A clinical evaluation of the long-term outcome of patients treated for bilateral fracture of the mandibular condyles

The stratospheric ozone layer plays a crucial role in protecting living organisms against ultraviolet radiation. Chlorofluorocarbons (CFC) contained in metered-dose inhalers (MDIs) contribute to ozone depletion and in accordance with the Montreal Protocol on Substances That Deplete the Ozone Layer established 10 years ago, phase-out strageies have been developed worldwide for this category of agents. Alternatives to CFC-containing inhalers have been developed, such as powder inhalers and those using hydrofluoroalkanes (HFAs) as propellants, which have been shown to be as safe and effective as CFC-containing inhalers and even offer interesting advantages over older inhalers. The transition to non-CFC MDIs requires a major effort to make the new products available and to ensure adequate comparision with the previous ones. It also requires a harmonization of actions taken by industry, government, licencing bodies and patients or health professional associations to ensure adequate information and education to the public and respiratory care providers.     

A review and economic evaluation of bronchodilator delivery methods in hospitalized patients

BACKGROUND: Bronchodilator delivery by metered dose inhaler (MDI) to treat airflow obstruction is considered to be less expensive and as effective as nebulized therapy. OBJECTIVES: To document the utilization of bronchodilator delivery methods in a tertiary care Canadian university teaching hospital and to perform an economic evaluation. METHODS: A prospective 6-week audit of 4 preselected hospital wards (respiratory, thoracic surgery, general surgery, and a general internal medicine clinical teaching unit) and a cost-minimization economic evaluation were performed. Bronchodilator (salbutamol and ipratropium bromide) doses, frequency, and delivery methods, either MDI or wet nebulizer (WN), were recorded for 95 patients treated with aerosolized bronchodilators. Direct costs for medications and hourly wages including benefits and equipment were obtained. Time and motion studies identified time allocated to MDI and WN delivery. We used sensitivity analyses to test assumptions that could significantly affect treatment costs, especially assumptions about medications, labor, and spacer devices. Costs are expressed in Canadian dollars (Can$1 = US$0.75). RESULTS: Sixty-seven patients (70.5%) were treated with WN, 6 (6.3%) with MDI, and 22 (23.2%) with both WN and MDI. Self-administration of salbutamol by MDI was the least expensive: $1.27 for 200-microgram doses and $1.73 for 400-microgram doses compared with $2.62 for a 2.5-mg dose delivered by WN. The difference in cost between equivalent treatments (400-microgram MDI vs 2.5-mg WN) is only $0.89. Sensitivity analyses showed that MDI was the least expensive therapy when self-administration was possible and for all levels of supervision if more than 4 minutes was needed to administer a WN treatment. CONCLUSIONS: Bronchodilator delivery by WN is commonly prescribed for hospitalized patients despite evidence for equivalency of effect using MDI and in the absence of substitution protocols. Previous studies have estimated a far greater cost differential based on unrealistic labor estimates. We found that supervision of patients using MDIs minimized the differential cost between WN and MDI therapy and that cost savings are maximal in patients who can self-administer MDI therapy. Methodologically sound economic evaluations can better identify true cost savings and variables that need further study.     

Misuse of metered-dose inhalers: helping patients get it right

For patients who are severely impaired by obstructive lung disease, bronchodilator and anti-inflammatory medications increase airflow, enhance secretion clearance, and can potentially improve gas exchange. As a result of reduced symptoms, patients may be able to better tolerate activities of daily living and to increase endurance for activities that have personal value. Inhaled forms of these drugs, generally administered by MDI, are preferred to oral forms because they deposit directly onto the airways and cause fewer side effects. But to produce these benefits, inhaled MDIs must be used correctly. The need to evaluate MDI use by every patient, and teach correct technique when indicated, cannot be overemphasized. Metered-dose inhaler technique, practice guidelines for inhaled medications, and knowledge of inhaled medication drug classes and side effects should be required competencies for home care nurses.     

