Asthma

Asthma

Asthma is a disease of the respiratory system in which the airways constrict, become inflamed, and are lined with excessive amounts of mucus, often in response to one or more "triggers," such as exposure to an environmental stimulant (or allergen ), cold air, exercise , or emotional stress. In children, the most common triggers are viral illnesses such as those that cause the common cold. This airway narrowing causes symptoms such as wheezing, shortness of breath , chest tightness, and coughing, which respond to bronchodilators. Between episodes, most patients feel fine.

Asthma

The Asthma disorder is a chronic or recurring inflammatory condition in which the airways develop increased responsiveness to various stimuli, characterized by bronchial hyper-responsiveness, inflammation, increased mucus production, and intermittent airway obstruction. The symptoms of asthma, which can range from mild to life threatening, can usually be controlled with a combination of drugs and lifestyle changes.

Public attention in the developed world has recently focused on asthma because of its rapidly increasing prevalence, affecting up to one in four urban children. Susceptibility to asthma can be explained in part by genetic factors, but no clear pattern of inheritance has been found. Asthma is a complex disease that is influenced by multiple genetic, developmental, and environmental factors, which interact to produce the overall condition.

Asthma - Symptoms

In some individuals, asthma is characterized by chronic respiratory impairment. In others it is an intermittent illness marked by episodic symptoms that may result from a number of triggering events, including upper respiratory infection, airborne allergens, and exercise.

An acute exacerbation of asthma is referred to as an asthma attack. The clinical hallmarks of an attack are shortness of breath ( dyspnea ) and wheezing. Although the latter is "often regarded as the sine qua non of asthma," some victims present primarily with coughing, and in the late stages of an attack, air motion may be so impaired that no wheezing may be heard. When present the cough may sometimes produce clear sputum. The onset may be sudden, with a sense of constriction in the chest, breathing becomes difficult, and wheezing occurs (primarily upon expiration, but can be in both respiratory phases).

Signs of an asthmatic episode are wheezing, rapid breathing ( tachypnea ), prolonged expiration, a rapid heart rate ( tachycardia ), rhonchous lung sounds ( audible through a stethoscope ), and over-inflation of the chest. During a serious asthma attack, the accessory muscles of respiration (sternocleidomastoid and scalene muscles of the neck) may be used, shown as in-drawing of tissues between the ribs and above the sternum and clavicles , and the presence of a paradoxical pulse (a pulse that is weaker during inhalation and stronger during exhalation). During very severe attacks, an asthma sufferer can turn blue from lack of oxygen, and can experience chest pain or even loss of consciousness. Severe asthma attacks may lead to respiratory arrest and death. Despite the severity of symptoms during an asthmatic episode, between attacks an asthmatic may show few signs of the disease.

Diagnosis, Pathophysiology, Treatment, Epidemiology.

To be continued. . .

Omeprazole before endoscopy beneficial in patients with gastrointestinal bleeding

Omeprazole before endoscopy beneficial in patients with gastrointestinal bleeding

A study published in the New England Journal of Medicine has evaluated the effect of pre-emptive infusion of omeprazole before endoscopy on the need for endoscopic therapy.

Over a 17-month period, consecutive patients admitted with upper GI bleeding were stabilised and then randomised to omeprazole 80-mg IV bolus followed by 8mg/hour infusion (n= 319) or matching placebo (n= 319) before endoscopy the next morning.

The following findings were reported:

• Need for endoscopic treatment was lower in the omeprazole compared with placebo group (60 of 314 patients included in analysis [19.1%] vs. 90 of 317 patients [28.4%], p = 0.007).
• There were no significant differences between the omeprazole and placebo group in:
• mean amount of blood transfused (1.54 and 1.88 units)
• number of patients who had recurrent bleeding (11 and 8),
• number who underwent emergency surgery (3 and 4),
• number who died within 30 days (8 and 7)
• Hospital stay was < p =" 0.005).">
• On endoscopy, fewer patients on omeprazole had actively bleeding ulcers (12 of 187, vs. 28 of 190 in the placebo group; p = 0.01) and more omeprazole-treated patients had ulcers with clean bases (120 vs. 90, p = 0.001).

The study concluded “infusion of high-dose omeprazole before endoscopy accelerated the resolution of signs of bleeding in ulcers and reduced the need for endoscopic therapy.”

