Reliability, validity and responsiveness of composite finger flexion in patients with traumatic hand injuries: A clinical measurement study

BACKGROUND

Composite finger flexion (CFF) is proposed to be a convenient alternative to total active motion (TAM) and total passive motion (TPM). Passive CFF (PCFF) may be useful for early monitoring in post-operative rehabilitation of traumatic hand injuries.

PURPOSE

To determine whether active and passive CFF are reliable, valid, and responsive measures of hand motion and of higher utility to the tester.

STUDY DESIGN

Cross-sectional observational clinical measurement study.

METHODS

Fifty hand injury patients were recruited from a hospital-based out-patient clinic. TAM, TPM, repeated measures of active CFF (ACFF) and PCFF, self-reported stiffness, patient reported wrist/hand evaluation (PRWHE) scores, and grip strength were recorded. Intraclass correlation coefficients (ICCs) and standard error of measurement were calculated for inter-rater and test-retest reliability. Criterion and construct validity were assessed using correlation coefficients. Responsiveness was explored by calculating correlation coefficients of change scores, effect sizes, and standardized response means. Time taken to measure CFF and TAM/TPM was recorded to consider utility.

RESULTS

The average age of participants was 47 years and 36% were female. Inter-rater and test-retest reliability estimates for ACFF and PCFF were excellent (ICCs = 0.95-98). Standard error of measurement values ranged from 0.21 to 0.33. The correlation coefficient for criterion validity between ACFF and TAM was -0.69; PCFF and TPM was -0.65; and ACFF and PCFF was 0.83. For construct validity, ACFF and TAM were similarly correlated with PRWHE. Correlations between changes in stiffness with ACFF and PCFF were 0.43 and 0.26, respectively. Effect sizes of ACFF and PCFF were small at 0.1 and 0.2. Time taken to measure CFF was much shorter than TAM/TPM.

CONCLUSIONS

The results of this study support the use of active and passive CFF as a reliable, valid, and efficient tool in the clinical setting. Further study is required to verify the responsiveness of CFF.

A Novel Approach to Reducing RN Distraction During Medication Access

Use of a noise-reducing headset to decrease distractions at medication stations was evaluated. Observational data demonstrated a statistically significant decrease in the frequency with, which RNs were visibly distracted when using the headset.

Abstract 461: Compositional Changes to High-Density Lipoproteins That Are Related to Increased Cardiocascular Disease Burden

Atherosclerosis is a vascular disease characterized by the build up of lipid derived plaques, and an individual’s risk of acute coronary syndrome is related to plaque burden and composition. Multiple risk markers for atherosclerosis and CVD act in a synergistic way through inflammatory pathways. One such inflammatory marker is serum amyloid A (SAA), which associates with HDL, negating its antiatherogeinc properties, which may have a causal role in atherosclerosis development.

This study examined if SAA was related to CVD burden, and if this influenced the antiatherogenic properties of HDL.

Subjects (n=240) referred to the rapid chest pain clinic at the Ulster Hospital UK, had atherosclerotic burden assessed by cardiac computerised tomography (CCT) and were classified as no CVD; mild CVD stenosis <50% and moderate/severe CVD stenosis >50%. HDL 2 and HDL 3 were isolated from serum by rapid ultracentrifugation. SAA was measured by an ELISA procedure, lipids by a colorimetric method and CETP activity by a fluorimetric assay.

Results: Although lipids were similar in HDL 2 across the groups, lipids decreased in HDL 3 with increasing CVD burden. In addition, the concentration of SAA and the activity of CETP increased with increasing CVD burden (see table). Additionally, ordinal regression analysis illustrated that HDL 3 -SAA and HDL 2 -CETP where independently related to CVD burden (p=0.001).

Conclusions: This study has shown that SAA was associated with increased CVD burden and that HDL had altered lipid composition and increased CETP activity. Thus, SAA and CETP may be useful biomarkers for the detection and assessment of CVD.

Funded by Heart-Research UK

Developing sustainable models of rural health care: a community development approach

Globally, small rural communities frequently are demographically similar to their neighbours and are consistently found to have a number of problems linked to the international phenomenon of rural decline and urban drift. For example, it is widely noted that rural populations have poor health status and aging populations. In Australia, multiple state and national policies and programs have been instigated to redress this situation. Yet few rural residents would agree that their town is the same as an apparently similar sized one nearby or across the country. This article reports a project that investigated the way government policies, health and community services, population characteristics and local peculiarities combined for residents in two small rural towns in New South Wales. Interviews and focus groups with policy makers, health and community service workers and community members identified the felt, expressed, normative and comparative needs of residents in the case-study towns. Key findings include substantial variation in service provision between towns because of historical funding allocations, workforce composition, natural disasters and distance from the nearest regional centre. Health and community services were more likely to be provided because of available funding, rather than identified community needs. While some services, such as mental illness intervention and GPs, are clearly in demand in rural areas, in these examples, more health services were not needed. Rather, flexibility in the services provided and work practices, role diversity for health and community workers and community profiling would be more effective to target services. The impact of industry, employment and recreation on health status cannot be ignored in local development.

