Problems encountered in setting up support groups in nursing

There has been much discussion on the value of support groups as a means of enabling nurses to deal with the emotional costs of their daily work. This paper describes a range of problems encountered while setting up support groups. Some of the groups were specifically to help nurses give up smoking while others were planned to help with a wide range of problems. From the findings, suggestions are made which may be of value to nurses in all specialties.     

Fixed‐dose vs free‐dose combinations for the management of hypertension—An analysis of 81 958 patients

Fixed‐dose combinations (FDC) have been developed to reduce the pill burden for hypertensive patients. Data on fixed‐dose or free‐dose (freeDC) ramipril/amlodipine (R/A) or candesartan/amlodipine (C/A) combination treatment initiation were assessed. 71 463 patients were prescribed R/A and 10 495 C/A. For both R/A and C/A, FDC patients were younger (both P < .001) and less comorbid. Prior MI (OR: 0.61 and 0.60), prior stroke (OR: 0.68 and 0.70) and CHD (OR: 0.68 and 0.64) were negatively associated with FDC use, whereas hyperlipidemia was positively associated (OR: 1.26 and 1.19). Use of antihypertensive comedication (OR: 0.78; OR: 0.55) and treatment discontinuation within 12 months (HR: 0.65 and 0.82) were less likely in FDC patients, who also showed superior adherence (mean MPR; both P < .001). Cost of the combination was higher for FDCs (both P < .001). FDCs improve persistence and adherence, although they are more commonly prescribed in patients with less cardiovascular disease.     

Oral Rizatriptan Versus Oral Sumatriptan: A Direct Comparative Study in the Acute Treatment of Migraine

Rizatriptan is a potent, oral, 5-HT_1B/1D agonist with more rapid absorption and higher bioavailability than oral sumatriptan. It was postulated that this would result in more rapid onset of effect. This randomized, double-blind, triple-dummy, parallel-groups study compared rizatriptan 5 mg, rizatriptan 10 mg, sumatriptan 100 mg, and placebo in 1268 outpatients treating a single migraine attack. Headache relief rates after rizatriptan 10 mg were consistently higher than sumatriptan at all time points up to 2 hours, with significance at 1 hour (37% versus 28%, P =0.010). All active agents were significantly superior to placebo with regard to headache relief and pain freedom at 2 hours ( P ≤0.001). The primary efficacy endpoint of time to pain relief through 2 hours demonstrated that, after adjustment for age imbalance, rizatriptan 10 mg had earlier onset than sumatriptan 100 mg ( P =0.032; hazard ratio 1.21). Rizatriptan 10 mg was also superior to sumatriptan on pain-free response ( P =0.032), reduction in functional disability ( P =0.015), and relief of nausea at 2 hours ( P =0.010). Significantly fewer drug-related clinical adverse events were reported after rizatriptan 10 mg (33%, P =0.014) compared with sumatriptan 100 mg (41%). We conclude that rizatriptan 10 mg has a rapid onset of action and relieves headache and associated symptoms more effectively than sumatriptan 100 mg.     

Interleukin-1β-stimulated invasion of articular cartilage by rheumatoid synovial fibroblasts is inhibited by antibodies to specific integrin receptors and by collagenase inhibitors

Objective. To study the role of integrin receptors in the invasion of cartilage by rheumatoid synovial fibroblasts (RSF). Methods. RSF were cocultured with cartilage slices alone or in the presence of various potential activators or inhibitors. The penetration of the cartilage surface by RSF was determined by live-cell imaging of fluorescent-labeled cells. Results. Interleukin-1β (IL-1β) and IL-8 stimulated the RSF invasion of cartilage. Invasion was specific for RSF and required a concentration gradient of IL-1β. The IL-1β-activated invasion of cartilage was inhibited by anti-IL-1 antibodies, IL-1 receptor antagonist, and collagenase inhibitors. RSF invasion was also inhibited by antibodies to α4, α5, αV, and β1 integrins. Conclusion. In this study, an IL-1β concentration gradient was required for RSF invasion into cartilage, raising the possibility that in vivo invasion may be induced by IL-1β released by chondrocytes. The IL-1β activation of RSF assayed in vitro may contribute to the RSF invasion of cartilage in vivo. Cartilage invasion requires the availability of β1 and α4, α5, and αV integrins and the presence of collagenase activity.     