N Engl J Med 2007; 356: 1631-40 (link to abstract)

HRT and the incidence of ovarian and breast cancer

HRT and the incidence of ovarian and breast cancer

Two major epidemiological studies published today look at the possible increased risk of ovarian and breast cancers associated with hormone replacement therapy (HRT). They have, inevitably, generated significant media interest.

A study published early online by the Lancet found that current use of HRT for prolonged periods is associated with a 20% increase in risk of ovarian cancer. The authors used data from the Million Women Study, a large prospective cohort study of UK women aged 50 and over that is investigating a range of factors that affect women's health. Data collected at recruitment includes whether the woman is using HRT, confirmed by subsequent questionnaire three years later if possible. Each participant is followed-up for death, emigration, or cancer registration, so that relevant events are reported to the study investigators.

This analysis aimed to determine whether use of HRT affected risk of ovarian cancer; it involved women from the cohort who were post-menopausal, had no history of cancer or bilateral oophorectomy, and for whom data on use of HRT was available. They were followed for averages of 5.3 years for incident ovarian cancer and 6.9 years for death. Primary outcome of the analysis was relative risk for ovarian cancer, adjusted for a range of relevant factors.

A total of 1.3 million women were recruited into the Million Women Study cohort. Of these, 948, 576 were included in the analysis. When they last reported data to the study, 50% reported current or past use of HRT - 30% were current users and 20% past users: the two groups were fairly similar with only past use of oral contraceptives and hysterectomy being major differences between them (both higher in HRT users). Mean duration of use was 7.7 years.

There were 2,273 ovarian cancers in total and 1,591 deaths from ovarian cancer. Women who were current users of HRT had a statistically significant increase in risk both of ovarian cancer (relative risk 1.20, 95% CI 1.09 to 1.32; p=0.0002) and death from ovarian cancer (RR 1.23, 95% CI 1.09 to 1.32; p=0.0002). Risk increased with duration of use, however past users were not at significantly increased risk. Crude incidence rate in the study population as a whole was 2.2 per 1,000 women; in never-users it was 2.2 per 1,000, and in users 2.6 per 1000 (rates for death from ovarian cancer 1.3, 1.3, and 1.6 per 1,000 respectively). From these figures, assuming that the differences are due to HRT the authors calculate that over a five year period there would be about one extra case of ovarian cancer for every 2,500 users (and one extra death per 3,300 users).

The authors conclude that women who use HRT are at greater risk of ovarian cancer and of death due to it. The risk increases with duration of use: mean duration of use in the study population was 7.7 years and this was associated with a 20% increase in risk. It is related to current use, not past use, and falls back to baseline level soon after use is stopped. An accompanying Comment discusses the paper and its implications; the author discusses some potential mechanisms for the effect, and notes the difference between pre-menopausal use of the same hormones as oral contraceptives, which is protective, and the data on HRT. He notes that although the absolute increase in risk is small, the large number of women who used HRT until recently meant that the toll in terms of cancers and mortality was significant.

The second paper reports that the rate of breast cancer in the US fell appreciably in 2003 compared to the rate in 2002; while a number of explanations are possible, the decrease seems to be related to reporting of results from the Women's Health Initiative in 2002 that was followed by a decrease in HRT use among post-menopausal women in the US.
The authors use data from a program (SEER) run by the US National Cancer Institute: this collects data from nine cancer registries reporting on 9% of the total US population. Data from the registries were adjusted for reporting delays and standardised to the US female population in 2000. Annual incidence rates were plotted and compared to determine trends.

The results show a sharp fall in incidence of 6.7% in 2003 compared to 2002; the incidence stabilised in 2004 with little further decrease. Analysis showed that the decrease actually started in mid-2002 and had begun to level off by mid-2003, and comparison between 2001 and 2004 showed an overall decrease of 8.6% (95% CI 6.8 to 10.4%). The decrease was age-specific and occurred only in women aged over 50; there was no significant change in incidence in younger women. It was also primarily in oestrogen-receptor positive tumours. Examination of trends since 1975 showed a steady increase in women aged over 50 from the late 1970's onwards, with rates rising by about 0.5% per year during most of the 1990's. Rates in women under 50 were substantially the same over the whole of this period.

The authors discuss a number of possible reasons for the changed incidence, but conclude that reductions in HRT use are the most likely. There is evidence that stopping HRT may cause clinically occult oestrogen-receptor positive breast cancers to stop growing or even regress soon after withdrawal, and evidence of studies involving hormonal manipulation therapies (e.g. tamoxifen) supports this. HRT prescriptions in the US declined sharply during 2002 and 2003 and stabilised at a lower level in 2004, from around 60 million to 21 million prescriptions per year.