Cumulative dose-response study of non-CFC propellant HFA 134a salbutamol sulfate metered-dose inhaler in patients with asthma

STUDY OBJECTIVE: This study compares the safety and efficacy of HFA 134a salbutamol sulfate (Airomir in the 3M CFC-free system [3M Pharmaceuticals]) and CFC 11/12 salbutamol (Ventolin [Allen & Hanburys]) in a cumulative dose-response (1, 1, 2, 4, 8 inhalations at 30-min intervals) study in asthmatic patients. DESIGN: Randomized, single-blind, two-period cross-over study. PARTICIPANTS: Twenty-four stable mild to moderate asthmatics. MEASUREMENTS AND RESULTS: At all cumulative inhalations, the changes in FEV1 (absolute, percent, and percent predicted) and FVC were equivalent. There was also no significant difference in heart rate, serum potassium level, BP, 12-lead ECG, Holter monitor recordings, or adverse events. Both HFA 134a salbutamol sulfate and CFC 11/12 salbutamol displayed a significant dose-response for FEV1, FEF25-75%, FVC, serum potassium, heart rate, and systolic BP. CONCLUSIONS: HFA 134a salbutamol sulfate and CFC 11/12 salbutamol produced clinically and statistically similar airway responses and side effects. These results indicate that HFA 134a salbutamol sulfate would be a safe and effective substitute for CFC 11/12 salbutamol.     

Proline, leucine, and alanine transport in placental microvillous membrane vesicles prepared from late gestational rats

The aerodynamic particle-size distribution for two doses of a Becloforte metered-dose inhaler (MDI) was measured by use of a twin-stage impinger (TSI), the new multi-stage (five-stage) liquid impinger (MSLI) and the Andersen cascade impactor (ACI) (n = 5 for each apparatus). The mean (s.d.) fine-particle doses measured by the three techniques for the Becloforte MDI were 40.3 (1.2), 45.7 (0.5) and 41.8 (0.4)% w/w, respectively; the median mass aerodynamic diameters (MMAD) measured using the MSLI and the ACI were 3.50 and 3.73 microns, respectively. The MSLI fine particle (< 6.8 microns) doses for 2, 5, 10, 20, 30 and 40 doses from Becloforte MDIs (n = 5 for each dose) were 49.7 (0.7), 52.9 (1.2), 45.3 (0.6), 45.5 (0.71), 45.9 (0.7) and 46.4 (0.7)% w/w, respectively. Values obtained using the ACI (< 5.8 microns) were 40.8 (1.0), 41.0 (0.8), 44.4 (0.5), 43.1 (0.4), 42.8 (0.5) and 40.4 (0.4)% w/w (n = 4). MMAD values measured with the MSLI were 3.39, 3.46, 3.75, 3.91, 4.15 and 4.45 microns, respectively; using the ACI they were 3.46, 3.54, 3.61, 3.66, 3.73 and 3.85 microns. The results indicate that the measured aerodynamic particle-size distributions of beclomethasone dipropionate MDIs are affected by the dose dispensed and by the apparatus used for measurement.     

Aerosol therapy

Aerosol therapy plays a major role in the diagnosis and treatment of various lung diseases. The aim of inhalation therapy is to deposit a reproducible and adequate dose of a specific drug to the airways, in order to achieve a high, local, clinical effect while avoiding serious systemic side effects. To achieve this goal, it is therefore important to have an efficient inhalation device to deliver different medications. However, the currently available therapeutic inhalation devices (nebuliser, pressurised metered-dose inhaler and dry powder inhaler) are not very efficient in aerosol delivery and have several disadvantages. Inhalation devices can be assessed by in vitro studies, filter studies and radiolabelled deposition studies. Several radiolabelled deposition studies have shown that nebulisers and pressurised metered-dose inhalers are not very efficient in aerosol delivery. In children, before 1997, only 0.5% to 15% of the total nebulised or actuated dose from a nebuliser or pressurised metered-dose inhaler actually reached the lungs. These numbers were somewhat improved in adults, 30% of the total nebulised or actuated dose reaching the airways. Aerosol therapy with dry powder inhalers was the most efficient before 1997, 30% of the total dose being deposited in the lungs of adults and children. In 1997, new developments in pressurised metered-dose inhalers much improved their efficiency in aerosol delivery. Lung deposition can be increased by up to 60% with use of a non-electrostatic holding chamber and/or a pressurised metered-dose inhaler with a hydrofluoroalkane propellant possessing superior aerosol characteristics. Several studies comparing the clinical efficiency of different inhalation devices have shown that the choice of an optimal inhalation device is crucial. In addition to the aerosol characteristics, ventilation parameters and airway morphology have an important bearing on deposition patterns. These parameters may be greatly influenced by the patient's acceptance of a specific inhalation device and therefore determine the choice of the device used. It is important for the clinical impact to develop more efficient inhalation devices, which need to be assessed for use in different age groups. These devices should be cheap, easy to use, portable, usable with all medications and environmentally safe.     

