Bronchodilators in asthma: bypassing controversies

Inhaled bronchodilators are used in acute asthma for relief of airway obstruction. Continuous monotherapy with beta 2 adrenergic can increase hyperresponsiveness because these drugs do not control inflammation. Asthma mortality and morbidity have been related to an increased beta 2-agonists use. Epidemiologic data however do not show a cause/effect relationship. Until controversies are cleared on, beta 2-agonists should be used for relieving acute asthma attacks, for preventing exercise-induced bronchospasm and eventually on an as needed basis. Long acting beta 2-agonists can be effective in moderate/severe asthma. Daily short acting beta 2 use by inhalation, a partial clinical response and its overuse in acute asthma suggest the need for antiinflammatory treatment.     

Long-term treatment with Pilogel/β-blocker in glaucoma patients

In a multicentre clinical trial thirteen patients with primary open angle glaucoma or ocular hypertension were followed during at least six months while selfinstilling Pilogel (once daily) and topical -blocker (twice daily). After six months of combination therapy there was an average decrease in intra-ocular pressure (IOP) of 33.6% 9.5 hours after Pilogel administration and an IOP decrease of 23.4% 22.5 hours after Pilogel administration. With topical -blocker alone, an average IOP decrease of 15% was measured. Throughout the study we observed in six patients (46.1%) a superficial punctate keratitis which mostly spontaneously cleared. We did not see any serious side-effects after six months of combination therapy.     

Detachable shape-memory sewing ring for heart valves

The novel sewing ring concept consists of a detachable ring snap connection between valve housing or stent and suture cuff. The suture cuff itself is a memory metal ring of nickel-titanium (NiTi) that is embedded within a textile fabric torus. After a special training program the ring can assume two geometric shapes when alternately cooled and heated. Due to this physical property, the sewing ring can be safely fixed within a groove of the housing or stent by changing between room and physiological temperature. This allows the surgeon first to implant the sewing ring followed by arbitrary positioning and final fixation of the valve by the shape-memory effect. Additional advantages are an increased stiffening of the valve base for minimizing potential leaflet dysfunction, and reduced time and risk of implantation, particularly when a reoperation is necessary.     

Workers' dermal exposure to UV-curable acrylates in the furniture and Parquet industry

The use of ultraviolet radiation-curable coatings (UV-coatings) has increased rapidly in the parquet and furniture industry. Work with UV-coatings involves risk from skin exposure to chemically reactive, concentrated acrylates that are known skin contact irritants and sensitizers. Yet, the methods and tools for measuring and quantifying dermal exposure from hazardous chemicals directly on the skin are limited and methods to measure skin exposure to UV-coatings in occupational or environmental settings have been lacking. Skin exposure to UV-coatings was measured employing a quantitative tape stripping method that we have developed for this purpose. A pilot study was performed at three workplaces. In the main study, workers' skin exposure to uncured UV-coatings was measured at seven workplaces and on two separate workdays (rounds 1 and 2) within a six-month period to determine exposure variation. Skin exposure was measured at four standardized sites on the hand, 3-4 times per work shift. The forehead was sampled once. A questionnaire was carried out with the workers in both rounds to find out factors that can affect skin exposure to UV-coatings.The pilot study indicated that both skin and surface contamination to TPGDA-containing UV-coatings were common and varied up to 2110 microgram on the sampling area of 10cm(2). In the main study skin contamination due to TPGDA was found on 16 of 23 workers, at 6 out of the 7 workplaces, and from 36 (5. 4%) of the 664 samples. In round one 8.6% (n=383) of the samples contained TPGDA and in round two 1.1 % (n=281).The average TPGDA mass on all the positive samples (n=36) was 30.4+/-77.0 microgram for the first and second rounds alone this mass was 30.6+/-80 (n=33) and 28.3+/-16.5 microgram (n=3), respectively. Despite the limited sampling area and sampling sites, we could find residues of TPGDA at all sampling times, even at the beginning of the work shift. This may be due to transfer of UV-coatings through contaminated equipment, shoes and surfaces. Our study indicates that there is a risk of harmful skin exposure to UV-coatings in the furniture and parquet industry.     