Circadian function in patients with advanced non-small-cell lung cancer

This study aimed to evaluate whether patients with advanced non-small-cell lung cancer experience disrupted rest–activity daily rhythms, poor sleep quality, weakness, and maintain attributes that are linked to circadian function such as fatigue. This report describes the rest–activity patterns of 33 non-small-cell lung cancer patients who participated in a randomised clinical trial evaluating the benefits of melatonin. Data are reported on circadian function, health-related quality of life (QoL), subjective sleep quality, and anxiety/depression levels prior to randomisation and treatment. Actigraphy data, an objective measure of circadian function, demonstrated that patients' rest–activity circadian function differs significantly from control subjects. Our patients reported poor sleep quality and high levels of fatigue. Ferrans and Powers QoL Index instrument found a high level of dissatisfaction with health-related QoL. Data from the European Organization for Research and Treatment for Cancer reported poor capacity to fulfil the activities of daily living. Patients studied in the hospital during or near chemotherapy had significantly more abnormal circadian function than those studied in the ambulatory setting. Our data indicate that measurement of circadian sleep/activity dynamics should be accomplished in the outpatient/home setting for a minimum of 4–7 circadian cycles to assure that they are most representative of the patients' true condition. We conclude that the daily sleep/activity patterns of patients with advanced lung cancer are disturbed. These are accompanied by marked disruption of QoL and function. These data argue for investigating how much of this poor functioning and QoL are actually caused by this circadian disruption, and, whether behavioural, light-based, and or pharmacologic strategies to correct the circadian/sleep activity patterns can improve function and QoL.

Therapeutic advances of new fluoroquinolones

Fluoroquinolone antimicrobials have been available for over 10 years. Recent modifications to nuclear side-chains have enhanced both the antimicrobial and pharmacokinetic profiles of this class. Rapidly increasing antimicrobial resistance among community and hospital bacterial pathogens has diminished therapeutic options. Infections caused by such pathogens, including drug-resistant Streptococcus pneumoniae and multi-resistant Enterobacteriaceae are now treatable by few classes of antibacterials, one of these being the fluoroquinolones. Ciprofloxacin was one of the first effective agents available in both iv. and oral formulations for the treatment of Gram-negative infection, resistant to other antibiotics. More recent developments, such as sparfloxacin and grepafloxacin, are more effective in vitro against Gram-positive pathogens, although their safety profile may be less promising. Fluoroquinolones not yet in widespread clinical use, including trovafloxacin, clinafloxacin and moxifloxacin, hold considerable promise as community 'respiratory antimicrobials' and the results of clinical trials are awaited with anticipation. In this review, the three generations of fluoroquinolone development are examined and the relative antimicrobial, pharmacokinetic, clinical and safety profiles of available and developmental quinolones are compared.

217. Interaction of cdyl (chromodomain y-chromosome like) with the nuclear transport protein importin α2

Spermatogenesis is a unique, ordered process governed by the precise expression of a specific set of genes at each stage. Progression through successive stages requires the shuttling of proteins and transcription factors into and out of the nucleus to implement changes in gene transcription. Major factors that mediate nucleocytoplasmic transport are members of the importin superfamily, of which there are five and 20 different importin α and β genes, respectively, in mouse. We have previously demonstrated that several importins display distinct mRNA and protein expression patterns in adult mouse testis1 indicating that specific importins carry a specific cargo at discrete stages of spermatogenesis. Identification of importin cargoes in the testis should help describe the potential developmental switches critical to the spermatogenic process. We performed a yeast two-hybrid screen using full length importin α2 as bait and an adult mouse testis library, identifying nine target proteins. Some of these proteins include nuclear components that may be important in eliciting changes in the nuclear structure during spermatogenesis, as well as those involved in cell cycle regulation, homologous chromosome pairing and recombination, transcriptional regulation and guanine nucleotide biosynthesis. One key candidate is CDYL, which has been implicated in male infertility. It is a chromodomain-containing protein that is predominantly expressed during spermiogenesis and has been previously described to participate in hyperacetylation of histone H4, which is believed to facilitate protamine replacement of histones during spermiogenesis. Verification of CDYL-importin α2 interaction was demonstrated using co-immunoprecipation and co-transfection, while immunohistochemical staining of testis sections indicated colocalisation in the same cell types (mainly elongating spermatids). Importantly, preliminary experiments indicated that increasing CDYL nuclear accumulation by over-expressing importin α2 can increase histone H4 acetylation. Our hypothesis is that importin α2 is central in nuclear targeting of CDYL to facilitate its hyperacetylation role during protamine-histone exchange. (1)Hogarth et al. (2005). Dev. Dynamics (submitted).