Assessment of patient acceptance and inhalation technique of a pressurized aerosol inhaler and two breath-actuated devices

OBJECTIVE: To assess inhalation technique in patients after written instruction alone, written and verbal instruction, and clinical use of two new inhalation devices. DESIGN: Randomized, crossover evaluation of the albuterol Diskhaler and the terbutaline Turbuhaler. SETTING: Canadian tertiary-care hospital. PATIENTS: Twenty hospitalized adults with asthma or chronic obstructive pulmonary disease currently using an albuterol metered-dose inhaler (MDI). Nineteen patients received Diskhaler, 16 received Turbuhaler, 15 received both inhalers, and 10 patients used both inhalers for three days each. INTERVENTIONS: Patients were randomized to receive either Diskhaler or Turbuhaler for three days. Inhaler technique was assessed after written instruction, written plus verbal instruction, at the first scheduled dose after instruction, and after three days of clinical use. Patients remaining in the hospital after three days crossed over to the other study inhaler and the same protocol was followed. MAIN OUTCOME MEASURES: Patient inhalation technique was assessed and compared for the MDI, Diskhaler, and Turbuhaler. RESULTS: Assessment of MDI technique revealed that 35 percent of patients used their MDI correctly on the first puff, and 42 percent used it correctly on the second puff. Following written instruction alone, correct technique was demonstrated by 32 percent of patients with Diskhaler and 6 percent with Turbuhaler. Technique significantly improved following verbal instruction, although 40 percent of the patients required up to three attempts to demonstrate correct technique on at least one of the study inhalers. After three days of clinical use, correct technique was demonstrated in only 54 percent of the Diskhaler and 64 percent of the Turbuhaler assessments. Performance at this assessment was, however, significantly better on the Turbuhaler than on the MDI (p = 0.01). Performance on the Diskhaler was not significantly different from the performance on the other inhalers. CONCLUSIONS: Written instruction alone is inadequate in teaching correct inhalation technique. Verbal instruction and technique assessment are essential for patients to achieve proper technique. Patients may perform better on the Turbuhaler than on other inhalation devices.     

Assessing metered-dose inhaler technique: comparison of observation vs. patient self-report

The purpose of this study was to develop and determine the validity of a patient-completed questionnaire that assesses metered-dose inhaler (MDI) technique. Self-reported MDI technique was compared to observed technique. The questionnaire included nine steps for MDI use, with two to three response choices for each step. A total of 159 patients were studied. Direct observation revealed that greater than 82% of patients exhibited inadequate technique (more than two out of nine steps incorrect). The mean percentage agreement between the questionnaire and observation was 77.4%. Questionnaire results where in higher agreement with observation when patients performed correct MDI technique.     