Venous graft repair following brachial artery thrombosis in a neonate

A case of venous graft repair to recover blood flow of a newborn's upper extremity, is described. Eventhough this complication remains uncommon, we emphasize on to avoid brachial artery for vascular monitorization and to perform microsurgical revision as elective procedure if conservative therapy is unsuccessful. Accepted: 4 February 1997     

A comparison of the incidence of the oculocardiac and oculorespiratory reflexes during sevoflurane or halothane anesthesia for strabismus surgery in children

We examined changes in the cardiorespiratory system of small children during surgical correction of strabismus with a laryngeal mask airway and spontaneous respiration with sevoflurane or halothane inhaled anesthesia. Fifty-one children, 1-7 yr old, having outpatient strabismus correction were randomized to sevoflurane (S) or halothane (H) in 66% nitrous oxide at 1.3 minimum alveolar concentration. Children breathed spontaneously through a laryngeal mask airway and were not pretreated with anticholinergics. The oculocardiac reflex (OCR), defined as a 20% decrease in heart rate (HR) from baseline, dysrhythmias, or sinoatrial arrest concomitant with ocular muscle traction occurred less frequently with sevoflurane than with halothane (S 38%, H79%, P = 0.009). The baseline HR was higher with sevoflurane (S 114 +/- 13 bpm, H 101 +/- 15 bpm, P = 0.002). The lowest HR occurred with halothane (S 95 +/- 22 bpm, H 73 +/- 19 bpm, P = 0.001). The incidence of dysrhythmias was higher in the halothane group (S 4%, H 42%, P = 0.004). Reductions in minute ventilation and PETCO(2) accompanied OCRs. Airway irritability was present with halothane only (S 0, H 3). Eleven children, of whom the majority had received halothane, required measures to correct SpO(2) < 95% or PETCO(2) > 60 mm Hg during maintenance anesthesia (S 11%, H 32%). Sevoflurane may be a more suitable anesthetic than halothane for operations involving traction on the ocular muscles with spontaneous respiration in children because of reduced incidence of OCR, airway irritability, and ventilatory disturbances. IMPLICATIONS: Some children experience a sudden slowing of the heart and impaired breathing when the surgeon pulls on the eye muscles during squint operations under anesthesia. Sevoflurane, a recently developed anesthetic vapor, may reduce this problem when compared with the established vapor halothane.     

Cholecystectomy: costs and health-related quality of life: a comparison of two techniques.

BACKGROUND: Outcomes of previous health economic evaluations comparing minilaparotomy cholecystectomy and laparoscopic cholecystectomy have been inconsistent. OBJECTIVE: To compare costs for minilaparotomy cholecystectomy and laparoscopic cholecystectomy and to study changes in quality of life induced by these operations. DESIGN: Single-blind, randomized controlled trial, run from 1 March 1997 to 30 April 1999. SETTING: One university hospital and four non-university hospitals in Sweden. MAIN MEASURE: : Cost and perceived health estimation according to the global quality of life instrument EuroQol-5D. RESULTS: Of 1719 cholecystectomy patients at five centres, 724 entered the trial and were treated with minilaparotomy cholecystectomy or laparoscopic cholecystectomy, 362 in each group. Total health care costs were less for minilaparotomy cholecystectomy than for laparoscopic cholecystectomy (median values US$2428 for minilaparotomy cholecystectomy versus US$2613 or US$3006 for laparoscopic cholecystectomy with 100 operations per year and reusable trocars or 50 operations per year and disposable trocars, respectively). There was no significant difference in total costs (including costs due to loss of production) between minilaparotomy cholecystectomy and laparoscopic cholecystectomy with 100 operations per year and reusable trocars in laparoscopic cholecystectomy (US$3731 versus US$3649, respectively). However, in calculations assuming 50 operations per year and disposable trocars in laparoscopic cholecystectomy, this technique was more expensive than minilaparotomy cholecystectomy (US$4042 versus US$3731). Health-related quality of life was slightly but significantly lower for the minilaparotomy cholecystectomy group 1 week after surgery. One month and 1 year postoperatively no difference between the randomized groups was found. CONCLUSION: Total costs did not differ between minilaparotomy cholecystectomy and laparoscopic cholecystectomy with high-volume surgery and disposable trocars, whereas laparoscopic cholecystectomy was more expensive with fewer operations and disposable trocars. The gain in health-related quality of life with laparoscopic cholecystectomy compared with minilaparotomy cholecystectomy was small and of limited duration.     