The MHRA has issued a statement on the two papers. The new evidence is being reviewed by experts, but is unlikely to result in major changes in current advice: this is that HRT is effective for short-term relief of menopausal symptoms but should be used in the lowest effective dose and the minimum duration.

Ovarian cancer study: Lancet, published early online 19 April 2007; DOI:10.1016/S0140-6736(07)60534-0 (link to abstract) and Lancet, published early online 19 April 2007; DOI:10.1016/S0140-6736(07)60535-2 (Comment; link to full text, may be available to subscribers only);
breast cancer study: New Engl J Med 2007; 356: 1670-4 (link to abstract, full text available free at time of posting)
The MHRA statement is available here
BBC News report;
there is full information on the Million Women Study on its website

Moderate-dose methylprednisolone effective for severe adult respiratory distress syndrome?

Moderate-dose methylprednisolone effective for severe adult respiratory distress syndrome?

According to the results of a randomised controlled trial (RCT) reported in the journal ‘Chest’, the use of early, moderate-dose, prolonged methylprednisolone therapy successfully down-regulates systemic inflammation, reduces organ dysfunction and improves outcome of patients with severe adult respiratory distress syndrome (ARDS).
The trial involved 91 patients in the ICUs of five hospitals in the US, who had severe early ARDS (within the first 72 hours); 66% had sepsis. Participants were randomised to receive methylprednisolone infusion (n=63) or placebo (n=28) for up to 28 days. Methylprednisolone was administered as a loading dose of 1 mg/kg followed by an infusion of 1 mg/kg/d from day 1 to day 14, 0.5 mg/kg/d from day 15 to day 21, 0.25 mg/kg/d from day 22 to day 25, and 0.125 mg/kg/d from day 26 to day 28. If the patient was extubated between days 1 and 14, the patient was advanced to day 15 of drug therapy and tapered according to schedule. Once enteral intake was resumed, the methylprednisolone was converted to a single oral dose. The study’s primary endpoint was a 1-point reduction in lung injury score (LIS) or successful extubation by day 7, and the results were analysed according to the intention-to-treat principle.

The main results were as follows:

• At Day 7, 69.8% of those receiving active treatment achieved a 1-point reduction in LIS compared to 35.7% in the placebo group (p = 0.002)
• At Day 7, 53.9% of those receiving active treatment were breathing without assistance versus 25.0% of the placebo group (p = 0.01).
• Active treatment was also associated with improvements in various secondary endpoints including a reduction in the duration of mechanical ventilation (5 days versus 9.5 days; p = 0.002), ICU stay (7 days versus 14.5 days; p = 0.007), ICU mortality (20.6% versus 42.9%; p = 0.03) and a reduced rate of infections (p = 0.0002).

The authors conclude that “the findings of this study provide evidence that glucocorticoid treatment-induced down-regulation of systemic inflammation in ARDS is associated with a significant improvement in pulmonary and extrapulmonary organ dysfunction and a reduction in duration of mechanical ventilation and ICU length of stay. ….A larger trial is necessary to confirm the mortality findings of this study. In a future trial, we recommend adding stratification by shock at study entry, and strict implementation and monitoring of a ventilator and weaning protocol”.

Chest 2007;131:954-963 (link to abstract)

Impact of oral anti-hyperglycaemic therapy on all-cause mortality in diabetics

Impact of oral anti-hyperglycaemic therapy on all-cause mortality in diabetics

The authors of this retrospective study note that several observational studies have produced conflicting results on the effect of different classes of oral anti-hyperglycaemics on all-cause mortality. It has also been difficult to draw conclusions due to ‘confounding by indication’, whereby patients with more severe disease are exposed to more aggressive therapy and are more likely to suffer from an adverse outcome.

In the present study, researchers studied data from a cohort of patients with diabetes from the Veterans Health Administration (VHA). They sought to evaluate the impact of several classes of oral anti-hyperglycaemics relative to sulfonylurea monotherapy on overall mortality, adjusting for a number of confounding factors in an attempt to limit any confounding by indication.