A new respiratory fluoroquinolone, oral gemifloxacin: a safety profile in context

Gemifloxacin is a broad-spectrum quinolone antibacterial with enhanced potency against Gram-positive bacteria, including multi-drug resistant Streptococcus pneumoniae, and retained potency against Gram-negative bacilli and bacterial strains resistant to other antibiotics. It has proven particularly effective in respiratory and urinary tract infection. This review presents safety data from 6775 patients included in clinical trials, receiving either the recommended 320 mg once daily oral dose of gemifloxacin, or standard dose of other quinolones, macrolides or beta-lactams (n = 5248). Studies in healthy volunteer and special populations are also reported. Adverse experiences (AEs) were observed in 44.7% of gemifloxacin-treated patients and 47.5% of those who received comparator drugs. Mild gastro-intestinal adverse drug reactions (ADRs) (diarrhoea 5.1%, nausea 3.9%) predominated. Rash, usually maculo-papular and in no case proceeding to more severe eruptions, was observed in 3.6% of those receiving gemifloxacin. A higher incidence of rash (>20%) was observed in young women and was the subject of further study. Adverse drug reactions suspected or probably related to treatment occurred in 17.4% of patients receiving gemifloxacin and in 20% of those receiving comparator antibiotics. Diarrhoea and nausea were experienced by 3.6 and 2.7%, respectively, of gemifloxacin-treated patients (4.6 and 3.2% of comparators), rash by 2.8% (0.6% of comparators) and headache by 1.2% (1.5% of comparators). Gemifloxacin-related vomiting (0.9%), dizziness (0.8%) and taste perversion (0.3%) were uncommon. Treatment discontinuation followed one or more adverse drug reactions in 2.2% of gemifloxacin-treated patients (0.9% due to rash) and 2.1% of comparator-treated patients. A total of 63 deaths (33 receiving gemifloxacin) occurred in the trial population: none were considered related to treatment. A slight prolongation in QT interval (2.56 ms (S.D. +/-24.5)) was observed in gemifloxacin-treated patients: no cardiac arrhythmias were reported. There was a low incidence of liver function tests (LFTs) classified as of potential clinical concern: gemifloxacin (0.4-1.2%), comparators (0.2-1.3%). Serious adverse events (SAEs), occurring during but not necessarily related to therapy, occurred in 3.6% of gemifloxacin-treated patients (4.3% of comparators). SAEs related to treatment agents were rare (0.4% in each group) and included rash (0.1%) and elevated liver enzymes (<0.1%). Gemifloxacin was well tolerated by the elderly, those with renal or hepatic impairment and when co-administered with omeprazole, digoxin, theophylline, warfarin (with which there were no significant interactions) and Maalox. In conclusion, gemifloxacin 320 mg once daily demonstrated a favourable safety and tolerability profile similar to that of comparator antibiotics, including other quinolones.

Oral gemifloxacin once daily for 5 days compared with sequential therapy with i.v. ceftriaxone/oral cefuroxime (maximum of 10 days) in the treatment of hospitalized patients with acute exacerbations of chronic bronchitis

In a randomized, open-label, controlled, multicentre study, the clinical and bacteriological efficacy, safety and tolerability of oral gemifloxacin (320 mg once daily, 5 days) was compared with sequential intravenous (i.v.) ceftriaxone (1 g once daily, maximum 3 days) followed by oral cefuroxime axetil (500 mg twice daily, maximum 7 days) in adult hospitalized patients with acute exacerbations of chronic bronchitis (AECB) (n = 274). The clinical success rates at follow-up (21-28 days post-therapy) in the clinical per-protocol population (the primary endpoint) were 86.8% (105/121) for gemifloxacin vs. 81.3% (91/112) for ceftriaxone/cefuroxime (treatment difference = 5.5,95% CI -3.9,14.9). The corresponding clinical results in the clinical intention-to-treat (ITT) population were 82.6% (114/138) vs. 72.1% (98/136), respectively (treatment difference = 10.5,95% CI 0.7, 20.4).Thus, gemifloxacin had significantly higher clinical success rates than ceftriaxone/cefuroxime. The median time to discharge was 9 days in the gemifloxacin group vs. 11 days in the ceftriaxone/cefuroxime group (P = 0.04, Wilcoxon test). At follow-up, 120/138 (87.0%) gemifloxacin-treated patients had been discharged from hospital, compared with 111/136 (81.6%) ceftriaxone/cefuroxime-treated patients in the clinical ITT population. Both treatments were generally well tolerated and there was no significant difference between the treatment groups in the incidence or type of adverse events reported. A 5-day course of oral gemifloxacin was shown by this study to be at least equivalent to sequential i.v. ceftriaxone/cefuroxime axetil (for up to 10 days) in patients with AECB who require hospital treatment.

