Comparing gatifloxacin and clarithromycin in pneumonia symptom resolution and process of care

In looking for outcome differences beyond rates of cure, we prospectively compared the symptom resolution, side effects, and processes of care between the use of clarithromycin and gatifloxacin for the treatment of radiographically confirmed community-acquired pneumonia. We conducted a multicenter, randomized, open-label study comparing gatifloxacin monotherapy to clarithromycin alone or combined with ceftriaxone for patients with multiple risk factors. We measured the return to usual activities and symptoms over seven interviews ending 42 days after randomization. Admission and hospital discharge decision support were provided to treating physicians. We enrolled 266 patients over the age of 18 years between September 2000 and June 2003. The groups were similar in age and gender, with a mean age of 53.5+/-19.4 years, and were 54% female. Patient severity as determined by the number of risk factors and the Pneumonia Severity Index was similar between groups; 95% of the patients were low risk. A total of 91% of patients completed at least five of seven symptom interviews. In the clarithromycin study arm, 64% received concomitant therapy with ceftriaxone. We found no significant difference in return to usual activities, pneumonia-specific symptom scores, and 12-item short-form health survey scores. Individual symptom scores were similar except for bad taste and injection site soreness, which were higher in clarithromycin patients. The rates of hospital admission and length of stay were similar. The cost of antibiotic was higher in the clarithromycin group: $257 versus $110 for gatifloxacin. We found that gatifloxacin monotherapy is similar to clarithromycin given with or without ceftriaxone for the treatment of community-acquired pneumonia, except that antibiotic cost, bad taste, and injection site soreness favor the use of gatifloxacin.     

Biologically inspired approaches to drug delivery for nerve regeneration

As the biological processes governing nerve regeneration have become elucidated over the past decades, interest has developed in manipulating these processes to improve nerve regeneration. Drug delivery to the regenerating nerve has the potential for major clinical applications in neurodegenerative diseases, spinal cord injury and peripheral nerve injury or sacrifice. This article reviews the evolution of the field of drug delivery to the regenerating nerve, from simple local applications of neurotrophic agents in solution and osmotic pump delivery, to the existing approaches involving novel biomaterials and genetically manipulated cell populations. A discussion of the various known nerve growth-promoting agents, and the chemical considerations involved in their delivery, is included. A perspective on the role of tissue engineering approaches for nerve regeneration in the future is offered.     

Open-access colonoscopy in Ontario: Associated factors and quality

BACKGROUND

Open-access (OA) colonoscopy may increase efficiency and decrease wait times; however, because the patient is seen for the first time at the endoscopy appointment, previous processes, such as information about the procedure, preparation and appropriate triage, may be suboptimal.

OBJECTIVE:

To identify factors associated with OA colonoscopy and to determine the relationship between OA colonoscopy and an important quality measure, incomplete colonoscopy.

METHODS:

A population-based analysis of all adult outpatients undergoing a first-time colonoscopy between 1997 and 2007 in Ontario was performed. Colonoscopy was considered to be OA if there were no visits in the preceding five years with the physician performing the colonoscopy. Using logistic regression, patient, physician and institution factors associated with OA colonoscopy were identified. Using propensity score matching, the relationship between OA colonoscopy and incomplete colonoscopy in 2006 was examined.

RESULTS:

A total of 1,079,259 colonoscopies were performed. Of these, 14% were OA in 1997 compared with 26% in 2007. Patients 50 to 69 years of age, those from higher-income neighbourhoods and those with less comorbidity were more likely to undergo OA colonoscopy. The odds of receiving OA colonoscopy were six times greater in a nonhospital clinic compared with a community hospital. Colonoscopy was more likely to be complete if the procedure was OA (OR 1.3 [95% CI 1.2 to 1.4]; P<0.0001).

CONCLUSIONS:

Rates of OA colonoscopy have increased substantially since 1997. Institution type was most strongly associated with OA colonoscopy. Colonoscopy completeness, a recognized quality indicator, does not appear to be compromised by OA colonoscopy.     

