Randomized controlled trial of adjuvant oral dexamethasone pulse therapy in pemphigus vulgaris: PEMPULS trial

OBJECTIVE: To determine the therapeutic effect of adjuvant dexamethasone pulse therapy when given in addition to conventional treatment of pemphigus vulgaris. DESIGN: A randomized, placebo-controlled trial. SETTING: International European, multicenter outpatient and inpatient study. PATIENTS: Of the 20 enrolled patients, 11 were randomized to the dexamethasone pulse (DP) group and 9 to the placebo pulse (PP) group. INTERVENTIONS: Oral dexamethasone in 300-mg pulses or PPs 3 days per month. During the intervention, the DP and PP groups received conventional treatment with prednisolone, 80 mg/d, which was tapered across 19 weeks, and azathioprine sodium, 3 mg/kg per day, until the end of the study. Monthly pulses were continued until prednisolone treatment was tapered to 0 mg. MAIN OUTCOME MEASURES: Number of patients in remission, time to and duration of remission, cumulative prednisolone dose, and occurrence of adverse events during 1 year of follow-up. RESULTS: Eight of the 11 DP-treated patients and all 9 PP-treated patients achieved remission. Mean time to remission was 173 days with DP and 176 days with PP. The mean duration of remission within the first year was 151 days for DP and 141 days for PP. Mean cumulative prednisolone dose was 5300 mg for DP and 4882 mg for PP. Weight gain (>5% of baseline) occurred in 8 DP-treated patients compared with 1 PP-treated patient (P<.01). We found no statistically significant difference (P>.05) of an adjuvant effect of DP on remission of pemphigus vulgaris. CONCLUSION: In patients with new pemphigus vulgaris disease activity, there was no benefit of oral DP therapy given in addition to conventional treatment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00127764.     

The medicalization of aboriginal children: a comparison of the lengths of hospital-stay of aboriginal and non-aboriginal children in Western Australia and the Northern Territory

This paper compares the lengths of hospital-stay of Aboriginal and non-Aboriginal children in Western Australia and the Northern Territory over the past few years. The comparison yields two trends: Aboriginal children stay longer in hospital than do non-Aboriginal children; within each racial group, children stay longer in hospital in the Northern Territory than in Western Australia. By-and-large, these trends continue irrespective of age, sex, diagnostic category, hospital and usual place of residence. It appears that factors in addition to high rates of infectious disease, severity of illness and remoteness of home address affect length of hospital stay. Two organizational factors are suggested: the latent, working logic of service institutions such as public hospitals and the tendency of government to institutionalize impoverished people. It is concluded however, that as health care becomes holistic and more the responsibility of Aboriginal people, there is every reason to predict a decrease in the lengths of hospital stay of Aboriginal children.     

Making choices in healthcare: the reality of scarcity

Processes are required to aid decision-makers in better managing existing resources in healthcare. To date, limited research has informed priority setting at the macro level, across broad service areas, within health organizations. As part of a participatory action research project, a macro-level resource allocation framework was developed and implemented in the Calgary Health Region (CHR). The approach relies on an expert panel of managers and clinicians who are charged with identifying, on the basis of evidence and local information, how resources might be reallocated to improve population well-being. The framework developed was seen as an improvement over historical allocation processes.     