Calcium diglutamate improves taste characteristics of lower-salt soup

OBJECTIVE

: To ascertain (1) whether the taste characteristics of a conventionally-salted (150 mM NaCl) soup can be reproduced in soups of substantially lower NaCl level with the help of added glutamate, and (2) whether calcium diglutamate (CDG) is equivalent to monosodium glutamate (MSG) in its effect on the taste of soup.

DESIGN

: Cross-sectional, with multiple measurements on each subject.

SETTING

: Healthy university students.

SUBJECTS

: A total of 107 volunteers, recruited by on-campus advertising.

METHODS

: Subjects tasted 32 soups, with all possible combinations of four NaCl concentrations (0-150 mM), four glutamate levels (0-43 mM), and two glutamate types (MSG, CDG).

MAIN OUTCOME MEASURES

: Ratings of each soup on six scales (liking, flavour-intensity, familiarity, naturalness of taste, richness of taste, saltiness).

RESULTS

: A 50 or 85 mM NaCl soup with added CDG or MSG is rated as high as, or higher than, a 150 mM NaCl soup free of added glutamate on five of the six scales (the exception being saltiness). CDG and MSG have equivalent effects.

CONCLUSIONS

: Addition of glutamate allows substantial reductions in Na content of soup, without significant deterioration of taste. CDG and MSG have equivalent effects, but use of CDG permits a greater reduction in Na intake.

Antibiotic therapy of community respiratory tract infections: strategies for optimal outcomes and minimized resistance emergence

Widespread, increasing antibiotic resistance amongst the major respiratory pathogens has compromised traditional therapy of the major infective respiratory syndromes, including bacterial pneumonia and acute exacerbations of chronic bronchitis. Guidelines for antibiotic prescribing dating from the 1980s to 1990s, which attempted to address such problems, were commonly too prescriptive and difficult to apply, and took little account of end-user practice or locally prevalent resistance levels. Further confusion was caused by conflicting recommendations emanating from differing specialty groups. The evidence that such guidelines benefited either clinical outcomes or treatment costs has been disputed. They have probably had little effect on resistance emergence. We report the recommendations of an independent, multi-national, inter-disciplinary group, which met to identify principles underlying prescribing and guideline formulation in an age of increasing bacterial resistance. Unnecessary prescribing was recognized as the major factor in influencing resistance and costs. Antibiotic therapy must be limited to syndromes in which bacterial infection is the predominant cause and should attempt maximal reduction in bacterial load, with the ultimate aim of bacterial eradication. It should be appropriate in type and context of local resistance prevalence, and optimal in dosage for the pathogen(s) involved. Prescribing should be based on pharmacodynamic principles that predict efficacy, bacterial eradication and prevention of resistance emergence. Pharmacoeconomic analyses confirm that bacteriologically more effective antibiotics can reduce overall management costs, particularly with respect to consequential morbidity and hospital admission. Application of these principles should positively benefit therapeutic outcomes, resistance avoidance and management costs and will more accurately guide antibiotic choices by both individuals and formulary/guideline committees.

Future of the quinolones

New fluoroquinolones and fluoronaphthyridones continue to provide the mainstay of antibiotic development, despite recent events associated with unexpected or uncharacteristically severe adverse drug reactions. These have included hepatotoxicity caused by trovafloxacin (suspended), cardiotoxicity associated with grepafloxacin, and phototoxicity caused by clinafloxacin (both withdrawn). Prolongation of the QT interval appears to be an emergent class effect, the implications of which are not yet fully understood. However, the second-generation agents ciprofloxacin and, latterly, levofloxacin have excellent safety profiles and provide standard optimal choices for therapy of a wide range of gram-negative pathogens. They are also useful for many respiratory infections, though the use of ciprofloxacin in pneumococcal pneumonia has been questioned and continued use of levofloxacin may act as a selection pressure for emergence of quinolone-resistant Streptococcus pneumoniae. Active conservation measures may be required to protect the class from this problem because alternatives, should high-level penicillin-resistance continue to spread, are few. The new 8-methoxy quinolones (moxifloxacin and gatifloxacin) are more highly potent against both penicillin-susceptible and multidrug-resistant S. pneumoniae, while retaining activity against enterobacteria. Clinical Phase III development has shown them to produce very satisfactory clinical and bacteriologic responses in respiratory infections and to be remarkably free of clinically significant adverse effects. Postmarketing surveillance of moxifloxacin in Germany has revealed no additional concerns. These agents are now licensed in many countries, including the United States, and add a further, broad-based respiratory dimension to the future of the class.