All users of oral anti-hyperglycaemic therapy were identified (n=39,721) and classified into the following cohorts

• sulfonylurea monotherapy (S)
• metformin monotherapy (M)
• metformin + sulfonylurea (MS)
• TZD use alone or in combination with other oral agents (TZD; all users were pooled together as there were few deaths in the various sub-groups)
• no drug therapy

The authors found no difference between all-cause mortality between the S cohort and any of the other treatment cohorts. The adjusted odds ratios (each group compared to S) were 0.87 (95% CI 0.68- 1.10) for M, 0.92 (0.82-1.05) for MS, and 1.04 (0.75-1.46) for TZD.

The authors note that the duration of retrospective data was a limitation of the study, and suggest that ‘future work should assess whether long-term exposure to oral anti-hyperglycaemic medications have the potential to reduce all-cause or cause-specific mortality.’

DRUGS in LACTATION; Breastfeeding mothers and medicines - general guidance

DRUGS in LACTATION

UK Drugs in Lactation Advisory Service

A joint service provided by the West Midlands and Trent Drug Information Services

Anti-asthma agents | Anti-coagulants | Anti-convulsants | Anti-depressants
Anti-diarrhoeals | Anti-histamines | Anti-hypertensives | Corticosteroids
Laxatives | Non-steroidal Anti-inflammatories | Vitamins

Breastfeeding mothers and medicines - general guidance

The following principles should be followed when prescribing for breastfeeding mothers :

• Avoid unnecessary drug use and limit use of over-the-counter (OTC) products
  
  
• Breastfeeding mothers should seek advice on the suitability of OTC products
  
  
• Assess the benefit/risk ratio for both mother and infant
  
  
• Avoid use of drugs known to cause serious toxicity in adults or children
  
  
• Drugs licensed for use in infants do not generally pose a hazard
  
  
• Neonates (and particularly premature infants) are at greater risk from exposure to drugs via breast milk, because of immature excretory functions and the consequent risk of drug accumulation
  
  
• Choose a regimen and route of administration which presents the minimum amount of drug to the infant
  
  
• It is best to avoid long-acting preparations, especially those of drugs likely to cause serious side effects (e.g. antipsychotic agents), as it is difficult to time feeds to avoid significant amounts of drug in breast milk
  
  
• Multiple drug regimens may pose an increased risk especially when adverse effects such as drowsiness are additive
  
  
• Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms
  
  
• Avoid new drugs if a therapeutically equivalent alternative that has been more widely used is available. A robust assessment of the balance of benefit to risk requires data both on the drug's passage into breast milk and its effects in infants: there is rarely enough information available for new drugs to allow such an assessment to be made. If a drug with limited data is deemed to be clinically necessary or for any further information, contact the UK Drugs in Lactation Advisory Service for further advice - click here for contact details.

Metformin and Glimepiride: Safe and Effective short-term in paediatric type 2 diabetes

Metformin and Glimepiride: Safe and Effective short-term in paediatric type 2 diabetes

Metformin and Glimepiride have similar efficacy and safety over six months in children with type 2 diabetes, according to a controlled trial.

The authors of the study comment that the incidence of type 2 diabetes in children is increasing rapidly, and that as the course of the condition may be more aggressive in this patient group early control is important. There is therefore a need for data on the safety and efficacy of oral hypoglycaemic agents in children.

Metformin is licensed in the US for this age group, however there are no sulphonylureas so licensed; this study aimed to compare the safety and efficacy of the two drugs in a paediatric population. It involved children with type 2 diabetes who were not adequately controlled on their existing treatment. After two weeks stabilisation, participants were grouped by age (<12> 12 years) and randomised to either metformin or glimepiride for the 24 weeks study period (12 weeks titration, 12 weeks maintenance). Primary outcome was mean change in haemoglobin A1c (A1C) from baseline to week 24.

A total of 285 children were randomised, with a mean age of 13.8 (range 8 to 17) at randomisation; they were significantly obese, with a mean BMI of about 31.7kg/m2. Of these, 284 received at least one dose of study drug and were evaluated for safety: 283 took at least one dose and had at least one A1C measurement to allow assessment of efficacy, thus becoming the intention to treat population.

Significant reduction of A1C:
Both drug groups (Metformin and Glimepiride) had a significant reduction of A1C from baseline by week 24: for glimepiride the reduction was 0.54% and for METFORMIN 0.71% (both differences statistically significant from baseline). Values taken at week 12 were similar. One patient in each group had a severe hypoglycaemic episode; adverse event rates in the two groups were similar, and adverse event rates considered possibly due to the drug were 7.7% in the glimepiride group and 13.4% in the metformin group.