Update on facial nerve repair

Facial paralysis is a complex clinical problem, and optimal management strategies continue to evolve. Areas of active investigation include improvements in neural repair techniques, and the examination of new anastomotic materials and methods, as well as the development of alternative neural bridging materials. Current controversies in nerve grafting techniques, the use of novel neural conduit materials, timing of facial nerve procedures, and frontiers in experimental nerve grafting techniques are reviewed.     

Sonographic estimation of fetal weight. The value of femur length in addition to head and abdomen measurements

Sonographic estimation of fetal weight in utero was performed in 167 live-born fetuses examined within one week of delivery. Regression models were based on measurements of abdominal circumference, head circumference, biparietal diameter, and femur length, both alone and in combination. The best results (1 S.D. = 7.5% of actual weight) were obtained by combining measurements of the fetal head, abdomen, and femur, most likely due to the strong linear relationship between femur length and crown-heel length.     

Estimating fetal age: computer-assisted analysis of multiple fetal growth parameters

Regression models for predicting menstrual age based on real-time sonographic measurements of four fetal parameters (biparietal diameter, head circumference, abdominal circumference, and femur length), used alone and in combination, were developed in a cross-sectional study of 361 fetuses between 14 and 42 menstrual weeks. The head circumference and femur length were the strongest individual predictors of age. A number of combinations of fetal parameters, including the combination of head circumference and femur length, provided age estimates that were significantly better (p = 0.05) than those using any single parameter alone. It was also demonstrated that simply averaging individual age estimates in a given case could provide results that were not significantly different from those obtained by using the same parameters in a complex regression equation. The advantages and potential pitfalls of this system of fetal dating are discussed.     

Use of femur length/abdominal circumference ratio in detecting the macrosomic fetus

The femur length/abdominal circumference ratio, expressed as FL/AC X 100, was determined in 156 fetuses and evaluated as a predictor of fetal macrosomia within one week prior to delivery. The normal range (mean +/- 2 SD) in the 105 normal-weight fetuses was 22.0 +/- 2, while the normal range in the 51 macrosomic fetuses was 20.5 +/- 2; these differences were highly significant (P = less than .0001). The predictive power of a positive ratio was 68%, with a sensitivity of 63%. This ratio was particularly useful in the subset (n = 9) of macrosomic fetuses whose mothers were diabetic, correctly identifying 89% of this group. Because it is age independent, this ratio should prove most helpful in identifying fetuses at risk for macrosomia in patients whose dates are not known, since it may become abnormal before the fetal weight falls above the 90th percentile at term (3,900 g). In patients whose dates are known, early fetal macrosomia is best predicted by evaluating the abdominal circumference against normal standards for age.     

Gene expression profiling in peripheral blood mononuclear cells from patients with sporadic amyotrophic lateral sclerosis (sALS)

The aim of this study was to identify gene expression profiles in peripheral blood mononuclear cells (PBMCs) from sporadic amyotrophic lateral sclerosis (sALS) patients to gain insights into the pathogenesis of ALS. We found that upregulation of LPS/TLR4-signaling associated genes was observed in the PMBCs from sALS patients after short-term cultivation, and that elevated levels of gene expression correlated with degree of peripheral blood monocyte activation and plasma LPS levels in sALS. Similar patterns of gene expression were reproduced in LPS stimulated PBMCs from healthy controls. These data suggest that chronic monocyte/macrophage activation may be through LPS/TLR4-signaling pathways in ALS.     

Evaluation and management of the patient with postoperative facial paralysis

Postoperative facial paralysis comprises a spectrum of injuries ranging from mild, temporary weakness to severe, permanent paralysis, affecting as little as one muscle group to as much as the full hemiface. Herein is presented an introductory review of iatrogenic facial paralysis, from initial evaluation and decision making to the full range of conservative and operative management.