Efficacy and safety of gemifloxacin 320 mg once-daily for 7 days in the treatment of adult lower respiratory tract infections

An open-label, non-comparative study assessed the clinical and bacteriological efficacy of gemifloxacin (320 mg, once-daily for 7 days) in lower respiratory tract infections (LRTI). Patients with acute exacerbation of chronic bronchitis (AECB, n=261) or community-acquired pneumonia (CAP, n=216) were enrolled into the study. Clinical success rates at follow-up (days 21-28) in the intent-to-treat (ITT) population were high, 83.1% in AECB patients (95% CI: 77.9, 87.4) and 82.9% in CAP patients (95% CI: 77.0, 87.5). High bacteriological success rates were achieved (bacteriological ITT population), 91.2% (52/57) in AECB patients (95% CI: 80.0, 96.7) and 77.9% (60/77) in CAP patients (95% CI: 66.8, 86.3). Gemifloxacin was well tolerated with a low incidence of adverse events. Gemifloxacin treatment resulted in high clinical and bacteriological success rates and is a well-tolerated therapy for the treatment of LRTIs.

Life's matrix: water in the cell

Water is a profoundly unusual liquid, and its peculiarities may make it uniquely suited to act as life's matrix. Even if this were not so, however, we should expect the effects of nanometre-scale confinement and inhomogeneities owing to surface effects to alter the liquid's properties in the cell relative to those in the bulk. Whether water's unusually high degree of local structure makes such influences even more marked than for 'normal' liquids remains an open question, with potentially important consequences for biomolecular interactions.

Efficacy of gemifloxacin in acute exacerbations of chronic bronchitis: a randomised, double-blind comparison with trovafloxacin

This randomised, double-blind, double-dummy, multinational study compared the efficacy and safety of gemifloxacin with trovafloxacin in the treatment of acute exacerbations of chronic bronchitis. There were 617 patients randomised: 303 to gemifloxacin and 314 to trovafloxacin. Clinical success rates at follow-up (clinical per-protocol population) were 91.5% for gemifloxacin and 87.6% for trovafloxacin. For the intent-to-treat population, the clinical efficacy of gemifloxacin was statistically significantly superior to that of trovafloxacin. In general, the in vitro activity of gemifloxacin against the major respiratory bacterial pathogens was superior to that of other antibiotics tested. Per-patient bacteriological success rates at follow-up (bacteriology per-protocol population) were 86.8% for gemifloxacin and 82.4% for trovafloxacin. Both agents were well tolerated. The clinical and bacteriological efficacy of a once-daily 5-day course of gemifloxacin is at least as good as that of a similar regimen of trovafloxacin in the treatment of acute exacerbations of chronic bronchitis.

Antimicrobial safety and tolerability: differences and dilemmas

The adverse drug reactions associated with antimicrobials have become a topic of major importance and concern in the last few years. Antimicrobial toxicity may take many forms, varying from mild, transient phenomena to dramatic, life-threatening events such as seizures or cardiac arrhythmias. We review the toxicity of antimicrobials in general and of the fluoroquinolones in particular and attempt to explain the adverse events by use of structure-adverse event relationships where possible. There are currently 5 main mechanisms that can be invoked to explain antimicrobial toxicity: direct effects, hypersensitivity, changes in microbial flora, drug interactions, and microbial lysis. The adverse drug reactions seen with fluoroquinolones are explained on the basis of these 5 mechanisms. The various organ systems affected by the fluoroquinolones are considered; then individual members of the fluoroquinolone class are reviewed. The unexpected and dramatic problems encountered with temafloxacin and trovafloxacin are discussed as well.

New antibiotics for community-acquired lower respiratory tract infections: improved activity at a cost?