Inadequate literacy is a barrier to asthma knowledge and self-care

STUDY OBJECTIVES: To determine the relationship of literacy to asthma knowledge and ability to use a metered-dose inhaler (MDI) among patients with asthma. DESIGN: Cross-sectional survey. SETTING: Emergency department and asthma clinic at an urban public hospital. PATIENTS: Convenience sample of 273 patients presenting to the emergency department for an asthma exacerbation and 210 patients presenting to a specialized asthma clinic for routine care. INTERVENTIONS: Measurement of literacy with the Rapid Estimate of Adult Literacy in Medicine, asthma knowledge (20 question oral test), and demonstration of MDI technique (six-item assessment). MEASUREMENTS AND RESULTS: Only 27% of patients read at the high-school level, although two thirds reported being high-school graduates; 33% read at the seventh- to eighth-grade level, 27% at the fourth- to sixth-grade level, and 13% at or below the third-grade level. Mean asthma knowledge scores (+/-SD) were directly related to reading levels: 15.1+/-2.5, 13.9+/-2.5, 13.4+/-2.8, 11.9+/-2.5, respectively (p < 0.01). Patient reading level was the strongest predictor of asthma knowledge score in multivariate analysis. Poor MDI technique (< or =3 correct steps) was found in 89% of patients reading at less than the third-grade level compared with 48% of patients reading at the high-school level. In multivariate regression analyses, reading level was the strongest predictor of MDI technique. CONCLUSIONS: Inadequate literacy was common and strongly correlated with poorer knowledge of asthma and improper MDI use.     

Lung deposition of fenoterol and flunisolide delivered using a novel device for inhaled medicines: comparison of RESPIMAT with conventional metered-dose inhalers with and without spacer devices

STUDY OBJECTIVES: To compare lung deposition of fenoterol or flunisolide administered from a novel, multidose inhalation device delivering liquid droplets (RESPIMAT; Boehringer Ingelheim Ltd; Bracknell, UK) or from conventional metered-dose inhalers (MDIs) with and without spacers. DESIGN: Two randomized, three-way crossover studies. SETTING: Clinical research laboratory. PARTICIPANTS: Healthy, nonsmoking volunteers. INTERVENTIONS: In one study, radiolabeled aerosols of fenoterol from the RESPIMAT device and from a conventional MDI with or without an Aerochamber spacer (Trudell Medical; London, Ontario Canada). In the second study, radiolabeled aerosols of flunisolide from a RESPIMAT device, from a RESPIMAT device modified by inclusion of a baffle/impactor in the mouthpiece, and from a conventional MDI with an Inhacort spacer (Boehringer Ingelheim; Ingelheim, Germany). MEASUREMENTS AND RESULTS: Assessment of the deposition of fenoterol or flunisolide in the lung and oropharynx using gamma scintigraphy. Safety was assessed based on reported adverse effects and spirometry (FEV1, FVC, and peak expiratory flow rate) to detect any paradoxical bronchoconstriction. The RESPIMAT device delivered significantly more fenoterol to the lungs than either an MDI alone or an MDI with Aerochamber (39.2% vs 11.0% and 9.9% of metered dose, respectively; p<0.01). Oropharyngeal deposition of fenoterol from the new device was lower than that from the MDI (37.1% vs 71.7%, respectively; p<0.01). The RESPIMAT device deposited significantly more flunisolide in the lungs compared with MDI plus spacer (44.6% vs 26.4%, respectively; p<0.01), while resulting in similar oropharyngeal deposition (26.2% vs 31.2%, respectively). Introduction of a baffle into the RESPIMAT system reduced lung deposition of flunisolide to 29.5%, and oropharyngeal deposition to 7.8% (p<0.01). CONCLUSION: The RESPIMAT device may prove to be an effective alternative to MDIs for the administration of inhaled bronchodilators and corticosteroids. The high lung deposition and low oropharyngeal deposition may lead to improved efficacy and tolerability of inhaled medications, especially corticosteroids.     