Immunogenicity, including vitiligo, and feasibility of vaccination with autologous GM-CSF-transduced tumor cells in metastatic melanoma patients.

PURPOSE: To determine the feasibility, toxicity, and immunologic effects of vaccination with autologous tumor cells retrovirally transduced with the GM-CSF gene, we performed a phase I/II vaccination study in stage IV metastatic melanoma patients. PATIENTS AND METHODS: Sixty-four patients were randomly assigned to receive three vaccinations of high-dose or low-dose tumor cells at 3-week intervals. Tumor cell vaccine preparation succeeded for 56 patients (88%), but because of progressive disease, the well-tolerated vaccination was completed in only 28 patients. We analyzed the priming of T cells against melanoma antigens, MART-1, tyrosinase, gp100, MAGE-A1, and MAGE-A3 using human leukocyte antigen/peptide tetramers and functional assays. RESULTS: The high-dose vaccination induced the infiltration of T cells into the tumor tissue. Three of 14 patients receiving the high-dose vaccine showed an increase in MART-1- or gp100-specific T cells in the peripheral blood during vaccination. Six patients experienced disease-free survival for more than 5 years, and two of these patients developed vitiligo at multiple sites after vaccination. MART-1- and gp100-specific T cells were found infiltrating in vitiligo skin. Upon vaccination, the T cells acquired an effector phenotype and produced interferon-gamma on specific antigenic stimulation. CONCLUSION: We conclude that vaccination with GM-CSF-transduced autologous tumor cells has limited toxicity and can enhance T-cell activation against melanocyte differentiation antigens, which can lead to vitiligo. Whether the induction of autoimmune vitiligo may prolong disease-free survival of metastatic melanoma patients who are surgically rendered as having no evidence of disease before vaccination is worthy of further investigation.     

Flavonoid and lignan intake and pancreatic cancer risk in the European prospective investigation into cancer and nutrition cohort

Despite the potential cancer preventive effects of flavonoids and lignans, their ability to reduce pancreatic cancer risk has not been demonstrated in epidemiological studies. Our aim was to examine the association between dietary intakes of flavonoids and lignans and pancreatic cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. A total of 865 exocrine pancreatic cancer cases occurred after 11.3 years of follow‐up of 477,309 cohort members. Dietary flavonoid and lignan intake was estimated through validated dietary questionnaires and the US Department of Agriculture (USDA) and Phenol Explorer databases. Hazard ratios (HR) and 95% confidence intervals (CIs) were calculated using age, sex and center‐stratified Cox proportional hazards models, adjusted for energy intake, body mass index (BMI), smoking, alcohol and diabetes status. Our results showed that neither overall dietary intake of flavonoids nor of lignans were associated with pancreatic cancer risk (multivariable‐adjusted HR for a doubling of intake = 1.03, 95% CI: 0.95–1.11 and 1.02; 95% CI: 0.89–1.17, respectively). Statistically significant associations were also not observed by flavonoid subclasses. An inverse association between intake of flavanones and pancreatic cancer risk was apparent, without reaching statistical significance, in microscopically confirmed cases (HR for a doubling of intake = 0.96, 95% CI: 0.91–1.00). In conclusion, we did not observe an association between intake of flavonoids, flavonoid subclasses or lignans and pancreatic cancer risk in the EPIC cohort.