Weight gain with Glimepiride:
Patients in the glimepiride group gained body weight (increase in BMI 0.26 kg/m2) whereas those in the Metformin group lost weight (decrease in BMI 0.33 kg/m2).

Comparative effectiveness:
The authors conclude that glimepiride was as effective as metformin in controlling A1C levels and similarly tolerated, although it was associated with a greater degree of weight gain.

[Editor's comment: six months is a relatively short-term study of a therapy for type 2 diabetes. While glimepiride does control blood glucose over this period, the increase in weight in what was already an obese population would raise some concern.]

Diabetes Care 2007; 30: 790-4 (link to abstract)

Garlic maybe not so useful in Hypercholesterolemia after all?

Garlic maybe not so useful in Hypercholesterolemia after all?

A study published in the Archives of Internal Medicine has investigated the effect of raw garlic and two garlic supplements on cholesterol concentrations in adults with moderate hypercholesterolaemia.
The trial involved 192 adults with low-density lipoprotein cholesterol (LDL-C) concentrations of 3.36-4.91 mmol/L who were randomised to receive one of the following: raw garlic, powdered garlic supplement, aged garlic extract supplement, or placebo (the garlic supplement doses were equivalent to 1 average-sized garlic clove). The products were consumed 6 days a week for 6 months. The primary outcome measure was of LDL-C concentrations at 6 months.

The researchers reported that the 6-month mean (SD) changes in LDL-C concentrations were +0.01 [0.50] mmol/L for raw garlic, +0.08 [0.44] mmol/L for the powdered supplement, +0.005 [0.46] mmol/L for the extract supplement and –0.10 [0.43] mmol/L for placebo (all p = not significant). Additionally, there were no statistically significant effects on high-density lipoprotein cholesterol, triglyceride levels, or total cholesterol–high-density lipoprotein cholesterol ratio.

The researchers concluded that none of the forms of garlic used in this study provided a statistically or clinically significant effect on LDL-C or other plasma lipid concentrations in adults with moderate hypercholesterolemia.

In a related editorial, the author comments that although the researchers of the study demonstrate that raw garlic and 2 popularly used supplements do not reduce LDL-C more than 0.26 mmol/L when used for 6 months vs. placebo for 6 months, the results do not demonstrate that garlic has no usefulness in the prevention of cardiovascular disease.

Effect of raw garlic vs commercial garlic supplements on plasma lipid concentrations in adults with moderate hypercholesterolemia: a randomized clinical trial. Arch Intern Med 2007; 167: 346-53 (link to abstract); Arch Intern Med 2007; 167: 325-6 (editorial, link to extract)
BBC News report

Ibuprofen vs Paracetamol or Codeine for acute pain in children

Ibuprofen vs Paracetamol or Codeine for acute pain in children

A double-blind study published in Pediatrics has investigated the efficacy of single dose paracetamol, codeine and ibuprofen for children presenting with pain from acute musculoskeletal injuries.

Outcome data was presented for 300 patients aged 6 to 17 years who had suffered pain from a musculoskeletal injury (to extremities, neck, and back) that occurred in the preceding 48 hours before presentation in the emergency department. Patients were randomised to receive either 15 mg/kg paracetamol (n=100), 10 mg/kg ibuprofen (n=100), or 1 mg/kg codeine (n=100). The primary outcome was change in pain from baseline to 60 minutes after treatment with study medication as measured by using a visual analogue scale.

The researchers reported that:

• Patients in the ibuprofen group had a significantly greater improvement in pain score (mean decrease: 24 mm) than those in the codeine group (mean decrease: 11 mm; p<0.001) p="0.001" p="0.98).
• At 60 minutes more patients in the ibuprofen group achieved adequate analgesia (as defined by a visual analogue scale <30mm)>vs. codeine (p=0.85); paracetamol vs. ibuprofen (p=0.026); codeine versus ibuprofen (p=0.006) .
• There was no significant difference between patients in the codeine and acetaminophen groups in the change in pain score at any time period or in the number of patients achieving adequate analgesia.

The researchers concluded that for the treatment of acute traumatic musculoskeletal injuries, ibuprofen provides the best analgesia among the 3 study medications.

Pediatrics. 2007 Mar;119 (3):460-7
Link to abstract

Ibuprofen best option for acute pain in children with musculoskeletal injuries?

Ibuprofen best option for acute pain in children with musculoskeletal injuries?