Estimating the cost of lost productivity in dyspepsia

In a two-day, randomised, double-blind, double-dummy, cross-over multicenter study, the bronchodilating effect of 100 micrograms of salbutamol (CAS 18559-94-9) inhaled from a new metered dose powder inhaler (MDPI; Taifun) was compared with that of an identical dose of salbutamol inhaled from a conventional pressurised metered dose inhaler connected to a spacer (pMDI + S). Thirty-six non-smoking, adult asthmatic outpatients with a baseline forced expiratory volume in 1 s (FEV1) between 35 and 70% of the predicted value participated in the study. After inhalation of the study medication pulmonary function, FEV1 and airway resistance (R(aw)), blood pressure (BP), and heart rate (HR) were measured up to 6 h. Area under the FEV1 vs. time curve (AUCFEV1) was used as the primary efficacy parameter, and the 90% confidence intervals (CI) were used to judge clinical equivalence. Other efficacy parameters were used in supportive analyses as secondary parameters. Both treatments produced a clear improvement in pulmonary function. The mean +/- SD AUCFEV1 were 893 +/- 281 and 889 +/- 2761.min after MDPI and pMDI + S, respectively. The 90% CI for the relative efficacy of the MDPI is from 98 to 103% of that of the pMDI + S. Also the other efficacy parameters gave similar results without significant differences: the mean +/- SD values of percent increase in FEV1 were 47.2 +/- 19.3 and 44.7 +/- 20.8, the maximum absolute value of FEV1 were 2.87 +/- 0.77 and 2.86 +/- 0.77, the maximum percent decrease in R(aw) 53.2 +/- 20.5 and 55.0 +/- 19.1, and the minimum absolute value of R(aw) 0.27 +/- 0.11 and 0.30 +/- 0.12 kPa.s.l-1 for the MDPI and pMDI + S, respectively. The salbutamol doses had no significant effect on BP or HR, and were equally well tolerated. Furthermore, 57.5% of the patients preferred the MDPI, 35% the pMDI + S, and 7.5% considered that there was no difference between the devices. In conclusion, this study demonstrates that the new MDPI is as effective and safe a device as a conventional pMDI connected to a spacer in administering inhaled salbutamol for asthmatic patients. Further, most patients considered the MDPI easier to handle, and preferred it over the pMDI + S.     

HIV-1 gp120-dependent induction of apoptosis in antigen-specific human T cell clones is characterized by ''tissue'' transglutaminase expression and prevented by cyclosporin A

Inhalation is the method of choice for delivering therapeutic agents to the lung. The advent of metered-dose inhalers (MDIs) has made inhalation easier, less expensive and more efficient. However, 20-50% of patients are unable to use MDIs correctly. The main problems are: 1) impact of aerosol particles in the mouth (responsible for side-effects); 2) poor co-ordination between firing the MDI and breathing; 3) and too fast an inspiration. Various spacer devices have been designed to overcome these problems. These are: large volume devices, which reduce the oral impact and select the respirable particles; devices equipped with a one-way valve that reduces co-ordination problems; indication of too rapid an inspiration by a high-flow mark. The introduction of these devices has resulted in an improved bronchial/oral deposition rate and a reduced incidence of side-effects. Training and education of patients is fundamental in ensuring the correct use of inhalers.     

Pharmacokinetics and dose proportionality of beclomethasone from three strengths of a CFC-free beclomethasone dipropionate metered-dose inhaler

As part of a development program to offer alternatives to chlorofluorocarbon (CFC) containing metered-dose inhalers, beclomethasone dipropionate has been formulated in a CFC-free system at three strengths: 50, 100, and 200 micrograms/actuation ex valve. To measure serum levels and dose proportionality of the beclomethasone derived from beclomethasone dipropionate, 13 mild to moderate asthmatic patients received a single dose of eight inhalations from each strength according to a double-blind crossover design. Seven patients were studied over 4 h and six patients over 12 h. For the total doses of 400, 800, and 1600 micrograms studied over 12 h, Cmax and AUC increased in a ratio of 1:1.8:3.1. A good correlation was seen between the fine-particle mass delivered and the in vivo performance of the three strengths. From a clinical point of view, the predictable increases in serum levels with an increase in dose will permit the clinician to effectively titrate a patient with this product.     