Marginal donor lungs: a reassessment

OBJECTIVE: Lung transplantation is limited by the shortage of suitable donors. To overcome this problem, many programs have begun to use marginal or extended donors after reports suggesting equivalent outcomes with no additional risk. As our use of extended donor lungs increased and our recipient selection criteria expanded, we believed it was appropriate to reevaluate outcomes with extended donor lungs compared with outcomes with standard donor lungs and recipients outside of the currently accepted guidelines. METHODS: We performed a retrospective review of 128 consecutive lung or heart-lung transplants from January 1, 1997, to June 30, 2000. The primary endpoint was 30-day mortality. Donors were considered extended if any one of the following criteria were met: age greater than 55 years, smoking longer than 20 pack-years, presence of chest radiographic film infiltrate, PO (2) of less than 300 mm Hg, or purulent secretions on bronchoscopy. Guideline and nonguideline recipients were defined on the basis of previously published criteria. RESULTS: Of a total of 123 donors, 63 (51%) were extended. Forty-eight donors failed 1 criterion, 10 failed 2 criteria, and 5 failed 3 criteria. One hundred twenty-eight transplants were performed. The 30-day mortality for the standard donor group was 4 (6.2%) of 65 versus 11 (17.5%) of 63 for the extended donor group (P =.047). CONCLUSIONS: Although many extended donor lungs will result in acceptable postoperative function, caution needs to be exercised in the uses of certain extended donor lungs because there seems to be an increased early mortality rate in that group of recipients. Nonguideline recipients appear to have acceptable early mortality, except when they received extended donor lungs.     

Treatment of patients with lung cancer and severe emphysema: lessons from lung volume reduction surgery

Lung volume reduction surgery (LVRS) is effective therapy for selected patients with end-stage emphysema. Surgery produces improved pulmonary function, increased exercise tolerance and enhanced quality of life. It has been shown to be superior to medical management over the short-term in randomized controlled trials. The experience gained by dealing with this select group of patients has had a substantial impact on management of lung cancer in some patients with advanced lung disease. Numerous surgical, anaesthetic, and nursing advances gained in dealing with lung volume reduction surgery (LVRS) procedures now allow surgery to be considered as the optimal cancer management technique. For some carefully selected candidates, cancer resection and LVRS can be performed simultaneously, with dual benefits. The physiologic principles underlying LVRS and selection guidelines will be reviewed. The impact on cancer management and the current strategy at Toronto General Hospital will also be presented.     

Carotid pressure is a better predictor of coronary artery disease severity than brachial pressure

The mechanisms relating pulse pressure to cardiovascular outcome may include surrogacy for coronary disease severity. Although pulse pressure is typically measured at the brachial artery, central pulse pressure and its principal determinant, large-artery stiffness, may relate more closely to disease severity. This study aimed to determine the relationships between large-artery stiffness and carotid and brachial blood pressures and coronary artery disease severity. One hundred fourteen male patients with coronary artery disease (age 60+/-8 years, mean+/-SD) and 57 age-matched healthy male controls (age 59+/-9 years) were recruited. Patients were classified into 2 groups based on the magnitude of their maximum coronary stenosis: moderate (50% to 89%) and severe (>/=90%). Large-artery stiffness was assessed as systemic arterial compliance and carotid-femoral pulse wave velocity. Mean pressure was not different between the 3 groups. Systemic compliance and carotid pulse pressure were significantly different between all 3 groups, with compliance lowest and pressure highest in the severe group (P<0.05). Pulse wave velocity was higher in patients with severe stenosis than in those with moderate stenosis (P<0.01) and those in the control group (P<0.001). Brachial pulse pressure was higher in patients than in controls (P<0.05), but there was no difference between the 2 disease groups. In separate multivariate analyses, carotid pressures and systemic arterial compliance were determinants of coronary artery disease severity, independent of age, smoking status, body mass index, mean arterial pressure, heart rate, cholesterol levels (total, LDL, and HDL), triglycerides, and beta-antagonist and lipid-lowering therapy (P<0.001), whereas brachial pressures and pulse wave velocity were not. In conclusion, central blood pressures and systemic arterial compliance are more sensitive markers of coronary artery disease severity than brachial pressures.     

Outcome of foot injuries in multiply injured patients

In the past, foot injuries in patients with multiple trauma were thought to be of lesser importance than fractures of long bones. In one prospective study from the authors' institutions, however, multiple-trauma patients with foot injuries were shown to have a poorer functional outcome compared with matched controls. To address these concerns, this article has two parts. The first part is an overview of general principles in the treatment of foot injuries in polytrauma patients. The treatment of specific injuries is beyond the scope of this article, but an approach is highlighted that can be remembered when decisions are made regarding these severely injured patients. The second part reviews the findings from the authors' study, focusing on functional outcomes of multiple-trauma patients with foot injuries.