A double-blind study published in Pediatrics has investigated the efficacy of single dose paracetamol, codeine and ibuprofen for children presenting with pain from acute musculoskeletal injuries.

Outcome data was presented for 300 patients aged 6 to 17 years who had suffered pain from a musculoskeletal injury (to extremities, neck, and back) that occurred in the preceding 48 hours before presentation in the emergency department.

Patients were randomised to receive either 15 mg/kg paracetamol (n=100), 10 mg/kg ibuprofen (n=100), or 1 mg/kg codeine (n=100).

The primary outcome was change in pain from baseline to 60 minutes after treatment with study medication as measured by using a visual analogue scale.

The researchers reported that:

• Patients in the ibuprofen group had a significantly greater improvement in pain score (mean decrease: 24 mm) than those in the codeine group (mean decrease: 11 mm; p<0.001) p="0.001)" p="0.98).
• At 60 minutes more patients in the ibuprofen group achieved adequate analgesia (as defined by a visual analogue scale <30mm) p="0.85);" p="0.026);" p="0.006).">
• There was no significant difference between patients in the codeine and acetaminophen groups in the change in pain score at any time period or in the number of patients achieving adequate analgesia.

The researchers concluded that for the treatment of acute traumatic musculoskeletal injuries, ibuprofen provides the best analgesia among the three study medications.

Pediatrics 2007; 119: 460-7 (link to abstract)

Clinical update - Post-Operative Pain

Clinical update - Post-Operative Pain

This article in the Lancet gives a brief and didactic overview of pain control in the postoperative (post-op) period. The authors note that poorly controlled and persistent pain after surgery does occur, and can result in a chronic pain state. It may also slow healing and increase the risk of complications.

They discuss appropriate methods of pain control following minor, intermediate, and major surgery.

After minor surgery, oral analgesia is normally sufficient, and they suggest paracetamol, NSAID, oxycodone, or tramadol as suitable agents.

Patients undergoing more extensive surgery may require parenteral analgesia, and more potent drugs including opioids, and they discuss the moat appropriate use of these.

They suggest that improved postoperative pain control can be helped by the use of simple multimodal regimens, and present a series of steps that could be used.

Lancet 2007; 369: 810-2 (link to full text, available to subscribers only).

Review: Asthma in pregnancy

Review: Asthma in pregnancy

This is the first in a series of occasional articles in the BMJ about how to manage a pre-existing medical condition during pregnancy. The article begins with a case scenario and addresses the following topics:

• How common is asthma in pregnancy?
• Does pregnancy affect asthma?
• Does asthma affect pregnancy?
• Management of asthma in pregnancy
• Does asthma affect labour and delivery?
• Does asthma affect postpartum period and breast feeding?

In terms of treatment, the article notes that it is safer to use asthma drugs in pregnancy than to leave asthma uncontrolled, as adverse perinatal outcomes are associated with uncontrolled asthma and reduced expiratory flow. Inhaled corticosteroids, theophylline, and short acting beta 2 agonists do not increase the risk of foetal congenital malformations, pre-eclampsia, preterm delivery, or low birth weight. The dose or regimen of asthma medications do not usually need to be changed in pregnancy.

Oral corticosteroids in the first trimester are associated with an increased risk of foetal cleft lip or palate. However, the increased incidence is small compared with the benefits of using such treatment and they should continue to be used in severe asthma and life threatening situations. Oral corticosteroids are also associated with preterm delivery and pre-eclampsia. Of note, 90% of prednisone is inactivated by the placenta, which limits foetal exposure and the risk of foetal withdrawal. Inhaled corticosteroids are safe in pregnancy, and they are not associated with foetal malformations or perinatal morbidity. Most studies in pregnancy have used budesonide, but the corticosteroid that was used successfully before pregnancy should be continued into childbirth.

Cromolyn sodium and short acting beta 2 agonists are safe to use during pregnancy. There are few data on long acting beta 2 agonists; salmeterol and formoterol have not been found to cause malformations, preterm delivery, or low birth weight in the limited number of women using them in prospective studies. Data on the safety of leukotriene modifiers in pregnancy are scarce therefore it seems reasonable to replace them with an inhaled corticosteroid at the start of pregnancy or with a long acting beta 2 agonist (if this is used as an "add on" therapy). Theophylline has been reported to be safe in human pregnancy at recommended doses; levels should be monitored because drug metabolism changes in pregnancy.

