Management of asthma in adults in primary care

Asthma is a chronic inflammatory disease of the airway which is often misdiagnosed and undertreated. Early diagnosis and vigilant asthma control are crucial to preventing permanent airway damage, improving quality of life and reducing healthcare burdens. The key approaches to asthma management should include patient empowerment through health education and self-management and, an effective patient-healthcare provider partnership.

Proper quality control of formulated foot-and-mouth disease vaccines in countries with prophylactic vaccination is necessary

Vaccination is considered as an important tool to control foot-and-mouth disease (FMD). A good quality vaccine containing relevant serotypes and matching strains is a pre-requisite for vaccination to be effective. The present study investigated the quality of different brands of FMD vaccine available in Pakistan, including three locally produced and two imported products. All the vaccines were found free of bacterial or fungal contamination. No adverse effects were noted in suckling mice and buffalo calves inoculated with the vaccines, showing that the vaccines were sterile and safe. The humoral immune response to the FMD vaccines was determined in buffalo calves for 234 days post-vaccination. Very low humoral immune responses against FMD serotypes O, A and Asia 1 viruses were detected to the locally produced vaccines. The imported vaccines, however, elicited a higher antibody response which persisted for a long period in one of the 2 vaccines. The present study highlights the need of assessing an independent vaccine quality control of finished FMD vaccine products.

Detection and genetic characterization of foot-and-mouth disease viruses in samples from clinically healthy animals in endemic settings

A total of 1501 oral swab samples from Pakistan, Afghanistan and Tajikistan were collected from clinically healthy animals between July 2008 and August 2009 and assayed for the presence of foot-and-mouth disease virus (FMDV) RNA. The oral swab samples from two (of four) live animal markets in Pakistan (n = 245), one (of three) live animal market in Afghanistan (n=61) and both the live animal markets in Tajikistan (n=120) all tested negative. However, 2 of 129 (∼2%) samples from Gondal and 11 of 123 (9%) from Chichawatni markets in Pakistan were positive for FMDV RNA. Similarly, 12 of 81 (15%) samples from Kabul and 10 of 20 (50%) from Badakhshan in Afghanistan were found to be positive. Serotypes A and O of FMDV were identified within these samples. Oral swab samples were also collected from dairy colonies in Harbanspura, Lahore (n=232) and Nagori, Karachi (n=136), but all tested negative for FMDV. In the Landhi dairy colony, Pakistan, a cohort of 179 apparently healthy animals was studied. On their arrival within the colony, thirty-nine (22%) of these animals were found positive for FMDV RNA (serotype A was identified), while 130 (72.6%) had antibodies to FMDV non-structural proteins. Thus, newly introduced animals may be a significant source of the disease in the colony. Only two animals from the cohort were detected as becoming positive for FMDV RNA during a follow-up period of 4months; however, only 10 animals remained negative for anti-NSP antibodies during this period.

Intravenous ketamine is as effective as midazolam/fentanyl for procedural sedation and analgesia in the emergency department

The study compared the effectiveness of ketamine and midazolam/fentanyl as procedural sedation and analgesia agents for reduction of fractures and dislocated joints. Forty-one adult patients were enrolled by convenience sampling. They were randomized to receive ketamine or midazolam/fentanyl. Depth of sedation, pain score, procedural outcome and memory of the procedure were documented. The ketamine group had deeper sedation, but there was no statistical difference in other variables between the two groups. Three patients in the midazolam/fentanyl group had oxygen desaturation. More adverse effects were associated with ketamine. Intravenous ketamine is as effective as midazolam/fentanyl for procedural sedation.