Opinions are changing as to the continued validity of traditional beta-lactam and macrolide therapy of community acquired LRTI, partly because of resistance and partly because of early evidence that suggests that some new agents may be more effective. Guidelines are altering to reflect this view, although there is conflicting evidence on their effects on outcome. Fluoroquinolones are becoming accepted in the treatment of community acquired pneumonia and are established choices for acute exacerbations of chronic bronchitis. The 8-methoxy fluoroquinolones, moxifloxacin and gatifloxacin, have excellent anti-pneumococcal activity and may become drugs of choice for penicillin/macrolide resistant infections. They appear free of the serious idiosyncratic reaction profiles, possibly related to the immunologically reactive 1-difluorophenyl substituent, which characterised the recently withdrawn temafloxacin, trovafloxacin and tosufloxacin. All quinolones so far tested appear to prolong the QTc interval, but only sparfloxacin and grepafloxacin caused clinical effects. Nevertheless, caution is required until this effect is fully investigated.

Quinolone generations: natural history or natural selection?

The quinolones have evolved from antibacterial agents with a limited spectrum of predominantly anti-gram-negative antimicrobial activity and a restricted number of indications to a class of widely used oral (and, in some cases, intravenous) antibiotics with extensive indications for infections caused by many bacterial pathogens in most body tissues and fluids. This evolutionary pattern has arisen through the development of new core and side-chain structures, with associated improvements in activity, pharmacokinetics and tolerability, and through the selection of molecules that remain useful and well tolerated. This review describes the progress of the quinolones from the first to the third (IIIa and IIIb) generations. Special attention is given to gemifloxacin, currently the most developmentally advanced third-generation quinolone, which has enhanced in vitro gram-positive antimicrobial activity and no troublesome adverse drug reactions. Preliminary data indicate that gemifloxacin should prove to be an important addition to the fluoroquinolone class. Further clinical trial data are awaited with interest.

Moxifloxacin (Avelox): an 8-methoxyquinolone antibacterial with enhanced potency

Moxifloxacin is a novel 8-methoxyquinolone with enhanced potency against important Gram-positive pathogens, notably Streptococcus pneumoniae. It retains class activity against Gram-negative bacteria. Currently available for oral use, it has a prolonged half-life, enabling once-daily administration and reflecting balanced renal and hepatic elimination. Clinical trials have demonstrated an excellent safety record with minor class effects in the skin and gastrointestinal systems. Potential for phototoxicity is minimal and moxifloxacin is free of clinically significant neurological, hepatic or cardiac effects. Investigated primarily in respiratory infections, moxifloxacin has shown excellent performance in community-acquired pneumonia (both pneumococcal and atypical), acute exacerbations of chronic bronchitis and acute maxillary sinusitis. It is available in many European countries and in the US where it is rapidly establishing clinical acceptance and formulary inclusion.

Future antibiotic trials

The true value of antibiotics in acute exacerbations of chronic bronchitis remains to be defined. Although short-term benefits are generally accepted, if prescription volume is an indicator, there is little evidence to support their use in mild exacerbations.Thus, most therapeutic episodes are probably unnecessary and certainly encourage bacterial resistance. In more severe exacerbations, trials must be designed to validate the potential benefits-if they exist-of pharmacologically-improved antibiotics by demonstration of both short- and longer-term benefits. The relevance of standard bacteriological and short-term clinical outcome assessments must be questioned. Alternative outcome measures, e.g., quality of life, may allow differentiation of antibiotic classes. Long-term assessment of symptom-free intervals, related to baseline status, might open pathways to the prevention of progressive, bacteria-initiated inflammatory damage to small airways. There is little excuse for continued ignorance of the nature of bacterial involvement in chronic bronchitis and the potential for more effective therapy.

The effects of grazing management on perennial ryegrass (Lolium perenne L.) herbage mass and persistence in south-eastern Australia

The effect of various grazing management treatments on newly sown and degraded perennial ryegrass pastures was studied at 6 different locations in the temperate high rainfall zone of southern Australia, as part of the Temperate Pasture Sustainability Key Program. The sites were located at Hamilton (2 sites, 1 grazed by cattle, 1 grazed by sheep) and Cavendish, western Victoria, Victor Harbor (Delamere), South Australia, and Ross and Parattah in Tasmania. Grazing management treatments significantly influenced the ryegrass mass and persistence of the pasture, but effects were not always consistent across sites. Autumn closure increased the perennial ryegrass content at Cavendish and Ross, as did the winter and summer closures at Ross. Spring closure increased the perennialryegrass content at Hamilton, Cavendish and Ross, but decreased it at Parattah, as did the summer closures at Parattah and Delamere. Fodder conservation decreased the ryegrass only at Parattah. At the Hamilton sheep site, and at Ross, mob stocking increased the ryegrass content, as did increased superphosphate treatments at Hamilton. Rotational grazing at Cavendish and Delamere increased the ryegrass content, as did the late spring or a late summer closure with a short autumn deferment at Cavendish and Ross, but both these treatments decreased ryegrass at Parattah. The treatments that had a negative effect at Parattah may have had a positive effect on cocksfoot at that site, creating competition for, and decreasing the ryegrass content. At most sites, treatments that included some spelling during spring to foster seed shedding, and spelling again in the following autumn to encourage germination seem to have been of benefit to the perennial ryegrass.