Acute effects of ambient ozone on asthmatic, wheezy, and healthy children

Southern California children (10 to 12 years old) participated in a two-season study to assess the potential acute respiratory effects of ambient ozone (O3). Asthmatic (n = 49), wheezy (n = 53), and healthy (n = 93) children completed a four-day (Friday through Monday) study protocol, once in spring and again in summer, that included the use of daily activity and symptom diaries, heart rate recording devices, personal O3 samplers, and maximal effort spirometry several times per day. Data from regional monitoring stations were used to establish ambient hourly O3 concentrations. Analyses revealed that the children spent more time outdoors and were more physically active in the spring. Girls spent less time outdoors and were less physically active than boys. Personal O3 samplers correlated poorly with, and generally gave lower readings than, outdoor ambient monitors. Higher personal O3 exposures were associated generally with increased inhaler use, more outdoor time, and more physical activity. Children with asthma spent more time outdoors and were more active in the spring on high-O3 days (measured by personal sampler), and had the most trouble breathing, the most wheezing, and the most inhaler use on these days. Activity pattern data suggested that children with asthma protected themselves by being less physically active outdoors during the summer on high-O3 days. Wheezy children had the most trouble breathing during the summer on low-O3 days (measured by personal sampler). Observed relationships between O3 and pulmonary function were erratic and difficult to reconcile with existing knowledge about the acute respiratory effects of air pollution. We conclude that although asthmatic and wheezy children behave differently from their healthy peers with regard to symptoms and patterns of activity when challenged by ambient ozone, the nature of these changes remains inconsistent and ill-defined.     

The factors determining survivorship in patients with colorectal carcinoma complicated by obstructive ileus of the large intestine

A total of 232 patients with obturation ileus, caused by locally advanced colorectal carcinoma, are operated over a 12-year period (1979-1990). In 160 patients (68.97 per cent) the tumor is located in the colon, and in 72 (31.03 per cent)-in the rectum. The operative interventions performed are distributed as follows: 122 (52.58 per cent) radical, and 110 (47.42 per cent) palliative. There are 84 patients (36.03 per cent) in IV clinical stage. Postoperative lethality among those subjected to radical operation amounts to 25.41 per cent, with leading underlying causes-peritonitis (35.08 per cent) and serious ileus intoxication (21.05 per cent). The survival over 1, 3 and 5-year periods among those radically operated is 74.59, 48.37 and 34.06 per cent, respectively. Histologically differentiated adenocarcinoma is demonstrated in 69.38 per cent, undifferentiated-in 17.50 per cent, and mucinous adenocarcinoma-in 13.12 per cent. The factors with a high prognostic value include: stage of primary tumor development, lymph involvement, type of operative intervention and histological variant of the neoplasm.     

Randomised crossover trial of salbutamol aerosol delivered by metered dose inhaler, jet nebuliser, and ultrasonic nebuliser in chronic lung disease

AIMS: To compare the efficacy of salbutamol delivered by metered dose inhaler (MDI), jet nebuliser, and ultrasonic nebuliser in ventilated infants with chronic lung disease. METHODS: Twenty preterm ventilated infants with chronic lung disease were enrolled in two studies. In study 1 (n = 10), each infant was given 200 micrograms of salbutamol at 4 hour intervals and in random sequence from a metered dose inhaler-spacer device, a jet nebuliser, and an ultrasonic nebuliser with a small medication cup. The infants were monitored for heart rate, transcutaneous pO2, pCO2, and oxygen saturation, respiratory system resistance and compliance before and after each treatment. Infants in study 2 (n = 10) were similarly studied except for the use of a different jet nebuliser. RESULTS: The mean (SEM) maximum percentage decreases in respiratory system resistance, observed at 30 minutes after aerosol delivery were study 1: MDI: 44.3 (4.3)%; jet: 32.3 (3.4)%; ultrasonic: 56.1 (3.2)%; study 2: MDI: 28.6 (1.0)%; jet: 16.9 (1.4)%; ultrasonic: 42.1 (1.6)%. During the first hour after treatment, a significantly faster heart rate and higher transcutaneous pO2 were associated with the use of the ultrasonic nebuliser or MDI than with the jet nebulisers in both studies. The use of the ultrasonic nebuliser but not the other devices also resulted in a lower transcutaneous pCO2 and improved respiratory system compliance in study 2. CONCLUSIONS: These findings suggest that among the devices tested, the delivery of salbutamol aerosol to the lower respiratory tract was greatest using the ultrasonic nebuliser, and least with the jet nebulisers.     

