponding figures for the lower level facilities were 44% and 77%, respectively. Increase in utilization among the poor was more than for other socio-economic categories. Women utilized health services more than men both before and after cost-sharing. Higher increases in utilization were noted among the over-five age group compared with the under-fives. There were no increases in utilization for preventive and inpatient services. With respect to quality of care, there were fewer drug stock-outs in 2002 compared with 2000 and 2001. There was no deterioration of other indicators such as cleanliness, compound maintenance and staff availability reported.

CONCLUSION

The study suggests that there is a financial barrier created by cost-sharing that decreases access to services, especially among the poor in Uganda. However, further studies are needed to clarify issues of utilization by age and gender.

A 300 year history of lead contamination in northern French Alps reconstructed from distant lake sediment records

Lead concentrations and isotopic ratios were measured along two well-dated sediment cores from two distant lakes: Anterne (2100 m a.s.l.) and Le Bourget (270 m a.s.l.), submitted to low and high direct human impact and covering the last 250 and 600 years, respectively. The measurement of lead in old sediment samples (>3000 BP) permits, in using mixing-models, the determination of lead concentration, flux and isotopic composition of purely anthropogenic origin. We thus show that since ca. 1800 AD the regional increase in lead contamination was mostly driven by coal consumption ((206)Pb/(207)Pb approximately 1.17-1.19; (206)Pb/(204)Pb approximately 18.3-18.6), which peaks around 1915 AD. The increasing usage of leaded gasoline, introduced in the 1920s, was recorded in both lakes by increasing Pb concentrations and decreasing Pb isotope ratios. A peak around 1970 ((206)Pb/(207)Pb approximately 1.13-1.16; (206)Pb/(204)Pb approximately 17.6-18.0) corresponds to the worldwide recorded leaded gasoline maximum of consumption. The 1973 oil crisis is characterised by a drastic drop of lead fluxes in both lakes (from approximately 35 to <20 mg cm(-2) yr(-1)). In the late 1980s, environmental policies made the Lake Anterne flux drop to pre-1900 values (<10 mg cm(-2) yr(-1)) while Lake Le Bourget is always submitted to an important flux (approximately 25 mg cm(-2) yr(-1)). The good match of our distant records, together and with a previously established series in an ice core from Mont Blanc, provides confidence in the use of sediments as archives of lead contamination. The integration of the Mont Blanc ice core results from Rosman et al. with our data highlights, from 1990 onward, a decoupling in lead sources between the high elevation sites (Lake Anterne and Mont Blanc ice core), submitted to a mixture of long-distance and regional contamination and the low elevation site (Lake Le Bourget), where regional contamination is predominant.

The potential for social mobilisation in Bangladesh: the organisation and functioning of two health insurance schemes

Health insurance schemes are usually assessed according to technical indicators. This approach, however, neglects the dynamic perspective of insurance schemes as an element of people's mobilisation for participation in organising and managing health care delivery and financing. The first part of this paper describes the technical performance and the level of community involvement in management of the two largest health insurance schemes in Bangladesh, both in the rural areas and in the non-government sector. Part two discusses these achievements in light of the schemes' potential role as a mechanism for people's management of health care. A review of documents and key-informant interviews were conducted. Key findings include that (1) subscribers currently are not actively participating in scheme management. However, existing family groups, involved in credit programmes may serve as entry-points for interaction. This is sustained by the 'natural link' between health insurance as a means of spreading the risks of treatment costs and credit programmes as a means of decreasing the relative impact of illness on household income. (2) The schemes' role could be further enhanced, by improving their technical performance and applying health care systems elements with the input of all partners involved. These issues are avoidance of service duplication with other providers; better protection of the poorer households; inclusion of hospital care in the coverage package; simplification of scheme administration by introduction of episode-based co-payments instead of the current itemised ones and concentrating the schemes at the level of community-based services, which may be self-financed and also self-managed by the community, given available sensitisation, training and interaction. A shift to episode-based co-payments would also introduce solidarity among patients and among individuals at higher risk, such as pregnant women and under-fives. Finally, action-research is needed to document the process of increased community involvement.

Acute bronchodilation with an intravenously administered leukotriene D4 antagonist, MK-679

Descriptive studies suggest an association between the release of the cysteinyl leukotrienes and clinical asthma. To help clarify this association, we tested the hypothesis that an intravenous infusion of a potent and specific investigational LTD4 receptor antagonist, MK-679, would cause rapid bronchodilation. In a three-period, randomized, double-blind, crossover study, single doses of MK-679, 125 and 500 mg, and placebo were given intravenously by bolus infusion to nine patients with moderate, stable asthma (FEV1 40 to 80% predicted) on individual study days separated by a week. Spirometry was preformed predose and at intervals for as long as 8 h postdosing; blood samples for MK-679 concentrations were drawn over this time. Fifteen minutes after the end of infusion, the FEV1 percent change from baseline increased a mean of 15.8 +/- 15.7 and 7.8 +/- 11.6% with the 500- and 125-mg doses, respectively, compared with a mean decrease of 2.6 +/- 6.2% with placebo (p = 0.01, overall; p = 0.003, 500 mg versus placebo). The mean end-of-infusion MK-679 plasma concentrations were 86.2 +/- 13.9 and 19.9 +/- 2.7 micrograms/ml for the 500- and 125-mg doses, respectively. MK-679 was well-tolerated, with no significant adverse experiences observed. We conclude that a single, intravenously administered, bolus infusion of MK-679 causes bronchodilation in patients with moderate, stable asthma.

Blood pressure and excretion of sodium, potassium, calcium and magnesium in 8- and 9-year old boys from 19 European centres

We have measured systolic and diastolic blood pressure and excretions of sodium, potassium, calcium and magnesium in groups of about 50 8- and 9-year-old boys from 19 European centres using standardized methods for the measurement of blood pressure and collection of urine, and by carrying out all analyses in one laboratory. Weight, height, pulse rate and environmental temperature were also studied. Mean systolic blood pressure ranged from 91 to 105 mm Hg and diastolic blood pressure from 51 to 66 mm Hg. Mean 24-h excretion of sodium was between 91 and 146 mmol/d, that of potassium between 29 and 60 mmol/d, that of calcium between 1.5 and 2.6 mmol/d and that of magnesium between 2.7 and 4.2 mmol/d. Mean sodium excretion tended to be lower and potassium excretion tended to be higher in the boys from the north-western parts of Europe. Relations between either systolic or diastolic blood pressure and electrolyte excretions were generally weak or absent. Most remarkable is that only the association between mean diastolic blood pressure and 24-h magnesium excretion (partial regression coefficient (b +/- s.e., -5.04 +/- 2.08 mm Hg/mmol/d) was statistically significant after adjusting for differences in creatinine excretion and environmental temperature. Mean systolic blood pressure was not significantly related with any of the variables measured. The partial regression coefficient (b +/- s.e.) for diastolic blood pressure on weight was 0.186 +/- 0.062 mm Hg/kg, on height 0.165 +/- 0.056 mm Hg/cm, on pulse rate 0.364 +/- 0.100 mm Hg/beats per min and on outside temperature -0.25 +/- 0.07 mm Hg/degrees C.

Feasibility study concerning the use of expert systems for the development of procedures in pharmaceutical analysis

The feasibility of using expert systems for the development of analytical procedures is investigated. A system for the computer generation of procedures to determine active drug substances in commercial formulations is proposed. It is shown that in nearly 85% of the cases investigated the present system immediately yields a correct procedure or conclusion. It is concluded that selecting methods and developing procedures with the use of expert systems is difficult but feasible.