Safety of the new fluoroquinolones compared with ciprofloxacin

Significant safety issues that have arisen with fluoroquinolones include phototoxicity, cardiotoxicity, tendinitis, CNS effects and drug interactions. Ciprofloxacin is well tolerated; the incidence of adverse events is low and serious adverse events are rare. Levofloxacin has a reduced CNS adverse event rate compared with ofloxacin. Sparfloxacin has significant phototoxicity and potential cardiac toxicity. Grepafloxacin has significantly increased adverse event rates, particularly gastrointestinal intolerance. Taste perversion and nausea are common. Trovafloxacin has an increased potential for CNS adverse reactions, notably dizziness. Post-marketing surveillance data indicate the possibility of serious hepatic reactions and pancreatitis. Interactions between fluoroquinolones and drugs metabolised by the hepatic cytochrome P450 system affect the clearance of theophylline and caffeine. Quinolone absorption is significantly reduced by co-administration of antacids. Hospitalised patients are likely to be receiving multiple-drug therapy, but drug interactions are avoidable. The interactions of specific fluoroquinolones should be checked prior to prescription.

New Fluoroquinolones: Real and Potential Roles

The second-generation fluoroquinolones have enjoyed successful clinical use for more than 10 years in many countries, and they have a valued and proven record of safety and efficacy. However, deficiencies with respect to gram-positive and anaerobic organisms limit the use of these agents in respiratory, intra-abdominal, and pelvic infections. New, third-generation agents with dramatically increased activity against gram-positive and anaerobic bacteria--notably, Streptococcus pneumoniae and Bacteroides fragilis--have shown high rates of efficacy in pneumonia, bronchitis, and surgical and gynecologic infections. Although most of these new drugs produce similar clinical results, adverse reaction profiles differ and may influence therapeutic choices.

Comparative tolerability of the newer fluoroquinolone antibacterials

The most common adverse effects of the fluoroquinolones involve the gastrointestinal tract, skin and CNS, and are mainly mild and reversible. Of the gastrointestinal events, nausea and vomiting are the most common. Mild hepatic reactions are a class effect, usually presenting as mild transaminase level increases without clinical symptoms. However, postmarketing surveillance has revealed significant hepatotoxicity with trovafloxacin. It is not currently known whether the severe reactions to trovafloxacin are specific to that agent or simply represent an extreme of an emerging class effect. The enormous worldwide usage of, and extensive published adverse effect data on the other fluoroquinolones and naphthyridones suggests the former. In perspective, rare but serious hepatotoxicity has been reported with other fluoroquinolones and the overall incidence of trovafloxacin hepatotoxicity is not dissimilar to that reported with flucloxacillin and amoxicillin-clavulanic acid. CNS reactions vary in severity and include dizziness, convulsions (notably with lomefloxacin) and psychoses. Fluoroquinolones differ in their pro-convulsive activity, relating to their differing potential as gamma-aminobutyric acid antagonists and binding to the N-methyl-D-aspartate receptor. The basis for the increased seizure potential following the coadministration of nonsteroidal anti-inflammatory drugs with certain fluoroquinolones is not fully understood. Fluoroquinolone phototoxicity, caused by the generation of toxic free oxygen species under exposure to UVA radiation, is significantly more common with 8-halogenated compounds. Certain patient groups, e.g. patients with cystic fibrosis, are predisposed to this adverse effect. Murine photocarcinogenicity has been demonstrated with lomefloxacin, but no such effects have been reported in humans. Prolongation of the QTc interval is also a class effect, although cardiac arrhythmias have only been linked with sparfloxacin. Among the newer fluoroquinolones, clinically significant cardiac events are rare or absent but possible interactions in patients receiving other drugs capable of causi ng QT prolongation should be anticipated. Tendinitis and rupture, usually of the Achilles tendon, are rare, class-effects of fluoroquinolones, most frequently reported with pefloxacin. Predisposing factors include aging, corticosteroid use, renal disease, haemodialysis and transplantation. Use of fluoroquinolones in paediatric patients remains contentious. However, accruing human data suggest that restrictions on paediatric use imposed because of fluoroquinolone-induced cartilage damage in juvenile animals, may soon be relaxed. Data from over 1700 children in the UK failed to disclose arthropathy and extensive paediatric use of norfloxacin in Japan and ciprofloxacin in developing countries has been free of articular effects.