Lower limb surveillance following autologous vein bypass should be life long

BACKGROUND: The aim of the study was to investigate whether infrainguinal vein graft surveillance can be stopped at 1 year without prejudicing graft or leg survival. METHODS: Data were collected prospectively on 351 infrainguinal vein bypass grafts (326 patients) that had been entered into a vein graft surveillance programme between 1988 and 1997. RESULTS: Some 104 grafts (30 per cent) developed significant new vein graft stenoses, 95 (91 per cent) of which occurred within 12 months. After 1 year, the risk of developing a significant graft stenosis was 3 per cent per year. Sixty-nine grafted limbs (20 per cent) developed new arterial inflow or run-off stenoses that required intervention, but only 37 (54 per cent) occurred within the first year, after which the risk was 9 per cent per year. The overall risk of developing a new vein graft or arterial stenosis after 1 year was 10 per cent per year. CONCLUSION: The incidence of vein graft stenosis decreases significantly 1 year after operation but there is still at risk of developing potentially graft-threatening arterial stenoses. Legs that have undergone infrainguinal vein bypass grafting should continue to be monitored in a surveillance programme for life.     

Exudative pleural effusion and pleural leukocytoclastic vasculitis in limited scleroderma

Chlorofluorocarbons (CFCs) damage stratospheric ozone permitting enhanced levels of ultraviolet B radiation to reach the Earth's surface. As a result, production of CFCs is now banned under the Montreal Protocol with the exception of their temporary continued use in pressurized metered dose inhalers used to treat those with airway disorders. Replacement propellants have now been identified and shown to be safe and a major exercise is under way to reformulate the commonly used aerosolized medicines with the new propellants. The new products are now undergoing clinical trials and the first reformulated beta-agonist and corticosteroid inhalers have reached the marketplace. The majority of the current products will have been changed over to the new types over the next 3 yrs, and each country will adapt a transition strategy to oversee this process. The politicians, the environmentalists, the pharmaceutical industry and the regulatory authorities have fulfilled their part in this changeover, and respiratory interested health professionals now need to address what this means for them and their patients so that there may be a seamless transition for the millions of people who use inhaled medicines worldwide.     

Nonadherence in tuberculosis treatment among HIV patients attending Bamrasnaradura Hospital, Nonthaburi

OBJECTIVE: To determine the clinical manifestations, outcome and nonadherence, in tuberculosis (TB) among HIV patients in Bamrasnaradura Hospital, Nonthaburi. DESIGN: A retrospective cohort study; hospital record files were reviewed over 11 months. A total of 200 consecutive HIV patients were entered and followed for a 6 months period of their TB treatment. Sociodemographic data, symptoms and signs and results of investigation tests were recorded at the time of presentation, while diagnosis, and clinical outcome were done at the end of the follow-up time. RESULTS: Extrapulmonary tuberculosis (58%) was more common than pure pulmonary involvement (42%). Lymphadenopathy (52%) was the commonest sign on physical examination. Chest X-rays were positive in 55 per cent cases, while AFB examination was positive in 48.5 per cent from the sputum and 46 per cent from lymph node aspirate specimens. After 6 months of treatment, 30 per cent patients were still alive, 12 per cent had died, and 50 per cent were lost to follow-up. Factors such as low socioeconomic status (p < 0.001), being newly diagnosed with TB (p < 0.001), past history of TB (p < 0.003), etc., were statistically significant in predicting the likely nonadherence in TB treatment among HIV patients. CONCLUSION: In HIV-infected individual, tuberculosis presents more often with extrapulmonary involvement, and the diagnosis is not difficult. While treatment of tuberculosis is successful, patients' compliance is the biggest problem in managing them.