Effects of pulse methylprednisolone on inflammatory mediators in peripheral blood,synovial fluid,and synovial membrane in rheumatoid arthritis

Objective. To establish whether the clinical efficacy of pulse methylprednisolone (MP; 1,000 mg intravenously) is related to the modulation of proinflammatory cytokines within the peripheral blood, synovial membrane, or synovial fluid compartments. Methods. Eighteen patients with active rheumatoid arthritis (RA) were studied. Peripheral blood (11 patients) and knee synovial fluid (9 patients, 10 knees) were obtained before and at 4 and 24 hours after MP therapy. Interleukin-1β (IL-1β), IL-8, and tumor necrosis factor α (TNFα) were measured by enzyme-linked immunosorbent assay and biologic assays; prostaglandin E₂ (PGE₂) was measured by competitive radioimmunoassay. In 10 patients, arthroscopically directed synovial biopsies were obtained before and at 24 hours after treatment, at disease relapse (4 patients), and after retreatment (1 patient). Membranes were stained by immunohistochemical techniques with monoclonal antibodies against TNFα, IL-8, IL-1β, and the IL-1 receptor antagonist protein (IL-1Ra). Results. MP therapy was associated with a rapid (within 24 hours) and substantial decrease in the expression of TNFα in the lining and sublining regions of the synovial membrane, as well as substantial decreases in the levels of TNFα in serum and synovial fluid. There was also reduced IL-8 expression in the synovial lining, as well as reduced synovial fluid IL-8 levels. No effect on synovial membrane IL-1β and IL-1Ra or synovial fluid IL-1β and PGE₂ was found. Conclusion. MP therapy rapidly reduces IL-8 and TNFα levels in the synovial compartment, with cytokine changes in the serum and synovial fluid reflecting the changes in the synovial membrane. Alterations in TNFα expression in the synovial membrane correlated with clinical response to, and subsequent relapse after, MP therapy.     

Adenosine A1 receptor promotion of multinucleated giant cell formation by human monocytes. A mechanism for methotrexate-induced nodulosis in rheumatoid arthritis

Objective. To determine why methotrexate (MTX) exacerbates rheumatoid nodules in some patients, despite the effective suppression of synovial inflammation. Methods. Phorbol myristate acetate (PMA)-induced differentiation of monocytes into multinucleated giant cells was used as an in vitro model to study the effects of adenosine on nodulosis. Results. MTX at 200-2,000 nM or the adenosine A₁ agonist N⁵-cyclopentyl adenosine (CPA) (10⁻¹² to 10^-9 M) or the A₂ antagonist 3,7-dimethyl-1-propargylxanthine markedly enhanced giant cell formation, whereas the adenosine A₁ antagonist 8-cyclopentyl-dipropylxanthine completely reversed these effects. PMA, CPA, and MTX induced adenosine release by cultured monocytes at concentrations consistent with those associated with predominantly A₁ effects. Furthermore, surface expression of A₁ receptors was found to remain unchanged on the differentiating cells throughout the culture period. Conclusion. Agents that inhibit adenosine A₁ receptors might be useful in the treatment of MTX-induced rheumatoid nodulosis, while still potentiating the A₂-mediated antiinflammatory effects of MTX on synovitis.     

The AIMS2-SF. A short form of the arthritis impact measurement scales 2

Objective. To develop a short form of the Arthritis Impact Measurement Scales 2 (AIMS2) questionnaire, preserving content validity as the priority criterion. Methods. A 2-step reduction procedure was used: 1) Delphi technique, with 1 panel of patients and 1 panel of experts each selecting 1 set of items independently; and 2) nominal group technique, where members of both panels reached consensus on the final selection of items, using information derived from item analysis. Psychometric properties of the AIMS2-Short Form (AIMS2-SF) and AIMS2 were compared using data from a cohort of 127 rheumatoid arthritis patients who completed the AIMS2 twice prior to the initiation of methotrexate (MTX) treatment and 3 months post-initiation of MTX treatment. Results. The 2 panels reached consensus on a 26-item AIMS2-SF (54.4% reduction from the AIMS2). Factor analysis showed preservation of the 5-component structure. Convergent validity (Physical and Symptom components with clinical variables: r = 0.24-0.59), test-retest reproducibility (intraclass correlation coefficient >0.7), and sensitivity to change at 3 months (standardized response mean 0.36-0.8, except Social Interaction component [0.08]) were very close to the values for the original AIMS2. Conclusion. The AIMS2-SF is a shorter version of the AIMS2 (i.e., available in 2-page format) and has psychometric properties similar to those of the AIMS2.