Therapy for pneumococcal infection at the millennium: doubts and certainties

Rapidly burgeoning worldwide multiple drug-resistant pneumococcal serotypes pose an urgent demand for new management approaches. Perhaps modern intensive care methods may have alternatives to offer. Indeed, standard assessments such as the admission APACHE II score may overestimate individual risk of death in severe CAP, and mortality can be reduced. However, among those at highest risk for mortality in the early phase of invasive disease, the conclusions reached 2-3 decades ago, that it is questionable whether a more effective drug than penicillin can be developed, and that a reduction in the number of deaths consequent to this infection can be accomplished only by widespread immunoprophylactic measures, remain inescapable. Clearly, as discussed elsewhere in this supplement, the continuing validity of these 20-year-old conclusions and the global prevalence of DRSP demand the development and marketing of new conjugate vaccines, although more widespread use of the existing 23-valent polysaccharide vaccine among high-risk populations is essential in the interim. With respect to resistance selection pressures, antibiotic prescription control may provide the answer. However, patient expectations of antibiotic therapy for trivial respiratory infection is high and, in the United Kingdom, 75% of previously healthy adults will receive it; those who do not will usually consult another physician in an effort to secure such therapy. Thus, without the intervention of government or managed care organizations, self-regulation in prescribing is unlikely. The evidence for beta-lactam treatment failure in meningitis has led to alternative approaches, with vancomycin as the primary agent. Penicillins may remain effective for otitis media, but oral cephalosporins are suspect. Data on pediatric pneumococcal pneumonia continue to suggest use of beta-lactams, at least for disease caused by strains with intermediate penicillin sensitivity. Pallares et al concluded that penicillins and cephalosporins remain the drugs of choice for severe pneumococcal pneumonia in adults. Others who share this conclusion often cite that study as evidence. However, in the case of penicillins, the mortality rate was 6% higher in a subgroup selected for monomicrobial infection and reduced risk factors for mortality when penicillin-resistant infection was present, and the overall mortality was 14% higher with penicillin-resistant strains (taking into account "all comers"). Those who depend on the findings of evidence-based medicine may accept the premise that penicillins and cephalosporins remain the drugs of choice, and agree with Goldstein and Garau that it would indeed be a mistake to adopt alternative therapies. Others may consider the deaths of 6 of 100 patients who were not in the highest-risk group too high a price to pay for statistical significance and may be skeptical of the continued use of beta-lactam therapy on higher-risk patients. In addition, the persistent selection pressure applied by continued use of beta-lactams offers a powerful population-based argument for alternatives. As DRSP continues to spread and resistant strains with penicillin MIC >2 mg/L become more prevalent, new agents such as the azabicyclo-methoxyquinolone, moxifloxacin, and perhaps grepafloxacin, but not the more toxic sparfloxacin and trovafloxacin, will undoubtedly flourish as treatments for CAP. By that time, the results of clinical studies on ketolides and oxazolidinones could offer further choices.

Principles for formulating parenteral nutrition for neonates

Total parenteral nutrition in humans began with work on neonates, and every year since then there have been important new discoveries. In the past 12 months there have been important new preliminary findings in parenteral nutrition cholestasis, and in bone mineralization. There has been further work on clinical pathways and other aspects of quality assurance, and scientists continue to find new aspects.

Four-level cervical corpectomy

STUDY DESIGN

Retrospective analysis of 31 cases of cervical spondylotic myelopathy treated by four-level subaxial cervical corpectomy.

OBJECTIVE

To determine whether extremes of anterior decompression and fusion have inordinate or unique levels of morbidity.

SUMMARY OF BACKGROUND DATA

There is a paucity of data on experience with four-level corpectomy. However, counsel against such surgery can be found.

MATERIALS AND METHODS

The records and studies of 31 consecutive cases of cervical spondylotic myelopathy, treated by four-level corpectomy, were retrospectively analyzed. Patients in 26 cases were observed longer than 2 years. No hardware was used in the procedures. External orthosis, worn for 6 months, was a Philadelphia-type collar in 25 patients and a halo vest in 6.

RESULTS

Three patients died within 3 weeks of surgery (9.7%). Delayed radiculopathy occurred in four patients after surgery, three had acute graft complications, and one had pseudomeningocele, for a morbidity rate of 25.8%. There was no infection or worsened myelopathy.

CONCLUSIONS

No unique morbidity is associated with extremes of subaxial decompression when compared with surgery of lesser extent.