BMJ 2007; 334: 582-5 (link to extract)

Preventing Type-2 Diabetes in At-Risk People (ARP)

Preventing type 2 diabetes in at risk people - the evidence from trials

An editorial in the Annals of Internal Medicine discusses recent trials that studied four potential drug interventions to delay the onset of type 2 diabetes in people at risk.

The drugs studied are rosiglitazone, metformin, ramipril, and acarbose.

Metformin and Acarbose were shown to reduce the onset of diabetes in trials published in 2002 and the recently published DREAM trial found that rosiglitazone also seemed to do so but ramipril did not. This editorial primarily discusses DREAM.

The authors briefly describe the study, and noted that it showed rosiglitazone to be effective in reducing progression to diabetes while ramipril was not. They are concerned, however, over the adverse effect profile of rosiglitazone, with an increased incidence of peripheral oedema, weight gain, and heart failure.

Overall, they emphasized that lifestyle changes remain the first line for prevention of diabetes, as those that work also have many other health benefits. Where patients cannot adopt or maintain such changes, drug treatment may be considered: in this situation, the chosen drug must be safe, as it will be taken long term by many people who will not actually benefit. It must also be more cost-effective than delaying treatment until diabetes develops.

On these criteria, rosiglitazone fails and other medications must be considered. Acarbose is associated with a high incidence of withdrawal due to adverse effects, therefore the authors suggest that METFORMIN is the best option, being effective, generally well tolerated, and relatively low cost.

They warn, however, that the long term benefits and cost-effectiveness of this approach are unproven, and thus more trials are needed.

Ann Intern Med 2007; 146: 461-3 (link to full text, may be available only to subscribers)
There is a NeLM InFocus review of DREAM

PharmaCIT possibilities in Rural Centres

We have all come to terms that Information Technology has come here to stay. Applications are wide and vast. Cities are fast getting linked-up on this information super-highway. Exchange of information has become at the speed of a "click-of-the-mouse".

With these foregoings, Pharmacy practice in Nigeria has not really benefited from this free flow of information.

Key in this aspect is the introduction of Pharmacy, Computer and Information Technology (PharmaCIT) in the Rural communities.

Healthcare practitioners, and Pharmacists in particular are to have unrestricted access to Drug information and methods of Pharmacy practices across the globe; current trends; new developments; new products & practices; better treatment alternatives; new re-formulations, newer ways of doing old things; rapidly advancing technologies, and lots more.

This will go a long way in equipping the pharmacist with the best available information to effectively and efficiently execute his duties. The Pharmacist in the rural hospitals can manage the basic health information technology (HIT), hence help in preventing medication errors. improving medication safety and quality patient care.

Most rural and community hospitals lack the resources to obtain basic health information technology to assist with improving quality care and patient safety that are often available in advance countries.

In essence, the funds have to be sourced to provide the equipment needed for the basic HIT programme. These hospitals could be funded by Govt healthcare allocations, NHIS (health insurance) or via International partnership.

Funding should be able to provide the structure, training and equipment. Others are Internet access, maintenance & repairs, power-supply, software & hardware requirements, etc.

Once this can be functional implemented on the community level, it will be easy to replicate in urban centres. Precedence has shown that it is usually difficult to start a project from the urban regions, then effectively transfer or integrate same in the rural communities. As soon as the lifestyle pattern, with emphasis on health is made attractive in the rural communities, the urban-drift will reduce substantially.

For healthcare delivery to improve in the rural areas, information technology, PharmaCIT, is the way forward.

Best Regards.

Tony.

InfoTech in Pharmacy

InfoTech in Pharmacy is relevant; such that in some instances, computerized pharmacy management information systems are used to verify if the prescribed medication and dosage is appropriate for the patient’s condition, automated dispensing cabinets to prevent the wrong medicines from being given to patients when a physician or pharmacist is not present, and computerized infusion pumps to ensure that intravenous fluids are appropriately administered to patients.

With all these, how can this be applied to, say, the Nigerian Healthcare delivery system.

Pharmacy & InfoTech...

Nice topic.

How relevant is this in Nigeria.

Cheers.

How relevant is Computer in Pharmacy

I've been wondering the relevance of Computer & Information Technology in the Pharmacy practice; and I have been looking for ways to learn the much I can in this aspect.

How do we incorporate the two aspects effectively so as to maximize both aspects synergistically.

I'll appreciate your comments.

Thank you.

Tony.