Comparison of asthma treatment given in addition to inhaled corticosteroids on airway inflammation and responsiveness.

There is increasing evidence that the assessment of eosinophilic airway inflammation using induced sputum and measurement of airway hyperresponsiveness provides additional, clinically important information concerning asthma control. The aim of this study was to directly compare the effects of different treatments on these markers in patients with asthma and persistent symptoms, despite the use of low-dose inhaled corticosteroids. A double-blind four-way crossover study was performed, which compared a 1-month treatment with budesonide 400 mug b.i.d., additional formoterol, additional montelukast and placebo in 49 patients with uncontrolled asthma despite budesonide 100 mug b.i.d., with each treatment separated by a 4-week washout period. The change in sputum eosinophil count with formoterol (2.4 to 3.8% change, 0.6-fold reduction, 95% confidence interval (CI) 0.5-0.9) differed significantly from placebo (2.8 to 2.5% change, 1.1-fold reduction, 95% CI 0.7-1.6) and high-dose budesonide (2.7 to 1.6% change, 1.6-fold reduction, 95% CI 1.2-2.2). The effects of montelukast did not differ from placebo. The changes in methacholine airway responsiveness were small and did not differ between treatments. High-dose budesonide had the broadest range of beneficial effects on other outcomes, including symptom scores, morning peak expiratory flow and forced expiratory volume in one second. In conclusion, treatment given in addition to low-dose inhaled corticosteroids results in modest benefits. Formoterol and high-dose budesonide have contrasting effects on eosinophilic airway inflammation.     

Patient-controlled analgesia. Does a concurrent opioid infusion improve pain management after surgery?

OBJECTIVE.--To assess the influence of a continuous (basal) morphine infusion as part of a patient-controlled analgesia (PCA) system on the postoperative analgesic requirement and on recovery parameters following abdominal hysterectomy. DESIGN.--Single-center, randomized, controlled protocol. SETTING.--University medical center. PARTICIPANTS.--A total of 230 adult women were randomly assigned to receive no morphine infusion (control group) or a continuous 0.5-, 1.0-, or 2.0-mg/h morphine infusion. Each patient was able to self-administer supplemental intravenous bolus doses of morphine (1 to 2 mg) using a PCA infuser. MAIN OUTCOME MEASURES.--Use of the PCA device, opioid-related side effects, recovery times, and the patients' assessment of pain and sedation on linear visual analog scales were recorded during the 72-hour study period. Follow-up questionnaires were completed by the patients and their health care professionals to assess the overall adequacy of PCA therapy. RESULTS.--Patients who received the 2-mg/h morphine infusions received significantly more opioid medication 9 to 72 hours after their operation than those who received no infusion (control group). The presence of a continuous morphine infusion of 0.5 to 2 mg/h did not significantly decrease the number of patient demands or supplemental bolus doses administered compared with the control group. Overall, 168 (84%) of the 199 patients who completed the 72-hour study were able to achieve adequate analgesia without requiring changes in the PCA regimen or experiencing major side effects. Recovery times and outcome variables were similar in all four groups. CONCLUSION.--The routine use of a continuous opioid infusion in combination with a standard PCA regimen does not improve pain management compared with PCA alone after abdominal hysterectomy.     

Visual disturbances, serum glycine levels and transurethral resection of the prostate

Transient visual disturbances have been noted in patients undergoing transurethral resection of the prostate. It has been suggested recently that these visual aberrations were secondary to high serum concentrations of glycine from the intravasation of irrigant solutions used during the procedure. We prospectively studied visual acuity, serum electrolytes, glucose, ammonia and glycine concentrations in 18 patients undergoing transurethral resection of the prostate. Of our patient population 22% experienced significant decreases in visual acuity. We found that all patients had significantly elevated serum glycine concentrations but that there was no correlation of visual symptomatology with serum electrolyte or glucose concentrations. Our data further suggest that impeded metabolism of glycine may be more important than the absolute serum concentration in symptomatic patients.     

Some practical perspectives for educating gifted children

This article identifies common characteristics of educationally related programs that form a common basis for understanding and working with gifted programs. Special approaches and programs for educational enrichment as well as specific activities that have been successful are discussed.     

Tinnitus and vertigo in patients with temporomandibular disorder.

The association of tinnitus and vertigo with temporomandibular disorder (TMD) has been debated for many years. The observation that patients with TMD have otologic symptoms is confounded because tinnitus and vertigo are common symptoms in the normal population. The present study was conducted to determine if tinnitus and vertigo are actually more prevalent in patients with TMD than in appropriate age-matched controls. One control group was recruited from patients seeking care for health maintenance and the other from patients seeking routine dental care. We surveyed 1032 patients: 338 had TMD and 694 served as two age-matched control groups. Tinnitus and vertigo symptoms were significantly more prevalent in the TMD group than in either of the control groups. The mechanism of the association of TMD and otologic symptoms is unknown.     

Standards of care for area mental health services

A provisional set of standards of care was derived from a quality assurance strand of a wider research project, which reported the development of evaluation strategies for area integrated mental health services (AIMHS). In contrast to most published standards, they apply to all facets of care in a comprehensive catchment area mental health service, whether clinical or functional, community or hospital based, urban or rural, or managed by the public, private or voluntary sectors. We review briefly existing sets of standards of mental health services and report the process of development of standards of care, each with sub-sets of performance indicators and examples. While the AIMHS standards and a companion quality assurance manual are still undergoing refinement, they offer a guide for mental health professionals to the provision of services, and a checklist to service-users of services that should be available to them at every stage of care in a mental health system.