The immune response of guinea pigs and buffalo calves to the locally prepared Brucella abortus strain 19 vaccine

Brucella abortus vaccine was prepared from strain 19 imported from Germany. The vaccine induced a good immune response in guinea pigs as evidenced by a serological titre of 328 international units (IU)/ml 10 days post-vaccination. Vaccinated guinea pigs also withstood an experimental challenge of 5,000 colony-forming units of a locally isolated virulent B. abortus strain. This vaccine, containing 7 x 10(10) viable organisms, induced a significant immune response in 8 to 10.5 month old female buffalo calves. Significant serum agglutination test (SAT) titres were seen on day 7 following vaccination. The highest SAT titres were observed on day 14 post-vaccination and the titres started declining thereafter. The rate of decrease was slow from day 14 to day 49 post-vaccination; however, a rapid decrease in titres was seen from day 49 to day 91 post-vaccination. Negligible SAT titres were observed on day 91 post-vaccination. Specific immunoglobulin G titres, as measured by 2-mercaptoethanol treated SAT, also followed a similar trend and the titre of all five of the calves that were vaccinated became zero on day 91 post-vaccination.

Comparison of carvedilol and atenolol for angina pectoris

The antianginal efficacy of carvedilol, a novel beta-blocking agent with vasodilating action, and atenolol were compared in 12 patients with stable effort angina and a positive stress test response. All patients received single doses of placebo, carvedilol, 25 and 50 mg, and atenolol, 50 mg. Heart rate at rest was reduced by 11 and 12 beats/min with both drugs, but only carvedilol, 50 mg, reduced blood pressure at rest. Both carvedilol, 50 mg, and atenolol, 50 mg, increased mean exercise time (24% and 34%, respectively, compared with placebo), time to angina (35% and 51%, respectively), and time to 1 mm of ST-segment depression (54% and 102%, respectively, p less than 0.05 carvedilol vs atenolol). Carvedilol, 25 mg, produced smaller, directionally similar changes in exercise performance, which did not reach statistical significance except for time to 1 mm of ST depression. Both drugs in the 50-mg dose reduced ST-segment depression similarly at maximal and submaximal work levels and lowered heart rate and rate-pressure product at maximal and submaximal work. Carvedilol, 50 mg alone, significantly lowered maximal systolic pressure and rate-pressure product at 1 mm of ST-segment depression. Despite some evidence of vasodilator activity for carvedilol, there was no significant difference in antianginal efficacy with a conventional beta-blocking drug.

Validation of a real-time electrocardiographic monitor for detection of myocardial ischemia secondary to coronary artery disease

A new real-time electrocardiographic (ECG) monitor (QMED Monitor OneTM) was evaluated to assess its accuracy in detecting ischemic ST-segment changes in 43 patients (34 men, 9 women, mean age 56 +/- 11 years) during exercise stress testing. The output of QMED was compared with ST-segment measurements from a Marquette CASE-II computer (ECGM) using a bipolar lead CM5, defining a positive ECG as at least 1 mm of planar or downsloping ST depression. Results were concordant in 33 patients, 15 with both positive and 18 both negative responses, yielding an accuracy (expressed as sensitivity, specificity, positive and negative predictive accuracy) of 83%, 72%, 68% and 86%, respectively. Seven false-positive QMED episodes occurred: 4 due to excess baseline wander or noise in the control ECG, which may have been prevented by reapplication of electrodes, and all 7 episodes were correctly discounted by inspection of the sample ischemic ECG output, yielding an accuracy of 81%, 100%, 100% and 85%. Mean duration and maximal magnitude of ST depression in patients with a positive ECG response was 7.9 +/- 7 minutes and 1.7 +/- 0.6 mm for QMED and 8.9 +/- 7 minutes and 2.2 +/- 0.7 mm for ECGM. The 3 false-negative QMED events were relatively brief and mild ischemic episodes and slight differences in electrode placement between the 2 systems may account for this discrepancy in 2 of the patients. Real-time ST monitoring with QMED is sufficiently reliable for clinical use. Optimal specificity depends on the ability to inspect sample ECG traces to verify a stable baseline and confirm episodes of ischemic ST-segment shift.